Transcript Medical Insurance Benefit System in relation with Pharmacy

Medical Insurance Benefit System
in relation with Pharmacy in Korea
and a few other countries
Dr. SOO JA NAM
Immediate past president
FAPA
August 16 2014 Jakarta
Pharmacy Service Reimbursement System in Korea
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Mandatory national medical insurance system was implemented in 1997
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All Koreans are covered by this system.
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Separation of dispensing and prescription was implemented in July 2000 .
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This is a mandatory system :
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Doctors should issue prescriptions outside for the outpatients.
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Pharmacists should dispense medicine only with the doctors’ prescriptions.
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Pharmacy Service Reimbursement System in Korea
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The separation system brought many changes with regards to the pharmacy
services and the pharmacists’ role in community pharmacies.
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Number of prescription dispensing cases was increased dramatically in
pharmacy after separation and the main practice of pharmacist became
dispensing and medication counseling.
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Sales volume of general medicines was relatively decreased in pharmacy
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Due to the changes of pharmacy service tendency, role of pharmacists was
expanding to the area of dispensing, medication counseling, health
promotion, drug adverse effect monitoring etc.
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Pharmacy Service Reimbursement System in Korea
1) Prescription Dispensing
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In the separation system dispensing, administration of prescription
medicines became the main task of community pharmacists in Korea.
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Consumers’ expectation about the safe and rational use of medicines,
quality assurance of medicines has been increasing and so their
expectation about better dispensing service of pharmacists is ever higher
than before.
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Review of prescriptions and medication counseling became legally
obligatory tasks of pharmacist now.
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Pharmacy Service Reimbursement System in Korea
2) Sales of general medicines, OTC
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Average length of life has been longer, interest in health has been higher,
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More medical information has been widely opened to the public.
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In the tendency as above, concept of self-medication has been expanded
as well.
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In the circumstances, role of community pharmacists has to be more
important for the selection of the proper general medicines.
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Pharmacists must carefully review patients’ health condition and if
needed pharmacists refer them to the medical institutes.
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Pharmacy Service Reimbursement System in Korea
3) Health promotion
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Korean pharmacy law does not stipulate health promotion activities of
pharmacists.
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Such activities, however, can be achieved through their health counseling
practices.
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Improvement of life pattern and living environments, diet and nutrition
counseling, and education of prevention methods can be included herewith.
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Pharmacy Service Reimbursement System in Korea
Composition of dispensing fee
1 Pharmacy administration fee (per visit),
2 Compounding fee (per visit),
3 Pharmacy counseling fee (per visit),
4 Dispensing basic fee (per dates),
5 Inventory maintenance fee (per dates).
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Outline of Japanese Dispensing fee system.
1. Japanese Dispensing fee system composed by 4parts:
a) Fee,
b) Medicine fee,
c) Fee for Pharmaceutical supervision to the patient
d) fee for medical devices.
2. Fee and fee for pharmaceutical supervision to the patient are
technical fee for the Pharmacist.
4. Dispensing fee in Japan is decided by the Government
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Pharmacy Service Reimbursement System in UK
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UK has a thorough separation system. Necessary medicines and devices are
supplied only by the pharmacy which owns pharmacist who has contract
with health authority.
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Pharmacists are solely allowed to dispense medicines according to the
doctors’ prescription except when the patients cannot visit pharmacies in
their town.
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In this case, clinic doctors can dispense medicines by themselves
The dispensing cost can be reimbursed to them.
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Prescription medicines can be sold through on line and e-mail system in UK.
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Pharmacy Service Reimbursement System in UK
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UK government gives reimbursement only to the community pharmacies
with NHS medicine services.
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Qualification for the NHS service must be obtained by the health
authority in the area.
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Qualification for the NHS service must be obtained by the health
authority in the area.
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Pharmaceutical Services Negotiating Committee (PSNC) and the
Department of Health (DH) are the organizations in charge of
reimbursemtnt matter in UK.
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They negotiate budget and prepare funds every year.
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Pharmacy Service Reimbursement System in UK
The pharmacy services are classified into 3 categories
a) Essential service
This is the service which is provided in every pharmacy in UK.
The service includes dispensing, refilling, promotion of healthy lifestyle,
support for self-care, and withdrawal of disposing medicines.
b) Enhanced service
Pharmacies which are entrusted by PCT provide this service according to
the request of the people in their community.
The service includes non smoking campaign, provision of emergency
contraceptives, treatment of minor ailment schemes etc.
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Pharmacy Service Reimbursement System in UK
c) Advanced service
This is the service provided by the pharmacy and pharmacist who have
approval through special education course.
It includes medication use review (MUR), prescription intervention services
(PIS). MUR is a kind of proactive intervention for a certain patient groups
such as aged patients or asthma patients and PIS is a reactive intervention
against improper prescriptions.
