Christine Leopold

Pharmaceutical policies in European countries in response to the global financial crisis

Objective: The objective of this paper is to analyze which pharmaceutical policies European countries applied during the global financial crisis. Methods: We undertook a survey with officials from public authorities for pharmaceutical pricing and reimbursement of 33 European countries represented in the PPRI (Pharmaceutical Pricing and Reimbursement Information) network based on a questionnaire. The survey was launched in September 2010 and repeated in February 2011 to obtain updated information. Results: During the survey period from January 2010 to February 2011, 89 measures were identified in 23 of the 33 countries surveyed which were implemented to contain public medicines expenditure. Price reductions, changes in the co-payments, in the VAT rates on medicines and in the distribution margins were among the most common measures. More than a dozen countries reported measures under discussion or planned, for the remaining year 2011 and beyond. The largest number of measures were implemented in Iceland, the Baltic states (Estonia, Latvia, Lithuania), Greece, Spain and Portugal, which were hit by the crisis at different times. Conclusions: Cost-containment has been an issue for high-income countries in Europe – no matter if hit by the crisis or not. In recent months, changes in pharmaceutical policies were reported from 23 European countries. Measures which can be implemented rather swiftly (e.g. price cuts, changes in co-payments and VAT rates on medicines) were among the most frequent measures. While the “crisis countries” (e.g. Baltic states, Greece, Spain) reacted with a bundle of measures, reforms in other countries (e.g. Poland, Germany) were not directly linked to the crisis, but also aimed at containing public spending. Since further reforms are under way, we recommend that the monitoring exercise is continued.

Differences in external price referencing in Europe—A descriptive overview

OBJECTIVE This study aimed to provide an up-to-date description as well as comparative analysis of the national characteristics of pharmaceutical external price referencing (EPR) in Europe. METHODS Review of the country-specific PPRI (Pharmaceutical Pricing and Reimbursement Information) Pharma Profiles written by representatives of the PPRI Network. The Profiles were analysed according to predefined criteria. RESULTS Of 28 analysed European countries 24 applied EPR in 2010. The majority of countries have statutory rules to implement EPR. Most countries had less than 10 countries in their reference baskets. Higher income countries tend to include higher income countries in their basket, whereas lower income countries refer to lower income countries. Taking the average price of all countries in the basket as the basis to calculate the national price was the most common strategy (n=8). The methodology of EPR has changed in most European countries over the past 10 years (n=19). CONCLUSIONS EPR is a widely used pricing policy in Europe and is still actively used as well as adjusted by national authorities. However, we still see room for improvement by implementing more detailed legislations in terms of the revision of prices and by identifying alternative countries in case a product is not on the market. We also see the need for formal information sharing (e.g. congresses dedicated to pricing strategies and systems) with other public pricing authorities to learn about the different EPR methodologies as well as the national experiences. These congresses might also give room to better understand national pricing methods including discussions on possible limitations of these pricing methods.

Effect of the economic recession on pharmaceutical policy and medicine sales in eight European countries

Abstract Objective To identify pharmaceutical policy changes during the economic recession in eight European countries and to determine whether policy measures resulted in lower sales of, and less expenditure on, pharmaceuticals. Methods Information on pharmaceutical policy changes between 2008 and 2011 in eight European countries was obtained from publications and pharmaceutical policy databases. Data on the volume and value of the quarterly sales of products between 2006 and 2011 in the 10 highest-selling therapeutic classes in each country were obtained from a pharmaceutical market research database. We compared these indicators in economically stable countries; Austria, Estonia and Finland, to those in economically less stable countries, Greece, Ireland, Portugal, Slovakia and Spain. Findings Economically stable countries implemented two to seven policy changes each, whereas less stable countries implemented 10 to 22 each. Of the 88 policy changes identified, 33 occurred in 2010 and 40 in 2011. They involved changing out-of-pocket payments for patients in 16 cases, price mark-up schemes in 13 and price cuts in 11. Sales volumes increased moderately in all countries except Greece and Portugal, which experienced slight declines after 2009. Sales values decreased in both groups of countries, but fell more in less stable countries. Conclusion Less economically stable countries implemented more pharmaceutical policy changes during the recession than economically stable countries. Unexpectedly, pharmaceutical sales volumes increased in almost all countries, whereas sales values declined, especially in less stable countries.

