Pricing and reimbursement

Worth regulation

To what extent is the market worth of a medicinal product or medical gadget ruled by regulation or regulation?

Medicinal merchandise which are reimbursed by the essential medical insurance are topic to authorities worth management. The costs of non-reimbursed merchandise are free and are usually not government-controlled.

A ready-to-use medicinal product (whether or not prescription-only or non-prescription) should, in precept, be listed on the speciality record (SL) established by the Federal Workplace of Public Well being to be reimbursed within the primary medical insurance (except it’s paid by hospitals out of a diagnosis-related group flat-rate). When deciding on the admission of a medicinal product to the SL, the Federal Workplace of Public Well being determines its record worth. This worth is the utmost worth that may be invoiced by healthcare suppliers and that will likely be reimbursed by medical insurance corporations. About 80 per cent of the gross sales of pharmaceutical merchandise in Switzerland relate to merchandise listed on the SL.

If a medicinal product shouldn’t be listed on the SL or is listed on the SL however is used off-label or outdoors a limitation of reimbursement, it have to be taken over by the medical insurance corporations in primary medical insurance if there isn’t a efficient and authorised therapy various in opposition to a deadly or extreme and persistent sickness, and a excessive therapeutic profit may be anticipated from its use. On this state of affairs, the medical insurance corporations decide the reimbursed quantity and negotiate a price participation with the pharmaceutical firm involved.

For medical gadgets used or utilized by sufferers themselves or individuals supporting in a non-professional capability or by healthcare suppliers offering nursing providers, the medical insurance corporations pay a sure fastened quantity per gadget that’s listed within the record of aids and gear independently of the value of the particular medical gadget in query. For medical gadgets utilized by medicinal healthcare professionals or hospitals not for nursing providers, the reimbursement is ruled by the tariff agreements regulating the reimbursement of their healthcare providers.

Negotiations between producers and suppliers

Should pharmaceutical and medical gadget producers negotiate the costs of their merchandise with public healthcare suppliers?

For reimbursed medicinal merchandise, the SL established by the Federal Workplace of Public Well being lists the utmost ex-factory worth and the SL worth. Healthcare suppliers can negotiate a cheaper price than the ex-factory worth with the pharmaceutical producers. Generally rebates are granted, particularly to hospitals. Costs of medical gadgets will also be negotiated. For non-reimbursed merchandise, costs may be negotiated amongst pharmaceutical producers and healthcare suppliers.

Reimbursement

Through which circumstances will the nationwide medical insurance system reimburse the price of medicines?

Beneath the essential medical insurance, medical insurance corporations pay or reimburse ready-to-use medicinal merchandise prescribed by physicians for outpatient therapy (or, below sure circumstances, chiropractors) which are listed on the SL if they’re used inside their indication. The SL itemizing could also be accompanied with limitations relating to reimbursement.

In two distinctive conditions, the prices of a product that’s both not listed on the SL, or is listed on the SL however used off-label or outdoors a limitation of reimbursement, are taken over by the essential medical insurance: in a state of affairs when there isn’t a efficient and authorised therapy various in opposition to a deadly or extreme and persistent sickness and a excessive therapeutic profit may be anticipated from its use, and within the state of affairs of a ‘therapy advanced’ (ie, when there’s a very slender connection between medical providers which are reimbursed and providers that aren’t or are solely partially reimbursed when the non-reimbursed providers are a essential situation for the therapy, or are of appreciable significance for the success of the therapy). In each conditions, the doctor of confidence of the respective medical insurance firm needs to be consulted, and the medical insurance firm has to approve reimbursement upfront and determines the extent of reimbursement after having negotiated a cost-contribution with the producer.

Within the inpatient sector, the prices of medicines are primarily paid via, and included in, flat-rate funds per case. For sure medicines, separate supplementary charges may be invoiced by the hospital to the medical insurance corporations.

Non-obligatory extra personal insurance coverage may additionally cowl sure authorised medicinal merchandise that aren’t listed within the SL.

Worth adjudication

If relevant, what’s the competent physique for selections relating to the pricing and reimbursability of medicinal merchandise?

The competent physique is the Swiss Federal Workplace of Public Well being. It decides on the admission of completed medicinal merchandise to the SL. A medicinal product is simply admitted to the SL if the applicant can present its efficacy, usefulness and economic system. The related standards for fixing the SL worth of an unique product are the costs of medicine in Switzerland with the identical indication or an analogous mode of motion and the common worth of the product in different nations. At present, the costs in 9 reference nations – Germany, Denmark, England, the Netherlands, France, Austria, Belgium, Finland and Sweden – are used for this comparability. For figuring out the SL worth, the Federal Workplace of Public Well being provides a distribution margin to the ex-factory worth decided in accordance with the 2 standards described above. The fulfilment of the circumstances for admission to the SL is, in precept, reviewed each three years. A evaluation of the circumstances for admission to the SL additionally takes place instantly after the expiration of the patent safety, in addition to within the following conditions: authorisation of a brand new indication by Swissmedic, restriction of a sign by Swissmedic, request for altering a limitation and request for a worth improve. The SL costs of generics are decided within the operate of the costs of their reference merchandise.

Low cost

Are producers or distributors of medicinal merchandise statutorily obliged to present a reduction to medical insurance schemes or third events?

There aren’t any statutory guidelines obliging producers or distributors of medicinal merchandise to present sure reductions. Healthcare suppliers should go on reductions that they’ve acquired on medicinal merchandise or in relation to providers reimbursed by the essential medical insurance to the debtor of the healthcare services or products (insurance coverage or affected person).



Supply hyperlink

About Author

Leave a Reply

Leave a Reply

Your email address will not be published.

Translate »