Pharmacists consult matters about patients’ understanding of their
medicines, side effect and interaction of medicines, and the details of
every essential, general, alternative, on line purchasing medicines for the
improvement of clinical and cost effects.
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Pharmacy Service Reimbursement System in UK
Reimbursement system in UK includes reimbursement for the medicines and
remuneration for the pharmacies. Reimbursement contains retained margin
and remuneration is made with fee/allowances.
1) Retained margin
The difference between the NHS reimbursed amount and the purchased
cost is the pharmacy profit. Reimbursement is decided according to the
drug tariff in NHS.
2) Fee/allowances
Compensation for the pharmacy dispensing service is done through
professional fee, basic service fee (opening fee, acting fee, refilling fee,
transitional payment, ETP allowances included), MUR fee, allowance for
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container (drug tariff April 2011).
Pharmacy Service Reimbursement System in Australia
1. Pharmaceutical Benefits Scheme (PBS)
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This is the first government supported benefit program for the purpose of
providing safe and low-priced medicines to the patients and was implemented
in 1960 in Australia.
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More than 90% of the whole essential medicines are in the scheme.
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Medication is the most popular health related activity of Australian people.
Thanks to the system which assists essential medicine costs, they can use
essential medicines more effectively with reasonable expenses.
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Medicare Australia is in charge of PBS at moment.
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Medicare Australia is monitoring PBS program in order to prevent any misuse of
the program and pays compensation for the pharmacy services and medicine
supplies (payment of PBS dispensed price).
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PBS price is consisted of pharmacy’s purchasing cost (manufacturing cost 14+ 7%
wholesale margin), pharmacy’s margin, dispensing fee and other fees.
Pharmacy Service Reimbursement System in Australia
2. Dispensing
Detailed pharmacy services with regards to dispensing are clinical
interventions, controlled drug monitoring, drug recalls, electronic health
records for prescribed supply, electronic prescriptions, medication adherence
programs, medicine use reviews, opiate dependence treatment programs etc.
3. Sales of medicines for pharmacy and health foods
Detailed items are complementary and alternative medicines, first aid and
wound management, health supplies, medicines for light diseases, smoking
cessations etc.
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Pharmacy Service Reimbursement System in Australia
4. Pharmacy health management services
It is not only mean the sales of the above items, but also the services given in
the separated consultation area for the improvement of patients’ health.
It includes chronic disease management, health checks/monitoring/screening,
healthy lifestyle supports, maternal and child healthcare, mental healthcare,
terminal patient pain relief, health promotion, withdraw of waste medicines,
healthy sex life service, sleep apnea clinic, vaccination etc.
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Pharmacy Service Reimbursement System in Germany
Germany has a good separation system. Prescription dispensing is allowed
only in pharmacy. And as of January 1, 1989, dispensing substitution was
allowed as well. According to the pharmacy law, pharmacist should provide
drug information and counseling to the patient, if it is needed for safe use of
medicines. Pharmacy purchases medicines not directly from manufacturers
but through wholesalers. In principle, manufacturers can decide medicine
prices freely without governmental interference but wholesalers and
pharmacies should follow government guidelines. Expensive medicines have
lower margin in general. Margin rate moves in a range of 30 to 68%.
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Pharmacy Service Reimbursement System in France
In France, medicines are sold exclusively in pharmacies according to the law.
No medicines are allowed to be sold in drug stores, supermarkets, and
through internet.
Only a few doctors in some area and hospitals can sell some specially
registered medicines to their outpatients.
Nobody but pharmacist can open and operate pharmacy in France.
A pharmacist needs to have his pharmacy degree.
He has to be a member of conseil national de l’ordre (CNOP) and has to be a
French or EU citizen.
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Pharmacy Service Reimbursement System in France
Opening time, numbers of working pharmacists, way of purchasing medicines
from wholesalers, advertisement of pharmacy are all under control of
government authority.
In France, there is no specific fee.
Dispensing is reimbursed through the sales profit of medicines.
Reimbursed sales price is decided by Comite Economique des Produits de
Sante (CEPS).
Pharmacy retail prices (PRP) of reimbursed medicines are under control of
authority but the prices of non-reimbursed medicines are freely decided.
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Pharmacy Service Reimbursement System in Switzerland
In Switzerland, legal status of pharmacist was revised in the federal health
insurance law in 2001 according to the social acknowledgement of pharmacist
as a service provider.
Reimbursement system was also revised. The new system sees the margin of
the reimbursed medicines in two categories: One for the logistic cost and
capital cost of pharmacists and wholesalers, and another for the service of
pharmacists.
Compensation for the pharmacy service is done with RBP which is regulated
for the pharmacy reimbursement . Swiss society of pharmacists (SSPh) and
Swiss union of health insurers make fee-schedule for the reimbursement of
dispensing medicines.
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Thank you!
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