MEMORANDUM - First Update 01.09.11
Health care system
Objectives
Improve efficiency and effectiveness in the health care system, inducing a more rational use of services and control of expenditures; generate additional savings in the area of pharmaceuticals to reduce the public spending on pharmaceutical to 1.25 per cent of GDP by end 2012 and to about 1 per cent of GDP in 2013 (in line with EU average); generate additional savings in hospital operating costs and devise a strategy to eliminate arrears.
The Government will take the following measures to reform the health system:
Financing
3.51. Review and increase overall NHS moderating fees (taxas moderadoras) through:
i. a substantial revision of existing exemption categories, including stricter means-testing in cooperation with Minister of Social Security; [by September-2011]
ii. increase of moderating fees in certain services while ensuring that primary care moderating fees are lower than those for outpatient specialist care visits and lower than emergency visits; [by September-2011]
iii. legislate automatic indexation to inflation of NHS moderating fees. [Q4-2011]
3.52. Cut substantially (by two thirds overall) tax allowances for healthcare, including private insurance by end-October.
3.53. In the light of the urgency and size of the savings needed in the health sector to address large arrears and budget limitations plans to achieve a self sustainable model for healthbenefits schemes for civil servants will be accelerated. The current plan foresee that the overall budgetary cost of existing schemes – ADSE, ADM (Armed Forces) and SAD (Police Services) - will be reduced by 30% in 2012 and by further 20% in 2013 at all levels of general government. The system would become self-financed by 2016. The budgetary costs of these schemes will be reduced by lowering the employer’s contribution and adjusting the scope of health benefits. [Q4-2011]
3.54. Produce a health sector strategic plan, in the context of and consistent with the mediumterm budget framework. [Q4-2011]
Pricing and reimbursement of pharmaceuticals
3.55. Set the maximum price of the first generic introduced in the market to 50% of the branded product with same active substance. [Q3-2011] Reduce automatically prices of drugs when their patent expires. [Q4-2011]
3.56. Move the responsibility of pricing medicines to the Ministry of Health (for example to the Infarmed). [Q4-2011]
3.57. Revise the existing reference-pricing system based on international prices by changing the countries of reference to the three EU countries with the lowest price levels or countries with comparable GDP per capita levels. [Q4-2011]
Prescription and monitoring of prescription
3.58. Make electronic prescription for medicines and diagnostic covered by public reimbursement fully compulsory for physicians in both the public and private sector. [Q3- 2011]
3.59. Improve the monitoring system of prescription of medicines and diagnostic and set in place a systematic assessment by individual doctor in terms of volume and value, vis-à-vis prescription guidelines and peers The assessment will be done through a dedicated unit under the Ministry of Health such as the Centro de Conferência de Facturas. Sanctions and penalties will be envisaged and enforced as a follow up to the assessment. [Q3-2011] . Feedback is to be provided to each physician on a regular basis (e.g. quarterly), in particular on prescription of costliest and most used medicines, starting from Q4-2011.
