A SYSTEMATIC REVIEW OF PRICING OF GENERICS MEDICINES AMONGST GREECE AND EU COUNTRIES.
This systematic review examines the pricing and market share of generic medicines in the pharmaceutical industry among Greece and other members of the European Union (EU). The systematic review starts with an extensive search of reliable sources that with consistency information. 250 research materials accessed from different online databases are searched and reviewed from which 8 are selected for the systematic review. The External Reference Pricing (ERP) models for different EU nations are analysed with the purpose of establishing the relationship between the ERP and generic pricing for the respective country. The pricing of generics in EU is analysed for 5 studies. It was found that the average price of generics is 68% and 53.7% the cost of the patented drugs in Greece and the rest of EU members respectively. The share of generics as a percentage of the total pharmaceutical market in Greece was found to be lower (19.18%) than the mean market share for remaining EU nations (46.18%). The standard deviations and correlations were evaluated to determine the level of dispersions from the mean values and to establish the relationship between the pricing and the market share of generics among Greece and other EU countries.
Sources of Information and Selection of the Study. 8
Data Collection Process and Items. 10
Summary of Measures and Synthesis of Results. 10
Pricing of Generics as Percentages of Patented Drugs. 20
Correlations between Pricing and Market Share. 22
Role of Stakeholders in Pricing and Market Share of Generics in Greece. 24
Price index by different pricing models. 27
Pharmaceutical Pricing Policy in Greece. 28
Overview of External Reference Pricing Systems in Europe. 29
List of Figures
Figure 1. PRISMA flow diagram. 13
Figure 2. The projected percentage of prescription and total sales of generics in Greece. 16
Figure 5. Percentage of generics in the market among 18 countries in EU. 30
List of Tables
Table 1. PICO table 1 for eligibility criteria. 8
Table 3. Summary of results. 13
Table 4. Projected percentage of prescription and total sales of generics in Greece. 15
Table 5. Results for 6 scales. 17
Table 6. Generic percentage market share for Greece and other EU nations. 18
Table 7. Pricing of generics as percentages of the patented or branded medicines. 20
Table 9. Values from the analysis of the correlation. 23
A critical evaluation and international comparison of pricing of generics medicines amongst Greece and EU countries
Introduction
Rationale
There are cost pressures that have been faced by the European nations relative to the budgets on healthcare that have been established in the continent over the years. The pressures have been caused by the increased rates of drug spending among individuals in various states. The context has been developed based on the notion that the savings obtained from the increased application of generic drugs can be helpful in guaranteeing that the healthcare services have been offered successfully. Therefore, there is a need to undertake an evaluation and international comparison of pricing of generics medicines among nations so as to provide insurers with adequate information on whether the generic drugs are being obtained at prices that are over the normal or not. The policies relative to reimbursement and pricing can be developed from the analysis that will have been carried out by researchers. Policy makers in different nations across the globe use the External Reference Pricing (ERP) to set prices for generics. ERP is a powerful tool that is used extensively to inform or set pharmaceutical prices in a given state. The pricing that has been applied on generic medicines in Greece and other nations in the EU has been found to be different based on the policies that have been developed over the years. This study explains the various aspects that help in comparing the prices as well as an evaluation of the ERP strategies that have been developed and implemented by the government administrators.
The pricing strategies that have been provided in Greece and other nations in the EU have been based on the policies and regulations that have been introduced by the government administrators over the years. The fixed pricing methods provide a clear illustration of the amount of prices that should be applied on medicines whether they are generic or original. The processes involved in introducing the pricing of generics medicines entail negotiations that are set by the government administrators. The prices of the wholesalers and the patients are immensely influenced by the new strategies applied by the national authorities since they help in introducing the prices that should be taken into consideration. The controls that have been placed on the direct prices may lead to induced lower prices or a slow price increase, which also affects the overall expenditure by the pharmaceutical in the healthcare industry across the continent (Vogler et al., 2011, p. 69). The regulation systems are different amongst Greece and the other EU nations, which will be discussed in the study.
Objectives
- To evaluate and compare the pricing of generic medicines among Greece and other EU nations.
