Nina Zimmermann

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.

The role of discounts and loss leaders in medicine procurement in Austrian hospitals - a primary survey of official and actual medicine prices

BackgroundKnowledge about the prices of medicines used in hospitals, particularly the actually achieved ones, is scant. There are indications of large discounts and the provision of medicines cost-free to Austrian hospitals. The study aims to survey the official and actual prices of medicines procured by Austrian hospitals and to compare them to the out-patient prices.MethodsPrimary price collection of the official hospital list prices and the actually achieved prices for 12 active ingredients as of the end of September 2009 in five general hospitals in Austria and analysis of the 15 most commonly used presentations.ResultsThe official hospital list prices per unit differed considerably (from 1,500 Euro for an oncology medicine to 0.20 Euro for a generic cardiovascular medicine). For eight on-patent medicines (indications: oncology, anti-inflammatory, neurology-multiple sclerosis and blood) actual hospital medicine prices equaled the list prices (seven medicines) or were lower (one medicine) in four hospitals, whereas one hospital always reported higher actual prices due to the application of a wholesale mark-up. The actual hospital prices of seven medicines (cardiology and immunomodulation) were below the official hospital prices in all hospitals; of these all cardiovascular medicines were provided free-of-charge. Hospital prices were always lower than out-patient prices (pharmacy retail price net and reimbursement price).ConclusionThe results suggest little headroom for hospitals to negotiate price reductions for “monopoly products”, i.e. medicines with no therapeutic alternative. Discounts and cost-free provision (loss leaders) appear to be granted for products of strategic importance for suppliers, e.g. cardiovascular medicines, whose treatment tends to be continued in primary care after discharge of the patient.

Price comparison of high-cost originator medicines in European countries.

ABSTRACT Background: In recent years, high-cost medicines have increasingly been challenging the public health budget in all countries including high-income economies. In this context, this study aims to survey, analyze and compare prices of medicines that likely contribute to high expenditure for the public payers in high-income countries. Methods: We chose the following 16 European countries: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, the Netherlands, Portugal, Sweden, Slovakia, Spain and United Kingdom. The ex-factory price data of 30 medicines in these countries were collected in national databases accessible through the Pharmaceutical Price Information (PPI) service of Gesundheit Österreich GmbH (Austrian Public Health Institute). Results: The ex-factory prices (median) per unit (e.g. per tablet, vial) ranged from 10.67 cent (levodopa + decarboxylase inhibitor) to 17,000 euro (ipilimumab). A total of 53% of the medicines surveyed had a unit ex-factory price (median) above 200 Euro. For two thirds of the medicines, price differences between the highest-priced country and lowest-priced country ranged between 25 and 100%; the remaining medicines, mainly low-priced medicines, had higher price differential, up to 251%. Medicines with unit prices of a few euros or less were medicines for the treatment of diseases in the nervous system (anti-depressants, medicines to treat Parkinson and for the management of neuropathic pain), of obstructive airway diseases and cardio-vascular medicines (lipid modifying agents). High-priced medicines were particularly cancer medicines. Conclusion: Medicine prices of Greece, Hungary, Slovakia and UK were frequently at the lower end, German and Swedish, as well as Danish and Irish prices at the upper end. For high-priced medicines, actual paid prices are likely to be lower due to confidential discounts and similar funding arrangements between industry and public payers. Pricing authorities refer to the higher undiscounted prices when they use price data from other countries for their pricing decisions.

Pharmaceutical policies in a crisis? Challenges and solutions identified at the PPRI Conference

In October 2015, the third international Pharmaceutical Pricing and Reimbursement Information (PPRI) Conference was held in Vienna to foster discussion on challenges in pricing and reimbursement policies for medicines. The research presented highlighted that commonly used pharmaceutical pricing and reimbursement policies are not sufficiently effective to address current challenges. Conference participants called for fundamental reforms to ensure access to medicines, particularly to new and potentially more effective and/or safe medicines, while safeguarding the financial sustainability of health systems and working towards universal health coverage.

