table of contents - sfk · more generic medicines in line with the trend in recent years, dutch...

2 facts anD figures 2010 3

Table of contents

Introduction 5

FactsandFigures2010-abriefoutline 9

1 TheNetherlands1.1 Development of expenditure 151.2 structural increase in expenditure on medicines 171.3 use of medicines by age group and gender 211.4 Pharmacy fees 231.5 industry agreements on medicine pricing 271.6 Development of medicine prices 301.7 Market shares per product group 321.8 the Drug reimbursement system 351.9 Medicine use in Western europe 37

2 Medicines 402.1 expenditure on medicines 402.2 Prescriptions 452.3 new medicines 482.4 integral financing for chronic conditions 502.5 non- and conditionally reimbursed medicines 59

3 Pharmacies 633.1 independent pharmacies versus pharmacy chains 633.2 community pharmacy turnover 653.3 Dispensing fees 673.4 financing of practice costs 703.5 the consequences of the nZa audits 723.6 Health insurer contracts 733.7 Personnel and workload 753.8 Pharmacists and the labour market 78 3.9 Quality indicators 81

4 Keyfiguresforpharmaceuticals2009 85


IntroductionTheFoundationforPharmaceuticalStatisticsthe foundation for Pharmaceutical statistics (sfK) has been collecting, monitoring and analysing detailed data on the use of medicines in the netherlands since 1990. sfK obtains its information from a panel of pharmacists who represent 1,836 of the 1,981 community pharmacies in the netherlands. Between them, the 1,836 pharmacies represented by the sfK panel dispense medicines, medical appliances and dressing materials to 15.3 million Dutch people. every time a pharmacy dispenses a prescription, sfK gathers and records data on the dispensed medicines and/or materials, the dispensing pharmacy, the reimbursing (or non-reimbursing) health insurer, the prescribing doctor and the patient for whom the prescription was issued. as a result sfK has the most comprehensive set of data in this field in the netherlands. thorough validation processes and proven statistical procedures guarantee the high quality and representativeness of sfK data.

the figures published in this report show national use of medicines dispensed by community pharmacists. the figures are calculated using a stratification technique developed by sfK that separates data supplied by the pharmacies affiliated with sfK and available data on non-participating pharmacies, taking into account factors such as the size of the patient population and the location of the pharmacy.

this report does not provide information on the use of medicines in hospitals. sfK has published a separate report in the form of the expensive and Orphan Drug Monitor, which was commissioned by the Dutch Ministry of Public Health, Welfare and sport and produced under the supervision of the Dutch Hospitals association (nVZ), the Dutch federation of university Medical centres (nfu) and the Dutch association of Hospital Pharmacists (nVZa). the most recent edition of the Monitor, which was published in april 2010, shows the development of expenditure on medicines covered by the policy rules on expensive medicines and orphan drugs during the period from 2004 to 2008.


DefinitionsWithin the context of this report ‘cost of medicines’ means either the pharmacy reimbursement price (for medicines that come under the WMg) or the pharmacy purchase price (for medicines that do not come under the WMg) as listed in the g standard of the Z index.

the Health care charges act (Wet tarieven gezondheidszorg, Wtg) was replaced by the Health care Market regulation act (Wet Marktordening gezondheidszorg, WMg), which entered into effect on 1 October 2006. services and fees covered by the Wtg are also covered by the WMg.

the term ‘expenditure on medicines’ means the cost of medicines plus pharmacy fees.

all of the expenditure documented in this report is expenditure on medicines covered by statutory health insurance. unless otherwise indicated, expenditure does not include Vat. Prescription medicines are subject to 6% Vat in the netherlands.

Protection of privacyWhen gathering and recording data on the use of medicines, sfK is extremely careful to protect the privacy of everyone concerned. Privacy regulations safeguard the privacy of the participating pharmacists and sfK only collects anonymised data on the prescribing doctor and the patient. the identity of the doctor is concealed from sfK by an encryption key which is entered in the pharmacy computer system by each of the participating pharmacies. sfK can only link the data on the different doctors and pharmacists if authorised to do so in writing by all of persons concerned. in an increasing number of regions sfK supports collaborative partnerships between pharmacists and doctors. Within the context of these collaborative partnerships pharmacists and doctors exchange data on the use of medicines via an online Data Warehouse that can be accessed via a secure section of the sfK website.

the patient’s identity remains permanently concealed from sfK by the patient number allocated by the pharmacy. it is not possible for sfK to link patient numbers to individual persons. naturally the pharmacy knows the identity of its customers, but this information is not disclosed to sfK.

sfK membership sfK membership is free of charge and is open to all community pharmacists in the netherlands. Pharmacists that supply sfK with data can refer to the latest monthly monitor report via the sfK website free of charge. they can also access, free of charge, detailed up-to-date data on the use of medicines dispensed by their own practice via the online sfK Data Warehouse. they can use this data as management information for their own pharmacy or as feedback information for the pharmacotherapy consultation with general practitioners. to facilitate the monitoring of the effectiveness of medicine use and to support practice-based programmes in the area of pharmacy patient care and the pharmacotherapy consultation, sfK produces, either for a fee or free of charge, theme reports that are customised for individual pharmacies or for a particular pharmacotherapy consultation. sfK produces these customised reports in association with the scientific institute of Dutch Pharmacists (Winap) and the Dutch institute for responsible Medicine use (iVM).


expenditure on medicines up by just 1%Asin2008,in2009therewasaverylimitedincreaseinexpenditureonmedicinesinthepharmacyindustry.In2009€4,789millionwasspentthroughcommunitypharmaciesonmedicinescoveredbystatutoryhealthinsur-ance.Thisis€47million(1.0%)morethanin2008.Thisincreaseinexpenditureisverylowincomparisonwithpreviousyears:expendi-tureonmedicinesincreasedbyanaverage of6%peryearintheyearspriorto2008.Theloweringofthepricesofgenericmedicinesinresponsetohealthinsurers’preferencepoliciesisthemainreasonforthelimitedincreaseinexpenditure.Theincreasinguseofexpensivemedicinesaccountedforanincreasein expenditure.

expectations for 2010TheFoundationforPharmaceuticalStatistics(SFK)expectsexpenditureonmedicines andpharmaceuticalproductsdispensedbycommunitypharmaciestoincreaseto€4,950millionin2010.Theexpectationfor2010isbasedonthevolumeofsalesduringthefirsthalfof2010andtheanticipatedvolume ofsalesduringthesecondhalfoftheyear. Factorssuchasthestructuralincreaseinexpenditureonmedicines,thepricecutspromptedbyhealthinsurers’preference policiesandtheloweringofmaximumprices

inlightofpricedevelopmentsinneighbouringcountrieshavebeentakenintoaccount.