- To develop an understanding of diverse concepts that affects the pricing of generic medicines.
- To determine factors that have led to the differences in pricing of generics among Greece and other EU countries
- To derive the concepts related to ERP policies in Greece and the EU nations.
Significance of the Study
There is a need to study the evaluation and international comparison of pricing of generic medicines amongst Greece and the EU countries, which will aid in developing improved strategies by the government administrators. The improved strategies will guarantee that the primary requirements of individuals in the communities are attained.
Research Questions
- What is the pricing of generic medicines in Greece?
- What is the difference between the cost of generic medicine in Greece and other European countries?
- Why is the cost of generic drugs higher in Greece than other European countries?
- Which countries in Europe have the biggest market of generic medicine?
- What is External Reference Pricing (ERP)?
- What are the pricing aspects related to the pricing of generics medicines in Greece and the EU nations?
- What are the primary pharmaceutical pricing policies in Greece?
Research Aim
The study is a systematic review that aims at discussing various aspects related to the pricing of generics medicines amongst the Greece and the EU countries, and the primary topics that will be covered include the external reference pricing, price caps, finance and organization of health services in EU member States, pharmaceutical pricing policy in Greece, overview of external reference pricing systems in Europe, generics in Greece most expensive in the EU and uptake remain low, and the impact of external reference pricing within and across countries.
Problem Statement
The provision of quality, accessible, and affordable medicines in a nation is essential in improving the health of individuals as well as promoting activities that improve the economic stability in the healthcare industry. The pricing of generic drugs has been found to be different among different members of the European Union, with Greece being those with high costs of generics. These differences in pricing of generics has created an immense impact on various processes being undertaken in Europe.
Methods
Protocol and Registration
There is no registration of this systematic review protocol on PROSPERO since it is not taking too long to warrant a registration. Registration is necessary for lengthy systematic reviews to make be peer-reviewed and to minimize the unnecessary duplication of the research.
Eligibility Criteria
This research is be based on the existing secondary data that was researched and published within the past 10 years. Limiting the research to this period helps in providing current and valid sources to explain the issue under discussion. All the sources are published in English or any other European language but translated to English. This ensures uniformity and makes the research work easier than it would have been if sources were in different languages.
Table 1. PICO table 1 for eligibility criteria.
| P (Participants/ Population) | Current Secondary data/research sources generics pricing in Greece and other EU members |
| I (intervention/indicator) | Selection of the relevant materials published within 10 years |
| C (comparison) | Selection of materials beyond 10 years and comparing the information |
| O (outcome) | Consistency in the secondary data review |
Source: Author, 2019.
Sources of Information and Selection of the Study
Various information sources were searched using the Google search engine. The databases and citation indexes that were searched include PubMed, Embase, and Web of Science. Other search sources for this review are National Library of Medicine, Access to Medicine Index, and ProQuest LLC among others. Whereas some of these online databases can be accessed freely without paying for any subscription fee, others charge a subscription fee. For example, one does not have to pay to access information in PubMed, while access to Web of Science materials requires membership registration.
The below table 2 shows 5 databases and indices as well as the data when they were accessed to source information for this review.
| Database/Index | Date Searched |
| PubMed | 20 March 2019 |
| Embase | 22 March 2019 |
| Web of Science | 25 March 2019 |
| National Library of Medicine | 28 March 2019 |
| Access to Medicine Index | 28 March 2019 |
Source: Author, 2019.
The study selection process for this study is based on the PRISMA flow diagram that is used for systematic review. The selection process was as independent as possible, with two authors being involved. Disagreements were solved through a consensus, and in cases where consensus failed, a third party was invited for consultation.
The data and information used in the study will be collected from various sources from publishers across the globe over the years. The references that will be applied for the study will cover a range of years since the information should be adequate and also recently updated. Therefore, the topic analysis will be based on ideas, concepts and debates that have been undertaken by scholars from diverse nations and over a period of time. The search engines that will be used for the collection of information will include the school libraries and Google, which will enhance the effectiveness and reliability of data and information (Quinlan et al., 2019).
