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Dispensing Doctors Can Refuse to Write Prescriptions in Hong Kong

Dispensing Doctors Can Refuse to Write Prescriptions in Hong Kong

Caveat Emptor or “Let The Buyer Be Aware”

No one wants to get ripped-off. Even worse is when you know you are being overcharged and the person doing the billing is a medical doctor.

Last month, my wife shared a Facebook post with me. A mother named Jamie* had asked if it was legal for a doctor to refuse to write a prescription in Hong Kong. Many doctors in Hong Kong also dispense medications, so by not giving Jamie a prescription, she was forced to buy her drugs from the clinic, rather than having the option of purchasing her medication at an outside pharmacy.

Since there is a lot of misinformation about the laws governing private healthcare in Hong Kong, I reached out to Jamie to answer her question.

Requesting Prescriptions in Hong Kong

It began as a regular doctor appointment on Friday June 15, 2018. Jamie saw a medical specialist at a private network medical clinic. After a satisfying consultation, Jamie went to pay the bill and requested a doctor’s prescription for her medications. This is her normal practice since she often obtains prescriptions in Hong Kong from her family doctor, who is located at another clinic within the network. Jamie usually gets a prescription for her chronic medications so that she can have medications dispensed by a registered pharmacist at a reasonable cost. This is very important since her insurance coverage for drugs has an annual limit.

Rather than fulfilling her request, the clinic nurse stated it was against company policy to provide written prescriptions. The nurse sternly told Jamie that she had to purchase drugs directly from the clinic dispensary.

Jamie did her best to explain how her family doctor would normally provide prescriptions, and that they also worked at a clinic within the network. How could this discrepancy be standard company policy? The nurse insisted that Jamie had to buy her drugs from the clinic. This put tremendous pressure on Jamie since she was with her daughter and didn’t want to cause a large scene in front of other patients.

Jamie paid the bill, purchased the medicine and left the clinic feeling confused and upset with her experience.

Jamie brought this conduct to the attention of her insurer, the clinic manager, the Consumer Council, and the Medical Council of Hong Kong. After hearing this story, I also contacted the clinic manager, who explained that this was a misunderstanding by the nurse involved.  She said the company has a policy that they will provide a prescription if one is requested by the patient. Apparently nurses were asked to track the number of outside prescriptions to determine if the clinic was maintaining adequate stock of these drugs. The nurse mistakenly interpreted this direction to mean that patients could not request written prescriptions. The manager said the nurse would follow-up with Jamie and apologize.

However, it seems strange that none of the other nurses or doctors attempted to correct their colleague’s misguided understanding of clinic policy. This makes me wonder if the pressure to minimize outside prescriptions is growing within the private health care sector in Hong Kong.

In the end, Jamie was charged $800 HKD ($100 USD) for a one-month supply of 28 tablets of brand name Nexium. She could have easily purchased this product, or a generic equivalent, from a local pharmacy, for about $300 ($38 USD). Not only did the doctor and the clinic overcharge Jamie, they also deprived her of choosing a personal pharmacist to professionally dispense her drugs.

The Wild “East” of Private Health Care

The truth is that the laws governing healthcare and drugs in Hong Kong haven’t fundamentally evolved since British colonial times.

Some laws governing pharmacy and non-Chinese drugs were slightly updated in 2015, but the legal framework is still based on the 1937 Pharmacy and Poisons Ordinance.

What’s more is that the government acknowledges that the laws governing private health care facilities have not had a substantial update since 1966! This creates a healthcare market that is largely lawless and unregulated.  Some laws governing private healthcare exist, yet they are minimally enforced by underfunded and ill-equipped regulators.

That’s why I sometimes refer to private healthcare in Hong Kong as the Wild “East”. Doctors in Hong Kong often prescribe a bewildering cocktail of drugs for a minor cold or stomach ache. Drugs are then dispensed by clinic staff with little or no professional training. There is no requirement that drugs must be double checked by a registered pharmacist, since dispensing doctors are the rule, rather than the exception.

Finally, there are no mandatory controls on the prices of health care services. Jamie and many other locals have told me that pricing often depends on if you have health insurance. If you tell the staff at the clinic that you have insurance, you might receive an unexpected 20% fee increase!

Is Refusing to Provide a Prescription Illegal in Hong Kong?

In short, the answer to this question is no. I have thoroughly reviewed the laws that govern medical clinics, physicians, and pharmacy, and there is nothing in the law that states that a doctor must provide patients with a written prescription. Many people would certainly conclude that this practice is wrong and possibly unethical. To be sure, I am not talking about prescriptions that are not clinically warranted. I am referring to legitimate prescriptions for treatments recommended by the doctor.