Theanticipatedgrowthwillbegeneratedmainlybytheincreasinguseofexpensivemedicines(medicinesthatcostmorethan €500perprescription).However,because theincreasinguseofexpensivemedicinestendstobypassregularpharmacies,thesepharmacieswillseeafallintheirturnover.

causes of growthIntheabsenceofinterventionbythegovern-mentormarketoperators,expenditureonmedicinesiscurrentlyincreasingatarateof 9to10%peryear.Theincreaseinexpenditureonmedicinesisastructuralphenomenonthatcanbeattributedtoashifttowardstheuseofnewer,generallymoreexpensive,medicines,demographicfactors(populationincreaseandageing),changesinprescriptionandmedicine-takingpatterns,theadditionofnewmedicinestothebasichealthservicespackagecoveredbystatutoryhealthinsurance,andtheshiftintheprovisionofhealthcarefromthehospitaltothehome.Thegrowthinthemarketshareofcommunitypharmaciesattheexpenseofthemarketshareofdispensinggeneralpractitionersinrecentyearshasalsocontributedtotheincreaseinexpenditure onmedicinesdispensedbycommunity pharmacies.

FactsandFigures2010-abriefoutline


Health insurer contracts based on indicators Havingdiscussedthepossibilitieswithpharmacists,in2009somehealthinsurersstartedofferingschemeswithfeesthatmoreaccuratelycovercostsinexchangeforprovenefficiencyand/orqualitygains.Inadditiontofinancialagreements,undercertaincon-ditionsinsurerssuchasAchmea/AgisandCZalsoagreetopaypharmacistsforqualityprocesses.HealthinsurersareincreasinglybasingtheiranalysisandassessmentofthequalityofpharmaceuticalcareprovidedbypharmacistsonindicatorssuchastheIGZ/KNMPqualityindicators.Althoughthesekindsofindicatorsarenotadoptedasabasisforfinancialcontracts,andalsoinvolve certainlimitations,insurersareclearly makingmoreandmoreagreementswithpharmacistsbasedonperformanceindicators.

More generic medicinesInlinewiththetrendinrecentyears,Dutchpharmacistscontinuedtodispensemore genericmedicines.In200997millionphar-macy-dispensedprescriptionsweredispensedasgenericproducts(anincreaseof10.3%).Thismeantthattheshareofprescriptionsdispensedasgenericmedicinesincreasedto57%.Theincreaseintheshareofpharmacy-dispensedgenericmedicinesisconsistentwiththeundertakingmadebypharmacistsintheindustryagreementswiththegovernmenttopromotetheuseof(cheaper)genericmedicines.Healthinsurers’preferencepoliciesalsoplayedanimportantroleinboththeincreaseinthenumberofgenericmedicinesdispensedbypharmacistsandintheloweringofthecosts oftheseproducts.Thecostshareofgenericmedicinesfellto12%.

More expensive medicinesTherehasbeenasharpincreaseinexpenditureonmedicinesthatcostmorethan€500perprescriptioninrecentyears.In2009turnover generatedbythesaleoftheseexpensivemedicinesincreasedby€139millionto€991million.Anincreasingshareoftheexpenditureontheseproductsbypassesregular(local)pharmacies.Thisphenomenonisalsoknownasselectiveorexclusivesupplyofspecialistmedicines.Therehasbeenasteepincrease inboththenumberofmedicinesthatare selectivelydistributedandthecorrespond-ingrevenues.Almostallofthisincreaseinrevenuesisreportedbycompaniesinvolvedinselectivesupply,verylittleofitisreportedbyregularcommunitypharmacists.Aswasthecasein2008,twoofthemedicinessupplied selectivelyorexclusivelytothepatient(theTNF-alphainhibitorsadalimumabandetanercept)arehighonthelistofboththetoptenmedicinesthatgeneratedthehighestexpendituresandthetoptenexpenditureincreasesin2009.

integral financingIn2009stepsweretakentochangethewaythatchronicdiseasecareisfinanced.Ratherthantherebeingaseparatepaymentforeachpartofthetreatment,agroupofcareproviderscanagreetoofferapackageofcareforasinglesetfee.Withintegralfinancingthearrange-mentoffinancingiscompletelydifferenttotheexistingsysteminwhichcareisfinancedperprovider.Atthemomentitlooksasifintegralfinancingwillbeusedprimarilyforcare,withthecostofthemedicinesbeingincorporated atalaterstage.Integralfinancinghasbeenop-tionalforthetreatmentofdiabetesmellitustype2andvascularriskmanagementsince1January

nZa fee increases far from adequate with the fall in pricesUnderthepressureoftheMedicinesPricingActvoluntarypricecutsinlightofindustryagreementsonmedicinepricing,andhealthinsurers’preferencepolicies,thepricesofprescriptionmedicinesvirtuallyhalvedduringtheperiodfrom1996to2010.Theintroductionofindividualpreferencepoli-ciesbyseveralhealthinsurers(Menzis,UVIT,CZandAgis)meantthatthepricesofmanygenericmedicinesfellby90%inmid2008.Pharmacistssawthecollectivepurchasingadvantagesneededtofinancetheshortfallinpharmacydispensingfeeswipedoutinonefellswoop.WhentheDutchMinistryofHealthoffsettheeffectofthesepricecutsbyrestrictingtheinsurers’medicinesbudgets,in2009UVITintroducedtheconcealedpricemodel.Inthismodeltheinsurernegotiatesalowerpricewiththemanufacturer,whilethepricethepatientischargedforthemedicine,remainsthesame.

Wider implementation of preference and concealed price policies in 2009 meant that prices fell by almost another 9%.

OnthebasisoftardyauditstheDutchHealthCareAuthority(NZa)increasedpharmacy dispensingfeeswitheffectfrom1January2009andagainwitheffectfrom1January2010.Howeverthefeesstilldonotcoverallthecosts.KNMPcriticisedNZaforfailingtobase its calculations on a consideration of thecostsofthevariousdifferenttypesofpharmacies,suchasoutpatientandchainstorepharmacies.IncalculatingthefeesNZaalsoomittedtoconsiderthefinancingcosts involvedinsettingupandtakingoverapharmacyandthecostsofinvestedequity.

KNMPalsoquestionedNZapolicyofallocatingpracticecoststotheissuingofnon-pharma-ceuticals.ThefactthatpharmacydispensingfeesfailtocovercostsledKNMPtocommenceproceedingsonthemeritsofthecase againstNZa.

