System of counting of reimbursement costs in the Czech Republic

1. System of counting of reimbursement costs in the Czech Republic Tomas Sechser Daniela Rrahmaniova Ministry of Health Czech Republic

2. [citace] CR PPR 29.10.2007 tosc@volny.cz Agenda • Cost containment • Reference price system • Generic substitution • Rational Pharmacotherapy

3. [PPRI Glossary] CR PPR 29.10.2007 tosc@volny.cz Cost containment • Measures taken to reduce expenditure or the rate of growth of expenditure, or the unit cost of services

4. CR PPR 29.10.2007 tosc@volny.cz Health Care Expenditurein the CR • total health care expenditure 7,1% GDP • Drug expenditure – 23% of total • All citizens are covered by health care insurance • General health insurance system build on solidarity, equity and availability of health

5. [Amendment of Public health insurance Act 2007] CR PPR 29.10.2007 tosc@volny.cz Cost containment - reimbursement • Reference price system • Generic substitution

6. [Amendment of Public health insurance Act 2007] CR PPR 29.10.2007 tosc@volny.cz Criteria for price setting • list of the „reference basket“ i.e. cross reference pricing • reference group – fully reimbursed and partially reimbursed (not efficient) • maximum price stipulated by (State Institute for Drug Control) =SÚKL (till now by Ministry of Finance) • maximum price of the 1st generics- 20% • innovative drugs

7. [Amendment of Public health insurance Act 2007] CR PPR 29.10.2007 tosc@volny.cz Criteria for reimbursementbasic reimbursement • basic reimbursement of the reference group • essentially similar – ATC clasification, the same efficacy, the same therapeutic use • ex-factory prices • basic reimbursement in partially reimbursed reference groups (lower efficiency) – maximum 60%

8. [Amendment of Public health insurance Act 2007] CR PPR 29.10.2007 tosc@volny.cz Criteria for reimbursementcurrent reimbursement • set of rules • → therapeutic effectiveness and safety • → severity of the treated disease • → cost effectiveness and cost vs outcomes (benefits) • → public interest • → way of administration, dosage form, strength and sice of the package • → usual therapeutic dosing • → necessary time of the treatment • → compliance, persistence, adherence • → interchangebility of other reimbursed product • budget impact of • guidelines and standard procedures – from the perspective of cost effectiveness and budget impact

9. [Amendment of Public health insurance Act 2007] CR PPR 29.10.2007 tosc@volny.cz What is the method/system for drug reimbursement? • reference reimbursement system •  the reimbursement is based on the content (amount) of an active substance in the given pharmacotherapeutic group •  the same reimbursement for the same amount •  the amount was expressed as DDD or in other units •  the same, reference reimbursement for the drug with the same effectiveness (efficacy)

10. [http://www.whocc.no/atcddd/] CR PPR 29.10.2007 tosc@volny.cz ATC DDD WHO • Basing detailed reimbursement, therapeutic group reference pricing and other specific pricing decisions on the ATC and DDD assignments is a misuse of the system. The DDD assignments are designed solely to maintain a stable system of drug consumption measurement, which can be used to follow and compare trends in the utilisation of drugs within and across therapeutic groups.

11. [Amendment of Public health insurance Act 2007] CR PPR 29.10.2007 tosc@volny.cz Cost containment - patients • individual accounts • anually 5000 CZK limit • In case of exceeding, the Insurance fund should pay back to patient his co-payment • till 60 days after the Q

12. [Amendment of Public health insurance Act 2007] CR PPR 29.10.2007 tosc@volny.cz Prescribing, dispensing and consumption • Positive list (Hospital Formulary) • Negative list • Guidelines and monitoring (standardization is expected) • Generic substitution (not prescribing) • Co-payment (less then 12%)