In fact, Jamie’s situation seems to contravene the Code of Professional Conduct for Registered Medical Practitioners, which states:

9.3 Patients should be given the choice of either receiving medicine directly from the doctor or taking a prescription from him.

However, these guidelines appear to be optional since they use the word “should” rather than “must”. Further, the introduction states that the the code is not a legal document. This contrasts with many other international codes of practice for healthcare professionals which are key components of the legal regulatory framework.

The practice of refusing to write a prescription limits patient choice as to where to obtain medicine. Because it could be considered an anti-competitive practice, I submitted a complaint to the Hong Kong Competition Commission on behalf of Jamie. Unfortunately, they feel that it isn’t anti-competitive because patients have the choice as to where they receive medical services. See the full response from the Competition Commission.

Murky Medical Practices

Now you might question the use of these personal stories rather than objective data. The data does exist although it is frequently obfuscated by the players in the private health care sector.

Bupa, a large insurer and healthcare provider, released a report in January 2018 that looked at the very issue of transparency in the private health care sector in Hong Kong. The report concludes that the lack of transparency in the Hong Kong health system negatively impacts patient safety, costs, quality of care, and the patient experience.

One of the most fascinating insights from the report is the variation in costs for the same medical procedure. Prices can vary substantial depending on the “room class” at private hospitals. Furthermore, the same room class (e.g., semi-private) may not be directly comparable between hospitals.

Lastly, the report raises the point about the lack of a sole regulator for healthcare in Hong Kong. The public system is closely regulated by the Food and Health Bureau whereas the private system is loosely regulated by the Department of Health. This in fact means that the public system is more in line with international norms of data transparency and reporting.

There are many good healthcare professionals and positive aspects of health care in Hong Kong. However, certain practices that harm patients and reduce the value of healthcare provided need to be addressed.

You can try to protect yourself by asking important questions before visiting a doctor. Ask them for their fee schedule and if they have different fees for patients with insurance and without insurance. Does the clinic allow you to request a written prescription that can be taken to an outside pharmacy? This could save money and allow you to get professional advice from a pharmacist of your choice. Finally, you should ask all clinics if they separate the doctor consultation fee and the fees for any required medicines. All these important questions will help you understand how you will be billed for a visit to a private doctor.

Have you had a disappointing healthcare, medication, or pharmacy experience in Hong Kong? Leave your comments below!

In my next post, I’ll share a personal story about a mother who was approaching menopause, and her struggles to find appropriate treatment in Hong Kong.

*The patient’s name has been changed to protect her privacy.

“Hair” is What You Need to Know about Male Pattern Hair Loss

“Hair” is What You Need to Know about Male Pattern Hair Loss

There’s a reason many men feel insecure as they begin to bald. Hair is a powerful symbol that can reflect your overall state of health.

Male pattern hair loss and male balding describe the medical condition called androgenic alopecia. Although typically occurring in men, it can also occur in women (sometimes called “female pattern” hair loss). But since it is Father’s Day, I’ll specifically be addressing the treatment options for men. As pharmacists, we’re most comfortable discussing the medications used for androgenic alopecia, but we’ll also address several non-drug choices, including hair transplant and cosmetic aids.

How common is male pattern hair loss?

The prevalence of androgenic alopecia increases with age and it is estimated that in Caucasians, about 50% of men will experience male pattern hair loss by the age of 50.  While in Asians, the prevalence is lower. A recent study in six cities in China found that about 30% of men aged 50-59 years old had male balding. Of the men included in this study, 30% had a positive family history of male pattern baldness.

What is the role of androgens?

Genetics does seem to play a role in the risk of male pattern hair loss. In addition to genetics, it is thought that hormones also play a role in causing hair loss. One such hormone is called dihydrotestosterone (DHT), which is a metabolite of testosterone. Both of these substances are androgens, the hormones that give men their manly characteristics, such as facial and armpit hair growth, deeper voices, and increased muscle mass.

Interestingly, excessive androgens can also cause hair loss in specific areas of the head that are sensitive to to the hormones. These hair follicles are stimulated by DHT, and begin to shrink, or miniaturize over time. Although the conventional thinking implicates DHT as the main culprit in male hair loss, others have argued that male pattern hair loss is primarily due to a hardening of tissue of the scalp leading to inflammation and decreased blood flow. This reduced flow of blood cutes of the supply of nutrients which contributes to the shortening and thinning of hair.

You probably know someone with the typical pattern of hair loss: first it begins near the temples, and then gradually moves to the top (vertex) of the head. This gives the hair an “M” shape pattern and spares the hair along the side of the head. Looks almost like a half circular donut!