Most pharmacies earning under dispencing feeTheNZafeesystemmakesadistinction betweenbasicservicesandadditional servicesandstipulatescorresponding maximumfees.From2010thebasic reimbursementfeesforthedispensingofregularandweeklyprescriptionsare€5.99and€3.29respectively.Thedispensingoftheseprescriptionsmayalsoinvolvethepro-visionofoneormoreadditionalservicesifthepharmacisthastopreparea(special)formula,iftheprescriptionisbeingdispensedforthefirsttimeorduringtheevening,duringthenightoronaSunday.Thefeesystemresultsinconsiderabledifferencesinturnoverfromonepharmacytoanother.AnSFKsurveyhasshownthat63%ofcommunitypharmacistsdonotearnthe€7.91dispensingfeethatNZahasestablishedasabenchmarkfeeforwhatitdefinesasa‘standardpharmacy’.Inadditiontothedifferentiatedfees,NZafeerulingalsostipulatesthemaximumpermittedincreaseinthefees.Intheory,thisofferspharmaciststhepossibilityofmakingwrittenagreementswithinsurersregardinghigherfees.AccordingtoasurveyconductedbyNZa,350suchcontractswereagreedin2010.However,althoughNZagiveshealthinsurersscopetonegotiate,itisdebatablewhetherpharmacistsareabletoderivefullbenefitfromthisarrangement.Variouspharmacistsexperiencedthenego-tiationsasa‘takeitorleaveitoption’ ofsigningastandardcontract.


Lower graduate employment rateIn2009142peoplegraduatedaspharmacists.Withagrowinginterestinthestudyofpharmacyandgrowingnumbersoffirst-yearpharmacystudentsfrom2002onwards,therehavebeenanincreasingnumberofgraduatessince2008.Approximately70%ofpharmacygraduates(99persons)chosetogointocommunitypharmacy.However,overall,thenumberofemployedcommunitypharmacistsfellby35in2009.With134pharmacistsleavingtheactiveprofession,2009wasthefirstyearinwhichtherewerefeweremployedcommunitypharmaciststhantheyearbefore.Giventheincreasingdemandforpharmaceuticalcare,thisisaworryingdevelopment.

2010,andforthetreatmentofCOPDsince 1July2010.Itisexpectedtobeintroducedasapossibilityforthetreatmentofheartfailureinduecourse.Ifthiscontinues,itisanticipatedthatintegralfinancingwillapplytoapproxi-matelyonethirdofallcommunitypharmacycustomers.Thecareinvolvedincardiovascularriskmanagementinparticularwillhaveacon-siderableimpactonpharmacy.Pharmaceuticalcareisnotyetincludedasacomponentinintegralfinancing.

economical use of medicines in the netherlandsComparedwithotherWesternEuropeancoun-tries,theDutchspendrelativelylittleondrugs:medicinesaccountforlessthan10%ofthetotalexpenditureoncareintheNetherlands. In2008theDutchspent€335ondrugs(in-cludingexpensivemedicines)percapita,whichmeantthattheper-capitaspendonmedicinesremainedthesameasin2007.Theaverageper-capitaspendonmedicinesinneighbouringcountriesrangesfrom18to68%more (Belgium:€395,Germany:€458,France: €564).Withtheincreaseintheuseofexpen-sivemedicines,whichinsomecountriesareonlyavailableviahospitals,theNetherlandsisedgingclosertotheWesternEuropeanaverage(€403).Yetatthesametimehealthinsurers’preferencepoliciesarehavingtheoppositeeffectbyloweringthepricesofgeneric medicines.

smaller increase in the number of pharmacies Attheendof2009therewere1,976communitypharmaciesintheNetherlands.Withjust 28pharmaciesmorethantherewerein2008,theincreaseinthenumberofpharmacieswasfarsmallerthaninpreviousyears.Thiswas

largelyduetotheestablishmentofspecialistpharmacists,suchasoutpatientpharmaciesandout-of-hourspharmacies.

Community pharmacists supply 92.1% of the Dutch population with medicines.

Theremainderofthepopulationhastorely onadispensinggeneralpractitioner(usually inruralareas).Theaveragecommunity pharmacyhasapatientpopulationof7,800persons.In2009theaveragepharmacyprac-ticefilled90,500prescriptionsworthatotal of€2,441,000(€29,000lessthanin2008).Thefallinturnoverislargelyduetotheloweringofthepricesofgenericproductsinresponsetohealthinsurers’preferencepoliciesandtherestrictedreimbursementofsleep-inducingmedicationandsedativesfrom1January2009.Pharmaciesestablishedmorethantenyearsagohaveseengreaterrevenuelossthantheaveragepharmacy.

greater workloadAsoftheendof2009communitypharmaciesintheNetherlandsemployedatotalof26,082persons(1.6%morethanin2008).In2009thenumberofemployedpharmacyassistantsincreasedby236personsto16,548.Withmostpharmacyassistantspreferringtoworkparttime,theaverageworkingweekof24.4hourswasconsiderablyshorterthanin2008.Withnationalmedicineuseincreasingfasterthanthenumberofemployedpharmacypersonnel,thereispressureonthelabourmarket.Theproces-singrate,anindicatoroftheproductivityandworkloadinapharmacy,increasedto18,700prescriptions.Thehigherprocessingrateispartlyduetothefactthatpharmacistshavebeenforcedtocutbackonpersonnelcostsbecause oftheinadequatepharmacydispensingfees.


Expenditureonmedicinescoveredbystatu-toryhealthinsurancethatweredispensedbycommunitypharmacistsintheNetherlandsamountedto€4,789millionin2009.Thismeantthatthelevelofexpenditurewas€47million(1.0%)higherthanin2008.Hence,2009wasthesecondyearinwhichtherewasaverylimitedincreaseinexpenditureinthepharmacyindustry.In2008expenditureincreasedby1.9%to€4,742million.Intheyearspriortothat,theincreaseinexpenditureonmedicinesaveragedat6%peryear.Asmallportionoftheincreaseinexpenditurecanbeattributedtomoreuseofmedicines.In2009thenumberofdefineddailydoses(DDD) dispensedbycommunitypharmaciesincreasedby2.7%.Thisincreaseismorethanwouldbeexpectedonthebasisofpopulationgrowthandageing.Onepossibleexplanationmightbethatthedoctorsprescribingthemedicinesaremoreconsistentlyfollowingguidelines

andstandardsthatreflect(new)therapeuticinsightsontheuseofmedicines.

Price cuts by preference policies Theloweringofthepricesofgenericmedicineswasthemainreasonforthelimitedincreaseinexpenditure.ThePharmaceuticalCareTransitionAgreementthatMinisterAbKlinkagreedwiththepharmaceuticalindustryattheendof2007meantthatthepricesofgenericmedicinesfellbymorethan10%atthebegin-ningof2008.ThispavedthewayformoreaggressivepricecutsinJune2008whenhealthinsurersintroducedtheirownindividualprefer-encepolicies,whichsparkedarealpricewarbetweensuppliersofgenericmedicines.Thepricesofthemostfrequentlydispensedgenericmedicinesfellbyanaverageof85%.2009wasthefirstyearinwhichfull-yearfigureswerebasedontheselowerprices.Widerimplemen-tationofhealthinsurers’preferencepolicies

TheNetherlands1.1 Development of expenditure

AnotherlimitedincreaseinexpenditureonmedicinesExpenditure on community-pharmacy dispensed medicines covered by statutory health insurance increased to € 4,789 million in 2009. This was just a 1% increase in relation to 2008. The use of expensive medicines accounted for an increase in expenditure, while the lowering of the prices of generic medicines and the restricted reimbursement of sleep-inducing medication and sedatives had the opposite effect.

