2.5.2 Health care
The authorities have committed to continue reforming the health care sector, controlling public expenditure, managing prices of pharmaceuticals, improve hospital management, increase centralized procurement of hospital supplies, manage demand for pharmaceuticals and health care through evidence -based- prescription protocols, commission private sector health care providers in a cost effective manner, modernize IT systems, developing a new electronic referral system for primary and secondary care that allows to formulate care pathways for patients.
i. To support rationalisation of expenditure, the authorities will:a. take concrete steps by December 2016 (and by December 2017, respectively), to increase: (i) the proportion of centralized procurement to 60 percent (and to 80 percent), (ii) the share of procurement by hospitals of pharmaceutical products by active substance to 2/3 (and to ¾) of the total, in line with agreed targets. This includes, as intermediate step, establishing a list of items that must be obtained through centralised procurement (by June 2016) and setting the requirement for hospitals to obtain the items through the centralised procurement system by issuing a circular (by September 2016). b. replace the means-tested 5 Euro fee for hospital visits with equivalent measures in demand management terms (May 2016), or otherwise ensure its application {that's a rather curious statement; the instititions are willing to waiver the 5 euro ticket, which they consider a sucess whilst they demand that it's brought back imidiatelly if any other measure fails }. c. take further structural measures by December 2016 as needed to ensure that the estimated gap between spending for 2017 and the claw back ceilings is reduced by at least 30 percent compared to the previous year. The achievement of the spending target will be assessed in June 2017 and December 2017. By December 2017 the authorities will take further structural measures as needed to ensure that the estimated gap between spending for 2018 and the claw back ceilings is reduced by at least an additional 30 percent compared to the previous year. The achievement of the spending target will be assessed in June 2018 and December 2018 {this means that the deficits will have to be cut by 30% no matter what the cosequences. If something like that happens the situation of the public health syetm will become even worse than it is now}. d. complete the set-up of the negotiating committee to start developing price volume and risk agreements, such as MEAs, especially for innovative and high cost drugs (June 2016). e. set-up a Health Technology Assessment centre to evaluate which products to reimburse and under what conditions and agreements, in line with existing guidelines and with evidence of best-practice in the EU (December 2017). Progress towards this long-term goal will be assessed every six months, June and December, starting from June 2016.
ii. To support generics penetration, the authorities should adopt further measures to: a) improve the incentive structure of pharmacists, including on profit structure, by December 2016; (b) promote the use of generics through public campaigning (by June 2016 onwards); (c) revise the current prescription targets for doctors (by December 2016); (d) increase the share of inpatient generic medicines to 50 by December 2016 (and to 60 percent by June 2017); (e) increase the share of outpatient generic medicines by volume to 40 by March 2017 (and to 60 percent by March 2018) {these cuts are supposed to cut on spending for medicine while they will particularly harm the Greek pharmaceutical industry}.
iii. To improve financial management of hospitals, the authorities will:(a) by June 2016, deliver a plan to conduct annual independent financial audits of hospital accounts, with implementation to begin in 2017, and for all hospitals to be covered by 2018 (progress towards this long-term goal will be assessed every six months, in June and December, starting from June 2016); (b) by December 2016, deliver a plan to adopt DRG or other international standard activity-based costing methodology in all hospitals and every three months they will document progress towards the implementation; (c) by December 2017 they will start implementing the new DRG or alternative activity-based costing system for all hospitals to be covered by June 2018 (progress towards this long-term goal will be assessed every three months, starting from June 2016). To this end, they will make use of the available Technical Assistance support.
