Évolution des collaborations européennes en matière de politiques de santé et d accès aux soins

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2 Chaire Francqui: leçon 4 Évolution des collaborations européennes en matière de politiques de santé et d accès aux soins Lieven Annemans ULB, 27 Avril 2017

3 The key principles of healthcare policy SUSTAINABILITY

4 Typical characteristics of the health care system Uncertainty Health insurance Moral hazard, adverse selection Asymmetric information Possibility of supplier-induced demand! Externalities Societal values OECD

5 Why care about the health of others? Egoistic Paternalistic Altruistic

6 ARTICLE 25 Toute personne a droit à un niveau de vie suffisant pour assurer sa santé, son bien-être et ceux de sa famille, notamment pour l'alimentation, l'habillement, le logement, les soins médicaux ainsi que pour les services sociaux nécessaires. Voir pour le texte de la Déclaration universelle des droits de l'homme dans plus de 300 langues. 6

7 the problem with is that there are not enough humankind kind humans

8 Inégalités en Belgique! H. Avalosse et al. Study in 4 million members of the Christian Mutalities 8

Indice standardisé (pour l'âge, le sexe et la région) x 2 150 140 143,2 devenir invalide - Belgique 2012 130 132,8 devenir invalide - Belgique 2006 population de référence 120 110 100

9 Indice standardisé (pour l'âge, le sexe et la région) x ,2 devenir invalide - Belgique ,8 devenir invalide - Belgique 2006 population de référence ,2 117,7 105,4 104, ,0 91, population de référence (indice 80,0 72,6 1. inférieurs 2. bas 3. moyens 4. hauts 5. supérieurs classes de secteurs statistiques de résidence 9

10 Other observations for lowest income category 20% less screening One third less dental care More smoking More sedentary behaviour 10

11 Postpone or cancel treatment for financial reasons Total population AROP AROP = At-risk-of-poverty = income < 60% of national median 15% of the population is AROP

12 12

13 It s not getting better 13

14 Losses of health due to inequity account for of the total costs of health care in the EU Johan P Mackenbach, Willem J Meerding, Anton E Kunst, 2011

15 EXAMPLE: unequal access to valuable innovative medicines Analysis of 2011 sales (in units and ) for 11 valuable* medicines launched in the EU in the period * Valuable = offering a proven therapeutical benefit and filling a medical need. 15

16 List of 11 valuable innovative medicines 16

17 Sales per 100,000 inhabitants Ratio GDP = 5 Data and analysis by IMS Additional data on volumes and prices requested 17

18 We have to change our policies "(The) toxic combination of bad policies, economics, and politics is, in large measure responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible." WHO Commission on Social Determinants of Health Final Report, 2008

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20 What can policy makers do to improve equity? 1. Selecting the right healthcare system 2. Influence out of pocket payments 3. Goal-oriented care 20

21 Belgium Compulsory income-related Contributions/taxes INAMI Mutualities Population and enterprises patients First level providers Second level providers Contracts/ conventions Service flows Financial flows Referral flows 21

22 The UK system: Let the state run it Compulsory income-related Contributions/taxes The state/nhs Population and enterprises patients First level providers Ownership of buildings and staff Salaries and budgets Second level providers Service flows Financial flows Referral flows More Equity and Solidarity Administrative economies Demotivation of providers Private circuit for essential care for people with higher income 22

23 Go Dutch? (OECD, WHO, 2013) Compulsory incomerelated Contributions Population and enterprises patients Central fund Flat rate, insurer specific contr. Voluntary competing insurers First level providers Contracts with and Payments to providers Second level providers Service flows Financial flows Referral flows 23

24 Advantages Increasing choice of consumer for insurance coverage and insurer Contributions mainly on ability to pay Gives providers incentives to produce costeffective care Government as facilitator and to control total expenditure 24

25 But. Fears about increased selection in function of risk (hidden risk selection) Concerns about cartels Concerns about the effect of flat rates for the poor and the effects of income related rates on the rich The maintenance of equity and solidarity? 25

26 Risk for commercialisation of necessary care? 26

27 cumulative percentage of health care costs PLUS de 20/80 rule!! 100,00 90,00 80,00 70,00 60,00 50,00 40,00 30,00 20,00 10,00 0,00 0,00 10,00 20,00 30,00 40,00 50,00 60,00 70,00 80,00 90,00 100,00 sample of the Belgian population ranked from low to high medical consumption 27

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29 What can policy makers do to improve equity? 1. Selecting the right system 2. Influence the out of pocket payments 3. Goal-oriented care 29

30 How to tackle inequalities: the 3D approach World Health report 2010

31 Some stories Annelies CFS meets many people, pays a lot out-of-pocket not accepted as chronically ill loses everything Jean-Pierre stops his medication for hypertension. Too much copayment for him

32 Less hospital admissions Less emergency visits Less non-evidence based surgery Less readmissions More focus on prevention.