3.60. Induce physicians at all levels of the system, both public and private, to prescribe generic medicines and the less costly available branded product. [Q3-2011]
3.61. Establish clear rules for the prescription of drugs and the realisation of complementary diagnostic exams (prescription guidelines for physicians) on the basis of international prescription guidelines. [Q4-2011]
3.62. Remove all effective entry barriers for generic medicines, in particular by reducing administrative/legal hurdles in order to speed up the use and reimbursement of generics. [Q4- 2011]
Pharmacies sector
3.63. Effectively implement the existing legislation regulating pharmacies. [Q4-2011]
3.64. Change the calculation of profit margin into a regressive mark-up and a flat fee for wholesale companies and pharmacies on the basis of the experience in other Member States. The new system should ensure a reduction in public spending on pharmaceuticals and encourage the sales of less expensive pharmaceuticals. The aim is that lower profits will contribute at least EUR 50 million to the reduction in public expense with drugs distribution. [Q4-2011]
3.65. If the new system of calculation of profit margin will not produce the expected savings in the distribution profits, introduce a contribution in the form of an average rebate (pay-back) which will be calculated on the mark-up. The rebate will reduce the mark-up by at least 3 percentage points. The rebate will be collected by the Government on a monthly basis through Centro de Conferência de Facturas, preserving the profitability of small pharmacies in remote areas with low turnover. [Q1 -2012]
Centralised purchasing and procurement
3.66. Set up the legislative and administrative framework for a centralised procurement system for the purchase of medical goods in the NHS (equipments, appliances, pharmaceuticals), through the recently created Central Purchasing Authority (SPMS), in order to reduce costs through price-volume agreements and fight waste. [Q3-2011]
3.67. Finalise the uniform coding system and a common registry for medical supplies developed by the INFARMED and SPMS based on international experience. Regularly update the registry. [Q4-2011]
3.68. Take measures to increase competition among private providers and reduce by at least 10 per cent the overall spending (including fees) of the NHS with private providers delivering diagnostic and therapeutical services to the NHS by end 2011 and by an additional 10% by end 2012. [Q4-2011]
3.69. Implement the centralised purchasing of medical goods through the recently created Central Purchasing Authority (SPMS), using the uniform coding system for medical supplies and pharmaceuticals. [Q1-2012]
3.70. Introduce a regular revision (at least every two years) of the fees paid to private providers with the aim of reducing the cost of more mature diagnostic and therapeutical services. [Q1-2012]
3.71. Assess compliance with European competition rules of the provision of services in the private healthcare sector and guarantee increasing competition among private providers [Q1- 2012]
Primary care services
3.72. The Government proceeds with the reinforcement of primary care services so as to further reduce unnecessary visits to specialists and emergencies and to improve care coordination through:
i. increasing the number of USF (Unidades de Saúde Familiares) units contracting with regional authorities (ARSs) using a mix of salary and performance-related payments as currently the case. Make sure that the new system leads to reduction in costs and more effective provision; [Q3-2011]
ii. set-up a mechanism to guarantee the presence of family doctors in needed areas to induce a more even distribution of family doctors across the country. [Q4-2011]
Hospital services
3.73. Set out a strategy and a binding timetable to clear all arrears in the health sector. The strategy will include the introduction of standardised and tight control procedures for all health sector entities to prevent the re-emergence of arrears. In addition, a mechanism is put in place to ensure strong coordination between the Ministry of Health and the Ministry of Finance for the application of the same monitoring and control criteria to all types of hospitals. [Q3-2011]
3.74. Hospitals SOEs will swiftly change the existing accounting framework and adopt accounting standards in line with the requirements for private companies and other SOEs. This will help improving the management of the enterprises and the quality of the financial oversight by the general government. [Q4-2012]
