Ok, so I’m checking out the Walmart light cocktail, and what do I see when I compare it my favorite Cranberry cocktail? OS has upped the % of juice to a total of 50%. but added apple and grape juice to the blend for a total of 50%. the OS light product used to be 27%juice, all cranberry. So if I want my cranberry, and I do, but I don’t want all the calories, what do I do? I’ll be buying the Walmart brand. This is the way I figure out the labels….since there are three juices and cranberry is the most, the amount of cranberry is somewhere between 16.5% and 49%. Don’t know, cant tell. Wish they would tell me.
On September 14, 2013 Floyd Mayweather (45-0, 26 KOs) took on Saul “Canelo” Alvarez (42-1-1, 30 KOs) in a match titled “The One.” It was the main event on a card that I believed would not be as fun and exciting as the undercard fight that included Lucas Matthysse and Danny Garcia. I was wrong. The match between Canelo and Mayweather was a chess match. It was professor versus student. Canelo came in with a game plan, but quickly realized the speed of Mayweather was superior to any previous opponent he has faced. At times, you could see Mayweather thinking in the ring.
The first two rounds were fought as expected. Mayweather was reading, studying and processing in his mind the necessary adjustments need to apply against Canelo. Mayweather started more aggressive that past fights, appearing to make a statement and let Canelo know Mayweather would control the fight. He used his jab and Canelo’s stationary head was an easy target. Canelo was trying to impose his size and power, as he appeared the (way) bigger fighter. The window of opportunity to make something happen in the first two rounds as Mayweather studied you came and went. Canelo was not successful, with the exception of a couple of body shots that electrified everyone except Mayweather.
In rounds 3-5 both fighters started to warm up. Mayweather was staying in the pocket and exchanging short counters and connecting. Canelo was looking for the body but was having little success as Mayweather would use the entire ring to create space between him and Canelo.
Canelo’s corner urged him to pick up the speed and attack more. At this point, Floyd was up on the cards and in control of the fight. However, the window of opportunity for Canelo was still alive. If Canelo could connect a solid hook on Mayweather, it could have changed the fights momentum to favor Saul. That window also came and went as Canelo was throwing and missing and getting countered. All the rights landed by Mayweather resulted in a cut and bruising underneath the left eye of Canelo.
Before the championship rounds, Canelo manifested his young age. Although a mature 23 year old, Canelo began to fatigue mentally as he had a Victor Ortiz moment. Frustrated by the signature Mayweather elbows and holding, Canelo engaged in a clench with Money and lifted his shoulder in an attempt to hit Mayweather’s jaw. The veteran referee Kenny Bayless caught it and warned Canelo.
With mental and physical fatigue setting in, Canelo was still searching for openings and gaps where he could catch Mayweather. The championship rounds showed a determined Canelo who refused to give up. Mayweather, meanwhile, used the entire ring to move away from Canelo, throw counter shots, and basically secure the win.
The fight went to the score cards and it was announced that it was a majority decision. This was very problematic as Mayweather clearly dominated at least 7 of the 12 rounds. He was clearly in control and Canelo was not successful in establishing any kind of offense, let alone dominance. CJ Ross, who also called the Bradley/Pacquiao fight in favor of Bradley scored last nights fight 114-114. Not sure what fight CJ was watching, but that was straight ridiculous. The other two scores were legit though:
“I’m a little shocked at whoever (CJ Ross) had him on the cards. Everything is a learning experience. I want to thank everyone who came out to support me and support Canelo. Canelo is a young strong champion. Mexico has produced some great champions. He can take a loss and bounce back,” Mayweather said after the fight.
“Simply I couldn’t catch him. He’s a very elusive and intelligent fighter and I couldn’t find him. Yes, he’s a smart fighter. He has a lot of experience and elusive. I simply didn’t know how to get him, ” said Saul after the fight.
Where was the blueprint? Oscar De La Hoya’s claim to have the formula, pulled out of the vault, was non-existent tonight. As I mentioned in my prediction, it was important for Canelo to fully ignore any piece of advice Oscar De La Hoya gave Canelo. I don’t think Canelo took any of it, but I do think it confused the hell out of Canelo. Canelo is a great champion, but the reality is that he was 1, 2, 3 years too early in fighting Mayweather. It was not his time and it was not wise to take on Mayweather straight after fighting against Austin Trout. Canelo needed a tune-up fight to apply what he learned in that fight and then challenge Mayweather.
