Revisão do Memorando - Saúde
Portugal: Second Review Under the Extended Arrangement, December 2011, IMF Country Report No. 11/363 , ATTACHMENT I. PORTUGAL—MEMORANDUM OF UNDERSTANDING ON SPECIFIC ECONOMIC POLICY CONDITIONALITY- Second Update—December 9, 2011
Health care system, pag 95 a 99 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 overall public spending on pharmaceutical to 1.25 percent of GDP by end 2012 and to about 1 per cent of GDP in 2013; 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. Following the approval of NHS moderating fees (taxas moderadoras), enact legislation reviewing and increasing overall NHS moderating fees (taxas moderadoras) by end December 2011 through:
i. a substantial revision of existing exemption categories, including stricter means-testing in cooperation with Minister of Social Security;
ii. an 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;
These measures should result in additional revenues of EUR 150 million in 2012 and anadditional 50 million in 2013.
3.52. 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 health-benefits schemes for civil servants will be accelerated. The current plan foresees 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]
3.53. Produce a health sector strategic plan, in the context of and consistent with the Medium-Term Fiscal Strategy. [Q4-2011]
Pricing and reimbursement of pharmaceuticals
3.54. The Government has approved legislation on setting the maximum price of the first generic introduced in the market to 50% of the branded product with the same activesubstance, and its enactment is expected by [Q4-2011]. Enact legislation which automatically reduces the prices of medicines when their patent expires. [Q4-2011]
3.55. Move the responsibility of pricing medicines to the Ministry of Health (for example to Infarmed). [Q4-2011]
3.56. The Government has approved legislation regarding the revision of the existing reference-pricing system based on international prices by using as countries of reference the three EU countries with the lowest price levels or countries with comparable GDP per capita levels; the enactment of this legislation is expected by [Q4-2011]. Countries of reference will be revised every year. [Ongoing]
Prescription and monitoring of prescription
3.57. Continue to improve the monitoring system of prescription of medicines and diagnostic and set in place a systematic assessment by individual doctors 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.
Feedback continues 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.
3.58. Devise and enforce a system of sanctions and penalties, as a complement to the assessment framework. [Q1-2012]
3.59. The Government has submitted legislation making it compulsory for physicians at all levels of the system, both public and private, to prescribe by International Nonproprietary Name (INN) to increase the use of generic medicines and the less costly available product.
Enactment of legislation is expected by [Q4-2011].
3.60. Establish clear rules for the prescription of medicines and the realisation of complementary diagnostic exams (prescription guidelines for physicians) on the basis of nternational prescription guidelines. [Q4-2011]
3.61. Enact legislation to 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]
Pharmaceutical retailers and wholesalers
3.62. Effectively implement the existing legislation regulating pharmacies. [Q4-2011]
3.63. The Government has approved legislation changing 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 expenditure on drugs distribution in 2012. Its enactment is expected by[Q4-2011]. Additional measures leading to further savings in public expenditure on the distribution of medicines should be taken by Q3-2012.
3.64. If the new system of calculation of profit margin will not produce the expected savings in the distribution profits, an additional contribution in the form of an average rebate (pay-back) will be introduced which will be calculated on the mark-up. The rebate will reduce the new mark-up on producer prices further by at least 2 percentage points on pharmacies and 4 percentage points on wholesalers. The rebate will be collected by the Government on a monthly basis through the Centro de Conferência de Facturas, preserving the profitability of small pharmacies in remote areas with low turnover. [Q3-2013]
Centralised purchasing and procurement
3.65. The Government has approved legislation regarding the administrative framework for a centralised procurement system for the purchase of medical goods in the NHS (equipments, appliances, medicines and services), through the recently created Central Purchasing
Authority (SPMS), in order to reduce costs through price-volume agreements and to fight waste. Its enactment is expected by [Q4-2011].
