2.10 Modernising the health care system Οι αποφάσεις για την Υγεία αλλού παίρνονται και σε άλλους δίνουμε αναφορά ....
GREECE
Memorandum of Understanding
on
Specific Economic Policy Conditionality The Government continues to implement the comprehensive health sector reform with the objective of
stabilising public health expenditure at, or below, 6 percent of GDP, while maintaining universal
access and improving the quality of care delivery. Policy measures include reducing the fragmented
governance structure, reinforcing and integrating the primary healthcare network, streamlining the
hospital network, strengthening central procurement and developing a strong monitoring and
assessment capability and e-health capacity.
The programme measures aim at achieving savings in the purchasing (accrual basis) of outpatient
medicines to reach spending of about EUR 2.440 billion and inpatient to reach spending of about EUR
0.66 billion in 2013 (accrual basis). The goal is to bring public spending on outpatient pharmaceuticals
to about 1 percent of GDP i.e. around EUR 2 billion euro (in line with the EU average) in 2014. Total
(outpatient plus inpatient) public expenditure on pharmaceuticals should be no more than 1.5 per cent
in 2013 and 1.3 per cent in 2014.
2.10.1 Governance
To strengthen health system governance, improve health policy coherence, reduce fragmentation in the
purchasing of health services and reduce administrative costs, the Government (i) ensures the effective
concentration of all health insurance funds, without exception, into EOPYY, monitoring the transfer of
staff and assets; (ii) ensures the effective transfer of all health-related decision making procedures and
responsibilities (including payroll expenditures) under the Ministry of Health.
1. From January 2014, hospital services will be purchased directly by EOPYY through
prospective budgets based on KEN-DRGs costing procedure (and payroll costs, should be at
least reported).
2. EOPYY ensures that the number of doctors is reduced in headcount by a further 10% in
2013.
2.10.2 Controlling pharmaceutical spending
In order to reach the 1 percent of GDP target in 2014, the Government steps up its efforts, and further
develops the set of incentives and obligations for all participants along the medicines supply chain
(including producers, wholesalers, pharmacies, doctors and patients) to promote the use of generic
medicines and the cost-effective use of medicines more generally.
2.10.2.1 Contingency measures to deliver the overall targets
1. The government applies an automatic claw-back mechanism (every six months) to
pharmaceutical producers which guarantees that the outpatient pharmaceutical expenditure
(EOPYY budget) does not exceed the above targets (Continuous). A note on the collection
of claw back for 2013 for the first half of 2013 is submitted by September 2013.
2. Activates contingency measures (including e.g. across-the-board cut in prices or entry fee
for the positive list), if, for any reason, the claw-back is not able to achieve the target. Such
measures produce an equivalent amount of savings. (October 2013).
3. In addition and if necessary, EOPYY introduces additional incentives and mechanisms,
including a prescription quota system for physicians, to ensure generic substitution
(September 2013).
176
2.10.2.2 Pricing of medicines
The Government:
1. Revises downward the price of medicines, based on the three EU countries with the lowest
prices (quarterly update of price list in line with the provisions of Council Directive
89/105/EEC, next list to be published by June 2013).
2. On the basis of the report on the impact of the new profit margins of pharmacies, reduce the
profit margins down to 15% by June 2013.
3. Ensures that EOPYY negotiates a 5% discount through price-volume agreements on
expensive medicines (200 medicines) sold in EOPYY pharmacies (Continuous for 2013
and 2014).
2.10.2.3 Prescribing and monitoring
The Government will,
1. Update the positive list of reimbursed medicines and the list of OTC medicines. These lists
must be updated at least twice a year (next update June 2013).
2. Ensures full coverage of e-prescription to doctors, outpatient facilities and providers
contracted by EOPYY and to all NHS facilities (health centres and hospitals) by June 2013.
E-prescribing is made compulsory and must include at least 90 percent of all outpatient
medical acts covered by public funds (medicines, referrals, diagnostics).
3. Finalise the implementation of the system (API) whereby pharmacies electronically register
any residual manual prescriptions from doctors into the e-prescription application
established by IDIKA. (December 2012, New Deadline May 2013).
4. Continue publishing prescription guidelines/protocols for physicians, with priority for the
most expensive and/or mostly used medicines, and makes them compulsory (Continuous).
5. Enforce the application of prescription guidelines through the e-prescription system starting
with at least 5 therapeutic groups by June 2013.
6. Further develop the e-prescription system by introducing compulsory ICD-10 by May 2013
and SPC filters in the e-prescription system (October 2013).
7. Enhance monitoring and assessment through:
i. detailed monthly auditing reports on the use of e-prescription in NHS facilities and by
providers contracted by EOPYY. These reports are shared with the European
Commission, ECB and IMF staff teams. (Continuous);
ii. regular assessment of the information obtained through the e-prescribing system.
