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The separation of prescribing
and dispensing has been increasing in Japan. In Japanese,
the separation of the function between the two professions,
i.e. doctors and pharmacists, is called iyaku-bungyo,
or simply bungyo.
The separation is not legally
required in Japan, meaning that doctors are still allowed
to dispense or sell the drugs they prescribe. The voluntary
increase in the rate of bungyo is attributed to the
changes in the circumstances of the Japanese healthcare
system, such as increased demand to cut national health
expenditures and an increased concern about damages of adverse
drug reactions.
The understanding of the importance
and necessity of bungyo among the people was also
very important because its implementation entails some disruption,
such as:
- patients having to visit
clinics and also pharmacies when they are sick
- doctors losing profits from
prescribing drugs
- and pharmacies having to
maintain sufficient stock of medicines
Good understanding of the merits
of bungyo has thus been essential for its promotion.
Separation has been also driven
by the elimination of yakkasa, the gap between the
discounted market price and the reimbursement price of a
particular drug. Previously high rates of yakkasa
encouraged medical institutions to request discounts, enabling
them to profit from drug sales. This in turn encouraged
widespread over-prescribing. In 1961 the costs of pharmaceuticals
accounted for 25% of the total healthcare costs, while in
1973 the ratio reached the height of 46%.
In the mid 1960s it was alleged
that margins between actual and reimbursed prices were the
major cause of skyrocketing costs of healthcare and that
these margins were giving doctors incentives to use more
pharmaceuticals than needed. It was in 1974 that the Ministry
of Health and Welfare (Korosho) took measures to
promote bungyo.
Present situation and future trends
Separation of prescribing and dispensing functions continues
to increase rapidly, and reached almost 44% in the year
to March 2002. The actual figure in each prefecture, however,
varies from 13% to 68%, and, out of 47 prefectures, nine
have a ratio of less than 30%.
Some observers predict that bungyo rates could reach
80% within the next five years. Others, including Korosho
officials, believe that while rates of separation will continue
to rise at 3-5% a year in the near future, bungyo
will plateau at around 70%.
The broader implementation of flat-sum reimbursement as
a means of paying healthcare providers will be one of the
main factors to drive up bungyo rates. the broader
implementation of flat-sum reimbursement as a means of paying
healthcare providers Set payments include the cost of drugs
required for the treatment of specific conditions under
this system, removing financial incentives completely from
prescribing decisions.
Retail pharmacies and Bungyo
The most important feature of bungyo is that patients
acquire prescribed pharmaceuticals at different places from
where they get medical care.
Bungyo is driving major changes in the retail pharmacy
sector, with chain organizations and specialist outlets
dealing only in prescription drugs accounting for an increasing
proportion of total pharmacy numbers. Many traditional pharmacies
are simply not equipped to deal with rapidly rising demand
for the dispensing of prescriptions. Space is a major factor,
with typically small shop areas preventing many outlets
from stocking a sufficient range of drugs.
Pharmacy chains generally enjoy prime locations and larger
stores. Major chains are pursuing aggressive expansion policies
in order to increase their geographical coverage and take
advantage of economies of scale. Matsumotokiyoshi,
the country's leading drugstore chain, plans to open around
90 new stores in the year to March 2003, taking its total
number of outlets to more than 600. Most will be established
in the west of the country, the only region where the company
is not currently present.
The market is becoming increasingly attractive to foreign
drugstore chains as rates of bungyo continue to rise.
US retail giant Wal-Mart has taken its first steps into
the Japanese market, while the American drugstore chain,
Walgreens, has indicated that it would seriously consider
a Japanese market entry if bungyo reached 70%.
By taking away the economic incentives previously attached
to prescribing, bungyo may also mean that more doctors
will focus on efficacy or pharmacoeconomic issues in their
prescribing decisions. In the long run, this could benefit
companies that launch new products with major improvements
over existing ones, rather than 'me too' products.
Further information on the Japanese
pharmaceutical market is available in the IMS
Market Prognosis International
report, which also covers: Australia, Belgium, Canada, France,
Germany, Italy, South Africa, Spain, Switzerland, the UK,
and the USA.
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