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Hospital prices prices–– Results of a European survey (PHIS) on purchasing strategies and pharmaceutical prices Nina Zimmermann PPRI Conference, Vienna 29 September 2011
Disclaimer Conflict of interest: nothing to disclose This presentation displays results of the PHIS project, which was commissioned and funded by the European Commission, Executive Agency for Health and Consumers (EAHC), and d co-funded f d db by the h Austrian Federal d l Ministry off Health.
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Outline » Medicines provision in the hospital sector Æ Introduction to the PHIS project » Hospital prices » Price survey » Summary and conclusions
Black hole hospital medicines » There are a number of studies on medicinal prices in the out-patient sector, BUT there is large information f gap on hospital medicines » „Pharmaceutical policies in the hospital sector need to be further investigated. […] » The pharmaceutical service in the in-patient sector plays secto p ays an a important po ta t role oea and d » influences the provision of pharmaceuticals, and also pharmaceutical expenditure, in the outpatient sector.” Recommendation of PPRI Report, p. 137 http://ppri.goeg.at/Downloads/Publications/PPRI_Report_final.pdf
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In-patient/ out-patient share of pharmaceutical expenditure 2008
2008 or latest available year (2007: AT, FI, DE, LV, NL; 2006: PT; 2005: PL) Pharmaceutical expenditure in the out-patient sector: public and private expenditure for prescription-only medicines (POM) and over-the-counter (OTC) medicines (AT, CZ, DE, FI, PL, SE), for pharmaceuticals and other medical non-durables (IT, LV, PT) Pharmaceutical expenditure in the in-patient sector: AT, DE, PL (estimation), CZ (In-patient data refers to hospital sector (including ambulatory care)), IT, NL, PT (estimation)
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Sources: PHIS D S Database b b by the h WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Vienna, out-patient data based on OECD Health Data, June 2011 (AT, CZ, DE, FI, IT, PL, PT, SE), Eurostat Public Health Database 2010 (LV), national sources (NL) and in-patient data based on PHIS Hospital Pharma reports (published at http://phis.goeg.at) or PHIS Pharma Profiles (not published)
Pharmaceutical Health Information System (PHIS) » Scope of the EU funded research project: » monitor and assess up-to-date health information and data for the field of medicines in a comprehensi comprehensive e health system approach in the EU (i.e. in- and outpatient sector) » Members: All EU MS, ALB, CA, HR, IS, NO, CH, ZA, TR; P+R authorities and hospital pharmacies Æ More than 60 institutions » Leading Institutions: GÖG/ÖBIG (AT, main partner), AIFA (IT), IHHII (BG), SOGETI (LU), SUKL (SK) » Establishment: Executive Agency for Health and Consumers (EAHC), Advisory Board: EAHC, DG SANCO, DG ENTR, DG Eurostat, OECD, WHO HQ + Euro » Period: September 2008 – April 2011
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PHIS Hospital Pharma European survey » National PHIS Hospital p Pharma Reports » Written by the PHIS network members (country representatives), supported by national hospital experts » Based on a uniform Template, assisted by the a common PHIS Glossary
Case studies » Countries: AT, NL, NO, PT, SK » Hospitals: AT (5), NL (3), NO (3), PT (3), SK (11) = 25 hospitals » General and public hospitals » Medicines: All available products for 12 selected active ingredients » Prices of 30 September 2009 » Prices collected » Official hospital list price » Actual hospital price » Out-patient public price 7
Procuring strategies for medicines used in hospitals, 2009/2010 See notes in the report Source: PHIS Hospital Pharma, based on PHIS Hospital Pharma reports and further surveys; 27 countries (EU MS excl. EL & LU; NO + TR)
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Availability of medicines in PHIS case study countries AT (5 hosp.)
NL (3 hosp.)
NO (2 hosp.)
PT (4 hosp.)
SK (8 hosp.)*
Prod.
original
generic
original
generic
original
generic
original
generic
original
generic
A
100%
n.a.
100%
n.a.
100%
n.a.
100%
n.a.
13%
n.a.
B
100%
n.a.
100%
n.a.
100%
n.a.
100%
n.a.
75%
n.a.
C
100%
n.a.
67%
n.a.
100%
n.a.
100%
n.a.
25%
n.a.
D
80%
n.a.
33%
n.a.
100%
n.a.
100%
n.a.
0%
n.a.
E
80%
20%
0%
100%
100%
100%
25%
75%
13%
100%
Oncology
Cardiology
Blood Rheumatoid arthritis Immunomodulation Antiinflammatory Neurology MS
F
0%
100%
0%
100%
100%
100%
0%
75%
0%
63%
G
100%
0%
100%
0%
0%
100%
100%
0%
50%
88%
H
100%
0%
100%
0%
100%
100%
100%
0%
88%
25%
I
80%
n.a.
0%
n.a.
100%
n.a.
100%
n.a.
0%
J
0%
100%
0%
67%
0%
100%
0%
100%
0%
n.a.