Data Collection Process and Items
In this systematic review, only relevant data has been extracted. A comprehensive worksheet has been developed to ensure that the data collected is relevant and consistent with the research questions. There is no inclusion of additional materials once the extraction of data has been complete. The exclusion of extra materials is to minimize errors and bias that would have reduced the accuracy of the systematic review.
Two people helped in assessing the eligibility of studies and extraction of data from study reports independently to improve the credibility of the sources. The data collection forms has been designed to meet the objective of this research paper and piloted for each new review. The data has been presented in a format that allows the meta-analysis to be carried out.
The assessment of the risk of bias for this paper entails a judgement and support for each entry in a table showing ‘Risk of biases’. In this table, each entry focuses on a specific feature of the study. Each entry has a judgement for risk of biases as either ‘high risk’, ‘low risk’ or ‘unclear risk’. The ‘unclear risk’ judgement is indicative of uncertainty or lack of information over the potential bias.
Summary of Measures and Synthesis of Results
Relative difference in prices of generic medicines was the primary measure of the study. The meta-analyses were carried out to determine the differences using random-effects model. Quantitative analyses were conducted on the pharmaceutical prices of generics and the analyses were limited to the data obtained from the period of follow-up. Mean prices of the similar drugs in different countries within the EU were evaluated and standard deviations for each set of data determined. The correlation coefficients for the percentages of pricing and market share in both categories (Greece and other EU members) were evaluated. The calculation of the correlation coefficients aimed at determining if there is any relationship between the pricing of generics and market share among Greece and other EU nations.
Group analysis was performed as part of additional analyses to help understand whether results of the review are robust. In this case, huge sets of data from the extracted sources are broken down into smaller subsets based on shared characteristics. The subsets were then analysed to determine whether summary effects vary in relation to specific characteristics of the included research works.
Results
Study Selection
A total of 8 studies were identified for inclusion in the review. An independent process of over 300 electronic database search was conducted where 250 databases were found and recorded as n=250. Out of this 250 sources, 97 were removed as duplicated materials. The remaining number of databases, 153, were screened by evaluating the titles and abstracts. Following the screening, 127 sources were excluded from the study due to irrelevancy, retaining 26 sources. Out of the 26, only 8 sources met the inclusion criteria. Among these 8, 7 have their trials completed, while 1 is undergoing trial. For instance, when searching to know the pricing of generics on Greece, the first search question was typed in the ProQuest ‘search’ space and the year 2017 added to limit the finding to the latest sources. Several sources popped up, and after examining all of them based on the years of publication as well as their relevancy, ‘Greece Pharmaceuticals & Healthcare Report – Q4 2018. 2018. London: Fitch Solutions Group Limited’ was selected. The same process was repeated, with changes in key words and the year of publications.
Below is the PRISMA flow diagram showing the selection process of the sources.
Figure 1. PRISMA flow diagram.
Source: Author, 2019.
Study Characteristics
The review was finally concentrated on 8 studies that were published in English. All studies were conducted and published within the past 10 years. The selected studies focus on generic market share, pricing and the manner in which the External Reference Pricing (ERP) affects Greece and other EU members.
| No | AUTHOR | YEAR | GENERICS MARKET SHARE | GENERICS PRICING | REMARKS | ||
| Greece | Average In Other EU Nations | Greece
(% of the patent) |
Average In Other EU Nations (% of the patent) | ||||
| 1 | Greece Pharmaceuticals & Healthcare Report | Q4 2018 | 17.9% | 37.2% | 63% | 51% | Generics to account for 25% of the total pharmaceutical market by 2017 |
| 2 | OECD Health Statistics | 2018 | 20% | 52% | More than 65% | 53% | Greek government wants at least 60% prescription of generics |
| 3 | Urbinati, Rémuzat, Kornfeld, Vataire, Cetinsoy, Aballéa, Mzoughi, and Toumi | 2014 | Penetration rate of 25% for Greece and Portugal | 80-85% for the United Kingdom, France, Poland, and Germany | 67% | Ranges from 45% Poland to 75% for the UK | Increase if generics reduced the budget expenditure by €808 million in Greece |
| 4 | Worldwide Generic Drug Market | 2017 | 16.1% | 38% | 73% | 56% | A projected increase in future |
| 5 | Labiris, Fanariotis, Kastanioti, Alexias, Protopapas, Karampitsakos, and Niakas | 2015 | 16.9% | 43.7% | 72% | 48.3% | An overall lack of confidence towards generic among the Greek Physicians |
Source: Author, 2019.
