Quinta avaliação: Health care system

Programa de assistência financeira a Portugal 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

3.41. The revision of NHS moderating fees (taxas moderadoras) will result in additional  revenues of EUR 150 million in 2012 and an additional 50 million in 2013. [Q4-2012]

3.42. 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 per cent in 2012 and by further 20 per cent in 2013  93   at all levels of general government. The system would become self-financed by 2016. The  costs of these schemes for the public budget  will be reduced by lowering the employer’s  contribution rate to 1.25% in 2013 and by adjusting the scope of health benefits. [Q3-2012]. 

Pricing and reimbursement of pharmaceuticals 

3.43. Enact legislation which automatically reduces the prices of medicines when their  patent expires to 50 per cent of their previous price. [Q4-2012]

3.44. The government implements an annual revision of prices of medicines and of  countries of reference in order to achieve cost savings. Second price revision to be published  in January 2013.

3.45. The government will monitor monthly pharmaceutical expenditures and ensure that  the overall public pharmaceutical expenditure does not exceed the target of 1.25 per cent of  GDP in 2012 and 1 per cent of GDP in 2013. [Ongoing]

Prescription and monitoring of prescription

3.46. Continue to improve the monitoring and assessment system of doctors' prescription  behaviour regarding medicines and diagnostic  in terms of volume and value and vis-à-vis  prescription guidelines and peers. 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. [Ongoing] 

3.47. Continue to devise and enforce a system of sanctions and penalties, as a complement  to the assessment framework [Ongoing]. Assess the possibility of establishing agreements  with private sector physicians for the application of prescription rules as applied in the NHS. 

3.48. Strictly monitor the implementation of the legislation making it compulsory for  physicians at all levels of the system, both public and private, to prescribe by International  Non-proprietary Name (INN) to increase the use of generic medicines and the less costly  available product. An implementation report will be published by December 2012.

3.49. Continue to publish prescription guidelines with reference to medicines and the  realisation of complementary diagnostic exams on the basis of international prescription  guidelines, audit their implementation and integrate them in the electronic prescription  system. A first set of guidelines is introduced in the e-prescription system by Q2 2013.

3.50. The government will produce a report assessing the effectiveness of the enacted  legislation aimed at removing 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. [Q1-2013]

3.51. The above measures should aim at gradually and substantially increasing the share of  generic medicines to at least 30 per cent of all outpatient prescription (in volume) in 2012.  Targets for substantial further increases in 2013 will be agreed in the sixth review. Pharmaceutical retailers and wholesalers 

3.52. The Government will produce an intermediate assessment of the savings related to  the revision of the calculation of profit margins for wholesale companies and pharmacies.  [Q3-2012].

3.53. If the revision does not produce the expected reduction in the distribution profits of at  least EUR 50 million, 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. [Q4-2013]

Centralised purchasing and procurement

3.54. Reinforce the centralised acquisition of vehicles, utilities, external services and other  cross functional goods and services by all entities included in the NHS, in order to reduce  costs through price volume agreements and fighting waste. A detailed  action plan will be  published by November 2012.

3.55. INFARMED will continue implementing the uniform coding system and a common  registry for medical supplies. [Ongoing]

3.56. Take further measures to increase competition among private providers and reduce by  an additional 10 percent the overall spending of the NHS with private providers delivering  diagnostic and therapeutic services (with particular reference to dialysis and rehabilitation).

Regularly evaluate and if necessary revise (at least every two years) the remuneration paid to  private providers with the aim of reducing the cost of more mature diagnostic and therapeutic  services. [Q4-2012]

3.57. 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. Assess the possibility of implementing the compulsory use of a  formulary in all hospitals to monitor the stock and flows of hospital medicines and medical  supplies and monitor compliance with central purchasing. [Ongoing]

3.58. Conduct an analysis of the market characteristics of relevant areas of service  provision such as dialysis and the pharmacies sector in view of ensuring competition and fair  prices in private markets.  [Q4-2013]

Primary care services

3.59. As part of the reorganisation of health services provision and notably the  concentration and specialisation of hospital services and the further development of a costeffective primary care service, the Government reinforces measures aimed at further reducing  unnecessary visits to specialists and emergencies and improving care coordination.

[Ongoing] 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. Extend performance  assessment to the other primary care units (UCSPs). Make sure that the new  system leads to a reduction in costs and more effective provision;

ii. setting-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. updating patients' registration lists and the national register in order to increase by at least 20 per cent the maximum number of patients per primary care/family doctor for health centres and by 10 per cent for the USF.  

Hospital services

3.60. Implement the strategy to clear arrears in the health sector, within the overall strategy  for settling and avoiding the re-emergence of arrears. Ensure standardised and tight control  procedures for all health sector entities to ensure expenditure commitments stay within the  budget allocated to each entity and therefore prevent the re-emergence of arrears. [Q3-2012]

3.61. Hospital SOEs will 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. [Q4-2013]

3.62. Implement measures aimed at achieving a reduction of at least EUR 200 million in  the operational costs of hospitals in 2012. 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. [Q4-2012]

3.63. Continue the publication of clinical guidelines and set in place an auditing system of their implementation. [Ongoing]

3.64. On the basis of the comprehensive set of indicators, produce regular annual reports  comparing hospital performance (benchmarking). Establish a web-portal with publicly  available information. The first report is to be published by end 2012 and its results should  be used to establish targets for less performing hospitals. [Q4-2012]

3.65. Continue work to ensure full interoperability of IT systems in hospitals, in order for  the ACSS to gather real time information on hospital accounting and activities and to produce  monthly reports to the Ministry of Health and the Ministry of Finance. [Ongoing]

3.66. Continue with the reorganisation and rationalisation of the hospital network through  specialisation, concentration and downsizing of hospital services, joint management (building  on the Decree-Law 30/2011) and joint operation of hospitals. The aim is to adjust hospital  provision within the same health region, notably in the presence of newly established PPP  hospitals, adjust the activity of some hospitals from curative care towards areas such as  rehabilitation, long-term and palliative care and revise emergency and transplantation  structures. These improvements aim at eliminating unnecessary duplication, achieving  economies of scale and deliver additional cuts in operating costs by at least 5 percent in 2013  while improving the quality of care provided. A detailed action plan is published  by 30  November 2012 and its implementation is finalised  by end-2013. Overall, from  2011 to 2013, hospital operational costs must be reduced by at least 15 per cent compared to 2010  level. [Q4-2012]

3.67. Annually update the inventory of all health staff and 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. [Q2-2013]

3.68. Update the current legal framework applying to the organisation of working time of healthcare staff, including introduction of rules to increase mobility within and across Health  Regions, adoption of flexible  time arrangements and review of payment mechanisms for  emergency work, the prevention regime and per call payments, notably by aligning overtime remuneration in the health care sector with the general legal framework recently adopted. In  this context, overtime compensation should be reduced by 20% in 2012 and another 20% in  2013.[Q4-2012]

Regional health authorities

3.69. Improve monitoring, internal control and  fiscal risks management systems of the  Administrações Regionais de Saúde. [Q4-2012]

Cross services

3.70. Roll-out the system of patient electronic medical records and ensure access to all  relevant health care facilities. [Ongoing]

3.71. Reduce costs for patient transportation by one third compared to 2010. [Q4-2012]