Article published in THE JOURNAL September 8, 2010
Spain spends 1.8% of GDP to buy medicines and is the fourth country in pharmaceutical expenditure per person in the EU15, while health spending is third from bottom. Pharmaceutical costs are not high prices but by the amount of drugs consumed. Spain is the second greatest amount of drugs consumed among 14 developed countries, according to a recent study commissioned by the British health secretary. The number of prescriptions per person has increased by 21% in the last six years, while the real price fell by 10%.
responsible for this situation are multiple (prescribers, pharmacies, distributors, industry) and the solvency of the health system requires action on the incentives of all stakeholders without excluding patients. When it is clear that a policy is not working properly and worsens welfare, ethical and responsible is to change for the better. This is the case of pharmaceutical co-payment. It is unacceptable that the Ministry of Health is hide behind the defense of repetitive and unhelpful actions on prices (two royal decrees so far this year) not to reform the public subsidy to the drug.
Public health finances 60% of drugs and about 90% of some mostly for chronic treatment. For pensioners and their dependents grant is 100% (free). Public mutual funds in the grant is 70% without charge for anyone. On average, the group of patients has gone to pay more than 20 out of 100 euros in 1979 to pay only about 6 today. This system suffers from two serious problems that worsen with time: the burden of copayment is distributed quite unequally and promotes overconsumption.
Half copayment is concentrated in a small group of patients: it supports a 5% of users for which is a heavy load. The co-payment paid by non-pensioners is distributed between users down considerably so that an effort is higher for lower income individuals.
The extension of insurance from 60% to free the pensioner or their beneficiaries, at the age you are and regardless of economic and represents a significant increase in the number of prescriptions that would not have occurred without this change (moral hazard): the consumption individual increases about 25% in the first year free. The financial impact to the public (free over moral hazard) may increase spending by more than 100%.
How can we improve the current system of pharmaceutical co-payment? Here are three criteria inspired by economic theory and experience of the comparative system that would improve both equity and efficiency of the grant pharmaceutical compatible with any budget target. Delete
arbitrary distinction between active and retired, unbecoming of a national health system, applying the same level of subsidy to the pharmaceutical consumption of all patients in general. For example, a copayment of 40% of the price, or 30% combined with a fixed payment per prescription (1 euro). The level of public subsidy will depend on the policy objective that can range from pure rationalization of expenditure (adjusting the parameters of the copayment keeping the average percentage of grant) and the effect of tax collection (reducing the aggregate subsidy).
Reduce barriers to access to treatment necessary and effective for this system could mean for patients who concentrate a very high consumption (maximum quarterly or annual expenditure by the patient, for example, 60 euros per quarter) and for patients actually very low income (pension and gratuity lower unemployment benefits to a very low income, unemployed and without subsidy).
encourage the prescription of medicines needed, effective and most cost-effective (cost per year of quality-adjusted life years gained, QALYs) using differential copayments based on clinical criteria established by scientific evidence. For example, level of subsidy than the general (including 80 to 100% of the price) for the medications necessary, effective and less costly. Overall level of subsidy (for example, 60%) for preferred drugs, chosen among those with the same indication with greater efficiency and lower cost per QALY (eg, simvastatin the lowest price for lowering cholesterol). And grant low (less than 30%) without low-income exemption or copayment avoidable (pay 100% of the price difference on the therapeutic equivalent of the preferred list) for more expensive drugs declared non-preferred (eg price brands than generic, or atorvastatin for lowering cholesterol), with exemptions when clinical factors, the substitution is not applicable for the preferred drug.
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