Table 4 below shows projected percentage of prescription and total sales of generics in Greece by The Worldwide Generic Drug Market (2017).
Table 4. Projected percentage of prescription and total sales of generics in Greece.
| Year | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 |
| Generic drug sales, % of prescription sales | 15.1 | 16.2 | 17.6 | 18.1 | 19 | 19.7 | 20.5 | 21.3 |
| Generic drug sales, % of total sales | 13.6 | 14.5 | 15.7 | 16.1 | 16.9 | 17.5 | 18.1 | 18.8 |
Source: The Worldwide Generic Drug Market, 2017.
The values in table 4 above are represented graphically and below are the line graphs showing the trends of generic drug sales in Greece.
Figure 2. The projected percentage of prescription and total sales of generics in Greece.
Source: The Worldwide Generic Drug Market, 2017.
From the above graph, there is a general increase in the use of generic medicines in Greece from the year 2013 to 2019. The sales of generics are also predicted to increase in 2020.
In the 2018 study that was conducted by Domeyer et al., 1402 participants were selected and interviewed with a female majority of 62.88%. The authors in this study aimed at determining the perception, attitude, and knowledge of pharmaceutical students towards generic medicines. According to the authors, the attitude of consumers influences the penetration of generic medicines in the pharmaceutical market. An attitude towards generics (ATTOGEN) questionnaire was designed and used to measure 6 items on the scale. These items include trust, knowledge, drug substitution, state audit, drug quality, and fiscal impact. The responses of all items were expressed on a 5-point scale.
The results for the 6 scales are shown the table 5 below.
Table 5. Results for 6 scales.
| Scale | Trust | State Audit | Knowledge | Drug Quality | Drug Substitution | Fiscal Impact |
| Mean | 2.877 | 3.251 | 1.537 | 2.708 | 3.828 | 2.299 |
| SD | 0.940 | 0.967 | 0.688 | 0.971 | 1.127 | 0.860 |
Source: Domeyer et al., 2018.
In the study that was conducted by Labiris et al. (2015) to determine Greek physicians’ perceptions on generic drugs in the era of austerity (2015), the general outcome from the responses of 908 of them revealed lack of confidence towards generics among physicians in this country.
The research carried out by Urbinati et al. (2014) shows an overall decrease in pharmaceutical expenditure among the seven European countries (Germany, France, Poland, Greece, Hungary, the United Kingdom, and Portugal) that were studied for a period of 5 years from 2012 to 2016. Countries like France and the United Kingdom recorded the highest reduction in drug budget by €5,589 million and €9,367 million respectively. Greece was far behind the in the list with a reduction of only €808 million in drug expenditure. Urbinati et al. (2014) note that the penetration and prices of generic medicines were among the key drivers of pharmaceutical expenditure.
The analysis of this study revealed the 85% of the Greek physicians did not want the introduction of automatic substitution process, while 61% viewed this new process as a tool to discriminate their patients based on their abilities to purchase the patent medicines.
Labiris et al. (2015) note that the Greek physicians portrayed a worse perception towards the generics than their counterparts from other European nations. The physicians were aware that generics are supposed to have similar manufacturing standards, same reactive agent, and safety profile as the original drugs. But they still associated them with increased adverse effects and suboptimal therapeutic outcome, particularly those originating from developing nations.
The results from the electronic questionnaire distributed to 173 senior students in three different schools of pharmacy in Greece reveal that majority of students were aware that generics are cheaper and they contain the same active ingredient as the original drugs. The interviewees were, however, concerned about the efficacy and safety of generics. The research further shows that the pharmacy students expressed a positive attitude towards generics but they were not adequately informed about the features of these drugs (Souliotis et al., 2019, p.186).