Our review found that providing drug insurance to people with chronic diseases who have no drug insurance appears to increase appropriate use of and

33 Our review found that providing drug insurance to people with chronic diseases who have no drug insurance appears to increase appropriate use of and adherence to drugs. The shift of financial responsibility to patients may lead to underuse of potentially important medications in people with chronic conditions

34 Differences in Western world

35 Recommendation 35

36 What can policy makers do to improve equity? 1. Selecting the right system 2. Influence the out of pocket payments 3. Goal-oriented care 36

37 Towards goaloriented care 37

38 Equitable health care = Care whereby the access, the process, and the outcomes of care are not influenced by the social class to which the patient belongs but by the health care needs of the patient.

39 Low need Need for support Acceptable wealth High need more solidarity invest more PROPORTIONAL UNIVERSALISM

40 Horizontal and vertical equity Vertical: those with higher income* should contribute more to the system. Horizontal: those with same health needs should receive the same quality of care, regardless of income. Vertical (bis): those in higher need should receive care in function of their need * From labour and from capital

41 Ask not what you can do for Europe, ask what Europe can do for you 41

42 42

43 Art EU action shall respect the responsibilities of the Member States for the definition of their health policy and for the organization and delivery of health services and medical care. 43

44 The European Commission 44

45 45

46 46

47 Investir dans la protection sociale 47

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49 CROSS-BORDER DIRECTIVE 49

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51 But this can also fail! Example: differential pricing P Ex-factory Selling Price in cluster j for product i P GDP / capita ij i n n Average SP for product i GDP / j j 1 j 1 j capita + corrected for prevalence of the disease in a cluster: the higher the relative prevalence the lower the price. j 51

52 Price clusters Max acceptable ex fact price in richest cluster ASP 1 Price is accepted by at least one country in each cluster GDP5 GDP4 GDP3 GDP2 GDP1 52

53 BUT: external reference pricing in western Europe Netherlands Portugal UK. Denmark Austria Greece Ireland Italy Luxembourg Sweden Germany Switzerland Spain Finland France Belgium 53

54 External reference pricing is part of the problem ERP is not compatible with differential pricing Prices determined ifo prices in other countries rather than ability/willingness to pay of a country Participating countries need to agree not to implement ERP as a method of setting prices or countries limit ERP to other members of cluster 54

55 Parallel trade is part of the problem Would lead to unwillingness of companies to step into the process, as ROI seriously reduced by parallel trade Introduction of possibility for public health exceptions for parallel trade 55

Multi-HTA Early dialogues See Website: http://www.earlydialogues.

HAS, France Participation of 5 to 8 HTA bodies at each meeting (in total 12 participating bodies) EMA invited

56 Multi-HTA Early dialogues See Website: Early Dialogue 10 EDs: 2 pre-pilots in 2012 / 8 pilots in 2013 (all on drugs) Coordinated and hosted by HAS, France Participation of 5 to 8 HTA bodies at each meeting (in total 12 participating bodies) EMA invited as observer Confidential Various therapeutic fields, Small and big companies SEED project: 10 more early dialogues carried out 7 drugs, 3 medical devices. 56

57 MOCA

58 MEMBER STATES INITIATIVES BeNeLuxA Elaborating a proof of concept for the coalition of the willing to collaborate on 4 elements: Health technology assessment in coherence with Joint Action 3 (mutual recognition, joint writing or editing, sharing expertise); Horizon scanning (elaborate methodology); Exchange of information on markets, prices, data (drug consumption, policy development, post marketing evidence, registries ); Pricing and reimbursement incl. joint negotiation ( pilots )

59 Determinants of health Health determinants, measurement and trends (Jones & Bartlett Learning) 2010

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61 Chaire Francqui: leçon 4 Évolution des collaborations européennes en matière de politiques de santé et d accès aux soins Lieven Annemans ULB, 27 Avril 2017

Making the case for Horizon Scanning

Making the case for Horizon Scanning Facing the challenges: Equity, Sustainability and Access Aldo Golja, Beneluxa Coordinator Ministry of Health, The Netherlands 1 Introduction Samuel Becket bridge, Dublin