People may see physicians as primary healthcare providers, but doctors can actually do more than just diagnose patients and recommend a course of action. In most states, physicians and other medical practitioners may also dispense prescription drugs directly to the patients from their clinic or office: a practice known as physician dispensing or in-office dispensing.
This practice is in contrast to the traditional model of pharmacy dispensing, where patients take a prescription written by their physician to a pharmacy to be filled. While physician dispensing is subject to varying levels of restrictions and regulations from State Boards of Pharmacy, the practice as a whole is somewhat controversial. This article reviews and analyzes arguments commonly put forward by proponents and opponents of in-office dispensing.
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Arguments in Favor of Physician Dispensing
- Improved Patient Compliance
The biggest benefit of physician dispensing is that it ensures that prescribed drugs get in the patient’s hands. Approximately 20-30% of prescriptions are never filled. Providing medication at the point of care eliminates this problem.
That said, it does not necessarily follow that these 20-30% of prescriptions would be properly followed if only the medications were provided to patients. A World Health Organization study showed that overall 50% of prescriptions are not properly followed by patients (including the 20-30% that are not filled), because of factors such as patient forgetfulness, limited language proficiency, lack of health literacy, or lack of belief in medication. It could be argued that patients who do not get their prescriptions filled are also less likely to comply with instructions even if they did, although there is an unfortunate lack of research in this area.
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Still, it seems obvious that getting the right drugs in patients’ hands through physician dispensing confers at least some benefit to patient compliance.
- Improved Treatment Timeliness
Even patients who do get their prescriptions filled do not necessarily do so right away. Sometimes the pharmacy may be inconveniently located or may not be able to dispense the prescribed medication right away, or the patient is not able or willing to get to the pharmacy in a timely manner. Dispensing medication in-office eliminates this issue and allows patients to start their treatment immediately.
While this benefit is obvious, it should not be overstated. Even in states where physician dispensing is generally not permitted (such as Texas, Utah, and New York), exceptions are often made for very small quantities of certain medications for acute conditions to allow patients to start their treatment immediately and then have the rest of their prescription filled at a pharmacy.
- 3 – Patient Convenience
In-office dispensing is more convenient for patients since they can avoid a trip to the pharmacy (and the possibility of repeat trips and/or waiting). This is especially beneficial to patients with physical disabilities, medical problems, mobility challenges, those living in areas without a pharmacy nearby or those who are very time-constrained. However, as seen below, this convenience often comes at a financial cost to patients, and possibly a medical cost as well.
- Patient Privacy
Physician dispensing companies argue that in-office dispensing provides additional patient privacy and confidentiality, as a doctor’s office is generally more private than a pharmacy. While this may be true in the case of some pharmacies, most pharmacists appear to take patient privacy seriously and have structured their operations accordingly. Patient privacy while picking up prescriptions is rarely mentioned as a significant health care issue.
- Improved Prescription Accuracy
Some proponents of allowing doctors to dispense medication claim that doing so reduces errors when a pharmacist misunderstands the physician’s intentions in the prescription. This argument is unconvincing. Not only are many prescriptions sent online today, but it is also a doctor’s responsibility to ensure that prescriptions are clearly written. Moreover, as noted below, pharmacists play an important role in reviewing prescriptions for possible errors, so removing them from the dispensing processing at best trades reduced handwriting errors for a host of other errors which are no longer addressed by a pharmacist’s second look.
Arguments Against Physician Dispensing
- Increase Patient Cost
Medications dispensed in a doctor’s office may cost more than at the pharmacy. For example, California legislators estimated in 2007 that physician dispensing companies were charging a markup of 40 to 50 times the cost of prescriptions. Moreover, many doctors who dispense medication only do so on a “cash and carry” basis and do not accept insurance, which could put a further financial burden on patients.
On the other hand, most states’ regulations require dispensing doctors to inform patients of the option to have their prescriptions filled at a pharmacy and many states limit the prices that doctors may charge. These should provide patient protection as long as regulations are appropriately designed and enforced.
- Conflict of Interest
There is a risk that dispensing doctors might be influenced by the financial incentive to prescribe more medications and to favor medications that they have in stock and/or from which they earn a greater return. While this has not been studied in the case of physician dispensing, there is significant evidence that financial incentives do distort some doctors’ prescribing behaviors.
- Patient Safety
Pharmacists play an important role in patient safety, including checking for errors in prescriptions and incompatibilities or adverse interaction effects between different medications prescribed to the patient, and advising and educating patients on their medication. Eliminating them from the dispensing process for some medications creates risk that their functions will not be adequately performed by staff at a doctor’s office, who might not have received the same level of training or who may have competing priorities or demands on their time.
Conclusion
While many arguments can be advanced for and against the practice of physician dispensing, the fundamental trade-off appears to be between patient compliance and convenience on one side vs. increased cost and the potential for distorted incentives or increased errors on the other. On balance, while there are significant potential advantages to patients and the health care system from in-office dispensing, it appears clear that a robust regulatory regime needs to be in place to minimize the potential downsides. It also appears clear that more data-driven studies of the impact of physician dispensing are needed.
Nicholas Benedict is Managing Director of King, Edward, specializing in pharmacy and health care. He has a B.A. from McGill University and an M.B.A. from the Wharton School of the University of Pennsylvania.
Jonathan Ni is a Writer for "Physician-Dispensing.com and a B.Sc. Economics Candidate at the Wharton School of the University of Pennsylvania.
