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The Evolving Hospital Reimbursement Environment Presents New Challenges for the Pharmaceutical Industry
Decision Resources, Inc, April 2011, Pages: 40
Historically, healthcare payers largely left hospitals to their own devices to define their reimbursement policies and decide how best to control their costs. Today, however, the climate in the hospital sector is undergoing a marked change. In an attempt to reduce costs and raise the general standard of secondary care, governments in many countries have begun to move from fee-for-service reimbursement or per diem payments to prospective payment systems that pay providers a predetermined amount according to specific definitions. Drug manufacturers will need to change in response to this shift from cost-based reimbursement to prospective payment.
Questions answered in this report:
- In the United States, the Medicare and Medicaid programs together provide healthcare coverage for close to100 million beneficiaries, including many of the most needy patients. How do Medicare and Medicaid reimburse hospitals, and to what extent do their payments cover costs? What influence do they have on the private sector? What impact will the Patient Protection and Affordable Care Act (PPACA), signed into law in March 2010, have on the U.S. hospital system?
- For 2011, the French government has set a hospital budget of €72.9 billion ($96.6 billion), an increase of 2.8% over 2010. What restrictions are applied to hospital pricing in France? What impact has tarification à l’activité (T2A; activity-based pricing) had on French hospitals? What has the government done to restrict hospital resale of medicines to outpatients and to promote the appropriate use of innovative and expensive medications?
- Soon after the implementation in 2004 of Germany’s new diagnosis-related group (DRG) reimbursement system, it became apparent that DRGs could not readily accommodate the cost of very expensive services. What procedures are in place for the payment of Zusatzentgelte (supplementary payments)? In what circumstances can new interventions be classified as Neue Untersuchungs- und Behandlungsmethoden (NUB; New Methods of Examination and Treatment)?
- In the United Kingdom, medicines classified as high-cost drugs are excluded from the Payment by Results (PbR) system for all of their licensed indications and for off-label use unless exceptions are explicitly stated. What are the conditions for the award of innovation payments? What plans does the U.K. government have for overhaul of the National Health Service, including the possible introduction of a “pathway-based” tariff system?
Scope of the report:
- Markets covered: United States, France, Germany, Italy, United Kingdom.
- Legislation assessed: Arzneimittelgesetz (Pharmaceutical Law); Balanced Budget Act of 1997; Gesetz zur Einführung des diagnoseorientierten Fallpauschalensystems (Act for the Introduction of a Diagnosis-Related Group System); Krankenhausentgeltgesetz (Hospital Payment Act); Krankenhausfinanzierungsreformgesetz (Hospital Funding Reform Act); Loi de Financement de la Sécurité Sociale 2004 (Social Security Finance Act of 2004); Patient Protection and Affordable Care Act (PPACA); Zweites Fallpauschalenänderungsgesetz (Second Diagnosis-Related Group Modification Act).
- Health insurance programs covered: Medicare, Medicaid, and commercial insurance in the United States; Assurance Maladie (statutory health insurance system) in France; Gesetzliche Krankenversicherung (GKV; statutory health insurance) system in Germany; Servizio Sanitario Nazionale (SSN; National Health Service) in Italy; National Health Service in the United Kingdom.
- Supplementary payment systems in use: Medicare add-on payments, outlier payments and pass-through payments in the United States; supplementary reimbursement for médicaments facturés en sus des GHS (drugs invoiced on top of the GHS) in France; Zusatzentgelte (supplementary payments) and payments for Neue Untersuchungs- und Behandlungsmethoden (NUB; New Methods of Examination and Treatment) in Gemany; innovation payments in the United Kingdom.
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