In the course of the audit, the National Audit Office reached the opinion that the state has been passive in using the levers that would help ensure the accessibility of medicinal products and a more feasible price for patients. In addition to the indifference of the Ministry of Social Affairs, this is a result of the weak competitive situation on the market, the conduct of physicians and pharmacists that does not comply with the established rules, and a lack of knowledge on the part of patients.
On the basis of the data of 2008, the average percentage of the medicinal products expenses borne by the patient (cost-sharing) in Europe was 18.9%. In 2011, cost-sharing amounted to 34.5% in Estonia. Only a few countries of the European Economic Area had a higher cost-sharing percentage than Estonia. In 2011, the expenses borne by the Republic of Estonia on compensation for medicinal products amounted to 91 million euros.
In the audit, the National Audit Office identified that the Estonian medicinal products market is mainly divided between two large wholesale companies that are also either indirectly or directly related to the majority of the pharmacies. 81% of the pharmacies in Estonia essentially lie within the sphere of influence of the two large wholesale companies. As such, pharmacies have no motivation or possibility for price bargaining and thus hospital pharmacies, being independent of the wholesale companies, have been able to acquire medicinal products at a 10% cheaper price than regular pharmacies. However, this results in the more expensive medicinal product being paid for by the patient. In order to improve competition, the National Audit Office proposed to the Ministry of Social Affairs that a company active in the field of wholesale of medicinal products may not, whether directly or indirectly, own pharmacies.
In the course of the audit, the National Audit Office identified that regardless of the requirement that has been in force for over seven years, pharmacists did not, for years, only prescribe the active ingredient on the majority of prescriptions, but rather the name of a specific medicinal product. The proportion of prescriptions with the name of a specific medicinal product decreased to a third of all prescriptions during the course of the audit, yet this proportion is still unjustifiably big. If the name of a medicinal product has been written on the prescription, the patient is unable to buy another medicinal product (which is often cheaper) with the same active ingredient. In the opinion of the National Audit Office, such disregard of the requirement by physicians was rendered possible by weak supervision by the Ministry of Social Affairs and the Health Board over the activities of physicians.
The options of patients are also restricted by the fact that the cheaper medicinal products are not always available in pharmacies. In the course of inspections carried out by the State Agency of Medicines, it was identified that the cheapest medicinal products with the same active ingredient or a package thereof (medicinal products are packaged in various packaging and in various quantities) were not on sale in 55% of pharmacies.
In addition to the insufficient supervision, the Ministry of Social Affairs has not, in its area of government, managed to organise the activities such that medicinal products would reach the Estonian market quickly: the process of granting marketing authorisations and adding products to the list of discount medicinal products lasts three times longer than permitted.
In the opinion of Tarmo Olgo, Head of the Performance Audit Department of the National Audit Office, the most pressing issue with the situation concerning compensation for medicinal products is the reserved operation of the Ministry of Social Affairs. “The indifference with regard to resolution of issues pertaining to the field is evident in both improvement of the competitive situation as well as enhancing the supervision over physicians and pharmacies and accelerating the process of proceedings for granting marketing authorisations for medicinal products and applications for adding products to the list of discount medicinal products,” Olgo stated.
In addition to the scarce competition and the insufficient activities by the pharmacies and physicians, the expenses on medicinal products borne by the patients are further increased by their low awareness. Upon compensation of expenses on medicinal products, the Estonian Health Insurance Fund proceeds from the reference price, i.e. the price of the medicinal product with the same active ingredient that is second cheapest. If a patient wishes to buy a more expensive medicinal product, they shall have to bear the additional expenses themselves.
For example, in the first half of 2011, the medicinal product with the active ingredient metoprolol was prescribed for over 73,000 patients (30 pills in packaging, à 50 mg). The medicinal product is mainly used for treating hypertension. The reference price of the medicinal product is 2.45 euros and six medicinal products with the respective active ingredient are on the market. The most popular medicinal product with this active ingredient is Betaloc ZOK 50 mg N30 that was bought by 43% of the patients. However, the price of this medicinal product is 6.34 euros, i.e. two and a half times more than the reference price. If the patients would instead buy the medicinal product with the reference price, every patient would save roughly 47 euros per year, and all patients combined would save about 1.47 million euros. The audit of the National Audit Office also indicated that if patients would only buy medicinal products with the reference price, they would save 7 million euros in total.
The results of the analysis of the National Audit Office indicated that roughly a third of the medicinal products with widely used active ingredients with a 75-100% discount are bought at a higher price than the reference price.
In Estonia, the Health Insurance Fund has the obligation of paying the sums for medicinal products necessary for outpatient treatment of insured persons and retail sale of medicinal products entered in the list of medicinal products of the Health Insurance Fund. This means that in case of certain illnesses and certain medicinal products, the Health Insurance Fund shall pay the pharmacy a proportion of the price of the medicinal product. On account of that, the patient is able to acquire the medicinal product at a cheaper price. This organisation helps improve the accessibility of medicinal products. Unless a medicinal product is added to the list, it is not likely for the patient to buy it from retail sale as the medicinal product would be too expensive. In order for the Health Insurance Fund to partially compensate the price of the medicinal product, the medicinal product must comply with several requirements.
In the course of the audit, the National Audit Office inspected the following:
- whether the activities of the state in the field of medicinal products help achieve the objectives of the field, i.e. whether the objectives are set and actually measurable;
- whether the medicinal products are accessible in Estonia;
- whether the use of medicinal products in Estonia is optimal, i.e. whether physicians issue prescriptions that are based on the active ingredient, patients buy cheaper medicinal products and whether the medicinal products are actually bought.
The audit of the National Audit Office included researching the behavioural patterns of patients and physicians as well as the work of the Ministry of Social Affairs, the Estonian Health Insurance Fund, Health Board, State Agency of Medicines and the Estonian Competition Authority during the last few years.
Head of Communication Service, National Audit Office
+372 640 0777
+372 513 4900
9/12/2012 11:00 AM
9/12/2012 4:38 PM
9/12/2012 4:38 PM