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European CommissionThe Second Economic Adjustment Programme for Greece. Fourth Reviewsystem, between EOPYY and hospitals and between EOPYY and social security funds remainimportant challenges. In addition, the much needed hospital reform must continue to achieve economiesof scale and scope in order to improve efficiency and quality of care and to generate savings. Thedevelopment of a primary care system based on registration with a family doctor and a referral systemis a crucial important step towards improving access while reducing the use of unnecessary costlyspecialist and emergency care. Further savings must also be generated in terms of pharmaceuticalspending to achieve the 2014 target. Pharmaceuticals policy must be made fully coherent: pricing,reimbursement, prescription, and consumption policies must work together to attain key policy targetsfor generic prescription and dispensing.67. The financial situation of EOPYY, remains difficult though significant positive developments canbe observed. This follows the implementation of a number of reforms and a closer monitoring ofspecific budget categories in EOPYY (see Box 10).• Delays in the transfer of contribution revenues to EOPYY from SSFs remain and the full applicationof the two clawback systems, which ensure a payback by pharmaceutical companies and privateproviders of all the expenditure in excess of the legal expenditure ceiling set for specific EOPYYspending categories, is needed to bring EOPYY closer to a balanced situation. The stock of unpaidarrears remains large, though a significant stock of old arrears has been settled. EOPYY continues topay ESY (NHS) hospitals with a very long delay, while ESY hospitals continue to submit invoiceswith a significant delay of 3 to 5 months.• To control consumption and spending, the authorities have adopted closer monitoring and price andquantity control measures. They have introduced a rebate and a clawback mechanism on thespending with private clinics and hospitals for three categories: diagnostic tests, physiotherapy andthe use of private clinics and hospitals. Unfortunately, the process of checking claims has due tostart in autumn 2013 has faced substantial delays and has only just started. Lack of control, lack ofprescription/ clinical guidelines and proper referrals may result in a clawback amount which is nonnegligible.• Stronger monitoring and control mechanisms and the auditing of claims can help controlconsumption of health care services reduce the effective clawback amount and ensure that spendingstays within budget targets. Nevertheless, improving invoicing and payment mechanisms is neededtogether with a more comprehensive change to the current resource allocation, budgeting andcosting procedures and financial flows across the system. The existing business intelligence andmonitoring unit at EOPYY needs to be further reinforced. This process should be intensified incoming months as part of the improvement in the organisational structure of EOPYY.68. Regarding the pharmaceutical sector, the implementation of the previous policies continues.Further steps have been taken to ensure the necessary savings to achieve the target for 2014.• Pricing has changed with the new 2013 legislation. Pricing now takes place twice a year and a newpricing formula is applied to off-patent (the lowest price between the average of the 3 lowest pricesor 50% of the price just before patent expiration) and generic medicines (65% of the referencemedicine just before patent expiration) that entered the market since 2012 (to the others a horizontalprice reduction was applied). Dynamic pricing for generics has also been introduced. These changesmay render generics more attractive than before: generics were considered relatively expensive inGreece compared to other EU countries and relative to off-patent medicines. Moreover, while alarge backlog of generic medicines has already been priced, the legal monthly pricing process fornew generics needs to be effectively in place as a new backlog of 2013 requests appears to havedeveloped.• The positive list has been updated following the price list. Changes to the reference price forreimbursement were introduced in autumn 2013 effectively reducing the reimbursement rate of moreexpensive medicines in the same ATC5 (same active substance) and ATC4 (same therapeutic) groupwhen generics are available. This reinforces the new pricing of generics, making these moreattractive to patients. The OTC list is to be further aligned with other EU countries and the fixedmark-up of 35% has been transformed into a maximum mark-up to increase competition in the OTCsector. If no significant price decreases materialise, the government will undertake a fullliberalisation of distribution channels.• E-prescription and prescription by active substance (INN) are compulsory. E-prescription coversmore than 90% of all outpatient pharmaceutical prescriptions under EOPYY. The API system,which e-registers manual prescriptions, covers about 80% of all manual prescriptions. The system of40