(Continuous);
iii. detailed quarterly reports on pharmaceutical prescription and expenditure which
include information on the volume and value of medicines, on the use of generics and
the use of off-patent medicines, and on the rebate received from pharmacies and from
pharmaceutical companies. These reports are shared with the European Commission,
ECB and IMF staff teams. (Continuous, Quarterly, new report July 2013);
iv. detailed reporting on individual prescription behaviour to each physician relative to
the average of comparable (specialty, patient workload) physicians (both in NHS
facilities and contracted by EOPYY and other social security funds until they merge)
and signals when they breach prescription guidelines. This feedback is provided at
least every month and a yearly report is published covering: 1) the volume and value
of the doctor's prescription in comparison to their peers and in comparison to
prescription guidelines; 2) the doctor's prescription of generic medicines vis-à-vis
branded and patent medicines and 3) the prescription of antibiotics. (Continuous); 177
8. Enforce sanctions and penalties as a follow-up to the assessment and reporting of
misconduct and conflict of interest in prescription behaviour and non-compliance with the
EOF prescription guidelines (Continuous);
9. Electronic monitoring and the introduction of cancelation mechanisms to barcodes of
pharmaceutical products should be finalized by collaboration of EOF and IDIKA
(September 2013).
2.10.2.4 Increasing use of generic medicines
Prior to the disbursement, the Government:
a. Ensures the application of compulsory prescription by international non- proprietary name
(INN) for an active substance notably by putting in place an automatic blockage
mechanism once prescription by branded name reaches 15% of the overall prescription
value of each doctor in real time.
b. Prices the large backlog of generic medicines waiting for a price in compliance with EU
Transparency Directive at a pace of 400 per month, with 400 medicines priced prior to
disbursement.
The Government also:
1. Increases the share of the generic medicines in total outpatient and reimbursed medicines to
reach 60 percent (in volume) by December 2013. This will be achieved by:
i. automatically reducing the maximum price of originator medicines when their
patent (exclusivity period) expires (off-patent branded medicines) to 50 percent
of its price at the time of the patent expiry. Further reduction will be achieved by
linking off-patent products to the average of the three lowest prices in the EU, to
be revised periodically with price list. Producers can offer lower prices, thus
allowing an increased competition in the market. (September 2013);
ii. setting the maximum price of the generic to 40 percent of the price of the
originator patented medicine with same active substance at the time its patent
(exclusivity period) expired. After this first reduction, the price of the generic
medicine is set to 80% of the downward revised price of the off-patient products
(when the exclusivity period expires) which is to be set on the basis of the
average of the three lowest prices in the EU as defined in point i. Producers are
allowed to offer lower prices, thus allowing an increased competition in the
market. (September 2013);
iii. ensuring dynamic competition in the market for generic medicines through a)
speeding up administrative and legal procedures, in line with EU legal
frameworks; b) applying price reductions of at least 10 percent of the maximum
price of each three new generic producer entering the market, according to
existing regulation (May 2013)
iv. deciding about the reimbursement of newly patented medicines (i.e. new
molecules) on the basis of objective and strict medical and cost-effective criteria
and, until internal capacity is in place, by relying on best practice health
technology assessment of their cost-effectiveness carried out in other member
states, while complying with Council Directive 89/105/EEC. (Continuous);
v. excluding from the list of reimbursed medicines those which are not effective or
cost-effective on the basis of objective criteria. (Continuous);
vi. in the frame of the Administrative Reform process of EOF, set up scientific
capacity in order to include cost effectiveness criteria in the reimbursement and
licensing process. 178
2. Takes further measures to ensure that at least 50 percent of the volume of medicines used by
public hospitals for inpatients is made up of generics with a price below that of similar
branded products and off-patent medicines. (Continuous)
3. Ensures that all public hospitals to procure at least 2/3 of pharmaceutical products by active
substance, using the centralised tenders procedures developed by EPY and by enforcing
compliance with therapeutic protocols and prescription guidelines. (Continuous)
2.10.3 Reviewing the provision of medical services contracted by EOPYY
1. The government monitors the implementation of the various policies introduced in late 2012
to improve the current financial situation of EOPYY and ensure that the budgetary
execution is closer to a balanced budget in 2013. Measures to monitor include: changes in
OGA contributions, in the benefit package, in cost-sharing for private care and in the fees
for diagnostic and physiotherapy services, as well as the use of price-volume agreements
and case-mix agreements with private providers and the use of a reference price system for
reimbursement of medical devices. (Continuous)
2. The government publishes a quarterly report on the prescription and expenditure of
diagnostic tests. (Continuous, quarterly, next report July 2013)
2.10.4 National Health System (NHS) service provision
2.10.4.1 Reorganisation and management of the health care sector
The Government:
1. Implements the plan for the reorganisation and restructuring, as set in Law 4052 / March
2012, with a view to reducing existing inefficiencies, utilising economies of scale and
scope, and improving quality of care for patients, thus contributing to better aligning
working organisation with Directive 2003/88/EC. This implies reducing hospital operating
costs by an additional 5% in 2013 and reducing beds substantially, as legislated by MD
OG1681/B (28-7-2011). This is to be achieved through:
i. increasing the mobility of healthcare staff (including doctors) within and across
health facilities and health regions;
ii. adjusting public hospital provision within and between hospitals within the
same district and health region;
iii. revising the activity of small hospitals towards specialisation in areas such as
rehabilitation, cancer treatment or terminal care where relevant;
iv. revising emergency and on-call;
v. optimising and balancing the resource allocation of heavy medical equipment
(e.g. scanners, radiotherapy facilities, etc.) on the basis of need.