iv. To assess and improve the performance of health care providers, both public and private, the authorities will: (a) by [June 2016] issue the appropriate legislation to re-activate and make permanent the annual auditing of private clinics; (b) by June 2016, develop an assessment of public sector capacity by region and by specialty and use this to commission private providers per region subject to insufficient public capacity (by December 2016) {the public health system is being completely privatized while no provision is made for the betterment of the horrible conditions of the health system as they are at this moment}; and they will develop a full electronic record for patients (progress towards this goal will be assessed every six months, in June and December, starting from June 2016); (c) by December 2016 finalise a new system of electronic referrals to secondary care, with priority for those to diagnostics and elective surgery (to be developed by September 2016), based on e-prescription and the electronic record. Based on the electronic referrals system, they will develop a monitoring system of patients' waiting times by treatment, with the goal to reduce them over time; (d)by June 2017, develop a plan to pre-approve referrals to private sector providers based on the electronic patient record, the system of electronic referrals, the system of waiting times and the mapping of public sector capacity (progress towards this long-term goal will be assessed every six months, in June and December, starting from June 2016);
v. Through the programme period, the authorities will: a. further reduce prices of drugs including by making greater use of price-volume agreements through the negotiating committeewherenecessary; b. develop additional measures to contain excessive spending on diagnostics; c. will develop additional prescription guidelines giving priority to those with the greatest cost and therapeutic implications; d. develop therapeutic protocols for the patient care pathways (primary and secondary care) for the pathways that have the greatest therapeutic and cost implications, tobeimplemented throughthe e-prescription system;
The progress towards adopting the necessary measures to meet the long-term commitments in this paragraph will be assessed every six months (June and December), starting from June 2016.
vi. As continuous / ongoing commitments, the authorities will: a. update on a regular basis and at least every [six] months thepositiveand the negative list on the basis of criteriaset in MD 2912/B/30.10.2012 and related regulation, subject to prescription guide lines, and with prices set at the level of the lowest three in the EU or lower if the authorities can negotiate rebates or price-volume agreements;
b. publish every six months a price bulletin to reduce pharmaceutical prices (February and August); c. execute the clawbacks every six months and perform regular audits; d. apply and collect outstanding clawsbacks (continuously until they are cleared) for pharmaceuticals, diagnostics and private clinics; e. assess existing measures to bring structural spending in line with claw back targets in each area providing reports detailing their features and outcomes (design, relevant legislation involved, outcomes) (June and September); f. continue tocollectrelevant datafrom EOPYY and regularly publish it with a lag of three weeks after the end of the respective month,, including through, (a) monthly reports with analysis and description of detailed data on healthcare expenditure in the areas of pharmaceuticals, diagnostics and private clinics (including information on the progress against the expenditure ceiling and clawback execution);(b) a monthly report on hospital financial data; (c) a quarterly report based on a set of activity related (input, process, output, outcome) indicators and financial data for hospitals; (d) an annual report on comparing hospital performance based on benchmarking indicators; (e) an annual report on human resources for the whole health care sector (to be used as a human resource planning instrument) with a focus on PHC; g. document the progress on the development of new protocols and registries for the most expensive pharmaceutical active substances and diagnostics procedures (bimonthly); h. document the progress on prescriptionguidelines (bimonthly); i. undertake regular and documentable public campaigning to support generics; j. document progress towards setting-up of the HTA centre.
The authorities will closely monitor and fully implement universal coverage of health care and inform citizens of their rights in that regard and they will proceed with the roll out of the new Primary Health Care system as envisaged in Law 4238 by December 2016. To this end, they will make use of the available Technical Assistance support. The progress towards this goal will be assessed in June and December.
The authorities have committed to continue reforming the health care sector, controlling public expenditure, managing prices of pharmaceuticals, improve hospital management, increase centralized procurement of hospital supplies, manage demand for pharmaceuticals and health care through evidence-based e-prescription protocols, commission private sector health care providers in a cost effective manner, modernize IT systems, developing a new electronic referral system for primary and secondary care that allows to formulate care pathways for patients.