3.66. Finalise the uniform coding system and a common registry for medical supplies developed by INFARMED and SPMS based on international experience. Regularly update the registry. [Q4-2011]
3.67. Take measures to increase competition among private providers and reduce by at least 10 percent the overall spending (including fees) of the NHS with private providers delivering diagnostic and therapeutic services to the NHS by end 2011 and by an additional 10% by end 2012, regardless of the savings achieved in 2011. [Q4-2011]
3.68. 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]
3.69. 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 therapeutic services. [Q1-2012]
3.70. 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
3.71. As part of the reorganisation of health services provision and notably the concentration and specialisation of hospital services and the further development of a cost-effective primary care service, the Government reinforces measures aimed at further reducing unnecessary visits to specialists and emergencies and improving care coordination [Q1- 2012]. This will be done 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 a reduction in costs and more effective provision;
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;
iii. moving human resources from hospital settings to primary care settings and reconsidering the role of nurses and other specialties in the provision of services;
iv. Increase by at least 20% the maximum number of patients per primary care/ family doctor for health centres and by 10% for the USF.
Hospital services
3.72. To avoid further accumulation of arrears, the 2012 budget ensures adequate allocations to the health sector. The settlement process will give priority to arrears in hospitals, improve the liquidity position of suppliers and likely allow hospitals to obtain discounts when re-negotiating delivery contracts. A strategy with a binding timetable to clear all arrears in the health sector, within the overall strategy for arrears, will be implemented.
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. [Q4-2011]
3.73. Hospital 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]
3.74. Implement 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 with a view to reducing capacity. [Q1-2012]
3.75. Continue the publication of clinical guidelines and set in place an auditing system of their implementation. [Q4-2011]
3.76. 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]
3.77. 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]
3.78. 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]
3.79. Continue with the reorganisation and rationalisation of the hospital network through specialisation, concentration and downsizing of hospital and emergency services, joint management (building on the Decree-Law 30/2011) and joint operation of hospitals. These improvements will deliver additional cuts in operating costs by at least 5 percent 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. [Q1-2012]
3.80. Move some hospital outpatient services to primary care units (USF). [Q1-2012]
3.81. Annually update the inventory of all health staff by specialty, age, region (including autonomous regions), health centre and hospital, public and private sector so as to be able to identify practising, professional and licensed staff and current and future staff needs. [Q1- 2012]
3.82. 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. [Q2-2012]
3.83. 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 to 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 and reduce substantially expenditure for on-call services through rationalisation of services and elimination of duplication. [Q1-2012]
3.84. Review the payment mechanism for the prevention regime and per call payment ("pagamento por chamada") in the light of promoting efficiency and reducing costs in the health system. [Q2-2012]
Regional health authorities
3.85. Improve monitoring, internal control and fiscal risks management systems of theAdministraçoes Regionais de Saude. [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 compared to 2010. [Q4-2012]
Health care system, pag 95 a 99 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 overall public spending on pharmaceutical to 1.25 percent of GDP by end 2012 and to about 1 per cent of GDP in 2013; 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. Following the approval of NHS moderating fees (taxas moderadoras), enact legislation reviewing and increasing overall NHS moderating fees (taxas moderadoras) by end December 2011 through:
i. a substantial revision of existing exemption categories, including stricter means-testing in cooperation with Minister of Social Security;
ii. an 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;
These measures should result in additional revenues of EUR 150 million in 2012 and anadditional 50 million in 2013.
3.52. 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 health-benefits schemes for civil servants will be accelerated. The current plan foresees 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]
3.53. Produce a health sector strategic plan, in the context of and consistent with the Medium-Term Fiscal Strategy. [Q4-2011]
Pricing and reimbursement of pharmaceuticals
3.54. The Government has approved legislation on setting the maximum price of the first generic introduced in the market to 50% of the branded product with the same activesubstance, and its enactment is expected by [Q4-2011]. Enact legislation which automatically reduces the prices of medicines when their patent expires. [Q4-2011]
3.55. Move the responsibility of pricing medicines to the Ministry of Health (for example to Infarmed). [Q4-2011]
3.56. The Government has approved legislation regarding the revision of the existing reference-pricing system based on international prices by using as countries of reference the three EU countries with the lowest price levels or countries with comparable GDP per capita levels; the enactment of this legislation is expected by [Q4-2011]. Countries of reference will be revised every year. [Ongoing]
Prescription and monitoring of prescription
3.57. Continue to improve the monitoring system of prescription of medicines and diagnostic and set in place a systematic assessment by individual doctors 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.
Feedback continues 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.
3.58. Devise and enforce a system of sanctions and penalties, as a complement to the assessment framework. [Q1-2012]
3.59. The Government has submitted legislation making it compulsory for physicians at all levels of the system, both public and private, to prescribe by International Nonproprietary Name (INN) to increase the use of generic medicines and the less costly available product.
