韩国医改的医药分离

ARTICLEINPRESSSocialScience&Medicine57(2003)529538PharmaceuticalreformandphysicianstrikesinKorea:separationofdrugprescribinganddispensingSoonmanKwon*DepartmentofHealthPolicyandManagement,SchoolofPublicHealth,SeoulNationalUniversity,28Yonkon-dong,Chongno-gu,Seoul110-799,RepublicofKoreaAbstractBeforetherecentpharmaceuticalreforminKoreathatmandatestheseparationofdrugprescribinganddispensing,physiciansandpharmacistsbothprescribedanddispenseddrugs,resultingintheoveruseandmisuseofdrugs.Thepharmaceuticalreformattemptstochangetheproviderseconomicincentivesbyeliminatingtheprovidersprotfromdrugsthathavebeenamajorsourceoftheirincome.Italsoinuencesthepharmaceuticalindustrythathasthrivedonofferinghighmarginstophysiciansratherthanonproducinghigh-qualitydrugs.However,physicianstrikesforcedthegovernmenttomodifysomecriticalelementsofthereformpackageandtoraisemedicalfeessubstantiallytocompensatefortheincomelossofphysicians.Lackofastrategicplanofimplementation,failuretoappreciatethechangeintheparadigmofhealthpolicyprocess,andfailuretoconvinceconsumersofthebenetsofthereform,arethemajorreasonsthatthehistoricreformoftheseparationofdrugprescribinganddispensinghasresultedingreatersocialcostthanexpected.r2003ElsevierScienceLtd.Allrightsreserved.Keywords:Separationofprescribinganddispensing;Pharmaceuticals;Physicianstrike;KoreaIntroductionAgingofthepopulation,growthofpopularaccep-tanceofdrugs,andremovalofnancialbarrierstousehaveledtothegrowthofdrugconsumption(Davis,1997).Consequently,pharmaceuticalexpenditureisanimportantcontributortooverallhealthcarecostescalation,andhealthcarepolicyinmanycountriesnowtargetsthepharmaceuticalsectorforcostcontain-ment(Mossialos&Abel-Smith,1996;Saltman&Figueras,1997).Koreafacedevenworseproblems.Untilrecently,physiciansandpharmacistswereallowedtobothprescribeanddispensedrugs,andtheirbehaviorwasdrivenbyeconomicincentives,whichresultedintheoveruseofdrugsandhighpharmaceuticalexpenditure.OtherAsiancountriessuchasChinaandJapanhad*Correspondingauthor.Fax:82-2-745-9104.E-mailaddress:kwonssnu.ac.kr(S.Kwon).similarproblems.Despitetheurgentneedforreform,strongoppositionbyphysiciansandpharmacistshadbeencriticalbarrierstoreforminKoreaforalongtime.Withoutthecooperationofthosetwokeyplayersindrugprescribinganddispensing,reformtoseparatetwofunctionsseemedimpossible.InJuly1,2000,theKoreangovernmentimplementedareformthatmandatedtheseparationofdrugprescribingfromdispensing.Thereformaimedtofundamentallychangetheinefcientpatternoftheprovisionandconsumptionofpharmaceuticals,toreducetheresultantoveruseandmisuseofdrugsandtocontainpharmaceuticalexpenditure.Italsoaffectedthepharmaceuticalindustrythatreliedonofferinghighmargins,ratherthanproducinghigh-qualitydrugs,inordertoaffectthephysiciansselectionofdrugs.However,thepharmaceuticalreformencounteredseverephysicianstrikesbecauseitattemptedtoeliminatetheirprotfromdrugs,amajorsourceoftheirincome.0277-9536/03/$-seefrontmatterr2003ElsevierScienceLtd.Allrightsreserved.PII:S0277-9536(02)00378-7530ARTICLEINPRESSS.Kwon/SocialScience&Medicine57(2003)529538Physicianstrikesdistortedthecontentsofthereformandcontributedtoreducingthesocialbenetofthereform.ThispaperaimstoexaminethecontextandprocessofthepharmaceuticalreforminKoreaandevaluateitsexpectedimpacts.ThisstudyreliesontheframeworkofhealthpolicyanalysissuggestedbyWalt(1994).1Healthcarepolicyorreformisthusexaminedintermsoftheinterrelationshipsofcontext,actors,contentsandprocessassociatedwithpolicyformulation,implementa-tionandevaluation.ThisstudyalsoaddressesthefundamentaleconomicissuesofthepharmaceuticalreformandexamineshowitaffectsthevestedeconomicinterestsofkeyactorsandhencechangestheoutcomeofthepharmaceuticalsectorandtheentirehealthcaresysteminKorea.ItistooearlytoevaluatetheKoreanpharmaceuticalreformbasedonempiricaldata,andthisstudyevaluatestheexpectedeffectsofthereformfromtheperspectiveofreformprocessaswellaseconomicincentives.ThispaperrstdiscussestheKoreanpharmaceuticalsectorandtheneedforpharmaceuticalreform.Thenthepaperexaminesthekeyactorsofthereform,processofpolicyformulation,andcriticalcontentsofthereformpolicy.Italsoevaluatestheimpactthereformisexpectedtohaveonhealthcareexpenditureandpharmaceuticalindustry.Finallyitdrawslessonsfromthereformsuchastheroleofstrategicimplementation,thechangeintheparadigmofhealthpolicyprocess,pharmaceuticalpolicyinfrastructure,andtheburdenonconsumers.ContextofthepharmaceuticalreformHealthcareandpharmaceuticalsinKoreaKoreahasnationalhealthinsurancewithuniversalcoverageofthepopulation.Rapidextensionofpopula-tioncoveragewasmadeattheexpenseoflimitedbenetcoveragewithlowcontribution.Despitesocialinsuranceforhealthcare,publicnancingaccountsforlessthan50%oftotalhealthcareexpenditureinKorea(Kwon,2002d).Healthcareprovidersarereimbursedonafee-for-servicebasis.Sincefeesarestrictlyregulated,physicianshavestrongincentivestoprovidemoreprotableservicesoritemswithhighermarginsinotherwords,thoseforwhichthedifferencebetweenthegovernmentreimbursementandactualcostsarethegreatest.Prot-maximizingbehaviorofhealthcareprovidersarethenormbecausefor-protprivatesectorispredominantinhealthcaredeliveryinKorea.Hospitalshavelittletodowiththesocialcapitalornon-protsectorbecauseinmostcasesentrepreneurialphysicianshaveexpandedthescaleoftheirclinicstohospitals.Rolesofphysicianclinicsandhospitalsarenotdifferentiated,andoutpatientclinicsareamajorsourceofprotformosthospitals.Membershipsofmedicalassociationandthehospitalassociationsoverlapbe-causephysiciansareownersandmanagersofhospitals.Thosetwoassociationshavelongbeenstrongalliesagainstgovernmenthealthcarepolicyingeneral,andthereimbursementpolicyinparticular.Inthepharmaceuticalsectortherewasnoseparationofdrugprescribinganddispensing,andphysiciansandpharmacistsbothprescribedanddispenseddrugs.Pharmacistslongplayedtheroleofprimaryhealthcareproviderswhenthesupplyofphysicianswasscarceincommunities.Drugs,andconsultationsthatpharmacistsprovided,werereadilyaccessibleprimaryhealthcaretoconsumers,whichisevidencedbythenumberofpharmaciescomparedtothatofphysicianclinics.Thetraditionoforientalmedicine,wheretherolesofphysiciansandpharmacistsarenotdifferentiated,hasalsoaffectedthepracticeofmedicineinEastAsia,andphysiciansbothprescribeanddispensedrugsinChina,HongKong,Japan,KoreaandTaiwan(Chouetal.,2001;Grant&Yuen,1998;Rodwin&Okamoto,2000).TraditionalmedicineinKoreadependsalotonmedicationinpatienttreatment,contributingtopeoplesperceptionthatthefeestheypayarecompensationfordrugsratherthanforphysicianlabor(consultation).Peoplealsotaketraditionalmedicinesforprevention,whichresultsinastrongpreferencetowardmedicines.NeedforthepharmaceuticalreformWithouttheseparationofdrugprescribinganddispensing,physiciansandpharmacistshadnancialinterestsnotnecessarilytoactinthebestinterestofpatients.Missingwasthemechanismofcheckandbalancebetweenthepharmacistandthephysicianintheprescriptionofdrugs.Thisresultedinthepossibilityofthemisuseofdrugs.Patientsdidnothaveaccesstoprescriptioninformationaboutthetypeandamountofmedicationtheytook,either.Thereforebyseparatingtheprescribinganddispensingofdrugs,reformaimedtoreducetheoveruseandmisuseofdrugs,improvethequalityoftheconsumptionofprescriptiondrugs,andenhancethepatientsrighttoknowabouttheirmedication.SeparationofdrugprescribinganddispensinginKoreahasmuchmoreimportantpolicyimplicationsthanthesimpledivisionoflaborbetweenphysiciansandpharmacists.Moreimportantly,sincethefeesformedicalservicesarestrictlyregulated,dispensingdrugshavebeenmoreprotableforphysiciansthanprovidingtheirownservices.Thegovernmentsetpricesforinsured1SeealsoKingdon(1995)forpolicyprocessingeneral.drugsonthebasisofthedatathatpharmaceuticalARTICLEINPRESSS.Kwon/SocialScience&Medicine57(2003)529538Table1Proportionofdrug-relatedrevenueinthetotalrevenueofphysicianclinics(Unit:%)a531InternalFamilyDermatologyUrologyPediatricsGeneralmedicinemedicinesurgery47.042.441.641.439.535.6aBasedonthenationalsamplethatcovers15.1%ofallphysicianclinics.Source:MinistryofHealthandWelfare(MOHW),Internalreport,2000(inKorean).manufacturersandwholesalersreported.Physicians,however,purchaseddrugsatcoststhatweremuchlowerthanthepricethattheinsurerreimbursed.Highermarginsfromdrugsinducedphysicianstoprescribeanddispensemoredrugsinordertoincreaseprot.Forinternalmedicine,almost50%oftherevenueofphysicianclinicscamefrompharmaceuticals(Table1).Forfamilymedicine,dermatology,urologyandpedia-trics,therevenuefromdrugsaccountedformorethan40%ofthetotalrevenue.Intertiaryandgeneralhospitals,theproportionsofdrugrevenuewere43.7%and45.4%,respectively,oftotalrevenue(MOHW,2000/2001).Themandatoryseparationofdrugprescrib-inganddispensingmeansthatthesubstantialprotfrompharmaceuticalsisnolongeravailabletophysi-ciansandhospitals.Evenifgovernmentcompensatedforprovidersincomelossbyraisingfees,incomefromhigherfeeswouldbeassessedandhencetaxable,whiletheprotfromdrugswouldnot.Physiciansandpharmacistspreferreddrugsforwhichpharmaceuticalmanufacturersandwholesalersoffereddeeperdiscountsbelowtheinsurancereimbursement.Selectionofdrugsbyprovidersdidnotdependontheirqualityorcost-effectiveness.Asaresult,unfairandillegalmarketingbypharmaceuticalmanufacturersandwholesalers,suchaspricecollusionandunder-the-tablebargainingwithphysiciansandpharmacists,character-izedthepharmaceuticalmanufacturinganddistributioninKorea.Theroleofresearchanddevelopmentwasminimal,andhigh-qualityoreffectivedrugsdidnotnecessarilyhavehighmarketshare,whichwasinsharpcontrasttomajorresearch-basedpharmaceuticalcom-paniesworldwide.Duetothenancialincentiveforphysiciansandpharmaciststodispensemoredrugsandconsumerseasieraccessibilitytodrugs,Koreansconsumedmoredrugsthanpeopleinotherdevelopedcountries.TheproportionofpharmaceuticalspendinginhealthcareexpenditureinKoreawas31%,whereasthatinOECDcountrieswasbelow20%onaverage(NHIC,1997b;OECD,1996).Becausegovernmentregulatedthedrugprice,highpharmaceuticalexpenditurewasrelatedtotheoveruseofdrugs.Whenpharmaceuticalspendingincludedphysicianfeesforprescribinganddispensing,itamountedtoasmuchas40%ofhealthcareexpenditureinKorea.Atthesametime,consumptionofmoredrugsresultedinanincreaseintheresistanceleveltoantibiotics.ProcessandcontentofthepharmaceuticalreformKeyactorsinthepharmaceuticalreformPhysiciansPhysiciansandpharmaciststriedveryhardtomain-tainthestatusquobyblockingthereform.Bothmedicalandpharmaceuticalassociations,withstronglobbyingcapacities,appealedtothepublicbyemphasizingthatthenewsystemwouldintroducesubstantialinconve-niencetoconsumeraccesstodrugsandbydeliberatelydevaluingitseffectsonpotentialcostsavingsandbetterhealth.Physiciansinparticularhadmajorimpactsonthepharmaceuticalreformthroughseveralnation-widestrikes,whichparalyzedtheentirehealthcaresystem.Physicianstrikessucceededinpushingthegovernmenttomodifysomecriticalelementsofthereform,andtoraisemedicalfeessubstantiallytocompensatefortheincomelossofphysicians.Mostphysiciansinhospitals,aswellasofce-basedphysiciansparticipatedinthestrikes.InKorea,theturnoverofhospital-basedphysiciansisveryhigh,withtheexceptionofuniversityhospitals.Inmostcases,afterworkingseveralyearsathospital,theyopentheirownclinics.Thetransientnatureofhospitalemploymentcanthusexplaintheactiveparticipationofhospital-basedphysiciansinthestrikes,althoughtheyarecurrentlypaidbythehospitalthroughasalaryarrangement.PharmacistsPharmacistsstronglyopposedthereformfromthebeginning,aswell.Butatlaterstages,severeconictsbetweenphysiciansandpharmacistsoverseveralcriticalissuesofthereformbegan,andtheywereinvolvedinazero-sumgametoinuencethepolicyprocessandcontenttotheirowninterests(examinedinlatersections).Theprofessionalpowerofphysiciansturnedouttobestrongerthanthatofpharmacists,andlongstrikesbyphysiciansdominatedpolicyimplementation.Althoughpharmacistsgotahighincreaseindispensingfeesinreturnfornotstriking,theseparationofdrugprescribinganddispensingwillfundamentallychange532ARTICLEINPRESSS.Kwon/SocialScience&Medicine57(2003)529538AdaptedfromPetersen(1994),whoappliedthisconcepttoThenewpresidentandcivicgroupsalsoplayedacriticaltheroleofpharmacists,whoplayedtheroleofprimaryhealthcareprovidersforalongtimeinKorea.Thedeclineintheprofessionalpowerofpharmacistswillacceleratebecausetheywillbemoredependentonphysiciansandlocateclosertophysicianclinics.Mergersandacquisitionsamongpharmaciesalreadybeganandwillchangethebusinessofpharmacies,whichwereinmostcasesoperatedbyasinglepharmacistandsmallinsize.Entryoflargecorporatechainstoresisalsoexpected.GovernmentOneofmajorrolesoftheMinistryofHealthandWelfareintheKoreanhealthcaresystemistosetthereimbursementprice(feeschedule)formedicalcareandpharmaceuticalsinthenationalhealthinsurancesystem.Inreturnforthestrictregulationoffeesforphysicianservices,governmenthasimplicitlyallowedmedicalproviderstogetprotsfromdrugs.Insomesense,therewasaniron-triangle2ofthepharmaceuticalindustry,medicalprovidersandgovernmentbureaucratsbecausegovernmentneveractivelyenforcedthepolicyofthemaximumallowablemarginonphysiciansof24%fromdrugs.Duetotheskepticismaboutthefeasibilityofthereform,thebureaucratsoftheMinistryofHealthandWelfarefailedtoplayamajorroleinpolicyformation,andlateryieldedtophysicianstrikesbysubstantiallyraisingphysicianfees.CivicgroupsHealthcarehasbeenaneglectedissueinKoreaforalongtime,andconsumerswerenotamajoractorinpharmaceuticalreform.Butcivicgroups,consistingmainlyofprogressiveacademiciansandthosewhousedtobeactiveinthedemocraticmovementsintheformermilitaryregime,playedapivotalroleinbreakingtheaforementionedirontriangleandformulatingpharma-ceuticalreform.ThecivicgroupswereempoweredbythenewpresidentKimDaeJoong.3TheymadepharmaceuticalreformamajorsocialissueandpushedthepresidentsoftheKoreanMedicalAssociationandKoreanPharmaceuticalAssociationtocometothetableandagreeonmajorissuesofreform.FormationofpharmaceuticalreformFirstlegislativeattemptsatthemandatoryseparationofdrugprescribinganddispensingweremadein1963.2ahealthpolicycommunitybasedoncloserelationsbetweenpowerfulinterests.3roleintherecenthealthcarenancingreformthemergerofhealthinsurancesocietiesintoasinglepayersystem(Kwon,2002c).However,manyattemptstointroducetheseparation,includingthepilotprogramduring19821985inMokpocity,didnotleadtoreformduetothestrongoppositionbyphysiciansandpharmacists(Park,1990).Evenwhenthesocialhealthinsuranceachieveduniversalcoverageofthepopulationin1989,theseparationofdrugprescribinganddispensingwasrejected,and,instead,healthinsurancebegantoprovidecoveragetodrugsprescribedanddispensedbypharmacists.TheamendmenttothePharmacyLawin1994speciedthattheseparationofprescribinganddispen-singofdrugsshouldbeimplementednolaterthan1999.(Theamendmentwastheby-productoftheconictamongpharmacistsandtraditionalmedicaldoctorsovertraditionaldrugs.)In1997,thenationalcommitteeonhealthcarereformproposedamodelforseparation,whichadoptedanincrementalapproachtobeimple-mentedin6yearsfrom1999to2005(NCHCR,1997).Althoughphysiciansandpharmaciststriedhardtodefertheseparationofdrugprescribinganddispensing,thenewpresidentwasde