Synthesis of the Results
The values in table 2 above showing the generic market share and pricing for Greece and other EU members can be regrouped for meta-analyses.
Table 6. Generic percentage market share for Greece and other EU nations.
| STUDY | GENERIC MARKET SHARE | |
| Greece (% of total pharmaceutical market) | Average for EU members (% of total pharmaceutical market)) | |
| Greece Pharmaceuticals & Healthcare Report | 17.9 | 37.2 |
| OECD Health Statistics | 20 | 52 |
| Urbinati et al. | 25 | 60 |
| Worldwide Generic Drug Market | 16.1 | 38 |
| Labiris et al. | 16.9 | 43.7 |
| AVERAGE | 19.18 | 46.18 |
| STANDARD DEVIATION | 3.19 | 8.70 |
Source: Author, 2019.
The analysis of the values in table 6 obtained from different studies yields 19.18% as the mean market share of generic medicines in Greece. The mean market share of generics in other European nations is has been found to be 46.18%. These percentages imply that the market share of generics in the Greek market is less than a half of the average value for other European nations. The standard deviation for the generics among other European nations is also found to be more than double the deviation of the percentage of generics on Greece. The greater standard deviation in the percentages of generics among the EU nations is indicative of higher dispersion from the mean value of the studies in comparison to the values for the values recorded for Greece alone.
The values in table 6 can be represented graphically as shown in figure 3 below.
Figure 3. Representation of the generics percentage of the market share among Greece and other EU nations.
Source: Author, 2019.
Pricing of Generics as Percentages of Patented Drugs
Table 7. Pricing of generics as percentages of the patented or branded medicines.
| STUDY | PRICING OF GENERICS | |
| Greece (% of pricing of the patent medicines) | Average for EU members (% of pricing of the patent medicines) | |
| Greece Pharmaceuticals & Healthcare Report | 63 | 51 |
| OECD Health Statistics | 65 | 53 |
| Urbinati et al. | 67 | 60 |
| Worldwide Generic Drug Market | 73 | 56 |
| Labiris et al. | 72 | 48.3 |
| AVERAGE | 68 | 53.66 |
| STANDARD DEVIATION | 3.90 | 4.05 |
Source: Author, 2019.
The above analysis in table 7 in the results section implies that the average pricing of generics relative to the patented or branded medicines in Greece is higher (68%) than the pricing in other members of the EU (53.66%). The high pricing of generics in Greece is significantly attributed to the higher costs that healthcare industries charge in comparison to pricing provided by the government of Greece. The standard deviations of pricing for the two categories are almost similar, with 3.9 and 4.05 for Greece and other members of EU respectively. These figures indicates that the level of dispersion from the mean values of the two categories is almost the same.
The pricing values in table 7 above can be represented graphically as shown in figure 4 below.
Figure 4. Pricing of generics as a percentage of the patented or branded prices in Greece and other EU nations.
Source: Author, 2019.
Correlations between Pricing and Market Share
Table 8. percentages of market share and pricing of generics for computation of the coefficients of correlation.
| STUDY | Greece (% of patent pricing) | EU members (% patent pricing) | Greece (% market share) | EU members (% market share) |
| Greece Pharmaceuticals & Healthcare Report | 63 | 51 | 17.9 | 37.2 |
| OECD Health Statistics | 65 | 53 | 20 | 52 |
| Urbinati et al. | 67 | 60 | 25 | 60 |
| Worldwide Generic Drug Market | 73 | 56 | 16.1 | 38 |
| Labiris et al. | 72 | 48.3 | 16.9 | 43.7 |
| AVERAGE | 68 | 53.66 | 19.18 | 46.18 |
Source: Author, 2019.
The values in table 7 above are then analysed using the Excel program to determine the correlation between pricing and market share of generics. The correlation coefficients are obtained from the analysis as shown in table 8 below.
Table 9. Values from the analysis of the correlation.
| Column 1 | Column 2 | Column 3 | Column 4 | |
| Column 1 | 1 | |||
| Column 2 | -0.010139334 | 1 | ||
| Column 3 | -0.424594925 | 0.693664067 | 1 | |
| Column 4 | -0.219312908 | 0.578189653 | 0.919135143 | 1 |
Source: Author, 2019.