K
100%
n.a.
100%
n.a.
100%
n.a.
100%
n.a.
13%
n.a.
L
60%
n.a.
33%
n.a.
100%
n.a.
100%
n.a.
63%
n.a.
100%
Source: PHIS Hospital Pharma case studies
Medicine prices Dependant on the delivery of the medicines to the hospital O t Out-patient ti t
I In-patient ti t
Ex-factory price
Ex-factory price AT
Manufacturer Pharmacy purchasing price
or
SK
Hospital list prices
Pharmacy purchasing price or wholesaler price
Wholesaler
NL
NO
Pharmacy retail price (net) Retailer
or
Official hospital purchasing price
PT
Actual hospital price (net) Hospital Pharmacy retail price (gross) State/Patient Source: PHIS Hospital Pharma Report 2010
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Price comparison
1. Intra-country comparison » AT, NL, NO, PT, SK
2. Cross-country comparison 3. Comparison on product level
Price comparison - intra-country comparison
Austria – oncologic medicine, prices per unit Actual hospital prices mostly equal hospital list price
AT_1, AT_2, AT_3, AT_4, AT_5 ... different Austrian hospitals participating in PHIS Hospital Pharma case studies reimbursement p price ... This p price is the basis for reimbursement of medicines in the out-patient sector, it is the maximum amount paid for by the Austrian sickness funds.
Out-patient public price
List price
Actual hospital prices
Reimbursement price
Source: PHIS Hospital Pharma Report 2010
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Price comparison - intra-country comparison
Austria – cardiovascular medicine, prices per unit g e n e r i c
g e n e r i c
Cost free List price
Actual hospital prices
Reimbursement price
AT_1, AT_2, AT_3, AT_4, AT_5 ... different Austrian hospitals participating in PHIS Hospital Pharma case studies reimbursement price ... This price is the basis for reimbursement of medicines in the out-patient sector, it is the maximum amount paid for by the Austrian health insurance institutions. AT_1* ... generic
Out‐patient public price
Source: PHIS Hospital Pharma Report 2010
Price comparison - intra-country comparison The Netherlands – anti-inflammatory medicine, prices per unit
NL_1, NL_2, NL_3 = different Dutch hospitals participating in the PHIS Hospital Pharma case studies Out-patient price: The public / retail price net 2009 is exclusive of flat rate service charge of € 7.28 on average for pharmacists (“prescription fee”). The indicated price equals the pharmacy purchasing price (net).
List price
Actual hospital prices
Out-patient public price Source: PHIS Hospital Pharma Report 2010
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Price comparison - intra-country comparison Norway – rheumatoid arthrithis medicine, prices per unit Actual hospital prices = Prices centrally procured by LIS
LIS ... Norwegian Drug Procurement Cooperation NO_1, NO_2, NO_3 … different Norwegian hospitals participating in PHIS Hospital Pharma case studies
Out-patient public price
List price
Actual hospital prices Source: PHIS Hospital Pharma Report 2010
Price comparison - intra-country comparison
Portugal – anti-inflammatory medicine, prices per unit
PT_1, PT_2, PT_3, PT_4 … different Portuguese hospitals participating in the PHIS Hospital Pharma case studies
List price
Actual hospital prices
Possible price with expected rebates
Source: PHIS Hospital Pharma Report 2010
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Price comparison - intra-country comparison Portugal – oncologic medicine, prices per unit
PT_1, PT_2, PT_3, PT_4 … different Portuguese hospitals participating in the PHIS Hospital Pharma case studies
List price
Out-patient public price Actual hospital prices
Source: PHIS Hospital Pharma Report 2010
Price comparison - intra-country comparison Slovakia – neurology/multiple sclerosis medicine, prices per unit
Centrally procured by General Health Insurance Company
* s are centrally purchased and financed byy the the Vseobecna zdravotna poisťovňa / General Health Care Insurance (VsZP)
Actual hospital prices
List price
Maximum purchase price for hospitals
Actual hospital prices
Out-patient public price
Source: PHIS Hospital Pharma Report 2010
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Price comparison - intra-country comparison Slovakia – cardiovascular medicine (generics), prices per unit Maximum purchase price
Mark up Actual hospital prices Out-patient public price
SK_1, SK_2, SK_3, SK_4, SK_5, SK_6, SK_7, SK_8 … different Slovak hospitals participating in PHIS Hospital case studies SK_3* ... different pack size
Actual hospital prices
Source: PHIS Hospital Pharma Report 2010
Price comparison
1.Intra-country y comparison p » AT, NL, NO, PT, SK
2.Cross-country comparison 3. Comparison on product l level l
