Impact of selective financing of drugs on pharmaceutical expenditure control in the province of Valladolid, Spain

Healthcare rationing in Spain: framework, descriptive analysis and consequences

This paper describes the main healthcare rationing policies implemented in Spain over the last 2 decades, and analyses the consequences of these policies on the healthcare system, patients, healthcare practitioners, the pharmaceutical industry and policymakers. The primary explicit healthcare rationing policies utilised in Spain include a catalogue that defines the healthcare rights of citizens. However, the existing system may lead to inequity between regions, and is not structured to direct resources towards the most cost-effective options. Health technology assessment requires further work before it can be utilised widely for the development of rationing strategies. Selective reimbursement of drugs and drug co-payments provide only short-term results and appear to have little long-term impact on expenditure. Implicit rationing instruments, especially waiting lists, have had a significant effect on healthcare quality and the welfare of citizens, and have contributed to keeping the Spanish healthcare budget under control. Newer regulations should integrate some form of economic evaluation within the policy-making processes associated with healthcare. Further research is needed to identify those efficient and equitable rationing instruments that are most likely to improve health interventions for an aging society that is increasingly demanding of health services.

[Do we spend too much on medications? Pharmaceutical expenditures, an absolutely essential item in European countries]

OBJECTIVE

To find out if the performance of the pharmaceutical expenditure between the most developed European countries come close more to a luxury good or a necessary good. To compare the pharmaceutical Spanish expenditure with the one of those countries.

DESIGN

Cross-sectional study.

SETTING

International. Europe.

PARTICIPANTS

European countries members of the Organisation for Economic Co-operation and Development (OECD) and the European Union.

METHODS

The data come from the OECD reports and other papers with the same source of information. The majority of the data refer to year 2000. The relationship between pharmaceutical expenditure and other variables as expenditure on health, on research and development (R&D), and socio-demographic variables are analysed with correlation and multiple linear regression.

RESULTS

In both groups of countries, the Gross Domestic Product per capita (GDPPC) is positively and significantly correlated with the expenditure per capita on health (public and total) and on R&D, but not with pharmaceutical expenditure per capita (PhEPC). The pharmaceutical expenditure as part of total expenditure on health (PhE/TE) or as percentage of GDP (PhE/GDP), is negatively and significantly correlated with income (GDPPC). The regression model accepts as explicative variables of PhE/GDP: the income (negatively), the employment in health (negatively) and the PhEPC (positively). The PhEPC in Spain is situated in the average of the most developed European countries, and expressed as PhE/TE or as PhE/GDP is situated in the group of the countries with greater pharmaceutical expenditure, the majority of them with a lower GDPPC to the Spanish one.

CONCLUSIONS

The performance of the pharmaceutical expenditure between the countries studied come close to a necessary good than to a luxury good. The PhEPC in Spain is situated in the average of these countries and, expressed as PhE/GDP or as PhE/TE, would be according to the Spanish income.

European healthcare policies for controlling drug expenditure

In the last 20 years, expenditures on pharmaceuticals - as well as total health expenditures - have grown faster than the gross national product in all European countries. The aim of this paper was to review policies that European governments apply to reduce or at least slow down public expenditure on pharmaceutical products. Such policies can target the industry, the wholesalers and retailers, prescribers, and patients. The objectives of pharmaceutical policies are multidimensional and must take into account issues relating to public health, public expenditure and industrial incentives. Both price levels and consumption patterns determine the level of total drug expenditure in a particular country, and both factors vary greatly across countries. Licensing and pricing policies intend to influence the supply side. Three types of pricing policies can be recognised: product price control, reference pricing and profit control. Profit control is mainly used in the UK. Reference pricing systems were first used in Germany and The Netherlands and are being considered in other countries. Product price control is still the most common method for establishing the price of drugs. For the aim of fiscal consolidation, price-freeze and price-cut measures have been frequently used in the 1980s and 1990s. They have affected all types of schemes. For drug wholesalers and retailers, most governments have defined profit margins. The differences in price levels as well as the introduction of a Single European Pharmaceutical Market has led to the phenomenon of parallel imports among member countries of the European Union. This may be facilitated by larger and more powerful wholesalers and the vertical integration between wholesalers and retailers. To control costs, the use of generic drugs is encouraged in most countries, but only few countries allow pharmacists to substitute generic drugs for proprietary brands. Various interventions are used to reduce the patients' demand for drugs by either denying or limiting reimbursement of products and providing an incentive for patients to reduce their consumption of drugs. These interventions include defining a list either of drugs reimbursed (positive list) or one of drugs not reimbursed (negative list), and patient co-payments, which require patients to pay a proportion of the cost of a prescribed product or a fixed charge. Policies intended to affect physicians' prescribing behaviour include guidelines, information (about price and less expensive alternatives) and feedback, and the use of budgetary restrictions.

