The 'blue prescription' scheme helps even out inequalities in health. Sanctions against doctors for erroneously issued blue prescriptions sit badly with our ideas of solidarity and health for all.
As a general practitioner in a small village in Vermont, USA, I always needed to take the patient's financial circumstances into account in my choice of examination and treatment. Was the patient's COPD treatment-refractory? Or could he not afford to buy the drugs prescribed?
Vermont is one of the more social-democratic states in the USA. I was nevertheless constantly reminded of the fact that I worked in a system that was (under)funded by a patchwork of public and private insurance schemes. I met patients who could not afford to buy medicines or prioritise their own health until their condition had become absolutely acute. A report from 2021 shows that 30 % of Americans refrained from seeking health care because of the costs involved, and 14 % were unable to pay for at least one of their regular medications (1). When the costs are paid for by insurance companies, financial concerns rule. Community – paying to ensure that everybody's health can be taken care of – becomes a distant concept.
As a doctor in Norway I am glad to be working in a system where health is not limited by patients' personal finances. Because that is what the 'blue prescription' scheme is about: that we have a community that provides health care to all when they need it. A low limit for patient user fees when they see a doctor, the 'blue prescription' scheme and the exemption card scheme enable chronically ill patients to prioritise their own health, irrespective of their personal finances or insurance policies.
But someone must pick up the bill. Publicly funded healthcare services are a good, and the more sophisticated the treatment, the higher the patients' expectations. In the process, the costs to the community increase. Insufficient cost-effectiveness was pointed out during the revision of the 'blue prescription' scheme as far back as 2004–06 (2, 3). At the time, 15 % of prescription errors were due to the conditions for reimbursement being unmet (4). In the period 2010–19, the reimbursement costs for drugs prescribed on a 'blue prescription' increased by 30 %, and in 2019, drugs worth NOK 11.7 billion were dispensed through the 'blue prescription' scheme (5).
In administering public funds, doctors have a great responsibility. An insufficient overview of the conditions for reimbursement, lack of decision-making support, lack of awareness of their gatekeeper role, time constraints and professional disagreement could be some of the reasons for erroneous use of the 'blue prescription' scheme (5).
The penalty scheme is a threat to clinically appropriate patient treatment
Now, however, the authorities think that sanctioning doctors who state invalid conditions for reimbursement is a good way to save costs associated with the 'blue prescription' scheme (6). The provision for a non-compliance penalty entered into force on 1 January 2022, despite repeated protests from the Norwegian Medical Association (7, 8). Turning the 'blue prescription' scheme into a conflict between health authorities and doctors is a step in the wrong direction. It is not the doctor who gains from a prescription error, but the patient. The penalty scheme is a threat to clinically appropriate patient treatment. We should rather investigate why so many drugs are needed and how we could increase our focus on preventive healthcare measures to ensure that fewer people fall prey to chronic illnesses.
Striking a balance between the doctor's roles as an administrator and therapist for the patient is gradually becoming more difficult. The community is also dependent on doctors' empathy for their fellow humans and their motivation to continue working in the health services. If someone is sanctioned for not continually questioning the patient's credibility, they lose the motivation to consider clinical trade-offs when faced with a medical grey area. The contract GP scheme is already suffering. Introducing non-compliance penalties and further expanding the bureaucratisation of medicine will not encourage recruitment of doctors to general practice (9). To be able to fulfil our many roles as doctors, we need to be trusted to practise our profession in the best interests of the community.