So what is next? I can see Mayweather and Danny Garcia getting it on at a 147lbs. Danny did very well against Lucas Matthysse and showed a little bit of technique and skill. It is no where near Mayweather, but it would be another good fight where Mayweather can out-do a young champion. There is also the possibility of Mayweather fighting A Khan. Khan just needs to win in December and make it exciting to be able to promote a fight against Money.
Canelo will need to have a tune-up fight to regain any confidence lost from last nights fight. He is a young man and has a lot of time to shine. He does have a lot to work on, though, if he ever wants to face Andre Ward.
“ Developed by Ninja Kiwi and based on their Bloons Tower Defense franchise, Bloons Adventure Time TD features the Bloon hordes invading the Land of Ooo! Finn and Jake will need all the help they can get to stop them. Players can recruit their favorite Adventure Time characters including Princess Bubblegum, Marceline, Ice King and more, as well as the monkeys from the Bloons TD franchise as they travel from kingdom to kingdom to send the Bloons packing. The free-to-play game will be available this summer. ”
The bloons have invaded the land of Ooo and it's up to Finn, Jake and the monkeys to stop them! Bloons Adventure Time TD is an awesome crossover between the award-winning animated series Adventure Time and the #1 Tower Defense game, Bloons TD!
*Build your defense with over 50 allies including fan favorites BMO, The COBRA, and Lumpy Space Princess!
Bloons Adventure Time TD is a crossover game between Ninja Kiwi's Bloons TD series and Cartoon Network's "Adventure Time" series. It was announced on March 8th 2018 on the Cartoon Network International News website[2](and later on other online articles) and on March 9th 2018 in the Ninja Kiwi weekly blogs.[3] [4]
It has been first soft-released on 14th July 2018 to Australia, New Zealand, Philippines and Singapore.
There are a total of 15 characters that can be obtained by playing the game and clearing adventures.
Premium Characters can only be obtained by paying for them with real-world money. Each Premium Character also has his/her own adventure that is unlocked with that hero, which unlock special allies.
There are a total of 52 allies in this game, three being obtained from completing a Premium character adventure, sorted in five different rarities. Most allies can only be equipped by respective character. Each character can equip one ally initially, and can increase to a maximum of four allies as they level up.
Each hero is armed with a weapon that falls within one of six categories: Swords, Darts, Wands, Bombs, Guns, or Instruments. Only one may be equipped at any time. Instrument type weapons are unique in that they have a special effect that extends to nearby towers as well as the hero using the weapon. Weapon rarities start at Uncommon. There are 89 weapons in the game, three of which come from the premium heroes.
Trinkets are items that give beneficial effects, like more damage or pierce, to the character that has it. They can also have special properties that can apply when a requirement is met, like a nearby hero or land/water/lava placement. Each hero can equip three trinkets, and can be increased to a max of ten. There are 152 trinkets in the game.
If the player doesn't want an item in their collection, have duplicates, or have unfavourable items from their wish orbs, they can shard them. Doing so gives them 10, 25, 100, 300 or 1000 shards for Common, Uncommon, Rare, Super Rare and Epic items respectively.
There are 56 tracks in the game. 12 of those tracks are from the premium heroes and are not able to be played unless purchased or during special events. The tracks are in sets, called adventures, in an area in Ooo. For example, Cyclops is an adventure containing three tracks located in Grasslands. Some of these can unlock things like a new hero or new sets to play on. All have a difficulty on them, out of five skulls, indicating how hard it is, with track difficulties too.
Officially, this game is also considered the first spin-off of Bloons Tower Defense 6 since it uses similar graphics for the Monkeys, Bloons, and MOABs as BTD6. Similar sound effects are also used too.
The music appears to be a remix of the BTD6 music, as the title screen theme is a fusion between BTD6's title theme and Adventure Time's theme.
However, there are some characters that have similar attacks to those towers: Wildberry Princess and Ice King's Ice Bolt upgrade as Tack Shooter, Ice King as Ice Monkey, and C4 Charlie as Bomb Shooter.