1


ThecombinedeffectsoftheMedicines PricingAct,morestringentclawback, industryagreementsonmedicinepricing,thePharmaceuticalCareTransitionAgree-mentandhealthinsurers’preferencepolicieshaveresultedinalimitedincreaseinexpen-ditureonmedicinesinrecentyears.However,therearestillsixunderlyingfactorsthatcontinuetogenerateastructuralincreaseinexpenditureonmedicinesof9to10%peryear.

shift toward the use of more expensive medicinesInrecentyearstherehasbeenasharpincreaseinexpenditureonmedicines thatcostmorethan€500perprescription.Revenuesderivedfromthesaleofthese productsincreasedfrom€256millionin2002to€988millionin2009.Thisworksoutatanannualaveragegrowthrateof21%duringthesaidperiod.Aspartofthetotalexpenditureonmedicines,theincreaseinexpenditureonexpensivemedicinesgeneratesastructuralincreaseofalmost3%peryear.Itisincrea-singlycommonfortheseexpensivemedicinestofindtheirwaytothepatientviachannelsotherthanregular(local)pharmacies.Thisphenomenonisalsoknownasexclusiveor

selectivedistribution.Themedicinesthatfindtheirwaytothepatientinthismannerhavecertaindefiningcharacteristics:theyarepro-ducedforarelativelysmallpatientgroup,theyusuallyhavetobeadministeredviainjection,andtheyareexpensive:withoutexception,thesemedicinescostmorethan€500perpre-scription.Ratherthansupplyingthesemedi-cinesviaallwholesalers,aswouldnormallythecase,themanufacturersoftheseproductschoosetodobusinesswithasinglesupplier.RedSwan,ApotheekZorg,Klinerva,MediZorgandAllogaareallexamplesofnationalsup-pliersinthismarket.Thefactthattheysupplymedicinesdirectlytothepatientmakesitimpossibleforregularpharmaciestosupplythemedicinesinquestion.Insomecasesthepatientcancollectaprescriptionforamedi-cinesuppliedexclusivelytothepatientfromthepharmacyoftheirchoice.ThisispossibleforexamplewithEnbrel.Boththenumberofmedicinesthatareselectivelydistributedandthecorrespondingrevenuescontinuedtoincreaserelativelystrongly.Expenditureonthesemedicinesamountedto€831millionin2009,anincreaseof16%inrelationto2008.Almostallofthecorrespondingincreaseinrevenueswasreportedbycompaniesthat

1.2 Structural increase in expenditure on medicines

Increasedominatedbyrisinguse ofexpensivemedicinesChanges in the composition of the population and medicine use account for a structural increase in expenditure on medicines of 9 to 10% per year.

alsoresultedinfurtherloweringofthepricesofgenericmedicinesin2009.InDecember2009thepricelevelofgenericmedicineswasmorethan22%lowerthaninDecember2008.

change in the pattern of expenditure on benzodiazepinesMinisterAbKlinkrestrictedreimbursementofsleep-inducingmedicationandsedativeswitheffectfrom2009.Withtheexceptionofanumberofspecificallydefinedsituations,ben-zodiazepinesceasedtobereimbursedaspartofthebasichealthservicespackagecoveredbystatutoryhealthinsuranceon1January2009.Ofthetotalamountspentonpharmacy-dispensedbenzodiazepines(€79million),communitypharmacistsreclaimed€23mil-lionfromhealthinsurers.Theremaining€56millionwaschargeddirectlytothepatient.In2008expenditureonpharmacy-dispensedbenzodiazepinescoveredbybasichealthinsuranceamountedtoalmost€91million.HencetheNetherlands’publichealthministerachievedtherequiredsaving.Yetthesaving

wasachievednotasaresultofthereduceduseofbenzodiazepines,whichwastheintendedeffectofthemeasure,butbygettingmainlythemoreelderlycareconsumerstobearagreatershareofthecollectivefinancialburden.

increasing use of expensive medicinesWithpricecutsandrestrictedentitlementtoreimbursedbenzodiazepinesloweringexpen-diture,theincreaseinexpenditureonmedicinesin2009wasprimarilyduetotheincreasinguseofexpensivemedicines.SFKdefinesexpensivemedicinesasmedicinesthatcostmorethan€500perprescription.Thetotalexpenditureonexpensivemedicinesroseby€136million,from€852millionin2008to€988millionin2009,anincreaseof16%.However,almostallofthisincreaseinexpenditurebypassesregular(local)pharmacies.Manymanufacturerschoosetosupplytheirexpensivemedicinesviaasinglewholesalerandoftenalsoviaasinglenationalpharmacychain.Theshareofexpensivemedi-cinesaspartofthetotalexpenditureincreasedfrom6.9%in2002to20.7%in2009.

1.1 Total expenditure on pharmaceuticals dispensed by community pharmacies (1 = 1 million euros)

In 2009 there was very little increase in expenditure on medicines covered by statutory health insurance. The increasing use of expensive medicines is expected to lead to further growth in expenditure in 2010.

source: foundation for Pharmaceutical statistics

5,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

3,419 3,702 3,967 3,909 4,145 4,302 4,652 4,742 4,789 4,950

4,000

3,000

2,000

1,000

0

prog

nose


addition of new medicines to the health insurance benefit packageTheDutchgovernmentdeterminesitspolicyontheadditionofnewmedicinestothestatutoryhealthinsurancebenefitpackageontheadviceoftheDutchHealthCareInsu-ranceBoard(CVZ).OnthebasisofthisadvicetheDutchMinistryofHealthjudgessomenewmedicinestobetherapeuticallyuniquebyandaddsthemtotheso-called‘Appendix1B’,whichlistsallnewandinnovativemedi-cinesthatarefullyreimbursedbythehealthinsurers.In2009thecostsofthemedicineslistedinAppendix1Bincreasedby6.5% to€747million.OfthemedicineslistedinAppendix1B,theSourcechodilatortio-tropium(Spiriva),accountsforthehighestrevenues.Expenditureonthismedicineamountedto€76million.