3.75. Provide detailed description of measures aimed at achieving a reduction of at least EUR 200 million in the operational costs of hospitals in 2012 (EUR 100 million in 2012 in addition to savings of over EUR 100 million already in 2011). This is to be achieved through the reduction in the number of management staff, concentration and rationalisation in state hospitals and health centres and annual ceilings to PPP contracts. [Q3-2011]
3.76. Continue the publication of clinical guidelines and set in place an auditing system of their implementation. [Q3-2011]
3.77. Improve selection criteria and adopt measures to ensure a more transparent selection of the chairs and members of hospital boards. Members will be required by law to be persons of recognised standing in health, management and health administration. [Q4-2011]
3.78. Set up a system for comparing hospital performance (benchmarking) on the basis of a comprehensive set of indicators and produce regular annual reports, the first one to be published by end 2012. Indicators are to include financial indicators. [Q1-2012]
3.79. Ensure full interoperability of IT systems in hospital, in order for the ACSS to gather real time information on hospital activities and to produce monthly reports to the Ministry of Health and the Ministry of Finance. [Q1-2012]
3.80. Continue with the reorganisation and rationalisation of the hospital network through specialisation and concentration of hospital and emergency services and joint management (building on the Decree-Law 30/2011) joint operation of hospitals. These improvements will deliver additional cuts in operating costs by at least 5 per cent in 2013. A detailed action plan is published by 30 November 2012 and its implementation is finalised by the first quarter 2013. Overall, from 2011 to 2013, hospital operational costs must be reduced by at least 15% compared to 2010 level. [Q2-2012]
3.81. Move some hospital outpatient services to primary care units (USF). [Q2-2012]
3.82. Annually update the inventory of all practising doctors by specialty, age, region, health centre and hospital, public and private sector so as to be able to identify practising, professional and licensed physicians and current and future staff needs by the above categories by October 2011. The inventory will subsequently be extended to other categories of staff. It will also include figures for the autonomous regions of Madeira and Azores. [Q1- 2012]
3.83. Prepare regular annual reports presenting plans for the allocation of human resources in the period up to 2014. The Report specifies plans to reallocate qualified and support staff within the NHS. [Q3-2011]
3.84. Introduce rules to increase mobility of healthcare staff (including doctors) within and across health regions. Adopt for all staff (including doctors) flexible time arrangements, with a view of reducing by at least 20% spending on overtime compensation in 2012 and another 20% in 2013. Implement a strict control of working hours and activities of staff in the hospital. [Q1-2012]
Regional health authorities
3.85. Improve monitoring, internal control and fiscal risks management systems of the Administraçoes Regionais de Saude by Q4-2012.
Cross services
3.86. Finalise the set-up of a system of patient electronic medical records. [Q2-2012]
3.87. Reduce costs for patient transportation by one third. [Q3-2011].
PORTUGAL- MEMORANDUM OF UNDERSTANDING ON SPECIFIC ECONOMIC POLICY CONDITIONALITY - First Update – 1 September 2011 link
Objectives
Improve efficiency and effectiveness in the health care system, inducing a more rational use of services and control of expenditures; generate additional savings in the area of pharmaceuticals to reduce the public spending on pharmaceutical to 1.25 per cent of GDP by end 2012 and to about 1 per cent of GDP in 2013 (in line with EU average); generate additional savings in hospital operating costs and devise a strategy to eliminate arrears.
The Government will take the following measures to reform the health system:
Financing
3.51. Review and increase overall NHS moderating fees (taxas moderadoras) through:
i. a substantial revision of existing exemption categories, including stricter means-testing in cooperation with Minister of Social Security; [by September-2011]
ii. increase of moderating fees in certain services while ensuring that primary care moderating fees are lower than those for outpatient specialist care visits and lower than emergency visits; [by September-2011]
iii. legislate automatic indexation to inflation of NHS moderating fees. [Q4-2011]
3.52. Cut substantially (by two thirds overall) tax allowances for healthcare, including private insurance by end-October.