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

Policy interventions related to medicines: Survey of measures taken in European countries during 2010–2015

BACKGROUND Policy-makers can use a menu of pharmaceutical policy options. This study aimed to survey these measures that were implemented in European countries between 2010 and 2015. METHODS We did bi-annual surveys with competent authorities of the Pharmaceutical Pricing and Reimbursement Information network. Additionally, we consulted posters produced by members of this network as well as further published literature. Information on 32 European countries (all European Union Member States excluding Luxembourg; Iceland, Norway, Serbia, Switzerland, Turkey) was included. RESULTS 557 measures were reported between January 2010 and December 2015. The most frequently mentioned measure was price reductions and price freezes, followed by changes in patient co-payments, modifications related to the reimbursement lists and changes in distribution remuneration. Most policy measures were identified in Portugal, Greece, Belgium, France, the Czech Republic, Iceland, Spain and Germany. 22% of the measures surveyed could be classified as austerity. CONCLUSIONS Countries that were strongly hit by the financial crisis implemented most policy changes, usually aiming to generate savings and briefly after the emergence of the crisis. Improvements in the economic situation tended to lead to an easing of austerity measures. Countries also implemented policies that aimed to enhance enforcement of existing measures and increase efficiency.

The Pharmaceutical Pricing and Reimbursement Information (PPRI) network – a decade of exchange of information and policy research?

Policy-makers throughout Europe and beyond have been working to develop and implement, and further adjust, the most appropriate mix of policy measures in pharmaceutical pricing and reimbursement to ensure equitable access to medicines despite limited budgets. The experience with policies in other countries is highly valuable information for them. In order to support policy-makers, the Pharmaceutical Pricing and Reimbursement Information (PPRI) network of competent authorities was established in 2005, with the aim to offer a platform for competent authorities of pharmaceutical pricing and reimbursement to exchange information and data and to establish a sustainable reporting system for country information. Within the decade of PPRIs existence, more than 60 country reports (information about medicines policies for the out-patient sector, hospital pharma reports, and integrated country profiles about the out-patient and the in-patient sectors) of 28 different countries and more than 60 country posters were produced. Comparative analyses were undertaken, e.g. in the PPRI report [1], the PHIS Hospital Pharma report [2] or in scientific articles [3-5]. A glossary [6] and indicators were developed and are regularly updated. These deliverables have been shared in the open domain (http://whocc.goeg.at/Publications/). In addition to these reports and tools, the instrument of PPRI network queries has proven its importance. A PPRI network query allows PPRI network members to ask for specific and quick information about a policy and situation in the other countries represented in the PPRI network [7]. In total, 319 PPRI queries have been launched until June 2015. The PPRI network is predominantly Europe-based. It has been growing over the years and currently comprises competent authorities for pharmaceutical pricing and reimbursement from 45 countries (thereof all 28 European Union Member States, another twelve European countries, and five non-European countries) as well as European and international institutions (European Commission, OECD, WHO, World Bank). Face-to-face meetings of the PPRI network are organised twice a year. The PPRI network is characterized by trust and mutual respect. The last decade has brought both new challenges (e.g. financial constraints due to the crisis, new premium-priced medicines) and opportunities (e.g. new policy tools such as managed-entry agreements, patent expiries of biotechnological medicines) for policy-makers. Participation in the PPRI network has supported them to deal with these developments and discuss possible solutions and collaborative approaches. In the light of on-going challenges, the PPRI network is well placed and prepared to continue playing its role as discussion and information exchange platform for the years to come.

Challenges and opportunities for pharmaceutical pricing and reimbursement policies

Even though access to affordable medicines is a human right, it is not ensured world-wide. The Priority Medicines Report 2013 [1] identified pharmaceutical gaps that continue to remain: diseases of public health importance for which pharmaceutical treatments either do not exist or are inadequate (see also K4). Where adequate treatments were available, access might be limited due to high costs of the medicines that can neither be funded by individuals nor by the communities. Ensuring equitable access to safe and effective medicines is a complex task. To prevent individuals from incurring into financial hardship when accessing health care, including medicines and to reduce the barriers to medicines access, quality of care and increasing equity, the World Health Organization (WHO) has been promoting Universal Health Coverage (UHC). During the last years a number of countries worldwide have been working towards UHC. Still, there is a disproportion in resource allocation for health care, including medicines, between countries at different levels of income. While expenditure is not necessarily a good indicator of better access, it is worth noting that in 2005/2006 (latest data available at international level) for example, 16% of the worlds population living in high-income countries accounted for over 78% of global expenditures on medicines [2].

Policy options to deal with high-cost medicines – survey with European policy-makers.

Background The affordability and financing of new, frequently high-cost, medicines pose challenges to governments world-wide. In Europe, the continual introduction of new premium-priced medicines is of special concern and requires adapted policy options. The aim of the study was to survey whether and which pricing and reimbursement policy options European countries have implemented for new premium-priced medicines.

Tendering for off-patent outpatient medicines: lessons learned from experiences in Belgium, Denmark and the Netherlands

To study the impact of tendering for off‐patent outpatient medicines in terms of savings for payers and availability of medicines, to explore stakeholder perceptions and to elaborate prerequisites for a successful implementation of the policy.