changes in prescription and medicine-taking patternsComparedwithotherEuropeancitizens, theaverageDutchpersonusesrelativelylittlemedication.Patientswhoconsultgeneral practitionersintheNetherlandsareprescribedmedicinesinapproximatelytwo-thirdsofcases.InmoresouthernEuropeancountriesthispercentagecanriseashighas90%.AccordingtothemarketintelligenceagencyIMSHealth,incountriessuchasBelgium,FranceandSpain,avisittothedoctorresultsintheprescriptionofanaverageof15to40%moremedicinesthanintheNetherlands. Nevertheless,per-capitamedicineuseisclearlyincreasingintheNetherlands.Duringtheperiodfrom2000to2009theaveragenumberofdefineddailydoses(DDD)dis-pensedperpatientincreasedby4%peryear.Chronicuseofmedicinesisalsoincreasing,asisevidentfromthegrowingnumberofrepeat

prescriptionsfilledbypharmacists.Thevastmajorityofprescriptionsissuedbydoctorsarerepeatprescriptions.In81%ofcases,thesamepharmacydispensesthesamerecentlydispensedprescriptionmedicinetothesamepatient.MeasuredintermsofthenumberofDDDs,theshareofrepeatprescriptionsisashighas86%.

ageing of the Dutch populationThepopulationoftheNetherlandsincludes2,472,000peoplewhoare65yearsofageorolder.Thisis15%ofthepopulation.Accor-dingtoStatisticsNetherlands(CBS),bytheyear2020thenumberofseniorcitizensintheNetherlandswillhaverisento3,281,000(20%ofthetotalpopulation).Atthecurrentrateofmedicineuseandcost,thechangingcompositionofthepopulationwillcause thetotalexpenditureonmedicinestoincreasebyanadditional€46millionperyearthroughto2020,whichis1.0%peryear.In2020theageingofthepopulationwillmeanthatmedicineuseisalmost10%higherthanin2009.Iftheincreaseinmedi-cineusethroughpopulationgrowthisalsofactoredintothecalculation,thestructuralincreaseduetodemographicdevelopmentswillbemorethan10%.AccordingtothepopulationgrowthforecastsproducedbyStatisticsNetherlands,populationagingwillpeakinaround2040.Dutchpeopleinthe65-plusagegroupusethreetimesasmuchmedicationastheaverageDutchperson.Peoplewhoare75yearsofageorolderuseuptoalmostfivetimestheamountofmedi-cationusedbytheaverageDutchperson.Peopleinthisagegroupalsotendtotakemedicinesonanongoingbasis(chronic medicineuse):morethanfouroutofeveryfiveprescriptionsthatseniorcitizens

engageinselectiveorexclusivesupply. Therewasverylittleincreaseinexpenditureviaregularcommunitypharmaciesduringtheperiodfrom2004to2009.

shift in the provision of health care from the hospital to the home Thereductioninthenumberofhospitaldaysandthenumberofhospitalbedsinrecentyearsissymptomaticoftheprogressiveshiftintheprovisionofhealthcarefromthehos-pitaltothehome.Hencedespitetheslightpopulationgrowththerehasbeenasharpreductioninthetotalnumberofhospitaldayssince1990.In1990theNetherlands

stillhadahospitalcapacityof43bedsper10,000inhabitants.Thishassincefallento28bedsper10,000inhabitants.Thisdevel-opmentcombinedwithshorterhospitalstays(theaveragehospitalstayhasshortenedbyalmost30%overthelasttenyears)hasledtoashiftfromintramuraltoextramuralcare.Fromafinancialpointofviewthepharmacyindustryservesasavalvewithinthehealthcarechain:savingsandcutselsewherewithinthechainfrequentlyleadtomorecostsinthepharmacyindustry.TheimpactofthisshiftontheincreaseintheuseofmedicinesintheNetherlandsisestimatedatapproximately3%peryear.

1.2 Expenditure on medicines supplied directly via selected and regular community pharmacists (1 = 1 million euros)

An increasing share of the revenues derived from the sale of medicines supplied directly to the patient bypasses regular pharmacies.


900

700

500

300

100

800

600

400

200

02004

41

266

2005

100

287

2006

165

289

2007

251

308

2008

399

316

2009

512

319

Regular community pharmacies National suppliers


senior citizensThecholesterol-loweringmedicineatorvastatin(Lipitor)wastopofthelist:peopleinthe65-plusagegroupspent€76milliononthisdrugin2008.Salmeterolwithananti-inflammatory(Seretide),whichisusedtotreatasthma/COPD,wasinsecondplace(€53million).Tiotropium(Spiriva),whichisalsousedtotreatasthma/COPD,wasinthirdplace(€48million).Gastricacidsuppressantpantoprazole(Pantozol)wasinfourthplace(€43million),andentanercept(Enbrel),whichisusedtotreatsevererheuma-toidarthritis,wasinfifthplace(€39million).Therewere3.8millionprescriptionsfortheplateletaggregationinhibitoracetylsalicylicacid,whichmadeitthemedicinemostfrequentlydispensedtoseniorcitizens.Metoprolol,whichisusedtotreathighbloodpressureandanginapectorisamongotherconditions,wasinsecondplacewith3.7millionpharmacy-dispensedpre-scriptions.Thecholesterol-loweringmedicinesimvastatinwasinthirdplacewith2.9millionprescriptions,thegastricacidsuppressantome-prazolewasinfourthplacewith2.8millionpre-scriptions,andthediureticfurosemideroundedoffthetopfivewith2.7millionprescriptions.

Men and womenWomenusemoremedicationthanmen. In2009communitypharmacistsdispensed108millionprescriptionsforwomenand 70millionprescriptionsformen.Medicineuseamongwomenistherefore1.5timesashighasamongmen.Useofhormonalcontra-ceptivesbywomenplaysasmallroleinthis.Thehigherlifeexpectancyamongwomenplaysismoreofafactor.Useofmedicinesishigheramongwomenthanmeninallagegroupswithexceptionofyoungchildren. 60%ofthedifferenceinmedicineusebetweenthesexesisattributabletothe‘femaleeffect’;theremaining40%ofthe differenceisanageeffect.Womenusemoreantidepressantsandsleep-inducingmedi-cationandsedativesthanmen,butfewerantithromboticsandcholesterol-loweringmedicines.Intermsofexpenditureonmedi-cines,thedifferencebetweenthesexesisnotapronounced,because,onaverage,menusemoreexpensivemedicines.Hencewomenspend1.2timesmoreonmedicinesthanmen.

