Limited opportunities to prevent improper prescription of pharmaceuticals

The Swedish National Audit Office has audited the central government's governance and supervision of the pharmaceutical prescription. The overall conclusion is that it is not effective.

The shortcomings are partly due to the fact that the responsible agencies are not equipped for effective supervision. For example, the Health and Care Inspectorate (IVO) is not able to use existing register data to search for doctors and others who improperly prescribe narcotics-classified pharmaceuticals or other desirable substances.

“In practice, this poses a great risk of serious malpractice going completely undetected. The regions warn that this is being exploited by organised crime,” says Auditor General Helena Lindberg.

Another anomaly that is difficult to prevent is when pharmaceuticals unduly burden the pharmaceutical benefits scheme – with taxpayers footing much of the bill. This concerns products such as potency-enhancing substances, botulinum toxin against wrinkles, diabetic products for slimming, growth hormones for body builders and emollient creams.

“Between November and December 2022 alone, the cost to society of improper prescription of new diabetic pharmaceuticals that are also effective against obesity amounted to about SEK 20 million,” says Gabriella Sjögren Lindquist, project leader for the audit.

The main problem here is that the Dental and Pharmaceutical Benefits Agency (TLV) does not have access to medical records and other information about individual care providers’ prescriptions, which would be needed to conduct effective supervision.

The situation is aggravated by the fact that IVO has very long processing times for its supervisory cases – more than a year on average. Since the most serious cases are escalated from the IVO to the Medical Responsibility Board (HSAN), which has equally long processing times, the improper prescription can continue for several years.

“It is our assessment that this violates the requirement in the Administrative Procedure Act for prompt processing,” notes Gabriella Sjögren Lindquist.

The regions have made several attempts to prevent improper use of the pharmaceutical benefits scheme by revoking workplace codes, which are needed to prescribe pharmaceuticals within the framework of the pharmaceutical benefits scheme. However, in most cases these decisions have been reversed by the National Board of Health and Welfare following an appeal by the prescribers, since under the legislation, care providers with prescription rights have the right to a workplace code.

The audit also shows that the Government’s governance through the central government grant for the pharmaceutical benefits scheme is not effective. In theory, the structure of the central government grant gives the regions incentives to keep expenses down. However, since the outcome of the agreement comes far too late to be included in the budgetary process, its effect in terms of governance is limited. The agencies’ knowledge management is also ineffective because it ultimately has a limited effect on which medicinal products are prescribed.