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Price comparison - cross-country comparison Actual hospital prices of oncologic medicines, per unit Major price differences - 3 of the 4 surveyed medicines were available in all countries - NO has by trend the lowest prices n.a. = not available * NL: same medicine but with a slightly different strength A: AT – average of prices in 5 hospitals, NL – average of prices in 3 hospitals, NO – average of prices in 2 hospitals, PT – average of prices in 4 hospitals, SK – price in 1 hospital; B: AT – average of prices in 5 hospitals, NL – average of prices in 3 hospitals, NO – average of prices in 2 hospitals, PT – average of prices in 4 hospitals, SK – average of prices in 6 hospitals; C: AT – average of prices in 5 hospitals, NL – average of prices in 3 hospitals, NO – average of prices in 2 hospitals, PT – average of prices in 4 hospitals, SK – price in 1 hospital; D: AT – average of prices in 4 hospitals, NL – price in 1 hospitals, NO – average of prices in 2 hospitals, PT – average of prices in 4 hospitals
Source: PHIS Hospital Pharma Report 2010
Price comparison - cross-country comparison
Actual hospital prices cardiovascular medicines, per unit
- Some medicines: costfree (AT, ~ PT) - All surveyed available in the participating countries - The availability of generics resulted in lower price levels
€ 0.00 = hospitals receive the medicines free of cost (AT) or at a price which – considering ex-post rebates – corresponds to € 0.00 (PT) * NL: prices of the same active ingredient but a different package size ** original brand except for NO and SK (generic medicines) E: AT – price in 1 hospital, NL – average of prices in 3 hospitals, NO – average of prices in 2 hospitals, PT – average of prices in 3 hospitals, SK – average of prices in 8 hospitals; F: AT – average of prices in 5 hospitals, NL – average of prices in 3 hospitals, NO – average of prices in 2 hospitals, PT – average of prices in 3 hospitals, SK – average of prices in 5 hospitals; G: AT – average of prices in 5 hospitals, NL – average of prices in 3 hospitals, NO – average of prices in 2 hospitals, PT – price in 1 hospital, SK – average of prices in 7 hospitals; H: AT – average of prices in 5 hospitals, NL – average of prices in 3 hospitals, NO – average of prices in 2 hospitals, PT – average of prices in 4 hospitals, SK – average of prices in 3 hospitals
Source: PHIS Hospital Pharma Report 2010
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Price comparison - cross-country comparison Difference between the official hospital list prices and the actual hospital prices
On-patent
vs.
Off-patent
Official hospital list price = 100
Oncologic s
Cardiology
Source: PHIS Hospital Pharma Report 2010
Price comparison
1.Intra-country y comparison p » AT, NL, NO, PT, SK
2.Cross-country comparison 3.Comparison on product l level l
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Price comparison on product level Prices of an oncologic medicine (on-patent), per unit € 1,000 € 900 € 800 € 700 € 600
AT
€ 500
NL
€ 400
NO
€ 300
PT
€ 200
SK
€ 100
n.a.
n.a.
€0
official hospital actual hospital out-patient price reimbursement list price price price (relevant for AT)
n.a. = not available * Rebate at the end of the year not considered in PT AT – average of prices in 5 hospitals, NL – average of prices in 3 hospitals, NO – average of prices in 2 hospitals, PT – average of prices in 4 hospitals, SK – price in 1 hospital;
Source: PHIS Hospital Pharma case studies
Price comparison on product level Prices of an oncologic medicine (on-patent), per unit € 1,000 € 900 € 800 Direct delivery by company to hospitals* € 700 – individual € 600 negotiations /€regional 500 purchasing € 400
Delivery by wholesalers to hospitals – market surveillance AT NL NO
€ 300
PT SK
€ 200 € 100 €0
n.a.
n.a.
official hospital actual hospital out-patient price reimbursement list price price price (relevant for AT)
Delivery by wholesalers to hospitals – central price tendering
n.a. = not available * Rebate at the end of the year not considered in PT AT – average of prices in 5 hospitals, NL – average of prices in 3 hospitals, NO – average of prices in 2 hospitals, PT – average of prices in 4 hospitals, SK – price in 1 hospital;
Source: PHIS Hospital Pharma case studies
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Medicine prices in hospitals Influencing factors (simplified) In-patient pricing/purchasing policy Out-patient pricing policy
Patent status Market situation of the medicine
Organisation of the hospital sector (central/decentral) Actual hospital price of a medicine
Reimbursement in- and outpatient
Consumption of the medicine Individual bargaining power Delivery to the hospital
Lessons learned / Discussion
»
Prices of medicines in hospitals:
»
» » »
»
Joint purchasing leads by trend to lower hospital prices Discounts are very common Æ even free products (AT, ~ PT, ~SK) On-patent medicines – low negotiation potential The availability of generics resulted in lower price levels also in hospitals
Relevant issues: » Transparency of the prices » Business economics and national economics ... Further analyses pending ...
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Contact Mag. (FH) Nina Zimmermann, MA
Stubenring 6 1010 Wien T: +43 1 515 61-132 F: +43 1 513 84 72 E:
[email protected] http://www goeg at http://ppri.goeg.at, http://www.goeg.at, http://ppri goeg at http://phis.goeg.at, http://whocc.goeg.at
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