• Katharina Schmalstieg-Bahr, Christiane A Müller, and Eva Hummers.
• Department of General Practice, University Medical Center Göttingen, Göttingen, Germany.
• Fam Pract. 2019 Nov 18; 36 (6): 785-790.

BackgroundIn Germany, almost 50% of prescriptions for benzodiazepines and drugs as Zolpidem and Zopiclone are as out-of-pocket (OOP) prescriptions-requiring patients to buy the drug at their own expense-although almost 90% of the population has statutory health insurance covering medication costs.ObjectiveTo understand why general practitioners (GPs) choose this prescribing method since needed medications are insurance covered, and unnecessary drugs should not be prescribed at all.MethodsIn this qualitative study, 17 semi-structured interviews with GPs were conducted, audio recorded and transcribed verbatim. Transcripts were analysed with grounded theory to extract a model explaining the described behaviour.ResultsKnowing the significant medical risks and insecurity about regulations makes GPs wish to avoid hypnotics and sedatives. They achieve this by 'Creating a barrier' (central phenomenon) and employing the strategy 'Using an out-of-pocket prescription', which not only generates costs for the patient but also reduces the physicians´ legal and financial accountability. The perceived patient type, expected problem duration and diagnosis influence the decision about the prescription form: patients with an alcohol or drug addiction or those with 'uncomplicated' insomnia are more likely to receive an OOP prescription. Patients with any psychiatric diagnosis will likely receive a statutory health insurance prescription.DiscussionCurrent regulations do not provide guidance to GPs regarding hypnotics and sedatives. A clear regulatory framework and guidelines could possibly reduce physicians' defensive attitudes about these drugs and their use of OOP prescriptions. The approach to use OOP prescriptions as a barrier to reduce patients' medication use lacks evidence regarding effectiveness.© The Author(s) 2019. Published by Oxford University Press.

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