Mitigating the regressivity of private mechanisms of financing healthcare: An Assessment of 29 countries.

Progressive financing of health care can help advance the equity and financial protection goals of health systems. All countries' health systems are financed in part through private mechanisms, including out-of-pocket payments and voluntary health insurance. Yet little is known about how these financing schemes are structured, and the extent to which policies in place mitigate regressivity. This study identifies the potential policies to mitigate regressivity in private financing, builds two qualitative tools to comparatively assess regressivity of these two sources of revenue, and applies this tool to a selection of 29 high-income countries. It provides new evidence on the variations in policy approaches taken, and resultant regressivity, of private mechanisms of financing health care. These results inform a comprehensive assessment of progressivity of health systems financing, considering all revenue streams, that appears in this special section of the journal.

Interface policies bridging outpatient and hospital sectors in Europe: can cross-sectorial collaboration in reimbursement and procurement improve access to affordable medicines?

INTRODUCTION: Pharmaceutical systems are frequently characterized by fragmentation, and competences for outpatient and inpatient sectors sit with different authorities, payers, and purchasers. This fragmentation of responsibilities can incentivize shifting expensive therapies and thus patients from one sector to the other. AREAS COVERED: Reimbursement and procurement policies in Europe addressing unwanted consequences of this fragmentation were identified through literature reviews and surveys with policy-makers. Good practice examples include cross-sectorial reimbursement lists managed by committees with representatives from the outpatient and hospital sectors, specific funding mechanisms, joint procurement involving purchasers from both sectors, actions against procurement contracts prohibiting generic competition, and an extension of Health Technology Assessment to the hospital sector. EXPERT OPINION: Recognizing fragmentation as a major challenge for pharmaceutical systems, policy-makers in some countries reacted by implementing policies to support cross-sectorial collaboration. However, only a handful of good practice examples exist for reimbursement and procurement policies in Europe. Though robust evaluations are lacking, there are indications that pharmaceutical policies which ensure collaboration at the interface of the outpatient and inpatient sectors would likely result in efficiency gains and better use of public budgets and may serve as lever to improve access to medicines.

In several European countries, the decision which medicines are funded by public money (reimbursement) and purchased by public institutions (public procurement) is taken independently for the outpatient sector and the hospital sector. There are different payers and procurers per sector, and even within a sector. Patients may be transferred between the sectors for financial reasons because one payer aims to shift the financial burden for the medication to the other sector.Policy-makers have understood the importance of better collaboration between the sectors, and some European countries introduced policies addressing the issue.The article presents examples of how reimbursement and procurement policies can be designed to improve the collaboration between the outpatient and hospital sectors. Committees that decide whether or not a medicine should be covered may contain representatives from both sectors; they may be mandated to take decisions that apply to medicines for outpatient use and administered in hospitals. Purchasers of both sectors may procure jointly a medicine. Supporting tools, such as the assessment of a medicine to support the decision on coverage and the price, may be used in both sectors. Financing solutions can reduce the incentive for one sector to shift a medicine to the other sector.These measures can help that patients gain improved access to affordable medicines. However, despite the introduction of such interface policies in some countries, policy-makers still need to continue working on overcoming the fragmentation in the pharmaceutical system.

Austria: health system summary, 2022

This Health system summary is based on the Austria: Health System Review published in 2018 in the Health Systems in Transition (HiT) series, and relevant reform updates highlighted by the Health Systems and Policies Monitor (HSPM) (www.hspm.org). For this edition, key data have been updated to those available in July 2022 to keep information as current as possible. Health system summaries use a concise format to communicate central features of country health systems and analyse available evidence on the organization, financing and delivery of health care. They also provide insights into key reforms and the varied challenges testing the performance of the health system.

Centralised Pharmaceutical Procurement: Learnings from Six European Countries.

Several European countries have introduced centralised procurement for all or some medicines. This article comparatively describes key features of national centralised pharmaceutical procurement (CPP) systems of six European countries (Cyprus, Denmark, Estonia, Italy, Norway and Portugal). Additionally, it aims to identify benefits, challenges and prerequisites for successful CPP, with a view to offering learnings for other countries. Information was collected based on literature and interviews with national procurement experts. While all countries studied established a designated procurement entity, other institutional and organisational features of the CPP systems vary across the countries. All CPP systems apply a mix of procurement procedures depending on the type of medicine (mainly tendering and negotiations). Reported benefits of CPP include lower purchase prices, stronger bargaining power of the public purchasers, enhanced transparency and governance, improved equity, and eventually improved access to medicines. Challenges that are to be met particularly in the starting phase are opposition of some users and the management of stakeholders with different expectations. Issues such as limited competition and non-availability of medicines may continue in the CPP setting. Compliance with good procurement principles is indispensable for any procurement, including CPP. Further prerequisites for successful CPP include a consistent, comprehensive and regularly updated procurement strategy, sufficient funding and appropriate staffing of the procurement entity, efficient processes including contract management and logistics, data collection and monitoring as well as interaction with users and suppliers.

Meteorological factors and non-pharmaceutical interventions explain local differences in the spread of SARS-CoV-2 in Austria.