What health conditions are associated with male pattern hair loss?

Potential risk factors that are linked to male hair loss include cardiovascular disease, prostate cancer, and decreased insulin sensitivity. A person who is obese, has type 2 diabetes mellitus, or has high blood pressure may have reduced sensitivity to insulin and trouble breaking down sugars. If you haven’t been to the doctor recently, then it would be a good idea to measure you weight, blood pressure, blood sugar and screen for prostate cancer (if appropriate). That way you can address any risk factors that may contribute to your baldness.

Generally no blood tests are needed to diagnose male pattern hair loss. However, it is worthwhile to see a doctor so that they can order some basic lab tests to rule out other causes of hair loss. For example, iron deficiency and low thyroid hormone can cause hair loss.

What drugs can cause hair loss?

Sometimes medications cause hair loss. If you regularly take medicines, check with your pharmacist or doctor to see if a drug could be causing your hair loss. The most common drugs that may cause hair loss include blood thinners (anticoagulants), hormone therapy (thyroid drugs, androgens), psychotropic drugs (antidepressants, antipsychotics, lithium), and cancer chemotherapy. Depending on your circumstances it may be possible to adjust your medications to solve your hair loss problem.

Male pattern hair loss treatments

Several treatment options are available. Many men begin with conventional drug treatments.

Minoxidil

Minoxidil is an old drug that was originally studied to treat high blood pressure. Patients began to notice the surprising side effect of hair growth so now it is mostly used on the scalp to manage hair loss.

In Hong Kong, there are about two dozen products containing minoxidil. The most common brand name is Regaine 倍健. Minoxidil comes as either a liquid or foam and it can be easily purchased from a pharmacy without a prescription.

Use it twice a day on the area of hair loss. Make sure the the skin is dry and not irritated. You’ll want to avoid swimming or showering for at least 30 minutes after applying the medicine in order to allow it to be absorbed into your skin. Generally you need to continue using it for at least a year to make a meaningful decision about the drug’s effectiveness. It is available in concentrations of 2-5%. The extra strength (5% concentration) may be more effective and cause hair to regrow sooner.

You’ll want to monitor for any itchiness, skin irritation (allergy), flushing, and excessive hair growth (hypertrichosis). Follow the product directions for full details on how to apply the medicine.

Finasteride

Finasteride is a strong blocker of an enzyme called 5-alpha-reductase. Pharmacologically it causes a dramatic drop in the levels of DHT in your blood. However, similar to minoxidil, it doesn’t work very quickly and needs to be taken on a daily basis for usually at least a year to see an effect.

The typical starting dose of finasteride is 1 mg per day. It is a prescription drug. The 1 mg strength product is called Propecia 保康絲, while the 5 mg product strength (used to treat enlarged prostate) is called Proscar 保列治. To save on medication cost, it is perfectly reasonable to use a tablet cutter and split a 5 mg tablet. Take one quarter of the 5 mg tablet on a daily basis. Because finasteride drastically reduces androgen levels, split or crushed tablets should not be handled by pregnant women.

Recently there has been greater concern about the risk of severe side effects from finasteride. Although they don’t appear to be common, some men experience depression, suicidal thoughts, breast enlargement, decrease libido, erectile dysfunction, and sexual dysfunction. There is also greater awareness of the “post-finasteride syndrome”, with some disabling side effects continuing long after stopping the medicine. Young men should discuss the risks and benefits with their doctor before starting treatment.

Non-drug treatment options

General non-drug treatments include eating a nutritionally balanced diet; avoiding tight hairstyles, such as braids, buns or ponytails; avoiding compulsively twisting, rubbing or pulling your hair; and treating your hair gently when washing and brushing. 

If you prefer not taking medicines, cosmetic aids such as creative hair styling, hairpieces and hair lightening can help improve hair appearance. Furthermore, you can explore hair transplant and low-level laser treatment with a dermatologist or plastic surgeon.

Conclusion

Many men will choose to do nothing about their hair loss. For those who are concerned about male pattern hair loss, it is important to address risk factors and make sure another medical condition or drug is not causing the hair loss. There are two conventional drug treatments for androgenic alopecia: minoxidil is a non-prescription drug that is applied directly to the skin whereas finasteride is a prescription drug taken by mouth on a daily basis. Men should discuss the drug treatment options with their pharmacist and doctor. They will help you use your preferred treatment correctly and can help you monitor for potential side effects.

Contributors: Jason Tong and Cheng Wai Chung.
A Chinese version of this post appeared here.

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