The authorities as prior action committed to reinstate previous key elements of reforms to the health system. In particular, they will a) amend Law 4332/2015 repealing part of Law 4052/2012 (reorganisation and restructuring of the health sector under the MoU) on the appointment of hospital CEOs; b) repeal MD FEK 1117/2015, in order to re-enforce sanctions and penalties as a follow-up to the assessment and reporting of misconduct and conflict of interest in prescription behaviour and non-compliance with the EOF prescription guidelines (re-establish prior MoU commitment); c) re-establish full INN prescription, including by repealing circular 26225/08.04.2015, with the exceptions as set out in art 6.4 to 6.6 of the MD FEK 3057/2012; d) reduce the price of all off-patent drugs to 50 percent and all generics to 32.5 percent of the patent price, by repealing the grandfathering clause for medicines already in the market in 2012; e) establish claw backs for 2015 for diagnostics and private clinics and delink the 2014 claw back for private clinics from the 2013 one.
By September 2015 extend the 2015 claw back ceilings for diagnostics, private clinics and pharmaceuticals to the next three years, and, by October 2015, the authorities will (a) apply and collect outstanding claws backs until H1-2015 for pharmaceuticals, diagnostics and private clinics; (b) publish a price bulletin to reduce pharmaceutical prices and publish it every six months; and c) review and limit the prices of diagnostic tests to bring structural spending in line with claw back targets (key deliverables). They will execute the claw backs every six months. By October 2015, the authorities will decide whether to re-establish a means-tested 5 Euro fee for hospital visits or to adopt equivalent measures in fiscal and demand management terms;
By December 2015, the authorities will take further structural measures (key deliverable) as needed to ensure that spending for 2016 is in line with the claw back ceilings, including developing new protocols for the most expensive pharmaceutical active substances and diagnostics procedures. Authorities will further reduce generic prices including by making greater use of price-volume agreements where necessary. Over the next three years, they will develop additional prescription guidelines giving priority to those with the greatest cost and therapeutic implications. Ambitious but feasible timelines will need to be set by the Authorities.
By December 2015 (and by December 2016, respectively), the authorities will take concrete steps to increase the proportion of centralized procurement to 60 percent (and to 80 percent), the share of outpatient generic medicines by volume to 40 (and to 60 percent), inpatient generic medicines to 50 (and to 60 percent) and the share of procurement by hospitals of pharmaceutical products by active substance to 2/3 (and to ¾) of the total, in 16 line with agreed targets. Generic penetration should be supported by further actions to improve the incentive structure of pharmacists, including on profit structure, by August 2016.
The authorities will introduce new drugs into the positive list on the basis of criteria set in MD 2912/B/30.10.2012 and related regulation, subject to prescription guidelines, and with prices set at the level of the lowest three in the EU or lower if the authorities can negotiate a rebate. By December 2017 the authorities will set-up an HTA centre that will inform the inclusion of medicines in the positive list.
To improve financial management of hospitals, the authorities will by December 2015 (key deliverable) deliver a plan to adopt DRG or other international standard activity-based costing methodology in hospitals within the next three years; by December 2017 they will implement the new DRG or alternative activity-based costing system; by June 2016 they will deliver a plan to conduct annual independent financial audits of hospital accounts, with implementation to begin in 2017, and for all hospitals to be covered by 2018. To this end, they will make use of the available Technical Assistance support.
To assess the performance of health care providers, both public and private, EOPYY will continue to collect and publish relevant data on a monthly/quarterly basis. By June 2016, the authorities will develop an assessment of public sector capacity by region and by specialty and will use this to review the need for commissioning private providers per region; and they will develop a new electronic record for patients. By August 2016 they will develop a new system of electronic referrals to secondary care based on e-prescription and the electronic record and allowing the monitoring of waiting times. By June 2017, the authorities will develop a plan to pre-approve referrals to private sector providers based on the electronic patient record, the system of electronic referrals and the mapping of public sector capacity. Over the next three years, the authorities will develop therapeutic protocols for the patient care pathways (primary and secondary care) for the pathways that have the greatest therapeutic and cost implications, to be implemented through the e-prescription system.
The authorities will closely monitor and fully implement universal coverage of health care and inform citizens of their rights in that regard and they will proceed with the roll out of the new Primary Health Care system and the issuing of an MD as envisaged in Law 4238 by December 2015. To this end, they will make use of the available Technical Assistance support.