The drivers behind regional differences of SARS-CoV-2 spread on finer spatio-temporal scales are yet to be fully understood. Here we develop a data-driven modelling approach based on an age-structured compartmental model that compares 116 Austrian regions to a suitably chosen control set of regions to explain variations in local transmission rates through a combination of meteorological factors, non-pharmaceutical interventions and mobility. We find that more than 60% of the observed regional variations can be explained by these factors. Decreasing temperature and humidity, increasing cloudiness, precipitation and the absence of mitigation measures for public events are the strongest drivers for increased virus transmission, leading in combination to a doubling of the transmission rates compared to regions with more favourable weather. We conjecture that regions with little mitigation measures for large events that experience shifts toward unfavourable weather conditions are particularly predisposed as nucleation points for the next seasonal SARS-CoV-2 waves.

Purchasing medicines for the public sector: Evaluation of the performance of centralised procurement in Portugal.

OBJECTIVE: The study aimed to evaluate centralised procurement of medicines (CPM) in Portugal. METHODS: Data were collected through different methods, including a review of the literature and (procurement) documents and an analysis of selected bids. Thirty-seven face-to-face interviews with representatives of public authorities, users (hospitals and regional health administrations), patient associations and pharmaceutical industry were held in Portugal in Q1/2020. RESULTS: CPM has contributed to improved transparency in processes and governance, to increased equity in access to medicines across the country and to lower workload for some users. The findings of the impact on medicine prices and availability are mixed. The benefits of CPM are undermined by some gaps: Lengthy, bureaucratic processes have resulted in delayed availability of medicines at the beginning of a year and in coping strategies of hospitals such as parallel individual procurements. The list of active ingredients under CPM has not been updated since 2016. The procurement agency does not routinely perform market consultations. Key performance indicators for CPM are lacking. CONCLUSIONS: Portuguese policy-makers are urged to develop an updated procurement strategy to provide guidance and clarity on the objectives of CPM, the role of the procurement agency and further authorities and key performance indicators.

Das österreichische Gesundheitssystem: Akteure, Daten, Analysen

Die vorliegende Analyse des österreichischen Gesundheitssystems beleuchtet aktuelle Entwicklungen in den Bereichen Organisation,Verwaltung, Finanzierung, Versorgung, Reformen und Leistungsfähigkeit des Gesundheitssystems. Die sich seit 2013 in Umsetzung befindliche große Reform steht dabei im Mittelpunkt. Das zentrale Anliegen dieser Reform, in deren Rahmen ein neues Steuerungssystem eingeführt wurde, ist die Stärkung der Koordination und Zusammenarbeit verschiedener Regierungsebenen und Selbstverwaltungsorgane durch die Förderungeiner gemeinsamen Planung und Entscheidungsfindung sowie in Ansätzen auch einer gemeinsamen Finanzierung. Trotz dieser Anstrengungen ist die organisatorische und finanzielle Struktur des österreichischenGesundheitssystems nach wie vor komplex und uneinheitlich. Die österreichische Bevölkerung weist einen guten Gesundheitszustand auf. Die Lebenserwartung bei Geburt liegt über dem EU-Durchschnitt und die niedrige vermeidbare Sterblichkeit zeigt, dass das Gesundheitsweseneffektiver ist als in den meisten EU-Ländern. Dennoch ist die Zahl der Menschen, die an Herz-Kreislauf-Erkrankungen und an Krebs sterben, imVergleich zum EU-28-Durchschnitt hoch. Tabak- und Alkoholkonsum stellen die größten Gesundheitsrisikofaktoren dar. Der Tabakkonsum ist im letzten Jahrzehnt nicht wie in den meisten EU-Ländern zurückgegangen und liegt aktuell deutlich über dem EU-28-Durchschnitt. In Bezug auf die Leistungsfähigkeit bietet das österreichischeGesundheitssystem einen guten und niederschwelligen Zugang zu Gesundheitsleistungen. Die österreichische Bevölkerung verzeichnet einen der niedrigsten unerfüllten Bedarfe an medizinischer Versorgunginnerhalb der EU. Praktisch die gesamte Bevölkerung ist durch die soziale Krankenversicherung abgesichert und hat Zugang zu einem breitgefächerten Leistungsangebot. Dennoch könnten die zunehmenden Unterschiedezwischen der Anzahl an Vertragsärzten und Wahlärzten zu sozialen und regionalen Ungleichheiten beim Zugang zur Gesundheitsversorgung beitragen. Das österreichische Gesundheitssystem ist relativ kostenintensiv. Es ist stark auf die intramurale Versorgung fokussiert, was sich an einer hohen Nutzung stationärer Leistungen und einem Ungleichgewicht in der Ressourcenallokation zwischen dem Krankenhaussektor und demextramuralen Sektor zeigt. Daher zielen die laufenden Reformen darauf ab, das Wachstum der Gesundheitsausgaben der öffentlichen Hand durch eine Ausgabenobergrenze zu senken und die übermäßige Nutzung stationärer Leistungen zu verringern. Die Effizienz der intramuralen Versorgung hat sich während der Reformperiode verbessert, jedoch stellt die fragmentierteFinanzierung zwischen dem intra- und dem extramuralen Sektor nach wie vor eine Herausforderung dar. Aktuelle Bemühungen, die darauf abzielen, die Primärversorgung nach neuem Modell flächendeckend auszubauen, sindein wichtiger Schritt, um Tätigkeiten aus dem großen und kostenintensivenKrankenhaussektor zu verlagern und die Qualifikationsprofile undEinsatzbereiche der medizinischen Fachkräfte zu erweitern.