vi. reducing administrative costs notably by removing deputy managers posts;
vii. reducing cost with outsourcing services such as IT services, laboratory services
and hospital servicing costs (e.g. cleaning services).
2. Produces an annual report comparing hospitals performance on the basis of the defined set
of benchmarking indicators (Continuous; next report 1st
June 2013)
3. Updates a report on human resources for the whole health care sector annually and uses it as
a human resource planning instrument. (Continuous; next report 1st
June 2013)
2.10.4.2 Accounting, costing, control, IT and monitoring systems
The Government ensures that: 179
1. The allocation of internal controllers to all hospitals is finalised and that all hospitals adopt
commitment registers. (December 2012, New deadline May 2013)
2. EOPYY publishes a monthly report with analysis and description of detailed data on
healthcare expenditure with a lag of three weeks after the end of the respective month. This
report will make possible the more detailed monitoring of budget execution, by including
both expenditure commitments/purchases (accrual basis) and actual payments (cash basis).
The report will also (1) describe performance on the execution of budget and accumulation
of arrears, and (2) recommend remedial actions to be taken. (Continuous)
3. Further measures are taken to improve the accounting, book-keeping of medical supplies
and billing systems, through:
i. the introduction of analytical cost accounting systems, with the implementation
of the respective action plan, due to be finalised, with complete hospital
coverage, by November 2013;
ii. the regular annual publication of balance sheets in all hospitals. (June 2013);
iii. the introduction of the uniform coding system for medical supplies developed
by the Health Procurement Commission (EPY) and the National Centre for
Medical Technology (EKEVYL) and the use of the observe.net system to
monitor the procurement and use of tenders for medical supplies.
(Continuous);
iv. the introduction of inbound hospital logistics and warehouse management
systems using barcode scanning systems for pharmaceuticals and medical
consumables. (December 2013);
v. implement necessary action to ensure timely invoicing of full treatment costs
(including staff payroll costs) - i.e. no later than 2 months to other EU countries
and private health insurers for the treatment of non-nationals/non-residents.
(Continuous);
vi. enforcing the collection of co-payments and implementing mechanisms that
fight corruption and eliminate informal payments in hospitals. (Continuous).
4. ELSTAT starts providing expenditure data in line with Eurostat, OECD and WHO
databases i.e. in line with the System of Health Accounts (joint questionnaire collection
exercise). (May 2013)
5. The programme of hospital computerisation allows for a measurement of financial and
activity data in hospital and health centres. Moreover, the Minister of Health defines a core
set of non-expenditure data (e.g. activity indicators) in line with Eurostat, OECD and WHO
health databases, which takes account of the future roll-out of DRG (diagnostic-related
groups) schemes in hospitals. (Continuous)
6. The government starts to develop a system of patient electronic medical records. (May
2013)
7. The Government, with technical assistance from experts across EU, continues to improve
the existing KEN/DRG system, with a view to developing a modern hospital costing system
for contracting (on the basis of prospective block contracts between EOPYY and NHS). The
existing set of KEN/DRGs is used in all hospitals The KEN/DRG Management Institute is
established by June 2013. DRGs will include a detailed item on costs of personnel.
(Continuous)
8. A follow up analysis of how hospital accounting schemes integrate DRGs at hospital level
in view of future activity-based cost reporting and prospective budgets payment for
hospitals will be submitted by September 2013 180
2.10.5 Centralised procurement
1. The Government increases substantially the number of expenditure items and therefore the
share of expenditure covered by centralised tender procedures through EPY up to 45% of all
the expenditure in medicines and medical devices by 2014. This share goes up to 60% in
2015. The Government ensures the use of such tender procedures. (Continuous)
2. EPY will undertake tender procedures for framework contracts for the most expensive
medicines sold in EOPYY pharmacies. (Continuous)
In compliance with EU procurement rules, the Government conducts the necessary tendering
procedures to implement a comprehensive and uniform health care information system (e-health
system) including the full and integrated system of hospitals' IT systems. (Continuous)
Πηγή
EUROPEAN ECONOMY
Occasional Papers 148 | May 2013
The Second Economic Adjustment Programme for Greece
Second Review – May 2013Δεν είναι ορατοί οι σύνδεσμοι (links).
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