The sick should not be pushed around

The sick should not be pushed around

Towards a more rightful medicines reimbursement system

Anyone in good basic health can suddenly fall ill. A disease that turns out to be chronic calls for continued medication along with other forms of therapy. The permanent or expensive medication is a burden on the sick person’s finances. The purpose of the medicines reimbursement system integrated into the Finnish health insurance is to ensure good-quality medication to all, irrespective of their wealth. The system reform criteria must be equally demanding.

The medicines reimbursement system included in the Finnish health insurance dates back to the 1960s. A progressive novelty in its time, the medicines reimbursement is today a patchwork of minor reforms made on top of each other over the decades.

When something old is being reformed, you have to go to the roots and foundations. The current system is based on the classification of diseases, people, medicines and circumstances. The patients ending up in the wrong category try to read the small print in the insurance policy, only to find that they must unfortunately pay most of their medicine cost.

The new medicines reimbursement system must be more solidly anchored in equality and justice: despite their different diseases, people are equal.

Nobody should be punished for their disease

The current medicines reimbursement system could be described as disease-oriented: certain diseases are included in the special reimbursement category while others are not. The reformed system should work on the cost basis – it could be based on the patients’ annual medicines expenses.

In accordance with the insurance nature of the health insurance system, each and every one should bear the proper risk for disease and medicines. If the risk materialises, we all pay the co-payment or deductible to obtain the reimbursement - as is the case with any insurance policy.

The reformed system would be independent of the nature and seriousness of the diseases. It would therefore be fairer than a disease-based system. Equality would be further enhanced by the initial patient co-payment, which will be introduced in the beginning of 2016. The initial patient co-payment will be 45 euros per year for every 18 year old patient. At the same time the basic reimbursement level will rise from 35 to 40 percent.

When the medicine expenses exceed the initial co-payment, the progressively growing reimbursement rate would allocate and target the society's support at the chronically ill who use most medicines. The reimbursement percentage would increase along with the annual medicine expenses of the patient.

The system would also include an annual expense ceiling. Once exceeded, the medicines would be free for the patient, or they would only pay a minor dispensing charge. In a cost-based model, the annual upper limit could be lower than currently.

A clear system for the sick

This medicines reimbursement system would be clearer and more understandable for the people. With the diseases and the necessary medicines no longer constituting the basis for the reimbursements, the patient would not be required to submit separate doctor's certificates to obtain the higher reimbursement rate. The need for therapy diagnosed by the doctor – in other words the medicine prescription – would be sufficient for the patient to receive the reimbursement.

Justice and equality would be achieved if the system treated everybody in the same predictable way, with all patients paying the same co-payment. The system would also enhance equality between the patients if everybody had access to the same public services.

Efficient and rapid regulation tool for State use

Predictability is very important, not only for the party paying the largest share of the system costs, in other words the State, but also to the users of the medicines reimbursement system.

The new reimbursement system would make it simple for the Government to regulate the universal patient co-payment which could increase or decrease as the public finances dictate. The annual ceiling value could likewise be adjusted without any slowly enacted legislative changes or politically difficult decisions that might compromise the rights of a particular patient group.

The new system would be efficient and less expensive to operate. The smallest reimbursements would be eliminated, both in terms of expenses and extra workload at Kela.

Kela could make more efficient use of the time now spent on the evaluation of the type B medical certificates, currently needed for the higher reimbursement rates. The healthcare system would liberate the annual workload of 50 doctors who could dedicate the time to patients, currently spent on writing certificates.  The additional work caused by the reimbursement system would also diminish at pharmacies who could allocate the time to medication counselling.

The new system would not entail any changes in the process of adopting the medicine reimbursement status or wholesale prices. The Pharmaceuticals Pricing Board PPB continues to decide on the reimbursement status and the underpinning wholesale prices.

However, PPB could cut on its extra work when special reimbursement status applications would no longer be needed.  It might be necessary to limit the reimbursability of certain novel medicines. Similarly to the current situation, the new system would not reimburse all medicines – those for mild or minor diseases would remain excluded from reimbursements, i.e. be in the zero category. The generic substitution at pharmacies and the reference price system would stay the same as they are now.

The reform of the medicines reimbursement system means defining how the money allocated to the health insurance system is distributed among the patients. In the near future, society must also think about the source of health insurance financing and the parties that will make the decisions on their distribution. Despite all this, Finland needs new uniform criteria for the payment of medicine reimbursements to the patients.

Promoting public health

Pharmacotherapies are constantly developing. The medicines reimbursement system should not cause unnecessary delays for the introduction of novel therapies.

The development of pharmacotherapies is a key means to improve the productivity and effectives of the service system. Improved pharmacotherapies can reform the operating modes of healthcare and the contents of the service, making them more effective and cost-efficient and, at the same time, improving their quality.  Clinical practice guidelines would be the tool of regulating medicine prescription operations. 

The medicines reimbursement system should support the social welfare and healthcare service system in the treatment of the patient. It should also promote the national health policy objectives.

People should be encouraged to care for their health and assume the responsibility for the success of their own medication. It will be possible for them to buy medicines even when the product is more expensive than the basic medicine. Adherence to treatment is not a money issue - what we need now is genuine co-operation throughout the entire integrated care pathway.