Austria: Health System Review.

This analysis of the Austrian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Two major reforms implemented in 2013 and 2017 are among the main issues today. The central aim of the reforms that put in place a new governance system was to strengthen coordination and cooperation between different levels of government and self-governing bodies by promoting joint planning, decision-making and financing. Yet despite these efforts, the Austrian health system remains complex and fragmented in its organizational and financial structure. The Austrian population has a good level of health. Life expectancy at birth is above the EU average and low amenable mortality rates indicate that health care is more effective than in most EU countries. Yet, the number of people dying from cardiovascular diseases and cancer is high compared to the EU-28 average. Tobacco and alcohol represent the major health risk factors. Tobacco consumption has not declined over the last decade like in most other EU countries and lies well above the EU-28 average. In terms of performance, the Austrian health system provides good access to health care services. Austrias residents report the lowest levels of unmet needs for medical care across the EU. Virtually all the population is covered by social health insurances and enjoys a broad benefit basket. Yet, rising imbalances between the numbers of contracted and non-contracted physicians may contribute to social and regional inequalities in accessing care. The Austrian health system is relatively costly. It has a strong focus on inpatient care as characterized by high hospital utilization and imbalances in resource allocation between the hospital and ambulatory care sector. The ongoing reforms therefore aim to bring down publicly financed health expenditure growth with a global budget cap and reduce overutilization of hospital care. Efficiency of inpatient care has improved over the reform period but the fragmented financing between the inpatient and ambulatory sector remain a challenge. Current reforms to strengthen primary health care are an important step to further shift activities out of the large and costly hospital sector and improve skill mix within the health workforce.

Austria: health system review

This analysis of the Austrian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Two major reforms implemented in 2013 and 2017 are among the main issues today. The central aim of the reforms that put in place a new governance system was to strengthen coordination and cooperation between different levels of government and self-governing bodies by promoting joint planning,decision-making and financing. Yet despite these efforts, the Austrian health system remains complex and fragmented in its organizational and financial structure.The Austrian population has a good level of health. Life expectancy at birth is above the EU average and low amenable mortality rates indicate that health care is more effective than in most EU countries. Yet, the number of people dying from cardiovascular diseases and cancer is high compared to the EU28 average. Tobacco and alcohol represent the major health risk factors. Tobacco consumption has not declined over the last decade like in most other EU countries and lies well above the EU28 average. In terms of performance, the Austrian health system provides good access to health care services. Austria’s residents report the lowest levels of unmet needs for medical care across the EU. Virtually all the population is covered by social health insurances and enjoys a broad benefit basket. Yet, rising imbalances between the numbers of contracted and non-contracted physicians may contribute to social and regional inequalities in accessing care. The Austrian health system is relatively costly. It has a strong focus on inpatient care as characterized by high hospital utilization and imbalances in resource allocation between the hospital and ambulatory care sector. The ongoing reforms therefore aim to bring down publicly financed health expenditure growth with a global budget cap and reduce overutilization of hospital care. Efficiency of inpatient care has improved over the reform period but the fragmented financing between the inpatient and ambulatory sector remain a challenge. Current reforms to strengthen primary health care are an important step to further shift activities out of the large and costly hospital sector and improve skill mix within the health workforce.

Does deregulation in community pharmacy impact accessibility of medicines, quality of pharmacy services and costs? Evidence from nine European countries.

OBJECTIVE: To analyse the impact of deregulation in community pharmacy on accessibility of medicines, quality of pharmacy services and costs. METHODS: We analysed and compared community pharmacy systems in five rather deregulated countries (England, Ireland, the Netherlands, Norway, Sweden) and four rather regulated countries (Austria, Denmark, Finland, Spain). Data were collected by literature review, a questionnaire survey and interviews. RESULTS: Following a deregulation, several new pharmacies and dispensaries of Over-the-Counter (OTC) medicines tended to be established, predominantly in urban areas. Unless prevented by regulation, specific stakeholders, e.g. wholesalers, were seen to gain market dominance which limited envisaged competition. There were indications for an increased workload for pharmacists in some deregulated countries. Economic pressure to increase the pharmacy turnover through the sale of OTC medicines and non-pharmaceuticals was observed in deregulated and regulated countries. Prices of OTC medicines were not found to decrease after a deregulation in pharmacy. CONCLUSIONS: Access to pharmacies usually increases after a deregulation but this is likely to favour urban populations with already good accessibility. Policy-makers are recommended to take action to ensure equitable accessibility and sustainable competition in a more deregulated environment. No association between pharmaceutical expenditure and the extent of regulation/deregulation appears to exist.