Perceptions of general practitioners towards pharmaceutical price war and assessment medicines price variation among general practitioners’ clinics in the state of Penang,Malaysia

Discussion

Currently, there is no dispensing separation in Malaysia. Dispensing separation is defined as separation between prescribing and dispensing where prescribing activity is done by doctors, while dispensing activity is done by pharmacists. ²¹ A traditional “dispensing doctors” system in which GPs dispenses medications as a part of their professional practice is still the adopted model in Malaysia. ²² Obviously dispensing doctors have dual roles in prescribing and dispensing medicines to patients. This is because the 1952 Poison Act in Malaysia granted the right for registered medical practitioners to prescribe and dispense medications in their clinics. ²³ In other words, GPs and doctors practising in the private sector in Malaysia can diagnose patients and also dispense the medications to them.

This consequence has created an intense competition between retail pharmacies and GPs to gain a share in the pharmaceutical market. ²⁴ This pilot study had shown that almost all of the respondents perceived that community pharmacies have created phenomenon of pharmaceutical price war and were trying to compete price with GPs. This finding is in line with the findings of Hassali et al. study, where the community pharmacist lowers medicine prices in order to attract customers. ⁵ Gijsbrechts et al. reported that the unhealthy pharmaceutical price war has driven community pharmacy practice into a profit orientated business. ²⁵ From the data obtained, the average medicine prices sold by GPs are more expensive compared to community pharmacies. This finding is in line with the findings of a study conducted by Alabid et al. in Penang, where they reported that the average medical cost for common cold was charged higher by GPs compared to the community pharmacy, with RM 19.02 and RM 14.35, respectively. ¹³ Hence, the profit margin of medication gained by GPs would be higher compared to the community pharmacies. Similar to our study findings, Chou et al. reported that the dispensing doctors in Taiwan earned huge profits from the types and amounts of drugs dispensed. ²⁶ Surprisingly, community pharmacy sold Tenormin® at extremely low price compared to GPs with 61.4% difference (RM 41.5 vs. RM 16.0, respectively). Taking these observations into consideration, the possibility explanation for low price of Tenormin would be the stock obtained by community pharmacy was from parallel import.^27–32 It is usual and normal to have price disparity of 20–30% between the GP and the community pharmacy; however, it would be unacceptable if the price difference reached 61.4% between the two health care services. Thus, the appropriate role of the Malaysian Pharmaceutical Service Division and other regulators in the oversight of the price difference between GPs and community pharmacy is yet to be defined.

In private sector, the difference in pricing of medicine is partly attributed to the different bonus schemes of products offered by pharmaceutical companies to the community pharmacies. Currently, the issue of different bonus schemes offered by pharmaceutical companies is being debated in Malaysia. Pharmaceutical companies often offer cheaper prices or extra quantities of pharmaceutical products if purchased in a bigger volume. ⁵ In our study, majority of the respondents agreed to have different bonus schemes based on the quantities ordered for pharmaceutical products. In general, pharmaceutical companies often have different bonus schemes to the health care providers as one of their marketing strategy. ³³ The inducement to have lower cost of pharmaceutical products has indirectly forced health care providers to purchase pharmaceutical products in bigger quantities. Hence, the chain pharmacies and big health care institutions were able to gain the advantage from this marketing strategy by the pharmaceutical companies. Moreover, within the context of different bonus schemes, pharmaceutical companies also often offer pharmaceutical bonus scheme with different prices for doctors and pharmacists. In fact, the price of medications for the bonus schemes given by the Pharmaceutical companies to the GPs is much cheaper at the mega chains pharmacies. ³⁴ In this study, majority of the respondents agreed to have bonus scheme with different prices for GPs and pharmacists. The intention of pharmaceutical company to have special price of pharmaceutical products to doctors, is to encourage doctors as prescribers to promote their pharmaceutical products. Hence as a business strategy, doctors would take it granted to have lower prices of pharmaceutical products in order to promote it. ³⁴

However, community pharmacist as one of the important component in the health care system was not satisfied with the current scheme offered by pharmaceutical companies. In Malaysia, it is reported that some doctors sold bulk of medicines to the community pharmacy through runner network in order to gain fast profit. ³⁵ Moreover, Hassali et al. revealed that this unfair bonus scheme had led to the development of runner network within pharmaceutical market. ⁵ In addition, few pharmaceutical companies have taken the initiative to step down some of the rewards to the doctors. ³⁶ In Malaysia, recently there was a campaign slogan: “Say No to Inducement to Medical Prescribers” which was advocated by the Malaysian fraternity of community pharmacists in the year 2013. The main purposes of the campaign are to curtail the unethical practices by pharmaceutical companies and to diminish the advent of runner network which has ruined the pharmaceutical system in terms of product origin. ³⁷

The Malaysian government offered Competition Act 2010 in the year 2010. The act was effective on business practice since 1st January 2012. Malaysia Competition Commission (MyCC) has taken the lead to enhance Its main role is to protect the competitive process for the benefit of businesses practice, consumers welfare and the economy. ³⁸ The Competition Act 2010 prohibited certain abuse of dominant for examples price discrimination. Regarding medicine procurement, majority of respondents emphasized on the quality of medicine and also profit margin as important factors. Quality or profit margin may be germane decision parameters when medications are being prescribed. In fact, the appropriateness of a medicine should have a clear medical benefit and indication for the use rather than the profit margin. ³⁹ While only 35% of the respondents considered the factor of Pharmaceutical companies product bonuses. In addition, healthcare professionals should remove personal gain and profit in the decision making of prescribing medicines. Besides that, most of the doctors (90%) prescribed generic medicine actively in their daily practice. A generic medicine is defined by the World Health Organization (WHO) as “a pharmaceutical product, usually intended to be interchangeable with an innovator product that is manufactured without a licence from the innovator company and marketed after the expiry date of the patent or other exclusive rights.” ⁴⁰ When a medicine’s patent protection has finished, other pharmaceutical company can produce the same compounds found in the originator product using similar or different process. ⁴¹ In line with this report, Alabid et al. reported the same finding that GPs were prescribing more generic medicines. ¹³ Under Malaysian generic medicines policy in year 2006, Malaysia encourages generic prescribing, generic dispensing, generic substitution and generic medicine use in Malaysia. ⁴²

Conclusion

The findings from this study highlighted that the pharmaceutical price war issue has caused negative impact to the community pharmacies and GPs in Malaysia. In order to preserve the viability of community pharmacies and GPs in the country, the authorities should monitor medicine prices especially at the private sector to ensure affordability and to ensure pricing of medicines are appropriate. In addition, under Malaysian Competition Act 2010, MyCC could play an important role in overcoming the unethical practices by pharmaceutical companies in offering different bonus schemes and price discrimination policy toward community pharmacies and GPs.