The game requires iOS 11 or higher to get for Apple devices and Android 5.0 or higher for Android, but also depends on the performance of the player's device.
What I have noticed with the soundtracks in Bloons Adventure Time TD is that not always is the music the same in all maps. Occasionally, I ...	 2018-11-05T04:34:37Z
I think that's a good idea. Given how so many are edibles, it makes sense to name them something distinct without resorting to naming ...	 2018-10-22T19:02:38Z
CMT.com has a piece up that features an interview with banjo picker Tony Trischka. It is focused on his recent release, Double Banjo Bluegrass Spectacular, which includes Tony and a host of celebrated banjoists in twin banjo arrangements. Earl Scruggs, Tom Adams, B?©la Fleck, Scott Vestal, Noam Pikelny and many more share the banjo duties with Trischka on this project.
The CMT piece focuses on Tony’s collaboration with actor/comedian/banjo player Steve Martin, who also appears on the new CD, and getting the opportunity to perform with Martin on The Ellen DeGeneres Show.
“When we were recording the album, I was sitting knee to knee with him while we were rehearsing the tunes,” he says. “The thing that really hit me is how powerful his playing still is. And I saw him in New York four or five months ago. Just the very first hit of ‘Salty Dog,’ there was just that sound. The tone is the thing with Earl. It’s just so deep and so right and so perfect and so there, you can’t even really explain what it is about it, but it takes your head off.”
Speaking of Trischka, Martin and television… The two will be appearing on The Late Show with David Letterman on April 26, so mark your calendars and set your TiVo.
Well I hope that you all had your fill of good cheer, and that the blessings just keep on coming for you in this new year. How did it get to be 2009?
I want you all to know that I am so touched that each of you drop by this space to chat and exchange ideas and just BE together. It means so much to me to share this journey with so many wonderful people, and to get glimpses of your days too.
I've been thinking hard during the last few months on a way to expand that sharing – to send a little piece of Blue Yonder out into the world, and at last I hit upon what I think will be a great way for us to connect, and hopefully for your own families to draw closer as well.
I will be sharing lots more information about that project in a day or two, so don't go too far, okay?
In the meantime, I give you the king… or the chief… or one, and then the other, and then maybe both at one time.
I know… I might be the last mama out there to give her poor boy his rightful crown, but he finally found it under our tree this year.
Two short days before Christmas though, he was running around the house hollaring his Comanche war cries, with chicken feathers stuck in his hair, when it occurred to me that he was going to need a headdress too.
I think I would make them a bit narrower next time, and maybe not so tall, but I guess they turned out pretty well, for a last minute cram session gift.
He likes it anyway, and that's what matters. Only he's been asking if I can please put "some bull horns on it, to make it look real tough." Hmmm. Gonna have to think on that one.
He likes to put on his crown and bark orders, and then don his headdress and tell everyone that he's "still the boss of you because the Chief is the king of his people too!"
Being that he's the smallest, but bears the biggest attitude, my husband says that what he really needs is a Napolean hat.
That is sooo cute! Every time I see your boys dress up I think about making some dress up clothes for my 7 year old. But, she never seems to play dress up by herself – maybe because she doesn’t have the right stuff? Have to think on that!
i love his headdress….what a great idea. i am looking forward to the upcoming project that you mentioned. i always love reading your blog.
I remember when my oldest was young – worrying that we didn’t have enough dress up stuff for full on imaginative play. Lo and behold, at child number 4, the dress up barrel is bursting at the seams! With silks, crowns and all manner of oversized garments. But that headdress totally takes the cake! Love it.
too funny…. little boss man. headdress is GREAT! oh, the happiest of happy new years to your fam… can’t wait to see what you’ve got cooked up!
I just wanted to say- I don’t even know if I’ve ever commented before, but I get so much mothering inspiration from you.
It’s your blog (among a very few others) that made me feel like if this third baby was a boy, I could do it. You have the most amazing little men out there!
Oh! I am so excited to see the picture but it is not showing up. It says that it is currently unavailable. Argh. I love your stuff.