1.3 Use of medicines by age group and gender

Highermedicineuseamong(older)womenHigher medicine use among senior citizens correlates with proportionally higher expenditure on medicines for this age group. In 2009 almost € 4.8 billion was spent on medicines dispensed by community pharmacists. Of this, € 1.9 billion (39%) could be traced to the 65-plus age group. Most money was spent on cholesterol-lowering medicines, gastric acid suppressants and medicines used to treat asthma/COPD.

presentattheirpharmaciesarerepeatpre-scriptions.Theaverageseniorcitizentakesthreedifferentmedicinesonadailybasis.

growth of the Dutch population and the community pharmacy catchment areaFiguresreleasedbyStatisticsNetherlands(CBS)showthattheDutchpopulationincreasedby0.5%in2009.Thenumberofinhabitantsincreasedfrom16,485,787in2009to16,574,989asof1January2010.AccordingStatisticsNetherlands,theperiodofrapidpopulationgrowthhasnowcometoanend:intheyearstocomepopulationgrowthwillfallto0.2%peryear.Inadditiontothegrowthofthepopulation,thecatch-mentareaofcommunitypharmacistsisalsogrowing.Inthinlypopulatedareaswhereit

isnoteconomicallyviabletooperateacom-munitypharmacy,pharmacycareisprovidedbydispensinggeneralpractitioners.FiguresissuedbytheDutchHealthCareInsuranceBoard(CVZ)showthatthemarketshareofcommunitypharmacistsisgrowingattheexpenseofthemarketshareofdispensinggeneralpractitioners.In199789.8%of peoplewithnationalhealthinsurancecoverwereregisteredwithacommunitypharmacy.In2008themarketshareofpharmacistswas92.1%.Thefiguresfor2009arenotknown.AccordingtotheNetherlandsInstituteforHealthServicesResearch(NIVEL),in1999andatthebeginningandendof2009thenumbersofdispensinggeneralpractitionersintheNetherlandswere648,542and439respectively.


TheHealthCareMarketRegulation Act(WMG),whichenteredintoeffecton 1October2006,replacingtheHealthCareChargesAct(WTG),setsthemaximumfeesthatpharmaciescanchargethemedicine userandthemedicineuser’sinsurer. TheWMGmakesadistinctionbetween dispensingfeesforservicesprovidedby pharmaciesandreimbursementfeesfor prescriptionmedicinessuppliedbythe pharmacies.

Dispensing feesDThedispensingfeeisasetfeethatapharmacycanchargeforeachprescriptionmedicineitdispenses.Dispensingfeeswereoriginallydeterminedonthebasisofrealisticreimbursementofpharmacypracticecostsandthestandardincomeforanestablishedpharmacistasstipulatedbythegovernment.DispensingfeesaresetbytheDutchHealthCareAuthority(NZa).Upuntil1July1998therewasastandarddispensingfeeforeachitemdispensedaspartofaprescription. On1July2008NZaintroduceddifferentiateddispensingfeeswhichweresupposedtoave-rageat€6.10.Aswellasabasicfeeforeach

itemdispensedaspartofaprescription, therewasafurtherfeeforadditionalservicesifaprescriptionwasdispensedforthefirsttimeorifthepharmacisthadtopreparea(special)formula,orasurchargeforprescrip-tionsdispensedintheevening,atnightor onaSunday.NZaalsointroducedaseparatefeeforprescriptionmedicinessuppliedvia aweeklydosagesystem.

AttheendofDecember2008NZasurprisedthepharmacyindustrybyintroducing aso-called‘flexiblefee’thatrangedfromamaximumfeethataveragedat€7.28toamaximallyincreasedfeeof€7.92.Theamountoftheclawbackwassupposedto benegotiable.Pharmacistscouldcharge themaximallyincreasedfee,orafeethatfellsomewherebetweenthemaximumfeeandthemaximallyincreasedfee,onthebasisofawrittenagreementbetweenthepharmacyandtheinsurer.Havingbaseditscalculationofthemaximallyincreasedfeeonthepracticecostsofasubsetofcommunitypharmacistsdefinedbyitself,NZathenmadethemaxi-mumfeemorethan8%lowerthanthemaximallyincreasedfee.NZadeliberately

1.4 Pharmacy fees

Higherdispensingfees, lowerreimbursementfeesIn 2009 community pharmacies were paid a total of € 1,108 million for their services. This includes the dispensing fees for medicines covered by the WMG (€ 1,073 million) and the pharmacy mark-up op medicines not covered by the WMG (€ 35 million). The dispensing fees are by far the most important component of pharmacy fees.

1.3 Use of medicines by age group in 2009 (in prescriptions)

People in the 75-plus age group use five times as much medication as the average Dutch person.


1.4 Expenditure on medicines by age group in 2009 (in euros)

Higher medicine use among senior citizens correlates with proportionally higher expenditure.


1.5 Use of medicines (in prescriptions) and expenditure on medicines (in euros) by gender in 2009

PrescriPtiOns exPenDiture

Men 9.3 291

Women 14.0 338

Average Dutch person 11.7 315


60

0-1 years 2-10 years 11-20 years 21-40 years 41-64 years 65-69 years 70-74 years >=75 years Average Dutch person

3.0 2.3 3.1 5.1 10.9 20.3 27.2 58.7 11.7

50

40

30

20

10

0

1,200

0-1 years 2-10 years 11-20 years 21-40 years 41-64 years 65-69 years 70-74 years >=75 years Average Dutch person

108 78 124 165 363 624 745 972 315

1,000

800

600

400

200

0


suppliersofgenericversionofthemedicinesinquestionenteredthemarket)pharmaciesnegotiatedmoresubstantialpurchasingadvantages.

Yet at the same time pharmacy dispensing fees lagged behind the development of pharmacy practice costs.

Hencepurchasingadvantagesbecame anessentialelementinthefinancingofpharmacypractices.Overthelastdecadetheexceedingofthemacrobudgetforexpenditureonmedicineshasrepeatedlybeenacauseofconcernforthegovernment.Howeverinrecentyearsthegovernmenthasmanagedtokeepexpenditurewithinbudgetarycon-straintsbyintroducingclawbackmeasuresandbymakingnationalagreementsregardingthedevelopmentofpricesofout-of-patentmedicines,whichhaveskimmedthepharma-cies’purchasingadvantages

claw backTheso-calledclawbackwasintroducedin1998.FollowingtheexamplesetintheUK, ElsBorst,thenMinisterofHealth,introducedastatutoryregulationthatmadeitcompul-soryforpharmaciestopassapercentageoftheirpurchasingadvantagesontothemedi-cineuserandtheinsurerintheformoflowerprices.Theclawbackwasinitiallylimitedtoaneffectiverateof3%.On8October1999,theMinisterofHealthsignedanagreementwiththeRoyalDutchAssociationfortheAdvancementofPharmacy(KNMP)fortheperiod2000-2002.Theagreementprovidedforagradualincreaseinthedispensingfeesinlinewithanincreaseintheclawbackfrom3%toaneffectiverateof6%(theclawbackwasofficiallyincreasedto6.82%withamaximum

of€6.80perdispensedmedicine).Thecalcu-lationoftheclawbackwasbasedonthefin-dingsofanauditbyPriceWaterhouseCoopers,whichrevealedtheextentofthepurchasingadvantagesnegotiatedbypharmacies. Thepartiesinvolvedsubscribedtotheprinciplethatatradingmarginof4%wasarealisticfeetocoverthecostsandrisksinvolvedinrunningapharmacy.Thiswasinkeepingwiththeoriginalsituationatthestartofthestartofthenineties,whenpurchasingadvantages of4%werelegallydefinedasastandardtradeprofitmargin.