From table 8 above, it is indicated that there is a negative, moderate correlation between pricing and market share of generics in Greece, which implies that an increase in price causes a moderate decrease in the pharmaceutical market of these drugs. On the other hand, there is a positive, moderate correlation between pricing and market share among other EU nations, which implies that an increase in price leads to a moderate increase in the market share of generic medicines among other members of the European Union.
Discussion
Role of Stakeholders in Pricing and Market Share of Generics in Greece
According to Labiris et al. (2015), the perception of prescribers towards medicines helps to predict the general efficacy of policy measures and prevents possible conflicts between the NHS authorities and care providers in Greece. Therefore, the knowledge of the physicians’ attitudes towards generics is among the essential pre-requisites before the implementation of such policy. Greek physicians are not convinced that generics have the potential to improve the economic performance of the country. Besides, the physicians associate the use of generics with suboptimal therapeutic outcomes (Xanthopoulou and Katsaliaki, 2019, p.52). As result, healthcare propose that these are types of drug should not be used to treat diseases with imminent irreversible damage to the health of the patient and in life-threatening states.
The study carried out by Labiris et al. (2015) indicates that the national campaign by the Greek government to alter the prescription pattern to incorporate more generics did not succeed in convincing the physicians. Labiris et al. (2015) concur with Tsiantou et al. (2009), who note that the poor results of this campaign was caused by the accusation of both pharmaceutical companies and doctors for illegal practical as well as the exclusion of physicians with the incorporation of the automatic substitution system. In addition, the campaign to increase the use of generics was accompanied by shortages due to inability of both the local manufacturers and importers to sustain the sector following the economic crisis (Tsiantou et al., 2009, p.542).
The negative attitude towards these drugs was also caused by the failure of the government to invest the revenues generated by generics to the pharmacovigilance and the system (Xanthopoulou and Katsaliaki, 2019, p.54). It was noted that most of the revenues that was collected from the generics was transferred to cover that national debt. Labiris et al. (2015, p.8) further note that the national campaign failed to address well-known issues pertaining generics and automatic substitution. Some of these issues that would have been addressed by the campaign team to improve the acceptability and market share were increased incidence of allergic reactions, reduced compliance of patients, and the negative attitude from beneficiaries.
According to Souliotis et al., it is essential to improve the preference for and knowledge of generics among professional in the healthcare sector early enough (2019, p.185). Starting early enough helps to build the required trust to increase the penetration of generics in the pharmaceutical market in order to attain measurable savings in the drug budget.
Knowledge and trust emerged as the most significant factors shaping the perception and attitude that students have towards generics (Domeyer et al., 2018, p.7). Initiatives and structures should also be put in place to address and correct the misconceptions and myths that patients and healthcare professionals have towards generic drugs. Domeyer et al. (2018, p.7) recommend that policymakers should strive empower physicians and other health care workers with extensive information regarding generic drugs to ensure a steady growth of their market in future. The Worldwide Generic Drug Market (2017, p.92) report shows that there exists a significant bias among both the population and prescribers for branded and patented medicines due to the narrative that the cheaper generic drugs are less effective. The report also state that the Greek government has been setting targets that aim at increasing the use of generics in order to cut down the healthcare budget. According to Xanthopoulou and Katsaliaki (2019, p.56), the high spending on medicine in Greece is associated with continued over-prescription of branded and patented drugs as well as the high incidences of chronic diseases in the country.
External Reference Pricing
The ERP is a strategy that has been applied by the EU nations, and the policy helps in rationalizing the prices as well as the costs that are applied on generics medicines in the continent. The application in diverse nations has been explained to be varying depending on the implementation, administration, methods, and objectives that have been intended by the government administrators within the region. The primary use of the ERP is to ensure that the global research interest has been attained. The pricing index also aids in controlling the in-patient drugs that have been highly priced so that they can be made available at considerable prices to individuals in the community. The authorities in a community and the government administrators can apply the use of international comparisons so as to undertake an evaluation of the appropriateness and fairness of the prices that have been actualized related to the cases that are comparative to them.