Oh man, did the napoleon hat ever get me to laughing. Let me know when you get around to that- I might need a few over here! *big grin*
As a mom to three boys myself (and one girl) it’s just so nice and encouraging to ‘hang out’ in the blogging world with another gal that ‘gets it’. You’ve inspired me to find new ways to encourage and educate my boys. And, I’m guaranteed a regular dose of laughter, of course!
Oh my! That headdress is amazing. “I guess it turned out pretty well” would be an understatement. And you did that at the last minute?!?!
Too funny, thanks for the chuckle. You’ve really got me thinking now, what could you be stirring up?
that is amazing! i think you did a phenomenal job on the headdress… you crack me up with your writing style. thanks!
I think the feathers are just right. I would take orders from that little man any day of the week! Great picture!
His expression is just great in that picture. Yeah, he’s cool. He’s in charge. He’s got the head dress to prove it. I’m excited to hear more about your project!
Impressive headdress, and an even more impressive boy! Really enjoyed this post. Looking forward to hearing your news
Love it!, I made a headpiece for my eldest boy for his birthday last year and he loves it, reminds me that I shouldn’t forget about the other boys, maybe for their birthday’s this year.
Effective policy initiatives to constrain lipid-lowering drug expenditure growth in South Korea | BMC Health Services Research | Full Text
The rapid growth of prescription drug expenditures is a major problem in South Korea. Accordingly, the South Korean government introduced a positive listing system in 2006. They also adopted various price reduction policies. Nevertheless, the total expenditure for lipid-lowering drugs have steadily increased throughout South Korea. The present study explores the factors that have influenced the increased expenditures of lipid-lowering drugs with a particular focus on the effects of statins in this process.
This paper investigates the National Health Insurance claims data for prescribed lipid-lowering drugs collected between January 1, 2005 and December 31, 2009. We specifically focused on statins and assessed the yearly variation of statin expenditure by calculating the increased rate of paired pharmaceutical expenditures over a 2 year period. Our study classified statins into three categories: new entrants, core medicines and exiting medicines. For core medicines, we further examined influencing factors such as price, amount of drugs consumed by volume, and prescription changes (substitutes for other drug).
Statin expenditure showed an average annual increase of 25.7% between 2005 and 2009. Among the different statins, the expenditure of atorvastatin showed a 36.6% annual increase rate, which was the most dramatic among all statins. Also we divided expenditure for core medicines by the price factor, volume factor, and prescription change. The result showed that annual weighted average prices of individual drug decreased each year, which clearly showed that price influenced statin expenditure in a negative direction. The use of generic drugs containing the same active ingredient as name-brand drugs increased and negatively affected statin expenditure (Generic Mix effect). However, the use of relatively expensive ingredients within statin increase, Ingredient Mix effect contributed to increased statin expenditure (Ingredient Mix effect). In particular, the volume effect was found to be critical for increasing statin expenditure as the amount of statin consumed increased steadily throughout the study period.
The recent rapid increase in statin expenditure can largely be attributed to an increase in consumption volume. In order to check drug expenditures effectively in our current situation, in which chronic diseases remain steadily on the rise, it is necessary to not only have supply-side initiatives such as price reduction, but also demand-side initiatives that could control drug consumption volume, for example: educational programs for rational prescription, generic drug promotional policies, and policies providing prescription targets.
In Korea, the National Health Insurance prescription drug expenditure has increased about 13.2% annually for the past decade (2001–2010) [1]. This cost makes it a major threat to the sustainability of Korea's National Health Insurance program. Accordingly, the Korean government has introduced various policies to check these costs that have continued to grow since 2006. In December 2006, they introduced the positive listing system, inducing pharmaceutical companies to consider cost-effectiveness as one of their major concerns [2], and required them to cut the price of original drugs by 20% when their patents expire. Also, from 2007 to 2010, they re-evaluated the cost-effectiveness of already listed drugs and lowered the cost of drugs with low cost-effectiveness or delisted them [3]. This re-evaluation of listed drugs was done mainly to drugs for chronic diseases like hyperlipidemia and hypertension. In 2009, pharmaceutical companies also introduced the price-volume agreement system.
