Ethical Hurdles in the Prioritization of Oncology Care.

With finite resources, healthcare payers must make difficult choices regarding spending and the ethical distribution of funds. Here, we describe some of the ethical issues surrounding inequity in healthcare in nine major European countries, using cancer care as an example. To identify relevant studies, we conducted a systematic literature search. The results of the literature review suggest that although prevention, access to early diagnosis, and radiotherapy are key factors associated with good outcomes in oncology, public and political attention often focusses on the availability of pharmacological treatments. In some countries this focus may divert funding towards cancer drugs, for example through specific cancer drugs funds, leading to reduced expenditure on other areas of cancer care, including prevention, and potentially on other diseases. In addition, as highly effective, expensive agents are developed, the use of value-based approaches may lead to unacceptable impacts on health budgets, leading to a potential need to re-evaluate current cost-effectiveness thresholds. We anticipate that the question of how to fund new therapies equitably will become even more challenging in the future, with the advent of expensive, innovative, breakthrough treatments in other therapeutic areas.

Comparing policies to enhance prescribing efficiency in Europe through increasing generic utilization: changes seen and global implications.

AIM: The aim of this article was to evaluate the influence of different demand-side measures to enhance the prescribing of generics in ambulatory care based on cross-national comparisons. METHODS: An observational retrospective study was conducted using administrative databases from across Europe, documenting changes in reimbursed utilization and expenditure of different proton pump inhibitors (PPIs) and statins between 2001 and 2007, alongside different reforms to enhance prescribing efficiency. Utilization was converted to defined daily doses (DDDs) and expenditures were converted to euros. Demand-side measures were collated under the '4 Es'--education, engineering, economics and enforcement--to enable comparisons on the nature and intensity of reforms between countries. RESULTS: There were considerable differences in the utilization of generics and patent-protected PPIs and statins among Western European countries. Decreased utilization of omeprazole and simvastatin, alongside increased utilization of esomeprazole, atorvastatin and rosuvastatin, was seen in countries with limited demand-side measures to counteract commercial pressures. Prescribing restrictions, or a combination of education, prescribing targets and financial incentives, had the greatest influence on enhancing the utilization of omeprazole and simvastatin. For example, there was a threefold reduction in the utilization of atorvastatin in Austria following prescribing restrictions. Multiple demand-side interventions generally had a greater influence than single interventions, with the impact appearing additive. Multiple interventions coupled with initiatives to lower prices of generics considerably enhanced prescribing efficiency. CONCLUSION: This cross-national study has demonstrated considerable variation in the utilization and expenditure of PPIs and statins across Europe, providing opportunities to further improve prescribing efficiency. The '4 Es' do provide an understandable methodology to document and compare the influence of different demand-side measures, with the influence varying by their extent and intensity. Further reforms are essential given current financial pressures. Consequently, further research will concentrate on the potential to develop a scoring system to help predict the possible impact of different demand-side measures on future utilization patterns.

Risk sharing arrangements for pharmaceuticals: potential considerations and recommendations for European payers.

BACKGROUND: There has been an increase in 'risk sharing' schemes for pharmaceuticals between healthcare institutions and pharmaceutical companies in Europe in recent years as an additional approach to provide continued comprehensive and equitable healthcare. There is though confusion surrounding the terminology as well as concerns with existing schemes. METHODS: A literature review was undertaken to identify existing schemes supplemented with additional internal documents or web-based references known to the authors. This was combined with the extensive knowledge of health authority personnel from 14 different countries and locations involved with these schemes. RESULTS AND DISCUSSION: A large number of 'risk sharing' schemes with pharmaceuticals are in existence incorporating both financial-based models and performance-based/outcomes-based models. In view of this, a new logical definition is proposed. This is "risk sharing' schemes should be considered as agreements concluded by payers and pharmaceutical companies to diminish the impact on payers' budgets for new and existing schemes brought about by uncertainty and/or the need to work within finite budgets". There are a number of concerns with existing schemes. These include potentially high administration costs, lack of transparency, conflicts of interest, and whether health authorities will end up funding an appreciable proportion of a new drug's development costs. In addition, there is a paucity of published evaluations of existing schemes with pharmaceuticals. CONCLUSION: We believe there are only a limited number of situations where 'risk sharing' schemes should be considered as well as factors that should be considered by payers in advance of implementation. This includes their objective, appropriateness, the availability of competent staff to fully evaluate proposed schemes as well as access to IT support. This also includes whether systematic evaluations have been built into proposed schemes.

[Evaluation of special GP-centered health care contracts in Germany by the participating GPs. present situation and future perspectives]. / Hausarztzentrierte Versorgung aus Sicht der teilnehmenden Arzte : Aktuelle Situation und Perspektiven.

BACKGROUND AND PURPOSE: In 2004, German statutory health care funds were given the possibility to offer their insured a special general practitioner-( GP-)centered health care contract (HZV), since 2007 they are obliged to do so. The aim of these contracts is to strengthen the role of the GP as a coordinator in the health care system. Until now, the evidence regarding the GPs' view on these contracts is poor. A written survey was conducted in Hesse in order to learn how the participating GPs evaluate the regional HZV. METHODS: In Apri 2008, a questionnaire was developed, tested and mailed to 2,815 GPs who were participating in the GP-centered health care contract at that time. All analyses where conducted with SPSS (version 15.0). RESULTS: A total of 686 questionnaires were returned (response rate 24.4%). Altogether, the GPs' feedback ranged from great approval to clear disapproval of the contract. However, 70.0% of the survey's participants evaluated the HZV in general to be positive, 60.1% felt it strengthens their role as a GP. Quality circles on good prescribing and GP-specific education, obligatory parts of the HZV, were evaluated to be especially positive (70.3% and 69.4%, respectively). Positive effects were also seen concerning coordination of care (53.3%) and cooperation with patients (36.3%). Improvements concerning cooperation with specialists and hospitals were reported less often (24.9% and 13.0%, respectively). Workload because of additional administration for the HZV was criticized. CONCLUSION: In future, special GP-centered health care contracts should focus on improvement of cooperation between GPs and other caregivers. Workload for additional administration should be reduced.

[Curriculum for "structured medical care"]. / Curriculum "strukturierte medizinische Versorgung".

In 2001, the Advisory Council for the Concerted Action in Health Care reported deficits of medical care in Germany and disclosed a potential for improvement in the quality and efficiency of care. The introduction and implementation of disease management programs counteracts these deficits by standardising medical care processes for defined patient groups in co-operation with participants from different sectors and professions. Thus, doctors are well advised to learn as much as possible about DMPs for two reasons: they both create and offer DMPs! And this gave rise to an initiative of the German Medical Association and the National Association of Statutory Health Insurance Physicians to create an advanced modularly constructed training program especially for doctors, which was first published on January 24th, 2003.