Abstract Chapter 14

Chapter 14 aims at illustrating regional pharmaceutical policies, analyzing public pharmaceutical expenditure trends and assessing the impact of direct distribution (distribuzione diretta, DD) by the admitting hospital at discharge or indirect distribution (distribuzione per conto, DPC) through local pharmacies of the prescribed medications after the first dose provided by the discharging hospital. To describe the phenomenon, we relied on a systematic analysis of regional pharmaceutical policies and pharmaceutical expenditure indicators from the Pharmaceutical Observatory. We used a fixed effects regression model on panel data to measure the impact of DD and DPC (2012-2016). Pharmaceutical policy is still very fragmented. In 2016 co-payments for drugs on gross pharmaceutical expenditure ranged from 8.7% in FVG to 20.8% in Valle d’Aosta; a minimum 31.9% in Abruzzo and a maximum 55,3% in Toscana of drugs used by patients at home were distributed via DD/DPC (with huge differences across regions in the proportion of DD and DPC); binding targets are the preferred option by the Southern Regions, whereas in some Northern Region clinicians are more involved in the definition of “prescription targets”. Regional fragmentation may be desirable if regional action is more focused on the appropriateness of prescriptions, but is less acceptable if it generates important differences in patient access to medications. As for the impact of DD and DPC, the adoption of specific distribution systems contributed to containing pharmaceutical expenditure, and a mixed distribution policy (with a minimum 15% DD and 5% DPC) had a larger impact than a “pure” DD model. The analysis shows that DD and DPC had a large impact on costs and a mixed model (DD+DPC) is better than DD alone. In any case, decisions on the drug distribution mix should not be driven only by their effects on costs.