If we divide factors for prescription drug expenditure into two categories – the price factor and the volume factor – most pharmaceutical regulations introduced in Korea between 2006 and 2009 utilized supply-side initiatives like the price and the drug-listing decision method [4]. As a result, the government rarely applied demand-side initiatives, which efficiently control prescription drug expenditures by checking their volume on the stage of drug prescription and usage. In this case, if the main reason for the increase in prescription drug expenditure wasn't price, but volume, then, the effect of policies focusing on price-cuts and unaccompanied by demand-side initiatives would remain limited and stay short-term in nature. Therefore, in order to approach the issue of constraining prescription drug expenditure increases, we need first to examine the various factors surrounding the phenomenon, including price, volume, and prescription changes, and their influence on prescription drug expenditure increases [5, 6].
When we examine the influences the three above-mentioned factors have on changes in prescription drug expenditures, we find that their influence varies according to the drug. This study examines the influence lipid-lowering drugs have on the prescription drug expenditure increase. The lipid-lowering drug expenditure increased sharply, doubling from 2005 to 2009 [7]. This drug was also influenced the most by various policy changes during this period. As the patent expired in August 2008, the price of the original atorvastatin lowered by 20%. In particular, as a result of re-evaluating the listed drugs, which indicated that there were no significant differences among statins in their effects on lowering LDL, the prices of all statins above a certain price were lowered two times by 5% ~ 37.5% (an average 10.3%) in April 2009 and in January 2010 [4]. Despite these changes, lipid-lowering drug expenditures continued to grow steadily [7]. It is necessary for us first to look into various factors influencing the lipid-lowering drug expenditure increase in detail. Results of the current study could offer useful suggestions for future plans to more effectively constrain the lipid-lowering drug expenditure increases.
For our study we used the Korean National Health Insurance Claims Database (KNHICD). The Korean National Health Insurance plan provides coverage for 97% of the entire South Korean population. NHI benefits not only cover outpatient, inpatient and emergency care, but also prescription drugs dispensed at pharmacies. We focused on lipid-lowering drugs that were prescribed and dispensed in outpatient settings between 2005 and 2009.
We defined lipid-lowering drugs in this study as drugs with an Anatomical-Therapeutic Classification System (ATC) code that corresponded to ‘C10 LIPID MODIFYING AGENTS’. Given that statins represent more than 90% of all pharmaceutical expenditures for lipid-lowering drugs, we decided to focus on statins alone as our final study target. We estimated the price of an individual drug using an annual weighted average price calculated as the annual expenditure divided by annual consumption. The amount of statin consumed was computed based on the Defined Daily Dose of the World Health Organization (WHO-DDD) at 2010 [8–10]. With the sole unit of DDD, it was feasible to compare the amount of drug consumed among identical active ingredients even when they had different strength and administration routes.
The current study was approved of by the Institutional Review Board (IRB) of Health Insurance Review and Assessment Services (HIRA).
We calculated the yearly variation of statin expenditures by measuring the increased rate of paired pharmaceutical expenditures for a 2 year period. We added "Expenditure" only to the price of the drugs and did not include compounding fees, etc. In Korea, patient co-payment is a certain percentage of total expenditures that compose drug prices plus compounding fees. Thus, "expenditures" in this study were defined as total drug cost including some of the patient co-payment. We adjusted for inflation by dividing the monetary time series by the Consumer Price Index (CPI) with the CPI being scaled so that 2009 value was 1.0 [11]. And we used exchange rate listed by the Bank of Korea (Additional file 1) [12]. Referring to the study of Chernew (2001), we categorized statins as new entrants, core medicines or exiting medicines (Figure 1) [6]. We defined new entrants as medicines that were not used during the previous year but were used in the base year. Core medicines were drugs that were used during both years. Exiting medicines were defined as drugs that were used during the previous year but were not used in the base year. We further divided new entrants into new molecular entities, new medicines, new generic medicines, and others. New molecular entities referred to compounds that the NHI covered during the specified year. We defined new medicines as drugs recently listed with new administration routes or chemical compositions but with their active ingredients already included in the NHI benefit list for the specified year. New generic medicines were primarily identified as newly launched generic drugs for which the original patent had expired. The rest of the drugs within the new entrants were classified as "others". These medications were already listed in NHI benefit list but were not used during the comparable period.
