EKIP– Expert Club for Economics and Politics A Different Opinion
Uncontrollably growing budget for medicines
Over the past few years, the growth in the cost of medicines paid by the NHIF has been between 15-20% on an annual basis. In 2018, the costs reached 1 billion, and the primary reaction of the institutions was the so-called limitation of payments for innovative medicines, entitled "moratorium", which fell on the second reading in the plenary hall after loud debates and scandals. Are such measures actually a solution to the problem of the constantly growing budget for medicines or is there a rational alternative?
The data that the National Health Insurance Fund (NHIF) presented for the first quarter of 2018 are eloquent in terms of overspending – a deficit of BGN 100 million. This is of course not news, because a deficit is formed annually under this item – on the one hand, due to the lack of clearly described rules for entering new molecules into the Positive Drug List (PLS), which the NHIF reimburses, and on the other – due to the lack of a public analysis of which groups and which medications account for the bulk of the costs.
The NHIF budget was increased by 407 million leva compared to last year, with the pharmaceutical item increasing by 25% or 200 million leva. The change in spending on pharmaceuticals compared to the first quarter of 2017 is 11%, and the change in oncology drugs compared to the same period of the previous year is 21%. It is important to say here that Bulgaria ranks first in the European Union in spending on pharmaceuticals as a percentage of the total healthcare budget - approximately 29%. At this rate, we will again witness an update of the budget in October, accompanied by numerous political scandals about the lack of money for hospital and outpatient care, as well as medicines.
What are the possible steps for the Ministry of Health and the NHIF?
Rational drug policy
Since the Ministry of Health (MoH) has stated that they will not seek an increase in the health contribution, the only way to maintain apparent fiscal stability in the sector is to optimize and efficiently spend existing funds.
The solution is the promised and unfulfilled pro-generic policy. These words echo in all party programs from the political spectrum – on the left, center and right. During the election, each of the parties promises a pro-generic drug policy, the goal of which is to increase access to medications, optimize the drug budget and save funds for us – the taxpayers. This policy is widely established in developed countries in Europe, which want to cope at least partially with the constantly growing health care budgets. Example countries are Germany, Great Britain, Denmark, France, the Netherlands, etc. In the USA, about 85% of prescribed medications are generic.
At the end of last year, an analysis was presented for a group of medications for the treatment of arterial hypertension, which proved that by implementing the correct progeneric policy for the next 2 years, funds worth 5 million leva could be saved, and if the model is replicated for other groups of medications, the savings could reach 200 million per year.
It is important to note that there is no social policy towards the most affected group of the Bulgarian population – those suffering from cardiovascular diseases. Their medications are reimbursed at the lowest rate (25%), while for other medications for less quantitatively affected groups, the NHIF pays the full cost of the medications. Another problem that exists in the system is the lack of information for patients – the alternatives for their treatment and the possibilities for changing their therapy to a cheaper and equally effective one. According to the Health Act, every doctor should inform his patient about the methods, possibilities and alternatives for his treatment, but this is not done in practice, due to the lack of incentives, or due to the abundance of such on the other side.
Understated control
Observing the growing costs at the macro level, it is good to pay attention to regional indicators. This year, the largest overspending for the first quarter concerns drugs for oncological diseases - 21% more than the previous year. In 2017, regional data was released, which showed that in the field of drugs for oncological diseases, some hospitals treat a patient at an average price of 19,774 leva, while others manage to do it just as effectively with ten times less money (2,516 leva). As for electronic control - the lack of an electronic prescription, as part of the National Health Information System (NHIS), creates prerequisites for easier administrative abuses, due to the fact that there is a delay from the reporting of data to the self-referral of the responsible authorities. The draft for the NHIS was supposed to be ready by the end of 2018, now the ministry states that it will be ready in December 2019. It is important to remind readers that in the last 10 years there have been two failed projects for the integration of the National Institute of Internal Revenue worth 20 million leva, as a result of poor administration by the institutions.
Decisions in the healthcare system require strong political will and a desire to create fiscal discipline in the sector. Any violation of this undermines the authority of the institutions and their representatives. As long as the debate is mainly about emotion, we cannot proceed to rational, data-based policies.