FromDecember2007toJune2008theclawbackwastemporarilyincreasedtoatransitionsurchargeof11.3%withinthecontextofthePharmaceuticalCareTransitionAgreementthattheMinisterofHealthagreedwiththepharmacyindustry.Themaximumdispen-singfeeof€6.80perdispensedmedicineremainedthesame.InMay2008,havingseentheextenttowhichpriceswerebeingaffectedbytheintroductionofpreferencepolicies,KNMPurgedNZaandtheDutchMinistryofHealthtosetdispensingfeesatalevelthatwouldcovercosts,giventhattheincomederivedfrompurchasingadvantageswasrapidlyevaporating.However,thegovernmentinsistedthatanotherauditwouldhavetobeconductedbeforesuchadecisioncouldbeconsidered.KNMPindicatedthatthecontinuityofpharmacybusinesseswasthreatenedtosuchanextentbythechangedmarketcon-ditionsthatthefeesneededtobeadjustedwithimmediateeffect.TheDutchTradeandIndustryAppealsTribunal(CBb)ruledinfavourofKNMP,whichmeantthattheclawbackschemewassuspendedwitheffectfrom1July2008.Onbasisofanotherauditof2007,NZaadoptedtheviewthatthesuspensionof

setamaximumfeethatdidnotcovercosts to‘encouragepharmaciststonegotiate’.Atthesametime,accordingtoNZa,themaximallyincreasedfeewasmeantto‘incentiviseinsu-rerstoagreealowerfee’.Thesuddennessoftheannouncementandtheimminentstartofthenew(contract)yearmeantthatphar-macistsandinsurerswereunabletopreparefortheintroductionofthisflexiblefee.Phar-macistsweregivenverylittletimetoadjusttothenewflexiblefee,forattheendofAprilNZaannouncedthatanewsetofdispensingfeesweretobeintroducedwitheffectfrom 1May2009.Inparticular,thefeefordis-pensingaprescriptionforthefirsttimewasadjustedupwards.Theincreaseinthefeewasintendedtoreflecttheextraworkinvolved indispensingamedicineforthefirsttime.However,giventhatNZacontinuedtoadheretotheprinciplethattheaveragemaximum feehadtobe€7.28,theotherdispensing feeswerereducedaccordingly.

In2009dispensingfeesamountedto€1,073million.Thiswas€190million(almost22%)morethanin2008.Thisincreaseisalmostentirelyduetothefactthatdispensingfeeswereincreasedfrom€6.05(astandarddis-pensingfeeof€6.00inthefirsthalfof2008andaaveragedifferentiatedfeeof€6.10 inthesecondhalfof2008to€7.92.

Thedispensingfeesfor010werealsoset atthelastmoment.AtthebeginningofDecember2009,NZasetafeethatwouldworkoutat€7.91:anincreaseof9%in relationtothefeesthatappliedfromMay2009onwards.Asin2009,inadditiontothemaximumfee,theNZafeesystemalsoincludedamaximallyincreasedfee.The maximallyincreasedfeeswere26%higher

thanthemaximumfee,averagingat€10.00.Hencethedifferencebetweenthemaximumfeeandthemaximallyincreasedfeeincreasedfrom€0.64to€2.09.NZagavenoexplana-tionforthisconsiderableincrease.Unlikepreviousyears,NZadidnotdefinetheamountofacost-coveringfee.Asin2009,theamountoftheclawbackwasnegotiable.However,althoughNZagiveshealthinsurersscopetonegotiate,pharmacistsareunlikelytobeabletoderivefullbenefitfromthisarrangement.

Purchase price reimbursement feesInprinciple,thepurchasepricereimburse-mentfeethatapharmacycanchargeforaprescriptionmedicineitdispensesisbasedonthelistpricespecifiedbythesupplierofthemedicine(themanufacturerortheimporter).Inpractice,pharmaciescanagreediscountsontheselistpriceswiththeirsuppliers. Thesepurchasingadvantageshaveoftenbeenasubjectofdebateinrecentyears.Upuntil1October1991thestatutoryrulingwasthatpharmacistswereentitledtochargethenetpurchasepricetheypaidforaprescriptionmedicineplusamarginof4%ofthecorres-pondinglistpricefortheprescription medicinestheysupplied.On1October1991,inordertoachieve savings,HansSimons,thenStateSecretaryofHealth,decidedtoreducedispensingfees.Inconnectionwiththismeasure,pharma-cieswereallowedtochargethelistpricesfortheprescriptionmedicinestheydispensed,whichmeantthattheyretainedalloftheirpurchasingadvantagesandcouldoffsetthesepurchasingadvantagesagainstthelossofincomeduetothereduceddispensingfees.Aspharmacistsbegantoadoptamorecom-mercialapproachandasmedicinepatentsexpired(whichincreasedcompetitionasnew


Inmid-November2002,outgoingDeputyHealthMinister,DeGeus,announcedthattheclawbackschemewastobeadjustedtoachieveanextrasavingof€280million(includingVAT)onexpenditureonmedicines.TheRoyalDutchPharmacistsAssociation(KNMP)challengedtheschemeonbehalfofthepharmacists.Followingproceedingsonthemeritsofthecase,inDecember2003theTradeandIndustryAppealsTribunal(CBb)reversedtherulingthatallowedtheintro-ductionoftheadjustedclawbackscheme.

industry agreement years 2004-2007FollowingthedecisionoftheCBb,theDutchMinistryofHealth,KNMPandtheAssociationofDutchHealthInsurers(ZN)immediatelybegantalksinanattempttofindasolutiontotheresultingimpasse.InconsultationwiththeAssociationoftheDutchGenericMedi-cinesIndustry(Bogin),thesetalksledtoanindustryagreementthatwassignedbythepartiesconcernedon13February2004. Themostsignificantaspectofthisagree-mentwasthedecisiontoreducetheprices ofgenericmedicinestoanaverageof40%

belowthelistpricestipulatedbythemanu-facturerswitheffectfrom1January2004. Inadditiontothis,thepriceofnewgenericmedicineswastobeatleast40%belowthepriceofthecorrespondingoriginalbrandnamemedicine.From1January2005Nefarma,theDutchpharmaceuticalindustryassociation,alsosignedtheindustryagree-ment.Inadditiontotheprovisionsofthe2004agreement,itwasagreedthatfrom 1January2005manufacturersofbrandedmedicineswouldreducethepricesofpre-scriptionmedicinesifgenericmedicinesthatwereidenticalintermsof‘substanceandadministration’werealsoavailable,orthatthemanufacturersofbrandedmedicineswouldreducethepricesofsingle-sourcemedicines(medicineswithnogeneric alternatives)asacompensatorymeasure.Nefarmamadethispromiseontheconditionthatthegovernmentrefrainedfrom tighteningtheDrugReimbursementSystem duringthecourseoftheindustryagreement. Theseagreementswerecontinuedin2006and2007.WiththeloweringofthemaximumpricesundertheMedicinesPricingActand

1.5 Industry agreements on medicine pricing

TransitionAgreementsavingsobjectivescomfortablyexceededThe years from 2004 to 2009 were characterised by agreements regarding the lowering of medicine prices. The agreed savings objectives were achieved from 2005 onwards. In 2008 and 2009 the savings objectives were exceeded by almost € 110 million and more than € 570 million respectively.

theclawbackschemeduringthesecondhalfof2008wasnotjustifiedandthatpharma-cistswererequiredtomakeupthedifferenceviaatemporaryincreaseintheclawbackto8.53%in2009and2010.

