Debate: How we can afford medicines in the future

Bt Dean Allan Flyvbjerg, Aarhus University, Health

"We must be able to afford expensive medicines". As was the case during the election campaign, this is the message from Minister for Health Sophie Løhde Jacobsen after yet another media storm breathed new life into the debate about the sky-high cost of medicines at the hospitals. This time the affair focused on a new treatment for cystic fibrosis with an annual cost of DKK two million per patient. Sophie Løhde Jacobsen consistently rejected the need for a national prioritising in relation to medicines, even though the increasing cost of medicines is currently forcing several regions to introduce stringent cost reduction plans.

This is without doubt a difficult and unpleasant discussion. Because what should an extra year or even an extra month of somebody’s life cost? Should a welfare state like Denmark even be thinking about prioritising? Shouldn’t all patients always receive the best available medicine, also if the medicine only prolongs life by a few months? But even though it is a difficult discussion, it remains a topic that Denmark’s leading politicians ought to take up to discussion.

The debate has a tendency to be about whether to prioritise or not. But everything is a prioritising. You cannot not prioritise. When politicians choose not to do something about the sky-rocketing cost of medicines, they are also prioritising. When politicians choose not to react to the fact that the chairmen of the regions, hospital directors and chief executives and some of the country's leading health economists repeatedly warn about the consequences of the increasing cost of medicines, then yes, this is also a prioritising.

Instead of viewing it as a question of either-or, we ought to have a wide-ranging discussion about the best way for us to deal with the cost of medicines in the future. Because we cannot ignore the reality. The reality is that the cost of hospital medicines has increased by seventy per cent since 2007. And there are no signs that this development is going to stop – on the contrary! Health economists have calculated that the cost of hospital medicines between now and 2020 will increase to more than DKK 22 billion. With a tight public budget, we cannot afford to have our cake and eat it too. The consequence will therefore be cutbacks elsewhere in the hospital sector. This is not only a future scenario. At present three of the country's five regions are rolling out major cost reduction plans, among other things because medicine costs are consuming more than expected of hospital budgets.

And what are the consequences of this? On 25 June, the Danish newspaper BT ran an article with new research from York University which shows that the opposition to prioritisation may end up costing more lives than those saved by the expensive medicines, because the cost of the medicines compromises the treatment of other patients. Medicines costing DKK 300,000 that can give one patient a single year of good life, cost years of good life elsewhere in the healthcare service. 

National priorities are certainly not an unknown phenomenon in the Danish health service. While there is not a stringent prioritisation between different hospital medicine products, the picture is quite different at pharmacies across the country. Here citizens can only obtain reimbursement for medicines if the authorities, in the form of the Reimbursement Committee and the Danish Health and Medicines Authority, think that the product is worth the money. Professor Kjeld Møller Pedersen has called it both absurd and self-contradictory to look at the correlation between price and effect for prescription-only medicines, but not to do the same when it comes to hospital medicines. I could not agree more!

In an attempt to manage the developments with regard to medicines, Danish Regions has set up two councils. These are the Coordinating Council for the Commissioning of New Hospital Medicines (abbreviated to KRIS in Danish) and the Danish Council for the Use of Expensive Hospital Medicines (RADS in Danish). Both councils are intended to contribute to enhancing the quality of treatment using medicines, while at the same time ensuring a uniform treatment throughout the country. A central problem with both councils is that they do not take price into account when approving new medicines. Danish Regions’ focus on the challenges in the area during the election campaign very clearly shows that the two councils have fundamentally been unable to solve the basic prioritisation issue.

As a start on the path to finding out what could be done, we could always look at the experiences of the countries that have already acknowledged that medicine prioritising is a national matter and not something that should take place at the individual hospital department.

The UK has had the national institute NICE since 1995. The institute analyses costs and effects and, on the basis of these, draws up guidelines for which treatments should be offered by the National Health Service in the UK.

Norway also has a national prioritising of medicines. Since 2007, a national council has presented recommendations for prioritising resources in the healthcare service. Since 2002 they have also had an economic evaluation of new medicines, with the establishment of a price ceiling for how much the healthcare service will pay for an extra year of life.

Germany has set up an independent body that carries out scientific studies of the effectiveness of medicine, among other things in relation to price.

Belgium and the Netherlands also have initiatives in the pipeline for prioritising. A central element in the Dutch focus is to obtain the necessary knowledge about the effects of new medicine. Unlike in Denmark, where the Danish Health and Medicines Authority stopped carrying out systematic Health Technology Assessment (MTA) reports in selected areas in 2012, this tool remains a central element in the Netherlands. Furthermore, efforts are being made to form a national, coordinated initiative for the pricing policy area. Last, but not least, Belgium and the Netherlands have decided to coordinate their mutual national initiatives.

The various European initiatives are not necessarily without problems. Both the UK and Norway face challenges in regard to the solutions chosen. But the socio-economic benefits of developing a coordinated national approach to medicine prioritising are obvious – also in relation to Denmark.

All parties involved in the development of new medicines and treatment of citizens must contribute to ensuring that citizens have access to the latest and most effective medicines. This ambition is achieved through a coordinated and knowledge-based approach, which also incorporates price and the social and economic aspects of a given treatment.

Such an initiative can be achieved through four Danish initiatives:

Firstly, by establishing an independent, national body – which is not at the same time a public sector organ – that continuously prepares systematic scientific reports on the effects of medicines. The body must also calculate the overall health economic costs of using different types of medicines, both those already in use and new products.

Secondly, a nationally coordinated price agreement basis must be created, which will form the basis for price negotiations between the regions and the pharmaceutical industry.

Thirdly, in close cooperation with government agencies and institutions, research institutions and hospital owners, a sharp focus must be placed on the collection of new knowledge and research into tailor-made medicines.

Fourthly, that the three above-named initiatives are carried out with inspiration from – and ideally in collaboration with – other countries on a Scandinavian or European level.

If this does not happen, the Danish health service will continue to be characterised by cutbacks in the future, thereby also heading towards increasing inefficiency. This will lead to incalculable consequences for the high level of quality of care that we fortunately still have.  

The feture article was published in Berlingske Tidende on 15 August 2015 (in Danish only)