The number of active ingredients in our study was 19(183 drugs) in 2005 but this was expanded to 30 active ingredients (271 drugs) in 2009 (Table 1).
*This table includes only those statins that were prescribed by doctors out of statins on the Korean National Health Insurance benefit list.
Table 2 divided statins on the KNHI (Korea National Health Insurance) benefit list into 7 different types according to their ingredients, additionally subdividing them into original and generic drugs. These included all statins on the KNHI benefit list between 2005 and 2009, regardless of whether they were actually prescribed or not. This table indicates that many atorvastatin generic drugs were placed on the benefit list at around same time in July 2008 when the patent expired.
*They include all statins on the KNHI benefit list between 2005 and 2009, regardless of whether they were actually prescribed or not.
**The original and generic drugs were categorized only according to their ingredients and contents. Different administration routes, dosage forms, and strength of unit were not taken into account.
We computed the yearly variation of statin expenditures starting in 2005 by calculating the increased rate of paired pharmaceutical expenditures observed over a two-year period. One can express spending increases for statins between the previous year (0) and base year (1) with the following equation when the targeted drugs were classified as new entrants, core medicines, and existing medicines:
We further divided expenditures for core medicines by the price of medication, amount of drugs consumed by volume, and prescription changes, which we have illustrated in the equation slightly further below. There are two possible factors that could have led to prescription changes: Generic Mix or Ingredient Mix. Generic Mix refers to cases where prescribed drugs were substituted for other medicines with identical generic names. Since the two drugs shared the same generic name, their ingredients, dosage type and action mechanisms were identical even as their prices differed. We determined whether pharmaceutical expenditures for 2 years showed any changes in the proportion of high/low priced drugs with the same ingredients. Ingredient Mix refers to the cases in which the existing drugs were replaced with other drugs in the same therapeutic category. For example, if a patient changed his or her drug from simvastatin to atorvastatin, one could express this as an Ingredient Mix since both medications belonged to the statin classification.
Our study demonstrated that statins accounted for 90% of total lipid-lowering drug expenditures. Annual expenditures for statins increased from 193 million won (188 million USD) in 2005 to 483 million won (378 million USD) in 2009 (an annual average of 25.7% during the study period). The annual statin DDD also showed an increase of 36.4% (from 129 million DDD in 2005 to 445 million DDD in 2009) while statin expenditure per DDD decreased 7.9% (1,506 won (1.47 USD) in 2005 to 1,085 won (0.85 USD) in 2009) (Table 3). As the patent expired in August 2008, the price of the original atorvastatin lowered by 20%. Also, as a result of re-evaluating the listed drugs, its insurance price lowered by an average of 11% in April 2009. Such a price reduction influenced the continuous decreasing of statin expenditure per DDD.
For a detailed analysis, we calculated drug expenditure percentages according to seven different statins. Our result showed that the percentage of simvastatin was the highest (41.9%) in 2005, followed by atorvastatin (31.2%) and pravastatin (9.2%). However, during the 4 year study period, simvastatin and lovastatin declined to 24.9% and 0.9% respectively. On the other hand, the percentage of atorvastatin increased rapidly to 49.0%, and the percentage of rosuvastatin rose to 11.8%. Atorvastatin particularly showed a rapid increase after 2008 when the original patent expired and generic drugs began to appear on the market. Pitavastatin use fluctuated slightly, increasing from 3.8% in 2006 to 7.6% in 2008, but decreasing to 6.4% in 2009 (Figure 2) (Additional file 2).
We also compared the amount of the seven statins consumed throughout this study. In 2005, simvastatin occupied 47.8% of the total statin DDD (Defined Daily Dose)followed by atorvastatin (20.6%), pravastatin (9.9%), lovastatin (9.0%), and rosuvastatin (8.4%). Our analysis demonstrated that there was significant fluctuation among the DDD proportion of the seven statins during the 4 year study period. The atorvastatin share, which ranked second in 2005, increased dramatically to 47.6% of the entire statin DDD in 2009. The percentage for simvastatin, on the other hand, plummeted to 24.5%. Use of rosuvastatin showed a slight increase (DDD proportion of 12.4%). In contrast, the DDD proportion of pravastatin decreased to 4.6% while lovastatin dropped to 0.9% (Figure 3).
