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Financing pharmaceutical care in the netherlands

Table of contents 1. A short introduction to the Dutch Healthcare system: • Financing streams within the healthcare system • Contracting process between pharmacies and insurance companies A brief overview • Examples of contracting • Pros and cons of the Dutch healthcare system in from a pharmacist 2. Official tasks of a pharmacist by law: • Performance descriptions Chris Prins, B.Sc 3. Financing pharmaceutical services: Utrecht University, • Negotiations between pharmacies and insurance companies Syreon Research Institute • Examples of negotiations • Medical Treatment Agreement Act 1. A short introduction to the Financing streams in the Dutch Healthcare System Dutch Healthcare system EXPENDITURE
FINANCING
EXPENDITURE PER ADULT
EACH YEAR
Other €7 Billion Other €7 Billion Individual contributions €2billion Taxes (VAT, etc) €1186,-
Col ected by government €17 Long Term Care contribution through income € 1029,-
Government contribution €3Bil ion Own Risk €3 Bil ion Own Risk € 369,-
Paid individual premiums Paid premiums to insurance companies € 1211,-
Employee contribution Employee contribution € 1577,-
Allowance for low income - € 297,-
Total €70 Billion Total €70 Billion each year Total €5075,- each year (official budget owner) An insurance company should theoratical y contract every pharmacy, in order to have geographically coverage of its patients.





Example of contracting The insurance company was In a relatively rural area in the Netherlands, there is only 1 pharmacy for approximately 40.000 patients. The court stated that the pharmacy was in a This pharmacy recognized he had some negotiating power. monopoly position and therefore he could not reject An insurance company with 40% marketshare does not the contract proposed by the insurance company want 16.000 patients to not have access to medicine! The pharmacist did not want to sign the contract because prices for services were too low. The insurance company took this case to court … Each pharmacy needs to buy up to
a maximum of 16 different products
of 4 active substances when dealing

with 4 insurance companies!
4 active substances with set dosage and 4 insurance companies: Up to 16 different products
GENERIC PREFERENCE PRICING POLICY Stabilization of pharmaceutical expenditure in public pharmacies Drug shortages in the last 10 years - Generic medicine prices tend to be lower, - Every half year the generic brand can change, because of bigger purchasing parties. causing confusion among patients. (Insurance companies vs Pharmacies) - Pharmacists have to explain the brand - Stabilization of pharmaceutical expenditure in switching, not the insurance companies! public pharmacies - Pharmacist hardly make any profit on the drug anymore. - Pharmacists have a massive increased administrative load, with nothing in return. Aggression towards pharmacy staff Savings each year - Drug shortage because of lower prices. (companies are not interested in this small country with extreme low prices) - Insurance companies are too powerful: "sign the contract at the bottom." - Next step: Therapeutic Preference Pricing?




2. Official tasks of a pharmacist These 13 performance indicators form the base for negotiations The Dutch Health Authority has set up 13 performance descriptions for pharmacists: between pharmacists and The distribution of medicine Patient counsel ing in case of new use of medicine insurance companies! Giving instructions in using pharmaceutical devices Conducting medication reviews on patients using chronic medication Pharmacotherapeutic coaching in case of policlinical visits Pharmacotherapeutic coaching in case of hospitalisation Pharmacotherapeutic coaching in case of hospital discharge Information sessions for pharmaceutical selfmanagement Giving advise on pharmaceutical "self-care" Keep in mind, the goal of insurance companies is to pay as
10. Giving advise on the use of medicine during travel little as possible.
11. Giving advise on the risks of il ness during travel 12. Mutual services 13. Additional performances These 13 performance descriptions form the base for negotiations between pharmacists and insurance The distribution of medicine 3. Financing pharmaceutical Patient counsel ing in case of new use of medicine Giving instructions in using pharmaceutical devices Conducting medication reviews on patients using chronic medication Pharmacotherapeutic coaching in case of policlinical visits Pharmacotherapeutic coaching in case of hospitalisation Pharmacotherapeutic coaching in case of hospital discharge Information sessions for pharmaceutical selfmanagement Giving advice on pharmaceutical "self-care" 10. Giving advice on the use of medicine during travel 11. Giving advice on the risks of il ness during travel 12. Mutual services 13. Additional performances Pharmacist: "I'd like you to make use of my skill and task of giving
information sessions for pharmaceutical selfmanagement, and pay As a pharmacist you have to show that your accordingly"