3. Programme implementationinternational classification of diseases – ICD10 classification – and some prescription guidelineshave been introduced in the e-prescription system. The automatic blockage mechanism whichactivates when branded prescription reaches 15% is in place and appears effective. Nevertheless, thedispensing and use of generic medicines remains puzzlingly low at about 18%-20% in both volumeand value. As a result, the authorities have introduced an average target of 60% generic prescriptionfor doctors. But more should also be done to inform and encourage patients and pharmacies todispense the cheapest pharmaceuticals within each active substance. More focus should be put onintroducing additional compulsory prescription protocols into the system – a process that has so farbeen very slow to implement.• The authorities have also introduced a spending cap and an effective prescription budget for eachdoctor which is equal to 80% of last year's prescription value. This system is in place since January2014 and is effectively binding on a monthly basis. As the expected reduction of spending, in casethe 60% target of generic uptake is fulfilled, is more than 20%, this cap on doctor budget has to beseen as safety net to guarantee planned savings if other mechanisms fail.• Despite the observed progress, pharmaceutical expenditure was above the monthly target for 2013by about EUR 150 million. The excess spending will be clawed back from companies or offset withexisting debts. While the claw back mechanism will ensure that the spending on pharmaceuticalsremains in line with the budget, efforts must be pursued to strengthen the structural measures justoutlined in view of the 2014 target. The outcome of these measures needs to be carefully monitoredin the coming months. Indeed, from 2013 to 2014 about EUR 500-600 million in savings will needto be generated to achieve the target set in the MoU. For this, also EOF and EOPYY capacity mustbe reinforced to ensure pricing and reimbursement is timely and effective in delivering a costeffectiveuse of pharmaceuticals and the necessary savings.69. Important steps have been taken on the hospital sector to improve the monitoring of financial andactivity data and ensure that financial execution in in line with the budget. Hospital reorganisationis also continuing. Data for 2013 indicates that financial execution will be within the budget in accrualterms. Most hospitals have now been allocated internal controllers and analytical cost accounting hasbeen progressively introduced on the basis of an action plan. The implementation of diagnostic-relatedgroups (DRGs) is going according to plan, although proper DRGs will not be ready for testing prior to2015. Additional steps are planned in terms of hospital network rationalisation. This may be conduciveto a better distribution of staff and heavy equipment across hospitals with the transformation of someinpatient facilities into outpatient and long-term care facilities. Steps taken so far show thatreorganisation, if implemented, can lead to important and additional savings in the sector.70. Nevertheless more could be done regarding ESY facilities and hospital spending in a number ofareas.• Centralised procurement has produced substantial savings, but still covers a minor share ofpharmaceutical expenditure and the process appears somewhat stalled. The share of generics, whileseeing an important increase, remains below the target set for many hospitals. It needs to beextended to cover a wider share of hospital purchasing. A substantial number of tenders are in thepipeline but have suffered substantial delays. These should be launched as a matter of urgency.• Data suggests important variation across hospitals for a wide set of indicators (such as staff andbeds, operating costs, average length of stay discharges and surgeries, bed occupancy rates, and useof generics). This suggests that there is considerable room to realise savings. The benchmarkingexercise of October 2013 could be used to identify the reform potential in each hospital vis-à-vis itspeers and serve as the basis for streamlining the current hospital network. Hospital reorganisationshould also consider reforming emergency and on-call structures to increase efficiency and thequality of care and to reduce overtime. Staff mobility is still limited and further steps should betaken to ensure that staff is allocated to areas of need, most notably to less-urban areas.• Last but not least, considerable concerns remain that a large albeit still unclear number of peoplemay not have adequate access to healthcare services and goods, although access to health centresand emergency care is available to all. As a result of the rise in long-term unemployment, there maybe a large number of people who do not officially have access to the full range of health services. Theauthorities have been unable to provide a clear estimate of the number of uncovered people so far.While access to health centres, emergency care and care for chronic disease is still provided, uninsuredpeople may have limited access to medicines, diagnostics and elective hospital care, though authoritiesreport anecdotal evidence that hospitals provide the treatment and simply do not charge any payment.An important step taken by the authorities was the distribution of health vouchers to the long-term41
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