From the moment the reimbursement act entered into force until 2014, the National He alth Fund saved almost PLN 3 billion on a reduction in drug prices made by manufacturers. However, the official lower price of many preparations does not translate into savings in the patient's pocket. Does it have to be this way? Why are drugs so expensive?
Why do we pay more for the same medicine during the next visit to the pharmacy, often even twice as much? Is thatexpensive drugsa necessity? We talk to Irena Rej, president of the Polish Pharmacy Chamber of Commerce, about how thedrug reimbursement systemworks in Poland and its consequences for patients.
- The new drug reimbursement act of January 2012 gave us hope that we would pay less. Meanwhile, patients still complain that drugs are too expensive for them.
Irena Rej : This may surprise many people, but drug prices in Poland are among the lowest in Europe. This is confirmed by an international institution that monitors the prices of medicinal preparations around the world. One may ask: why, if it is so good, is it so bad? The fact that we have the cheapest drugs in Europe does not mean that they are cheap for our patients in terms of income. Especially in the case of older people, they can be a heavy burden on the home budget. If someone has diabetes, his blood cholesterol level is usually elevated, so he needs to be given anticholesterol drugs; he usually has high blood pressure, so there are drugs to regulate blood pressure, and that makes a lot of money. The problem comes from, among others since only a fraction of those eligible for reimbursement take advantage of this privilege. I say: some, because doctors, although they are obliged to prescribe reimbursed drugs to their insured persons, often fail to fulfill this obligation. The drug reimbursement system in our country is so complicated that doctors are afraid that they will write the prescription incorrectly and that there will be pen alties from the National He alth Fund. Therefore, they take "shortcuts" and prescribe drugs at 100%.
I.R .: Our system is based on four types of payment: free, lump sum, 50% and 30%. Preparations must meet certain conditions as to the type and application on the basis of which they remainincluded in at least one of the reimbursement levels. But some drugs have two levels of reward because they are used to treat two different diseases. It is easy for a doctor to get lost in all this. And it is he who decides on the amount of the discount, marking it with an appropriate symbol on the prescription. In addition, new lists of reimbursed drugs are published every two months. Some preparations are removed from the basket, so patients lose the opportunity to buy them at a discount, others are added to the basket. New prices are set every two months. The differences may be in the range of a few or a dozen zlotys, but there was a moment when the price of the drug was increased by PLN 80 for patients with epilepsy. A row broke out and they backed out. To reduce the price, a separate cap for epilepsy drugs had to be created.
I.R .: It is a myth that the price is dictated by the manufacturer. He only produces drugs and then sells them to the Ministry of He alth for a negotiated amount. A manufacturer who does not lower the price cannot count on the fact that his drug will be on the reimbursement list. Then the drugs are grouped, let's call them similar, and the basis, or the reimbursement limit, is established. In the past, when creating groups of similar drugs, the dose, form and active substance were taken into account, today the similarity is widely understood - the indications are also compared. The basis of the limit is the average of the three cheapest drugs in the group. This is the maximum amount to which the National He alth Fund pays a drug - regardless of its retail price.
According to an expertIrena Rej, president of the "Farmacja Polska" Chamber of CommerceIrena Rej has been the president of the "Polish Pharmacy" Chamber of Commerce for 20 years. He is in the top 50 of the 100 Most Influential People in He althcare. Authority in the pharmaceutical world, speaker at numerous conferences and seminars devoted to this environment.
I.R .: Since all three values determining the price of the drug: limit, retail price, and remuneration, are officially established, the pharmacist cannot change them. This means that the patient has no reason to engage in drug tourism, because the prices of reimbursed drugs in all pharmacies in the country are the same. A pharmacy that wants to sell reimbursed drugs undertakes to comply with the prices included in the lists of reimbursed products. There is a pen alty for offering drugs at a different price. There is also a fine of up to 50,000. PLN for advertising a pharmacy and the use of any form of incentive to buy drugsreimbursed. Due to the rigid prices, patients lost many privileges, such as: discounts, various promotions resulting from agreements between pharmacists and manufacturers or wholesalers, loy alty cards.