ERP implementation differs from one nation to the other based on the rules and regulations that govern operations in the continent. The other aspect is based on the how calculations are undertaken in the nation, for instance, the drug prices can decrease immensely if the reference countries are increased (BMI Research, 2010). There are some factors that should be taken into consideration when the government administrators and company managers are choosing a reference country, and they include the pharmaceutical pricing systems, finance performance of the nation, exact comparator products, concealed prices compared with the actual, and the disease burden of the nation being used as a reference point (WHO, 2015).
The application of the ERP strategy has been proved to be effective in Greece and other EU nations, but there are some instances where it has created adverse impacts and proper measures should be taken into consideration to guarantee that the negative consequences have been handled. The primary concern of the implementation of the ERP is the related to the concept that it can lead to a condition where the high-income nations demand low prices, which results to problems being faced by the low-income nations across the globe.
The price leakages that are ERP-related can affect the decisions developed by the manufacturers on the amount that should be set on a given brand of medicine in the healthcare centre and other industries in the international market. The concept also affects the converging of markets since the linking of high and low income markets may lead to high levels of convergence if the market segments are separate. The low-income nations can experienced increased rates of prices, which makes it difficult for patients to access the medications required for the health progress and improvement. In the high-income nations, despite the concept that the imported prices will be lower, the lower revenues in the nation will be adversely affected and the nations can experienced a reduced return on the R&D investment, thus a situation where fewer new medicines will be obtained from the market segment. The holders of the marketing authorization may also prefer having their products and services delivered to high-income nations and the high prices will be applied as the references of pricing by the low-income countries.
There is a need to ensure that the assessment process applied by the ERP promoted transparency since it is a complex process. Transparency helps in guaranteeing that there is improvement on the decision-making and accountability processes that aid in reducing the uncertainty that can be experienced by manufacturers, and also help in eliminating corruption and discrimination (Espin et al., 2014).
Price Caps
Price index by different pricing models
The pricing models that have been adopted by the nation of Greece and other EU nations have been categorized into diverse categories, which include the nations that use the ERP system in pricing, nations that apply the reference pricing formally, and the nations that apply the pricing method without further considerations of other strategies that can be adopted. Greece is one of the nations that has been found to apply the reference pricing formally among other countries including Hungary, Slovakia, and Norway.
The nations that apply the pricing strategy supported by the IRP have also been explained to have an index that is cross-sectional and is averagely slightly lower compared to other nations including Sweden. The nations that apply a formal IRP based on the lower price are considered to have the lowest index when compared to nations like Sweden. Therefore, the average prices that are applied will have a higher index (Panteli et al., 2016, p. 30).
Pharmaceutical Pricing Policy in Greece
Healthcare services include the most essential factors in a nation that help in sustaining the health policies and should be provided at accessible and affordable prices. In most nations in Europe, the purchasers of pharmaceutical medicines is the public sector and the negotiating power of the healthcare services is enhanced by the determination of the pricing strategies that have been implemented. The European nations have been understood to apply the External Reference Pricing (ERP), which is a method that regulates the prices that have been provided by the healthcare professionals and managers. The government administrators help in setting the price based on the needs of individuals in the society as well as the re-referencing rates. The other factors that determine the ERP include the functional characteristics and the endogenous structures that have been implemented to govern diverse operations in a nation.
Greece is one of the nations that is considered as a dynamic player of the system that has been established based on the European ERP. The application of the ERP relates to the on-patent medicines that are sold in diverse healthcare centres, which affects the reimbursement processes. The legislation states that the prices that should be applied on the on-patent medicines should be set on average based on the prices of the three lowest ex-factories in the country. Prices of various medicines in Greece are reviewed frequently relative to the requirements of the ERP (Panteli et al., 2016, p. 45).
The pricing models are aimed at guaranteeing that the fittings are flexible and affordable and also attain the national necessities and standards. The process helps in guaranteeing that the primary requirements of individuals in the nation have been attained despite the differences existing that are related to the cost of living and availability of resources among families. Therefore, the ERP model has been applied effectively in the nation of Europe by Greece to guarantee that there are improved strategies to reduce cases of discrimination in the nation (Vogler et al., 2011, p.69).