Lastly, we explored the significant factors that influenced drug expenditure changes during the study period. We found that core medicines contributed the most to statin expenditure increases. Exiting medicines led the expenditure decrease of 13.4% in 2006 but had no significant influence thereafter. New entrants positively affected statin expenditure between 2006 and 2008 (from 2.7% to 10.5%) but rarely affected it in 2009 (1.0%).
Drug prices, which showed a continuous decrease, seemed to reduce the expenditures for statin. Especially, price factor contributed the most statin expenditure decreases, because insurance price of statins lowered by an average of 11.0% in 2009. However consumption volume increased annually and contributed to a substantial increase in statin expenditures. Since the patent for atorvastatin expired in 2008 and use of generic drugs increased, Generic Mix drove a statin expenditure decrease while the Ingredient Mix effect led to an expenditure increase of 5.3% (assuming the average rate of increase was 100%). This resulted from an increased use of more expensive active ingredients within the statin (Table 4).
Recently, hyperlipidemia has been on the rise in South Korea. Between 2005 and 2010, the prevalence of hyperlipidemia among people over 30 increased from 8.0% to 13.5%, while the prevalence of hypertension and diabetes rose from 24.6% to 26.9% and from 9.1% to 9.7% respectively [13]. Additionally, drug expenditures for lipid-lowering drugs doubled between 2005 and 2009. Moreover, compared to 2009, the use of lipid-lowering drugs in South Korea increased 27.4% in 2011 [7].
As is well known, hyperlipidemia is a major risk factor in contracting cardiovascular diseases. Hobbs (2004) reported that there is a more than 30% chance of cardiovascular disease development when cholesterol levels increase by 10%. If cholesterol levels increase by 30%, the risk of cardiovascular disease doubles [14]. In order to properly control hyperlipidemia, various recommendations have been made that include receiving lipid-lowering drugs along with maintaining a healthy diet and getting ample exercise [14–19].
Considering the notable effects of cardiovascular disease prevention, hyperlipidemia patients should take lipid-lowering drugs when necessary. In situations where the number of hyperlipidemia patients are rapidly increasing, the resulting increase in lipid-lowering drug prescriptions means an increasing burden to prescription drug costs. This study was designed to find a more effective way to constrain lipid-lowering prescription drug expenditures by examining the various primary factors influencing increases in expenditures.
By focusing on statins, which accounted for 90% of both lipid-lowering drug expenditures and consumption volume, we sought to identify the factors that drove expenditure increases. For our detailed analyses, we examined price, the amount of drugs consumed (volume), and prescription changes (substitutes for other drugs). For the amount of drugs consumed, we applied the DDD in order to standardize the volume of drugs with identical active ingredients regardless of their different administration routes, dosage forms, or strength and unit. Our current study's findings implied that increased expenditure for lipid-lowering drugs in South Korea was driven mainly by core medicines. Further analyses revealed that drug price consistently lowered statin expenditures while Generic Mix (the relative gap between consumption of name-brand and generic drugs) also reduced statin expenditures. This reflected the increasing use of generic drugs and could explain why most of the new entrants were considered ‘new products (generic).’ Additionally, prescription changes raised statin expenditures slightly due to an increased use of relatively expensive ingredients (Ingredient Mix effect). The results of this study also demonstrated that volume increases drove statin expenditures increases. Previous investigations analyzing South Korean drug expenditures from 2001 to 2006 also reported that volume increased due to an increasing number of patients, with prescriptions and prescribed days also acting as a main contributor [20–22]. Characteristically, after 2008, when the atorvastatin patent expired and various generic drugs began to appear on the market, atorvastatin expenditures increased significantly. This appears to be due to the fact that the production of generic drugs opened the possibility for doctors to prescribe a wider variety of lipid-lowering drugs. This conclusion is consistent with findings from a previous study by Kwon (2013), which found that the release of generic drugs on the market tended to not only replace the original drug market, but to also increase the overall market share for medication composed of essentially the same ingredients [4].