Is Europe still heading to a common price level for on-patent medicines? An exploratory study among 15 Western European countries

BACKGROUND Previous studies have suggested that medicines prices in Europe converge over time as a result of policy measures such as external price referencing. OBJECTIVE To explore whether ex-factory prices of on-patented medicines in Western European countries have converged over a recent period of time. METHODS Prices of ten on-patent medicines in five years (2007, 2008, 2010, 2011, 2012) of 15 European countries were analyzed. The unit of analysis was the ex-factory price in Euro per defined daily dose (exchange rate indexed to 2007). A score (deviation from the average price) per country as well as the ranges were calculated for all medicines. RESULTS The prices between countries and selected products varied to a great extent from as low as an average price of € 1.3/DDD for sitagliptin in 2010-2012 to an average of € 221.5/DDD for alemtuzumab in 2011. Between 2008 and 2012, a price divergence was seen which was fully driven by two countries, Germany (up to 27% more expensive than the average) and Greece (up to 32% cheaper than the average). All other countries had stable prices and centered around the country average. Prices of less expensive as well as expensive medicines remained relatively stable or decreased over time, while only the price of sirolimus relatively increased. CONCLUSIONS Our study period included the time of the recession and several pricing policy measures may have affected the prices of medicines. Instead of the expected price convergence we observed a price divergence driven by price changes in only two of the 15 countries. All other European countries remained stable around the country average. Further research is needed to expand the study to a bigger sample size, and include prescribing data and Eastern European countries.

Impact of pharmaceutical policy interventions on utilization of antipsychotic medicines in Finland and Portugal in times of economic recession: interrupted time series analyses

ObjectivesTo analyze the impacts of pharmaceutical sector policies implemented to contain country spending during the economic recession – a reference price system in Finland and a mix of policies including changes in reimbursement rates, a generic promotion campaign and discounts granted to the public payer in Portugal – on utilization of, as a proxy for access to, antipsychotic medicines.MethodologyWe obtained monthly IMS Health sales data in standard units of antipsychotic medicines in Portugal and Finland for the period January 2007 to December 2011. We used an interrupted time series design to estimate changes in overall use and generic market shares by comparing pre-policy and post-policy levels and trends.ResultsBoth countries’ policy approaches were associated with slight, likely unintended, decreases in overall use of antipsychotic medicines and with increases in generic market shares of major antipsychotic products. In Finland, quetiapine and risperidone generic market shares increased substantially (estimates one year post-policy compared to before, quetiapine: 6.80% [3.92%, 9.68%]; risperidone: 11.13% [6.79%, 15.48%]. The policy interventions in Portugal resulted in a substantially increased generic market share for amisulpride (estimate one year post-policy compared to before: 22.95% [21.01%, 24.90%]; generic risperidone already dominated the market prior to the policy interventions.ConclusionsDifferent policy approaches to contain pharmaceutical expenditures in times of the economic recession in Finland and Portugal had intended – increased use of generics – and likely unintended – slightly decreased overall sales, possibly consistent with decreased access to needed medicines – impacts. These findings highlight the importance of monitoring and evaluating the effects of pharmaceutical policy interventions on use of medicines and health outcomes.