services are of added value! Insurance company: "Why should I pay you for giving information
sessions for pharmaceutical selfmanagement" Pharmacist: "So your asthma and COPD patients will use their
inhalators correctly, or diabetics measuring their glucose levels in the right way." "Increasing the effectiveness of adherence interventions may have a far greater impact Insurance company: "I don't care whether they use it correctly or not.
Why should I?" on the health of the population than any improvement in specific medical treatments" Interventions for helping patients to follow prescriptions for medic ations RB Haynes, H McDonald, AX Garg, P Montague Pharmacists: "This study shows that with additional
Additional conclusion:
interventions (PHARMACOP) savings of €227,- per patient
can be realised each year. This intervention also results in "Based on the cost-saving strategy, health
the prevention of 0.07 hospital-treated exacerbations per
insurance companies should be stimulated to
patient per year." reimburse these type of interventions.
Insurance company: "… How much money do you want?"
Furthermore, community pharmacists are well positioned - and are recommended - to integrate
COPD specific pharmaceutical care as part of
their daily practices"
+/- 300,000 COPD patients in the Netherlands… 300,000 * €227,- = €68.100.000,-
Smeele IJM, Van Weel C, Van Schayck CP, Van der Molen T, Thoonen B, Schermer T, et al. NHG-Standaard COPD. Huisarts Wet
Improving inhaler adherence in patients with chronic obstructive pulmonary disease: a cost-effectiveness analysis. van Boven JF1,
Improving inhaler adherence in patients with chronic obstructive pulmonary disease: a cost-effectiveness analysis. van Boven JF1,
Tommelein E, Boussery K, Mehuys E, Vegter S, Brusselle GG, Rutten-van Mölken MP, Postma MJ.
Tommelein E, Boussery K, Mehuys E, Vegter S, Brusselle GG, Rutten-van Mölken MP, Postma MJ.
Insurance companies in the Netherlands are afraid of hospitalization, and rightly so… One more important thing… • 195,372 Community Acquired Pneumonia cases among 16,7 mil ion "Wet Geneeskundige Behandelovereenkomst" • 63% (123,357) of the included patients were hospitalized for 1 or more "Medical Treatment Agreement Act" • 5.9% (n = 7241) spent at least one night in the Intensive Care Unit (ICU) This law states that a pharmacist is responsible for the • Mean costs ranged from €482,- per episode for 0–9 year olds treated in
treatment outcomes of a patient he distributes medication to. the outpatient hospital setting and up to €16.374,- per episode for 50–64
year olds admitted to the ICU
Conclusion: Effective interventions, targeted at older adults, to prevent
Why is this important? pneumonia could reduce the (financial) burden due to pneumonia!
Incidence, direct costs and duration of hospitalization of patients hospitalized with community acquired pneumonia: A nationwide retrospective claims database analysis. Mark H. Rozenbauma, et al. A pharmacist being held responsible for his actions, will have more incentive to properly execute his job. Bottom line:
In the Netherlands, 40.000 prescriptions are amended/changed by pharmacists each day, for various reasons: - Dosage alterations  Lower dosage for children (antibiotics), Taking responsibility for good higher dosage in case of kidney failure pharmaceutical care, as well as - Drug interactions  Interaction between paroxetin and quantifying and reporting your actions as a pharmacist is a first step in - Contra-indications  Ketoconazol and pregnancy achieving ánd providing better - Wrong description of use  Apply the crème thick vs thin healthcare for a fair price. - Wrong form of drugs  Tablets instead of a oral suspension - Unavailabilty of drugs  Finding the most suitable alternative


In a constantly changing field of
work, we have to remind
ourselves of Darwin.

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Impact of science a stakeholder's perspective

How Science Shapes Economic Professor of Economics, Georgia State University; Research Associate NBER Vienna, May 6, 2015 Paula Stephan Georgia State University & NBER • Discuss relationship between scientific research and economic growth and methods used to explore the • Make case that although there is strong relationship, caution is called for in assuming that relationship is

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Cruising Club of America Seasickness "Perhaps no malady to which mankind is subject is productive of so much real suffering, with so low a percentage of mortality, as the peculiar affliction known as seasickness." (Scientific American, 1912). In reviewing the 2012 Newport to Bermuda Race medical reports, there were 54 cases of self-reported seasickness on board vessels. I suspect, however, that the number of reported cases of seasickness significantly underestimates the actual incidence of this illness that may present in a full range of stages ranging from slight queasiness to severe nausea and vomiting. Anecdotally, I suspect that mild cases were not formally logged and some of the cases occurred without any thought toward preventative measures. As a sailing community, we pride ourselves in taking safety seriously. Vessels and crew must comply with strict requirements in order to be certified to participate in the Newport to Bermuda Race. Race participants and organizers spend considerable time preparing for events that are unlikely to happen, but should they occur, could be catastrophic. Potential problems include such scenarios as dismasting, blown sails, failed thru-hulls, sinking, losing one's rudder, and retrieving of crew in man overboard situations. Preparation for the Newport to Bermuda Race is labor intensive with considerable attention to a long list of details for safety's sake. Unfortunately, one situation, which participants do not seem to take as seriously and is much more likely to occur, is seasickness. Make no mistake about it, seasickness can also be life threatening. The 2012 Race underscores the seriousness of this illness with one vessel requiring an evacuation, which was precipitated by seasickness. Another vessel on the return trip was also abandoned with seasickness playing a major role in the event. This illness is a malady, which not only endangers the victim but also may place the rest of the crew in harm's way. Given the proper circumstance, no person is completely immune. Seasickness is not unique to sailors, as "motion sickness," the same illness, may occur in aircraft, automobiles, buses, your favorite carnival ride, and even trains. It is caused by the brain's inability to properly process sensory information, particularly from the inner ear, or the labyrinth apparatus, which is responsible for our sense of balance and position in relation to the rest of the environment around us. Seasickness occurs when our visual cues are mismatched with what our brain perceives. It is precipitated when we are unable to anticipate or line up visual cues with a particular, or perceived, motion. An excellent example is when sailors have to spend time in the bilge, while repairing an engine offshore. In this example, our brain senses a motion, vessel's movement, but the associated visual cues are absent. Add the smell of diesel fuel and the rest is readily predictable. Interestingly seasickness can also affect an individual in the absence of motion as may occur while viewing an action packed video game.