As mentioned in our introduction, the price of lipid-lowering drugs decreased during two significant periods between 2005 and 2009. Nevertheless, overall lipid-lowering drug expenditures continued to increase during 2008 and 2009. This was due to increases in the number of patients using these drugs and the number of their administration dates, as is shown in the increase in the entire DDD. In other words, the increase in lipid-lowering drug consumption was the main factor for expenditure increases. Therefore, it is clear that supply-side initiatives focusing on lowering prices would not be enough to effectively constrain drug expenditure increases.
Godman [23] argues that taking only one between supply-side initiative and demand-side initiative results in a limited effect on the constraint of prescription drug increases. Furthermore, one can maximize prescribing efficiency only when combining the two initiatives. He also argues that combining various demand-side initiatives amplifies the effect. In fact, the kind of increase in statin utilization witnessed in Korea is similar to statin utilization trends across Europe [23]. However, while statin use increased in the U.K. and Sweden, accompanying expenditures did not increase proportionally. One can impute these efficient expenditure numbers to their use of combined demand-side measures such as target prescription, compulsory INN prescription, positive and negative financial incentives, and mandatory generic substitutions. In Germany as well, in order to constrain the prescription drug expenditure and encourage generic drug prescription, authorities introduced target prescription as a cost-saving measure. This system was accompanied by offering immediate feedback so that doctors could monitor their own performance. It was through this combination of target prescription accompanied by educational methods and introducing a price-reference system that Germany was able to activate a relatively cheaper generic drug market [24, 25]. In Korea, where the number of individuals with chronic illnesses have continued to rise, the authorities have made efforts to develop demand-side initiatives in addition to supply-side initiatives like lowering prices in order to effectively constrain prescription drug expenditure increases. For example, there is the prescribing incentive scheme (IPS), a system in which doctors are offered 30% of the saved drug cost if they voluntarily improve their prescription behavior and save drug costs. Also, in April 2012, Korea introduced a new price system where the highest price of both original and generic drugs is lowered to 53.55% of the original drug price, twelve months after the date the generic drug was listed and at the same time as the original drug’s patent expired. Because of this, the difference between the prices of original and generic drugs disappeared as well as the difference in co-payments. One could expect that the generic drug market could shrink slightly if one were to introduce this system. These initiatives clearly had some significant effect on limiting the prescription drug expenditures. Nevertheless, it would still be preferable to introduce more diverse demand-side initiatives to continue checking prescription drug expenditure increases and to maximize prescription efficiency.
The present study had several limitations. First, it was difficult to accurately measure drug usage volume. We confined our study to medications used for hyperlipidemia and measured consumption volume by adopting the DDD. However, drug consumption data presented in DDDs only gave a rough estimate of consumption and not an exact picture of actual use [26]. Second, the study method we used was not sufficient for assessing the impact of introducing new drugs on changes in drug expenditures [27]. Every year, pharmaceutical companies launch newly developed drugs and products while removing many existing drugs from the market. For this reason, studies are usually conducted either every year or once every 3 years, a short period for new entrants to acquire a certain level of the market share. Therefore, one might underestimate the influence of new entrants on current drug expenditures with those of the previous year. However, statins had few “new molecular entities” among “new drugs,” and most of the new drugs in our study sample were generic and had already acquired expired patents. Therefore, this common limitation that could have led to us underestimating our results would not have impacted our analysis.
As chronic diseases including hyperlipidemia increase steadily in South Korea, it is necessary to introduce not only supply-side measures but also various demand-side measures such as educational courses for rational prescription, programs promoting cost-effective prescription drug usage, and a prescription target system to effectively constrain prescription drug expenditure increases.
This study was supported by Health Insurance Review and Assessment Service (HIRA). The authors would like to thank the HIRA for cooperation and contributions.
GB (the first author) was a principal collaborator in designing this study. She undertook data analysis tasks of this study and the prepared the manuscript for submission. SJ (Corresponding author) was actively involved in this study's planning and enactment. She led the design of this research and contributed to the interpretation of the results. CP took part in designing the research and data analysis. She contributed to interpreting the results and the discussions. HL participated in analyzing the data and shared the interpretation of the results with other authors. EH took part in interpreting the results and also participated in preparing the manuscript for submission. DSK contributed to interpreting the results and the discussions. All authors read and approved the final manuscript.