A multinational pharmacoeconomic evaluation of acute major depressive disorder (MDD): a comparison of cost-effectiveness between venlafaxine, SSRIs and TCAs

METHODS

We conducted a multinational pharmacoeconomic evaluation comparing the immediate release form of a new class of serotonin norepinephrine reuptake inhibitor (SNRI), venlafaxine IR to the selective serotonin reuptake inhibitors (SSRIs) and the tricyclic antidepressants (TCAs) in the treatment of acute major depressive disorder (MDD) in 10 countries (Germany, Italy, Netherlands, Poland, Spain, Sweden, Switzerland, United Kingdom, United States, and Venezuela). We designed a decision analytic model assessing the acute phase of MDD treatment within a 6-month time horizon. Six decision tree models were customized with country-specific estimates from a clinical management analysis, meta-analytic rates from two published meta-analyses, and a resource valuation of treatment costs representing the inpatient and outpatient settings within each country. The meta-analyses provided the clinical rates of success defined as a 50% reduction in depression scores on the Hamilton Depression Scale (HAM-D) or the Montgomery-Asberg Depression Rating Scale (MADRS). Treatment regimen costs were determined from standard lists, fee schedules, and communication with local health economists in each country. The meta-analytic rates were applied to the decision analytic model to calculate the expected cost and expected outcomes for each antidepressant comparator. Cost-effectiveness was determined using the expected values for both a successful outcome, and a composite measure of outcome termed symptom-free days. A policy analysis was conducted to examine the health system budget impact in each country of increasing the utilization of the most effective antidepressant found in our study.

RESULTS

Initiating treatment of MDD with venlafaxine IR yielded a lower expected cost compared to the SSRIs and TCAs in all countries except Poland in the inpatient setting, and Italy and Poland within the outpatient settings. The weighted average expected cost per patient varied from US$632 (Poland) to US$5647 (US) in the six-month acute phase treatment of MDD. The estimated total budgetary impact for each 1% of venlafaxine utilization, assuming a population of one million MDD patients, ranged from US$1600 (Italy) to US$29,049 (US).

CONCLUSIONS

Within the inpatient and outpatient treatment settings, venlafaxine IR was a more cost-effective treatment of MDD compared to the SSRIs and TCAs. Additionally, the results of this investigation indicate that increased utilization of venlafaxine in most settings across Europe and the Americas will have favorable impact on health care payer budgets. ADR, adverse drug reaction; CMA, clinical management analysis; ECT, electroconvulsive therapy; HAM-D, Hamilton Depression Scale; MADRS, Montgomery-Asberg depression rating scale; MDD, major depressive disorder; SFD, symptom-free day; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant; WHO, world health organization.

[Drug regulation: theory and practice]

Regulation of drugs from the public administration is an activity which is produced in different countries independently from the sanitary model they own. In the field of public financing of drugs there have been several measures to improve the efficiency of their use. However, the analysis of the impact of these measures is complex and this may justify the shortage of objectivable results, especially at long term. The objective of this study is to perform a systematic review of such measures due to the need to have information about the different alternatives before making a decision. The introduction of an isolated measure is in many cases compensated by other changes in other regulating or aiding fields which suggests the creation of an integral strategy which affects different fields (supply/demand of drugs and prescribers). It seems necessary to suggest a social debate taking as a basis the scientific information available at the moment and promote the taking of decisions which lead to a rational use of the available pharmacological resources.