The impact of decentralised drug-budgets in Sweden - a survey of physicians' attitudes towards costs and cost-effectiveness.

In Sweden decentralised drug-budgets at health-care facility levels were introduced in 1997 in an attempt to contain increasing pharmaceutical expenditures. This paper reports the findings of a postal survey which investigates whether decentralised drug-budgets according to a so-called primary-care based model in Swedish health care have led to increased cost awareness and changed attitudes towards cost-minimisation and cost-effectiveness as decision-making criteria among physicians. In particular, it was investigated whether there were differences in this respect between general practitioners (GPs) and specialists. The postal survey was sent to 1,520 Swedish physicians from a stratified sample of Swedish county councils. A total of 738 physicians responded (response rate 49%). Statistical analysis was performed of logistic regression analysis and independent or paired samples t-tests. The results suggest that GPs have a higher degree of cost awareness than specialists. Physicians with experience of decentralised drug-budgets have a higher degree of cost awareness than other physicians. However, the rating of the top four decision-making criteria; therapeutic effects, side effects, compliance and cost-effectiveness, were not significantly different when comparing GPs against specialists, and physicians practising in county councils with decentralised drug-budgets against other physicians. The main barriers to considering costs to a greater extent were perceived difficulties in switching drugs and a fear among physicians of losing credibility among patients. In conclusion, decentralisation of drug-budgets according to the Swedish primary-care based model increases cost awareness, especially among GPs. Such responsibility, however, does not create strong incentives for physicians to reconsider the importance of cost-effectiveness in relation to other decision-making criteria when prescribing. Parallel interventions are needed to meet the objective of cost-effective prescribing.