I.R .: It is true that innovative drugs cost the most, because before they are introduced to the market, they undergo a strictly defined research process, starting from in vitro, i.e. on cages of tissues isolated from the body and artificially grown bacteria, viruses, fungi, through in vivo, that is, on animals, and ending with clinical trials. All procedures are formalized and controlled, which costs extra money. There is a 20-year patent protection period for the composition and method of production. If the manufacturer does not earn, he will not conduct scientific work on perfecting the old ones and looking for new drugs, and diseases will prevail.
I.R .: But they are also not cheap at all. Our companies are doing a fantastic thing: they refine generic drugs. For example, they change the form of administration to be more patient-friendly: instead of nasal drops - an aerosol. It is important that we have modern drugs. Today we are switching to targeted, topical medications. If we find a gene that is damaging something and find a way to block that gene, we first of all eliminate the causes, not the symptoms of the disease. This is the role of new biological and biosimilar drugs, more and more of which appear on our market. They are not yet thoroughly investigated. It takes at least 10 years to learn about their side effects. The equivalent of an innovative biological drug undergoes all clinical trials. Research money is needed, so drugs can't be cheap.
I.R .: There is a free market here. The price is set by the manufacturer. The wholesaler usually imposes a 14% margin, the pharmacy - about 30%, but may impose a 50% or 10% margin, and therefore prices vary in different pharmacies. Pharmacists have two options: they go either for a high turnover and a small turnover, or a high turnover and a small turnover. Hence the differences. And because they are not making money on reimbursed drugs, they are pushing up the prices of over-the-counter drugs. Another thing is that cheap drugs are often reimbursed, for which the patient could pay 100%. Medicines with a price of a few zlotys are abundant on the reimbursement lists. The patient would probably prefer to receive an additional payment for more expensive drugs, which he is often unable to buy.
ImportantHow is it in other countries?
Medicines are reimbursed in the worldvariously. Additional insurance is a popular solution. Insurance companies offer various packages. Some insurers sign contracts with five or ten companies for specific drugs, which will be reimbursed, for example, for 3 years. Then the manufacturer is guaranteed too, lower costs and a lower price. And with us, with such frequent changes of the basket, the costs are borne by the manufacturer (he pays for submitting the application), experts who give opinions on the drug, members of the commission, and all this accumulates in the price of drugs.
I.R .: If we were to sort out the principles of financing treatment and subsidizing drugs, which are sometimes contradictory to logic, we would spend less. Medicines would be cheaper if not for 100% prescriptions and setting such and not other limits. Because what if the price of a heartburn medication will be reduced by a zloty when the drug for which I paid 10 zlotys is withdrawn from the reimbursement list, and now I have to pay 80 zlotys. Normally you should look at what diseases are social in nature. Why was only an oncology package created … Cancer is a terrible disease, but people are also plagued by other diseases, such as cardiovascular diseases, diabetes, rheumatism, psoriasis, depression, being overweight is a huge problem, and you need to take this into account when creating reimbursement lists. It should be considered whether it is better to give young people who are overweight cheap drugs to prevent diabetes and cardiovascular diseases, or to treat these diseases later. Patients with type 2 diabetes, in the first stage of the disease, treated only with diet and exercise, do not have a discount on blood glucose test strips, and just like other diabetics, they should frequently measure their blood glucose levels. The cost of a drug for specific patients often depends on the severity of the disease. People who take the higher dose of the active ingredient pay less for the drug than those who take the lower dose. It's hard to accept it.
I.R .: If there is constant pressure to reduce drug prices, more and more manufacturers will withdraw from reimbursed drugs and prices will increase. If the drug is cheap, patients buy it in stock and throw it away. A lot of drugs are wasted. Education is needed to change that. If you have decided to treat a runny nose with an antibiotic, choose it until the end. With us, the pharmacist has no time for the patient. Pharmaceutical care is only on paper. If the pharmacist asked the patient: why do you take it with this, please stop taking these supplements, because they lower the absorption of the drug, the treatment results would be better and we would take less drugs.
I.R.The patient's financial situation can be improved by a wise replacement of drugs with cheaper alternatives, which should be done at the doctor's, not at the pharmacy. Because if the patient goes to pharmacies for a year and buys various substitutes, the doctor will eventually not know what he was really taking. When writing a prescription, the doctor should ask if the patient will buy the drug for PLN 60, and if not, propose a cheaper alternative. Why don't doctors get free price lists? If prices change every two months, it's impossible to keep up.
monthly "Zdrowie"