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03.10.2011 Hospital prices prices–– Results of a European survey (PHIS) on purchasing strategies and pharmaceutical prices Nina Zimmermann PPRI Confe...
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03.10.2011

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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