3.53. In the light of the urgency and size of the savings needed in the health sector to address large arrears and budget limitations plans to achieve a self sustainable model for healthbenefits schemes for civil servants will be accelerated. The current plan foresee that the overall budgetary cost of existing schemes – ADSE, ADM (Armed Forces) and SAD (Police Services) - will be reduced by 30% in 2012 and by further 20% in 2013 at all levels of general government. The system would become self-financed by 2016. The budgetary costs of these schemes will be reduced by lowering the employer’s contribution and adjusting the scope of health benefits. [Q4-2011]
3.54. Produce a health sector strategic plan, in the context of and consistent with the mediumterm budget framework. [Q4-2011]
Pricing and reimbursement of pharmaceuticals
3.55. Set the maximum price of the first generic introduced in the market to 50% of the branded product with same active substance. [Q3-2011] Reduce automatically prices of drugs when their patent expires. [Q4-2011]
3.56. Move the responsibility of pricing medicines to the Ministry of Health (for example to the Infarmed). [Q4-2011]
3.57. Revise the existing reference-pricing system based on international prices by changing the countries of reference to the three EU countries with the lowest price levels or countries with comparable GDP per capita levels. [Q4-2011]
Prescription and monitoring of prescription
3.58. Make electronic prescription for medicines and diagnostic covered by public reimbursement fully compulsory for physicians in both the public and private sector. [Q3- 2011]
3.59. Improve the monitoring system of prescription of medicines and diagnostic and set in place a systematic assessment by individual doctor in terms of volume and value, vis-à-vis prescription guidelines and peers The assessment will be done through a dedicated unit under the Ministry of Health such as the Centro de Conferência de Facturas. Sanctions and penalties will be envisaged and enforced as a follow up to the assessment. [Q3-2011] . Feedback is to be provided to each physician on a regular basis (e.g. quarterly), in particular on prescription of costliest and most used medicines, starting from Q4-2011.
3.60. Induce physicians at all levels of the system, both public and private, to prescribe generic medicines and the less costly available branded product. [Q3-2011]
3.61. Establish clear rules for the prescription of drugs and the realisation of complementary diagnostic exams (prescription guidelines for physicians) on the basis of international prescription guidelines. [Q4-2011]
3.62. Remove all effective entry barriers for generic medicines, in particular by reducing administrative/legal hurdles in order to speed up the use and reimbursement of generics. [Q4- 2011]
Pharmacies sector
3.63. Effectively implement the existing legislation regulating pharmacies. [Q4-2011]
3.64. Change the calculation of profit margin into a regressive mark-up and a flat fee for wholesale companies and pharmacies on the basis of the experience in other Member States. The new system should ensure a reduction in public spending on pharmaceuticals and encourage the sales of less expensive pharmaceuticals. The aim is that lower profits will contribute at least EUR 50 million to the reduction in public expense with drugs distribution. [Q4-2011]
3.65. If the new system of calculation of profit margin will not produce the expected savings in the distribution profits, introduce a contribution in the form of an average rebate (pay-back) which will be calculated on the mark-up. The rebate will reduce the mark-up by at least 3 percentage points. The rebate will be collected by the Government on a monthly basis through Centro de Conferência de Facturas, preserving the profitability of small pharmacies in remote areas with low turnover. [Q1 -2012]
Centralised purchasing and procurement
3.66. Set up the legislative and administrative framework for a centralised procurement system for the purchase of medical goods in the NHS (equipments, appliances, pharmaceuticals), through the recently created Central Purchasing Authority (SPMS), in order to reduce costs through price-volume agreements and fight waste. [Q3-2011]
3.67. Finalise the uniform coding system and a common registry for medical supplies developed by the INFARMED and SPMS based on international experience. Regularly update the registry. [Q4-2011]
3.68. Take measures to increase competition among private providers and reduce by at least 10 per cent the overall spending (including fees) of the NHS with private providers delivering diagnostic and therapeutical services to the NHS by end 2011 and by an additional 10% by end 2012. [Q4-2011]
3.69. Implement the centralised purchasing of medical goods through the recently created Central Purchasing Authority (SPMS), using the uniform coding system for medical supplies and pharmaceuticals. [Q1-2012]
3.70. Introduce a regular revision (at least every two years) of the fees paid to private providers with the aim of reducing the cost of more mature diagnostic and therapeutical services. [Q1-2012]
