As the prescription data from INSIGHT Health shows, discount agreements from large health insurers not only lead to changes in the supply of medicines to their own insured. There are also spillover effects on the care of those insured by other health insurance funds. In the case of discount agreements with large insurers such as the AOK Group, every pharmacy is ultimately required to keep the respective discount products in stock. Obviously, these products are now also being issued to policyholders from other health insurers who, according to the legal regulations, should actually receive products from other manufacturers - be it because of discount agreements or because of the obligation to sell one of the three cheapest products if the doctor gives the aut-idem cross not set and thus allowed an exchange. Such a surprising effect was shown, for example, B. with the two top-selling active ingredients in the third AOK tender, simvastatin and omeprazole, whose contracts started on June 1, 2009. The two active ingredients represent almost 18 % of the AOK output volume of the 63 active ingredients in this tender. In the period from April 2009 to March 2010 (MAT March 2010), simvastatin and omeprazole accounted for approx. EUR 370 million based on pharmacy retail prices (AVP).

>> Example 1/Simvastatin: The cholesterol-lowering drug Simvastatin is one of the most important patent-free active ingredients on the market. In the third AOK tender, one manufacturer was awarded the contract for all five regional lots (see info box: Territorial lots of the AOK tenders). It has therefore taken a very strong position in the market, as AOK insured persons alone currently account for 41 % of all simvastatin prescriptions within the statutory health insurance (MAT March 2010).
According to figures from INSIGHT Health, the pharmaceutical company (the tender winner) was already one of the top 5 providers in the statutory health insurance market with 7 % of all simvastatin prescriptions. With a market share of 39 % in the GKV and almost 81 % within the AOK, it is now well ahead of the competition as of March 2010 (see Fig. 1).
AOK discount partner for Simvastatin is also gaining significantly from other health insurance companies
Outside the AOK, the following picture emerges for the AOK discount partner: In May 2009, the manufacturer had a market share of just under 7 % for simvastatin, and in March 2010 it already had 11 %. What is the reason for this increase of four % points? Initially, further discount agreements for simvastatin with other health insurance companies could be responsible for this. In fact, the manufacturer's discount contracts with over 40 health insurance companies expired during this period, and these insurance companies currently have other discount partners for simvastatin. Only another discount agreement with a smaller cash register was added.
The reason for the increasing market share of the AOK discount partner outside of AOK lies largely in the implementation of the discount agreements with other large health insurance companies. For example, the company was able to almost double its share of DAK and Knappschaft, which had already concluded contracts for simvastatin with it and 4 and 13 other manufacturers in previous years: from 13 to 24 % and 10 to 19 % (see Fig. 1).
The following effect is also noteworthy: Even at the two largest health insurance companies Barmer GEK and TK, which do not have a discount agreement with the manufacturer, more patients were switched from another simvastatin product to the AOK discount product in the last three quarters than vice versa AOK discount product on a competing product. This is shown by figures from patient tracking from INSIGHT Health, which can be used to track the prescription histories of several million anonymized patients over several years.

Example 2/Omeprazole:
For the patent-free gastric medicine omeprazole, the active substance with the highest spending in the third AOK tender, a generics manufacturer was awarded the contract for all five non-residents, which was previously only known in industry circles. The changeover to this discount partner did not go as planned for a number of reasons: First of all, the ability to deliver was questioned. This was followed by a debate about the substitutability of the different pack sizes that continues to this day. The manufacturer only included the pack sizes of 15, 28, 56 and 98 capsules, which are not very common on the market, in the AOK discount agreement. However, the packs of 30, 50, 60 and 100 pieces are not discounted. Since then, this has repeatedly led to the question of whether a pharmacist may also issue a pack of 98, 60 or even 56 when prescribing a pack of 100 omeprazole. This circumstance led the industry association Pro Generika to make the smug comment “Number of the month September 2009: 100 = 98 = 60 = 56”.
In this tense context, it is not surprising that the active substance-related implementation rates of the discount agreement (i.e. without taking package sizes into account) lag far behind those of other discount active ingredients. Due to the pack size issue, the average implementation rate in March 2010 was - i.e. H. ten months after the discount agreement came into force – with not even 13 % (see Fig. 2.)
Non-discounted omeprazole products from the AOK discount partner also gain additional benefits
What is astonishing, however, is that the discount partner's pack sizes of 30, 50, 60 and 100 pieces, which do not enjoy a discount, were able to record significant gains. A special analysis by INSIGHT Health shows that the manufacturer's non-discounted omeprazole products accounted for over 20 % of its omeprazole prescriptions for AOK insured persons, particularly in the starting phase of the AOK contract. Although this proportion was reduced to around 13 % by March 2010, overall more than 16 times as many non-discounted omeprazole products from the discount partner were prescribed within the AOK compared to May 2009.
As with simvastatin, there were also spillover effects with omeprazole on the sale of products from the AOK discount partner to insured persons from other health insurers. The market share outside the AOK doubled from 0.5 to over % (Fig. 2).
The patient-centered figures from INSIGHT Health show a similar development: In the last three quarters, twice as many insured people outside the AOK switched from omeprazole products from other manufacturers to the AOK discount products than vice versa. And the AOK discount partner was also able to score points with other health insurance companies when it came to recruiting new patients on omeprazole.
These effects are all the more remarkable because the manufacturer has not concluded a discount agreement for omeprazole with any other health insurance provider and has not had an omeprazole competing product on the market since June 2009 that was one of the three cheapest.
Conclusion
As can be seen from both examples, discount agreements in the generic market cannot be evaluated in isolation. On the one hand, products with high market shares, which are mainly due to discount agreements with large health insurance companies, are increasingly being sold to policyholders of health insurance companies with whom no discount agreement exists. This applies to both established, larger generic companies and smaller providers. On the other hand, if there is a discount agreement for an active substance, not only the discounted but also the non-discounted products from the manufacturer are given to the insured, although there is no legal basis for this.
For the care of patients under everyday conditions, this means that not only changes are relevant for the insured of the discount funds, but also the care of patients from other funds is noticeably influenced. What is interesting here is the fact that, in addition to aut-idem quotas and discount agreements, other components (still) also play a role in the dispensing of medicines, last but not least presumably the respective stockpiling in the pharmacies. However, this is a factor that was already of greater importance for the distribution of medicines to the insured before the discount era. This also raises the question of the extent to which discount agreements actually lead to more switching by insured persons to other generic products (and thus possibly influencing compliance) than would have been the case without discount agreements or was the case in the past. <<

by: Christian Bensing/
Dr. Andre Kleinfeld