Medicines discarded in household garbage: analysis of a pharmaceutical waste sample in Vienna

ObjectivesTo analyze a sample of pharmaceutical waste drawn from household garbage in Vienna, with the aim to learn whether and which medicines end up unused in normal household waste.MethodsWe obtained a pharmaceutical waste sample from the Vienna Municipal Waste Department. This was drawn by their staff in a representative search in October and November 2009. We did a manual investigation of the sample which contained packs and loose blisters, excluded medical devices and traced loose blisters back to medicines packs. We reported information on the prescription status, origin, therapeutic group, dose form, contents and expiry date. We performed descriptive statistics for the total data set and for sub-groups (e.g. items still containing some of original content).ResultsIn total, 152 packs were identified, of which the majority was prescription-only medicines (74%). Cardiovascular medicines accounted for the highest share (24%). 87% of the packs were in oral form. 95% of the packs had not expired. 14.5% of the total data set contained contents but the range of content left in the packs varied. Results on the packs with contents differed from the total: the shares of Over-the Counter medicines (36%), of medicines of the respiratory system (18%) and of the musculo-skeletal system (18%), for dermal use (23%) and of expired medicines (19%) were higher compared to the full data set.ConclusionsThe study showed that some medicines end up unused or partially used in normal household garbage in Vienna. Our results did not confirm speculations about a high percentage of unused medicines improperly discarded. There is room for improved patient information and counseling to enhance medication adherence and a proper discharge of medicines.

Drivers of expenditure on primary care prescription drugs in 10 high-income countries with universal health coverage

BACKGROUND: Managing expenditures on pharmaceuticals is important for health systems to sustain universal access to necessary medicines. We sought to estimate the size and sources of differences in expenditures on primary care medications among high-income countries with universal health care systems. METHODS: We compared data on the 2015 volume and cost per day of primary care prescription drug therapies purchased in 10 high-income countries with various systems of universal health care coverage (7 from Europe, in addition to Australia, Canada and New Zealand). We measured total per capita expenditure on 6 categories of primary care prescription drugs: hypertension treatments, pain medications, lipid-lowering medicines, noninsulin diabetes treatments, gastrointestinal preparations and antidepressants. We quantified the contributions of 5 drivers of the observed differences in per capita expenditures. RESULTS: Across countries, the average annual per capita expenditure on the primary care medicines studied varied by more than 600%: from

Discounts and Rebates Granted for Medicines for Hospital Use in Five European Countries

23 in New Zealand to

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171 in Switzerland. The volume of therapies purchased varied by 41%: from 198 days per capita in Norway to 279 days per capita in Germany. Most of the differences in average expenditures per capita were driven by a combination of differences in the average mix of drugs selected within therapeutic categories and differences in the prices paid for medicines prescribed. INTERPRETATION: Significant international differences in average expenditures on primary care medications are driven primarily by factors that contribute to the average daily cost of therapy, rather than differences in the volume of therapy used. Average expenditures were lower among single-payer financing systems that appeared to promote lower prices and the selection of lower-cost treatment options.

An analysis of expenditures on primary care prescription drugs in the United States versus ten comparable countries

Objective: The study aimed to survey price reductions such as discounts and rebates granted for medicines used in hospitals. Methods: We collected official list prices and actual hospital prices of 12 medicines in 25 hospitals in European countries (Austria, the Netherlands, Norway, Portugal and Slovakia). Results: In all five countries price reductions were granted for some of the medicines surveyed. They usually had the form of discounts; additionally, ex-post rebates were reported from Austria and Portugal. For oncology, anti-inflammatory diseases, neurology-multiple sclerosis and blood no price reductions or only minor discounts/rebates on medicines prices were surveyed, whereas discounts/rebates were routinely granted for cardiovascular medicines and medicines for immunomodulation. Price reductions of 100 percent were found in Austria, Portugal and Slovakia. With the exception of Slovakia, the extent of the discounts/rebates did not differ substantially among the hospitals of a country. The highest median price reductions were identified in Norway, followed by the Netherlands. Price reductions for medicines procured by central tendering tended to be higher than those obtained in decentralized procurement. Conclusions: The study shows the existence of discounts and rebates granted for specific medicines for hospital use. The results suggest product-specific patterns. Hospitals appear to have little leeway to negotiate price reductions for medicines to which no therapeutic alternatives are available. High price reductions, including cost-free provision of medicines, tend to be granted for medicines whose treatment is likely to continue in primary care after discharge of the patient.