Enactment of legislation is expected by [Q4-2011].
3.60. Establish clear rules for the prescription of medicines and the realisation of complementary diagnostic exams (prescription guidelines for physicians) on the basis of nternational prescription guidelines. [Q4-2011]
3.61. Enact legislation to 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]
Pharmaceutical retailers and wholesalers
3.62. Effectively implement the existing legislation regulating pharmacies. [Q4-2011]
3.63. The Government has approved legislation changing 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 expenditure on drugs distribution in 2012. Its enactment is expected by[Q4-2011]. Additional measures leading to further savings in public expenditure on the distribution of medicines should be taken by Q3-2012.
3.64. If the new system of calculation of profit margin will not produce the expected savings in the distribution profits, an additional contribution in the form of an average rebate (pay-back) will be introduced which will be calculated on the mark-up. The rebate will reduce the new mark-up on producer prices further by at least 2 percentage points on pharmacies and 4 percentage points on wholesalers. The rebate will be collected by the Government on a monthly basis through the Centro de Conferência de Facturas, preserving the profitability of small pharmacies in remote areas with low turnover. [Q3-2013]
Centralised purchasing and procurement
3.65. The Government has approved legislation regarding the administrative framework for a centralised procurement system for the purchase of medical goods in the NHS (equipments, appliances, medicines and services), through the recently created Central Purchasing
Authority (SPMS), in order to reduce costs through price-volume agreements and to fight waste. Its enactment is expected by [Q4-2011].
3.66. Finalise the uniform coding system and a common registry for medical supplies developed by INFARMED and SPMS based on international experience. Regularly update the registry. [Q4-2011]
3.67. Take measures to increase competition among private providers and reduce by at least 10 percent the overall spending (including fees) of the NHS with private providers delivering diagnostic and therapeutic services to the NHS by end 2011 and by an additional 10% by end 2012, regardless of the savings achieved in 2011. [Q4-2011]
3.68. 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]
3.69. 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 therapeutic services. [Q1-2012]
3.70. 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
3.71. As part of the reorganisation of health services provision and notably the concentration and specialisation of hospital services and the further development of a cost-effective primary care service, the Government reinforces measures aimed at further reducing unnecessary visits to specialists and emergencies and improving care coordination [Q1- 2012]. This will be done 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 a reduction in costs and more effective provision;
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;
iii. moving human resources from hospital settings to primary care settings and reconsidering the role of nurses and other specialties in the provision of services;
iv. Increase by at least 20% the maximum number of patients per primary care/ family doctor for health centres and by 10% for the USF.
Hospital services
3.72. To avoid further accumulation of arrears, the 2012 budget ensures adequate allocations to the health sector. The settlement process will give priority to arrears in hospitals, improve the liquidity position of suppliers and likely allow hospitals to obtain discounts when re-negotiating delivery contracts. A strategy with a binding timetable to clear all arrears in the health sector, within the overall strategy for arrears, will be implemented.
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. [Q4-2011]
3.73. Hospital 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]
3.74. Implement 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 with a view to reducing capacity. [Q1-2012]
3.75. Continue the publication of clinical guidelines and set in place an auditing system of their implementation. [Q4-2011]
3.76. 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]
3.77. 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]
3.78. 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]
3.79. Continue with the reorganisation and rationalisation of the hospital network through specialisation, concentration and downsizing of hospital and emergency services, joint management (building on the Decree-Law 30/2011) and joint operation of hospitals. These improvements will deliver additional cuts in operating costs by at least 5 percent 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. [Q1-2012]
3.80. Move some hospital outpatient services to primary care units (USF). [Q1-2012]
3.81. Annually update the inventory of all health staff by specialty, age, region (including autonomous regions), health centre and hospital, public and private sector so as to be able to identify practising, professional and licensed staff and current and future staff needs. [Q1- 2012]
3.82. 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. [Q2-2012]
3.83. 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 to 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 and reduce substantially expenditure for on-call services through rationalisation of services and elimination of duplication. [Q1-2012]
3.84. Review the payment mechanism for the prevention regime and per call payment ("pagamento por chamada") in the light of promoting efficiency and reducing costs in the health system. [Q2-2012]
Regional health authorities
3.85. Improve monitoring, internal control and fiscal risks management systems of theAdministraçoes Regionais de Saude. [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 compared to 2010. [Q4-2012]
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