Reform of the Lithuanian health system

Martynas Marcinkevičius Advisor to the Minister of Health

Dynamics of Compulsory Health Insurance Fund ’s Budget and Gross Domestic Product (GDP) from 1998 to 2011 GDP, bil. LTL CHIF budget, bil LTL 98,1 111,5 92,0 95,7 98,8 82,8

Percentage of GDP

44,7 43,7 45,7 48,6 52,1 57,0 62,7 72,1

4,3 4,2 4,0 3,8 3,7 3,7 3,8 4,0 4,1 4,1 4,1 4,8 4 ,2 4,3

1,94 1,83 1,83 1,87 1,92 2,1 2,39 2,89 3,41 4,0 4,58 4,46 4,0 4,2 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 plan

Number of beds and hospitals

Ligoninių skaičius 100 000 gyv.

5 4 3 2 1 0 O la n di ja Sl ov ėn ija K ro at ija V en g ri ja S lo va ki ja M ak ed on ija Če ki ja L at vi ja E st ija L ie tu ES va n au jų n ar ių

Šaltinis: Europos sveikatos duomenų bazė. http://www.euro.who.int/HFADB

Lovų skaičius 1000 gyv.

9 8 7 4 3 6 5 2 1 0 D an ija N or ve g ija Sl ov ėn ija O la nd ija L en ki ja K ro at ija E st ija S lo va ki ja V en g ri ja L at vi ja Č ek ija L ie tu va E S

Šaltinis: Europos sveikatos duomenų bazė. http://www.euro.who.int/HFADB

Health care system reforms. Funding

 Transition from the budget-based to the insurance-based system  Patient fund institution (1997)  All health care institutions became public institutions (1997) (according to the pattern of state limited companies)

Health care system reforms. Health care institution

 Introduction of General Practitioner institutions (nearly half of them are private)  Three stages of hospital reduction (2002,2004,2010-2011)  Expansion of the network of nursing hospitals

Reorganisation of the hospital network in 2010-2011

Reorganisation of hospitals. Goals

  Goals  Improving the quality of treatment and patient security   Strengthening the primary care and outpatient levels by transposing funds and professionals from the in-patient level Efficient use of existing resources Trends  Restructuring of health care services (RRR reform)  Optimisation of the network of health care institutions

Region and district hospitals

 Region hospitals must meet two basic criteria: more than 1,100 major surgeries and more than 300 childbirths  District hospitals  With surgery and obstetrics (if tending to over 300 childbirths)  With surgery (if performing over 660 major surgeries)  Without surgery and obstetrics

Optimisation of the hospital network and services (ongoing)

 The number of health care institutions (legal entities) decreased by 11  More than 70 different services (surgery, obstetrics, neurology, psychiatry, cardiology, etc.) are no longer bought from different hospitals

Optimisation of the hospital network

 Principles:  Integrating mono-profile hospitals into multi-profile ones  Merge geographically proximate institutions  Network:  2 University research and treatment centres  8 National level hospitals  8 Regional level hospitals  39 District level hospitals (including 10 with surgery and obstetrics unit and 12 with surgery unit)

Localisation of personal health care institutions by category

Kretinga

Klaipėda

Skuodas Mažeikiai N. Akmenė Joniškis Plungė Gargždai

Telšiai

Biržai Kuršėnai

Šiauliai

Pasvalys Pakruojis

Panevėžys

Kupiškis Radviliškis Kelmė Šilalė Anykščiai Raseiniai Šilutė Kėdainiai Rokiškis

Utena

Zarasai Visaginas Ignalina

Tauragė

Ukmergė Molėtai Jurbarkas Šakiai

Kaunas

Jonava Kaišiadorys Širvintos

Vilnius

Kazlų Rūda Elektrėnai

Marijampolė

Vilkaviškis Prienai Trakai Švenčionys Region hospitals Kalvarija

Alytus

Šalčininkai District hospitals Lazdijai Varėna

Druskininkai

Municipalities without multi-profile hospitals

New Pharmaceutical Policy in Lithuania

Goals of the Plan

   Stop growth in expenditures of the Compulsory Health Insurance Fund on reimbursable medicinal products Reduce public expenditures

on all

medicinal products (

reimbursable/non reimbursable

) 28 measures of the Plan Involve

all players

of the pharmaceutical market: manufacturers of ethic/generic medicinal products, wholesalers, pharmacy chains, individual pharmacies, medical doctors and competent authorities

Means to save expenditures of the Compulsory Health Insurance Fund (CHIF) budget

Options for clustering medicinal products in the Price-list Expenditures of the CHIF on the reimbursement of medicinal products for the year 2008 Clustering medicinal products of the same therapeutic action for the basic price Clustering medicinal products of the same active substance for the basic price Price-cutting of the generic medicinal products Reimbursement of complex medicinal products according to the lowest price of the component Signing agreements on the limitation of expenditures 352.469.704 15 mln LTL 3 mln LTL Valid at the moment (expenditure reduction 10 mln LTL in year 2009) 5 mln LTL The unification of retail prices and copayments Protects from the uncontrolled rise in expenditure 5-10 mln LTL 5-10 mln LTL 1 producer original 1 producer generic 2 producers 3 producers 4 producers

Total

12.856.132 93.478.775 29.814.468 147.433.243

636.052.322

5 mln LTL 3 mln LTL

Predictive saving for the calendar year ~ 50-60 mln LTL

Means to reduce patient expenditures on the purchasing of the medicinal product

Setting maximum mark-ups for prescription medicinal products The unification of retail prices and copayments Obligation to present visual information about the prices and other means to strengthen control over the sales of medicinal products Obligation of doctors to prescribe the exact quantity of medicinal product Obligation if doctors regarding rational pharmacotherapy 40-60 mln LTL 20-40 mln LTL 20-30 mln LTL 5 mln LTL 5-10 mln LTL

Predictive saving for the calendar year ~ 90-145 mln LTL

Compulsory Health Insurance budget’s expenditure for reimbursed pharmaceutical and medical devices for ambulatory care, million euros 300

16

200 100 94 93 93 103 170 127 93 89 89 125 105 94 99 110 107 122 139 155 147 179 198 201 202 217 186 189 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 CHIFB Expenditure for pharmaceutical and MD CHIF budget for pharmaceutical and MD

2005/2010 ratio between reimbursable amount for medicinal products and MA and the patient mark-up amount (mln LTL) as well as dynamics of patient mark-up

+20.9 % +3.9 % -22.6%

1000,0 900,0 800,0 700,0 600,0 500,0 400,0 300,0 200,0 100,0 0,0 116,9 480,4

+20,7 %

141,1 538,4

+21,4 %

170,1 624,4 205,7 683,2 213.8

696,2 165,4 653,3 2005 2006 Reimbursed amount, Lt 2007 2008 2009 Patient mark-up amount, Lt 2010

Changes in prices for medicinal products in 2010

     After introducing regulation of prices for non-reimbursable medicines, prices for medicines decreased by around 10% (by approximately 30 mln LTL). The average mark-up on prescription for reimbursable medicines decreased by as much as 22.6%, and patients saved around 49 mln LTL.

For the first time since 2002, a reduction in expenditure of the Compulsory Health Insurance Fund budget on reimbursable medicinal products has been recorded. In 2010 expenditure on medicines was by 6%, or 43 mln LTL, lower than in 2009. In 2011, the decreasing trend in prices and patient mark-ups for medicinal products remains.

Savings will enable starting to reimburse new modern medicines and to include new diseases and indications.

Nearest plans and goals

 Introduction of voluntary health insurance  Correct payment service (DRG etc.)  Quality assurance and measurement  Introduction of e-health