Factors that influence medical scheme insured consumers to co-pay for prescription medicines at private community pharmacies in Pretoria, Gauteng Province, South Africa
Background: South African medical scheme members needlessly purchase high cost originator prescription medicines which attract out of pocket co-payments at pharmacies. This is despite availability of low priced generic medicines that are paid for in full by medical schemes. Co-payments result from misalignment between prices of the dispensed medicine and that of the alternative medicine which appears on the medical scheme's formulary list and for which the scheme is prepared to pay for in full. To establish what factors caused such misalignment, perspectives of medical scheme members and key informants which included pharmacists, regulators and representatives of medical schemes were explored. The study focused on co-payments for prescription medicines dispensed at private sector retail pharmacies in Pretoria, South Africa. Aim: The aim of the study was to explore views about co-payments and identify factors that motivate and influence Pretoria medical scheme members to co-pay when purchasing prescription medicines at pharmacies, despite being insured by medical scheme insurance organizations. Methodology: An exploratory qualitative research study was performed. Semi-structured interviews were conducted among purposefully selected medical scheme members (12) and 9 key informants. Key informants consisted of dispensing pharmacists (6), regulators of health professionals and medical schemes (2) and a senior official (1) with experience in the regulation of medicines and operations within medical scheme organizations. From a total of twelve interviewed medical scheme members, eight were interviewed at preselected retail pharmacies after they had made a co-payment and the other four selected because they did not make a co-payment. To ensure diversity in views about co-payments and related factors, dispensing pharmacists, co-paying and non co-paying medical scheme members were accessed from six pharmacies that are located in two separate locations of different socioeconomic status in Pretoria, that is, the Pretoria East suburban area and Pretoria city centre which is close to Pretoria central station and taxi routes. Three pharmacies were identified from each of the two different geographical locations, one independent and two corporate pharmacies per socioeconomic area. One pharmacist was interviewed from each of the selected pharmacies and medical scheme members were accessed from across the six pharmacies. The remainder of the key informants such as the regulators, were interviewed during office hours at venues of their choice which included areas of work. A pilot study was conducted among medical scheme members and pharmacists to test the applicability of interview tools. All interviews were conducted face-to-face by the researcher and recorded. The electronic record was independently compared with the researcher's enhanced notes for data accuracy. Codes identified during data analysis were derived from the interview notes and recordings and translated into organized text for theme development in a manner that referenced them to each study objective. Themes were arrived at after combining similar codes which were noted as representing a particular description for use during data interpretation and report writing. Ethics: Ethical clearance was sought from the UWC Senate Research Committee and granted. Prior to conducting interviews, written consent was obtained from all participants. Research details were explained and also provided on the participant information sheet wherein voluntary participation was emphasized. Anonymity and confidentiality was maintained throughout. Results: All patients and pharmacists expressed confusion about the medical scheme rules and related co-payments. There were differing co-payment perspectives among scheme members depending on socioeconomic status, with affordability being a key factor among those of lower socio-economic status whilst convenience and lack of comprehensible information about co-payments was prioritised amongst those members of higher socioeconomic status. Key influences on patient's purchasing decisions were health professionals (both doctors and pharmacists), with friends, family members and advertisements less influential. Patients and medical schemes generally preferred to utilise large chain pharmacies and patients, in particular, had a poor perception of the quality of generics. In general, the first prescribed medicine was highly favoured by patients and this influenced medicine preferences during subsequent prescriptions, especially for non communicable disease (NCD) medicines. Pharmacists did not apply the generic substitution policy in a manner that benefited the consumer because the lowest priced generic was frequently not kept as pharmacy stock. Co-payments appeared to create a divide between corporate and independent pharmacies. Some regulators tended to blame patients, pharmacists and medical schemes rather than the lack of adequate enforcement of national policies and regulations. Inadequate monitoring and enforcement of pro-consumer policies were found to be the main factors that contributed to co-payments. Conclusions and Recommendations: The introduction of regulations on minimum requirements for stock available at private sector retail pharmacies should be considered to ensure availability of the lowest priced generic at all times. This would ensure that co-payments are reduced and the desired consumer benefits that should accrue from the existing generic substitution policy are realized and maximized. To prevent perception-based and self-initiated co-payment behavior among consumers, vigorous and continued education about the value and equivalence of generics should be championed at the highest level of government with the execution of this critical responsibility not left to those with profit driven motives. Consumers might benefit from extensive education about the purchasing choices made at pharmacies and, in particular, the negative financial consequences associated with choosing a preferred but highly priced originator versus a low cost generic medicine which is used to treat the same ailment. Enforcement of policies by dedicated government agencies could further protect consumers from preventable high cost of healthcare and of medicines in particular.