Overview of External Reference Pricing Systems in Europe
In Europe, Greece has been considered as one of the poorest nations despite the notion that its expenditure on drugs is increased and a quarter of the total drugs are generics based on the analysis of diverse prescriptions that have been provided by the medical professionals recently. The debt crisis facing the nation has led to the development of austerity measures that were introduced between 2010 and 2017 by the government administrators of Greece, which was aimed at guaranteeing that the issue had been solved. However, the loan repayment team commonly known as the International Monetary Fund (IMF) failed to implement a successful process in the nation.
There are increased cases of financial pressures that have been faced by the government administrators of Greece, but there are strategies that have been developed and implemented to ensure that the amounts spent on brand-name drugs and novel have been attained successfully. Based on the concept that most of the generic drug versions were being neglected in the nation, the European Commission developed measures to ensure that most medicine types in Greece were generics during the year 2018 (Domeyer et al., 2018, p.263).
The charts that have been developed indicate that the nation Greece is near the bottom relative to the use of generics in the EU, and only a quarter of the total amount of medicine being generics. The chart below provides a clear illustration of the comparisons that have been developed relative to the pricing of generics medicines amongst Greece and EU countries. There is evidence that German citizens have a higher chance of getting medicine prescribed that is generic compared to the percentage of the individuals in Greece (Panteli et al., 2016, p. 54).
Figure 5. Percentage of generics in the market among 18 countries in EU.
Source: OECD Health Statistics, 2016.
Greece as a nation has been widely understood to rely on pharmaceuticals that have been branded, which is primarily caused by the interests within the healthcare industry and the government that has been adopted by the doctors, nurses, and the healthcare professionals in various communities in the country. The healthcare professionals also prescribe medicines that are considered as being expensive and new and create an impact on the amount of capital used by the administrators. Resistance has also been faced by the patients and physicians who consider generic medicine as inferior and understand its application in the society (Domeyer et al., 2018, p.262).
However, there are austerity measures that have been developed and implemented by the managers and government administrators to guarantee that the country has been removed from the oversight measures that have been introduced by the EU. The process is also aimed at ensuring that the EU creates more competition by removing the restrictions on persons allowed to open pharmacies as well as ensure that there is the introduction of electronic systems that can be used to monitor various operations undertaken in the healthcare industry including prescription of medicine to patients (Vogler et al., 2011, p.69).
The other strategies that have been introduced by the government administrators include introducing incentives that will assist pharmacists to sell an increased amount of generic drugs, which are required for the third bailout agreement. However, critics of the decision have developed arguments based on the notion that the margins attained by pharmacists exceed the amount of discounts that can be received from selling generic medicine. The issue that is also faced by Greece is the ability to maintain the connections that have been developed in the pharmaceutical industry over the years. The pricing that has been provided by the government for the generic medicines has not been attained since most healthcare industries offer higher prices while prescribing the drugs. The aim of the government administrators is to facilitate effectiveness in maintaining the connections that contribute to improving the economic stability of the nation (Domeyer et al., 2018, p.262).
Limitations
The limitation of this study is that the sample for the study was not uniformly stratified. Besides, there was average reliability on some subscales of the questionnaire.
Conclusion
The high pricing of generics has led to accruing of debts from state-run hospitals and National Organisation for Healthcare Provision to drug manufacturers in Greece. The study indicated a negative, moderate correlation between pricing and market share of generics in Greece. This relationship between the prices of generics and market share means that an increase in price causes a moderate decrease in share of the pharmaceutical market. Reducing the cost of generics is likely to increase the prescription of these drugs in Greece. The market share in generics should be increased at a more rapid rate than the current one in order to maintain a level of pharmaceutical expenditure that is sustainable. Considering the economic crises that the country has experienced in the recent past, it is important that the expenditure on drugs is put under control.
The sources for the systematic review will not require any funding since it will utilize information from scholarly materials that have been published over the years. Therefore, the author did not receive any financial support to carry out this study. Thus, this study was conducted independently without any form of external influence. Additionally, there is no conflict of interests related to this review.
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