Terugbetalingssystemen voor geneesmiddelen ... - Pharma

16 Drug Reimbursement Systems KCE Reports 147
The use of external price referencing, combined with national pricing and
reimbursement regulations, influence manufacturers’ decisions and timeframes for
applying for reimbursement in a particular country and, as a result, the time of access to
drugs in countries.
Additional pricing tools such as price freezes and/or cuts are applied in all countries
except Austria and Sweden. Moreover, all countries but Austria use internal reference
pricing. This system limits the reimbursement of drugs by establishing a maximum price
or reimbursement level for a group of pharmaceutical products. The Netherlands
applies clusters with therapeutically equivalent drugs whereas in Belgium and France the
internal reference pricing scheme only clusters drugs with same active chemical
ingredients. In Sweden the accepted price of drugs is based on the price of
therapeutically similar drugs.
2.1.4.2 Risk sharing agreements
Risk sharing agreements are another tool to control the budget impact. Different types
of risk sharing agreements exist, ranging from price-volume agreements on the
aggregate level to pay for performance on the individual patient level. France is the only
country that frequently uses financial based risk sharing agreements by means of pricevolume
contracts. In Belgium financial based risk sharing agreement with a company are
also possible. So far only a few agreements have been made but revisions in the
procedure in 2010 may lead to an increase in these arrangements in the coming years.
Such agreements can only be negotiated for drugs with a recognised added therapeutic
value but for which the expert committee formulated no or a negative reimbursement
advice. Although the Swedish central reimbursement agency does not use financial risk
sharing agreements, county councils are allowed to make these agreements. This,
however, rarely occurs.
2.1.4.3 Stimulating appropriate use
Besides price regulations, several tools are used to encourage appropriate use of
pharmaceuticals. All countries publish to various extents prescription guidelines (HVB´s
prescribing guidelines in Austria, INAMI/RIZIV guidelines in Belgium, HAS guidelines in
France, CFH guidelines in the Netherlands and DTC guidelines from county councils in
Sweden). In France, the national health insurer also sends representatives to prescribing
physicians to increase the impact of guidelines (Délégués Assurance Maladie). Policies
can also target prescribers by monitoring prescription behaviour (e.g. feedbacks)
possibly combined with financial incentives.
2.1.4.4 Co-payments and deductibles
All countries use co-payments and/or deductibles for pharmaceuticals. Table 3
summarises the cost-sharing arrangements. In the Netherlands outpatient drugs on the
positive list are fully reimbursed but patients pay a general compulsory deductible,
irrespective of the type of health care consumed. In France the reimbursement rates
vary depending on disease severity and the level of medical service rendered (SMR), but
the majority of the remaining out-of-pocket costs are borne by the complementary
health insurance, which covers almost the entire population. Since 2008, a deductible
per package is applied for outpatient drugs. Similarly, Austria applies prescription fees
for outpatient drugs, meaning that patients have to pay a deductible per drug package. In
Sweden, patients are fully reimbursed for outpatient drugs once they have reached a
drug specific co-payment limit. In Belgium, patients pay a co-insurance for
pharmaceuticals (i.e. a percentage of the reimbursement basis). There are five
reimbursement categories defining the level of co-insurance. The reimbursement
categories are meant to reflect the therapeutic necessity of the drug. The co-insurance
is capped per drug package.
Moreover, Belgium implemented an income-dependent ceiling for total out-of-pocket
expenditures (excluding supplements) for all partially reimbursed health care, including
pharmaceuticals.