3.71. Assess compliance with European competition rules of the provision of services in the private healthcare sector and guarantee increasing competition among private providers [Q1- 2012]
Primary care services
3.72. The Government proceeds with the reinforcement of primary care services so as to further reduce unnecessary visits to specialists and emergencies and to improve care coordination through:
i. increasing the number of USF (Unidades de Saúde Familiares) units contracting with regional authorities (ARSs) using a mix of salary and performance-related payments as currently the case. Make sure that the new system leads to reduction in costs and more effective provision; [Q3-2011]
ii. set-up a mechanism to guarantee the presence of family doctors in needed areas to induce a more even distribution of family doctors across the country. [Q4-2011]
Hospital services
3.73. Set out a strategy and a binding timetable to clear all arrears in the health sector. The strategy will include the introduction of standardised and tight control procedures for all health sector entities to prevent the re-emergence of arrears. In addition, a mechanism is put in place to ensure strong coordination between the Ministry of Health and the Ministry of Finance for the application of the same monitoring and control criteria to all types of hospitals. [Q3-2011]
3.74. Hospitals SOEs will swiftly change the existing accounting framework and adopt accounting standards in line with the requirements for private companies and other SOEs. This will help improving the management of the enterprises and the quality of the financial oversight by the general government. [Q4-2012]
3.75. Provide detailed description of measures aimed at achieving a reduction of at least EUR 200 million in the operational costs of hospitals in 2012 (EUR 100 million in 2012 in addition to savings of over EUR 100 million already in 2011). This is to be achieved through the reduction in the number of management staff, concentration and rationalisation in state hospitals and health centres and annual ceilings to PPP contracts. [Q3-2011]
3.76. Continue the publication of clinical guidelines and set in place an auditing system of their implementation. [Q3-2011]
3.77. Improve selection criteria and adopt measures to ensure a more transparent selection of the chairs and members of hospital boards. Members will be required by law to be persons of recognised standing in health, management and health administration. [Q4-2011]
3.78. Set up a system for comparing hospital performance (benchmarking) on the basis of a comprehensive set of indicators and produce regular annual reports, the first one to be published by end 2012. Indicators are to include financial indicators. [Q1-2012]
3.79. Ensure full interoperability of IT systems in hospital, in order for the ACSS to gather real time information on hospital activities and to produce monthly reports to the Ministry of Health and the Ministry of Finance. [Q1-2012]
3.80. Continue with the reorganisation and rationalisation of the hospital network through specialisation and concentration of hospital and emergency services and joint management (building on the Decree-Law 30/2011) joint operation of hospitals. These improvements will deliver additional cuts in operating costs by at least 5 per cent in 2013. A detailed action plan is published by 30 November 2012 and its implementation is finalised by the first quarter 2013. Overall, from 2011 to 2013, hospital operational costs must be reduced by at least 15% compared to 2010 level. [Q2-2012]
3.81. Move some hospital outpatient services to primary care units (USF). [Q2-2012]
3.82. Annually update the inventory of all practising doctors by specialty, age, region, health centre and hospital, public and private sector so as to be able to identify practising, professional and licensed physicians and current and future staff needs by the above categories by October 2011. The inventory will subsequently be extended to other categories of staff. It will also include figures for the autonomous regions of Madeira and Azores. [Q1- 2012]
3.83. Prepare regular annual reports presenting plans for the allocation of human resources in the period up to 2014. The Report specifies plans to reallocate qualified and support staff within the NHS. [Q3-2011]
3.84. Introduce rules to increase mobility of healthcare staff (including doctors) within and across health regions. Adopt for all staff (including doctors) flexible time arrangements, with a view of reducing by at least 20% spending on overtime compensation in 2012 and another 20% in 2013. Implement a strict control of working hours and activities of staff in the hospital. [Q1-2012]
Regional health authorities
3.85. Improve monitoring, internal control and fiscal risks management systems of the Administraçoes Regionais de Saude by Q4-2012.
Cross services
3.86. Finalise the set-up of a system of patient electronic medical records. [Q2-2012]
3.87. Reduce costs for patient transportation by one third. [Q3-2011].
PORTUGAL- MEMORANDUM OF UNDERSTANDING ON SPECIFIC ECONOMIC POLICY CONDITIONALITY - First Update – 1 September 2011 link
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