Afterdeductingtheclawback,thecostof medicinesfellby€146millionto€3,681 millionin2009.Thiswasthefirsttimethatthecostofmedicineshadfallensince2004.

Thefallinthecostswasprimarilyduetothepricecutspromptedbythehealthinsurers’preferencepoliciesandrestrictedentitlementtoreimbursedsleep-inducingmedicationandsedatives.Almostalloftheincreaseinthecostofexpensivemedicinesbypassesregularpharmacies.Thisleadtoanevenlowertotalcostofmedicinesperpharmacy.

1.6 Cost of medicines and community pharmacy fees (1 = 1 million euros)


4,000

2005 2006

Cost of medicines Pharmacy fees

2007 2008 2009 2005 2006 2007 2008 2009

3,343 3,479 3,778 3,827 3,681 802 874824 915 1,108

3,500

2,500

1,500

500

3,000

2,000

1,000

0


1.7 Agreed savings objectives in industry agreements on medicine pricing (amounts include VAT and the cost of medicines dispensed by dispensing general practitioners)


1,400

1,000

600

200

1,600

1,200

800

400

02004

622

2005

685

2006

843

2007

971

2008

1,311

2009

1,427

theexpiryofthepatentsofvariousmedicines,thesavingsobjectivesdefinedintheindustryagreementshavebeenachievedeveryyearsince2005.

Pharmaceutical care transition agreement 2008-2009On17September2007,MinisterofHealth, AbKlink,signedanotheragreementwithBogin,KNMP,NefarmaandZN.Ontheonehand,thisagreementwasacontinuationandrefinementofthecutbackagreementsenshrinedinearlierindustryagreements.Hencethepartiesagreedthatthepricesofgenericmedicinesweretobereducedbyafurther10%in2008andthat,fromthenon,newgenericmedicineswouldcostnomorethanhalfthepriceofthecorresponding originalbrandnamemedicine.ItwasalsoagreedthatfromDecember2007toJune2008theclawbackwouldbeincreasedfrom6.82%to11.3%asatransitionsurcharge.Thismeantthat,inadditiontothe€215million(includingVAT)inpurchasingadvan-tagesthatpharmaciesgavebackviatheexistingclawbackscheme,afurther€50million(includingVAT)wasskimmedoffthepharmacies’purchasingadvantages.Besidesthefinancialagreements,intheTransitionAgreement2008-2009itwasagreedthatthepartieswouldcollaborateonthedevelopmentofaphasedplan,which,overaperiodoftwoyears,wouldgraduallycreatenewmarketconditionsthatwouldincentivisethelinks

inthevaluechaintodelivermaximumaddedvalueforthecustomerwhichwouldallowfortheexisting(pricing)regulationstobephasedout.ThepartiestotheTransitionAgreementalsoagreedthatpharmacistsneededtheportionofthepurchasingadvantagesthatremainedfollowingthedeductionofthe clawbacktofinancetheirpracticecosts. Iftherewasanyfurthercutbackonorskim-mingofpharmacists’purchasingadvantages,thepharmacistswouldhavetobecompen-satedbyanincreaseinpharmacyfeeswhichwouldbeagreedonacasebycasebasis.

Inviewofthepurchasingadvantagesthatpharmacistswerealreadygivingbackviatheclawbackandbearinginmindthepurchasingadvantagesneededbypharmaciststofinancepracticecosts,thepartiestotheTransitionAgreementconcludedthatin2008therewasscopetoincreasethesavingsobjectiveby€340millionto€1,311million.Follow-ingthesigningoftheTransitionAgreementMinisterKlinkconcludedthatiffurtherpricecutsresultedinfurthersavings,pharma-cistswouldbecompensatedbyanincreaseinpharmacydispensingfees.Theimpactofthehealthinsurers’preferencepolicieshassincemeantthatthesavingsobjectivewasexceededbyalmost€110millionin2008andbymorethan€570millionin2009.However,thepartiestotheTransitionAgreementhavenotyetdecidedwhattodowiththerevenuesderivedfromtheseadditionalsavings.


thisdevelopment,in2009UVITintroducedasystemofprivatelynegotiatedpricesintheformoftheso-calledconcealedpricemodel,inwhichthemedicinesupplierdoesnotreducethepubliclyannouncedpricesofmedicines,butoffersUVITprivatelynegotiateddiscount.Themodelmetwithseverecriticism,becauseitwasnotclearhowthepurchasingadvantagegainedbyUVITbenefittedtheinsured,andalsobecausepharmacistswereobligedtosupplycertaingenericproductswhencheaperversionswereavailable.Duringthecourseof2009UVITannouncedthatmedicinescoveredbythecon-cealedpricepolicywouldnotcounttowardsthecompulsorypolicyexcess.In2009healthinsu-rerscontinuedtoexpandtheimplementationofboththepreferencepolicyandtheconcealedpricepolicy,whichmeantthatthepricelevelfellbyalmostanother9%.Inthefirstquarterof2010thepricelevelwas0.9%lowerthaninthefourthquarterof2009.Thisfallinthepricelevelisprimarilyattributabletofurtherlower-ingofthepricesofgenericmedicines.

new maximum pricesTheMedicinesPricingAct(WetGenees-middelenPrijzen,WGP)alsocontributedtothefallingprices.Indictatingthemaximumpricesofprescriptionmedicines,theacthascausedthepriceleveltofallbyanaverageof3to4%peryearinrecentyears.AtthemomenttheWGPisthegovernment’smostimportantinstrumentforexertinginfluenceonmedicineprices.TheWGPmakesitcom-pulsoryformedicinesupplierstopricetheirproductsonparwiththeaverageprices infourneighbouringcountries,Belgium, Germany,FranceandtheUK.Since1996 thegovernmenthassetthemaximumpricestwiceayear:inMarchandOctober.Themaxi-mumpricessetinApril2010contributedtoa0.8%fallinthepricelevelofprescriptionmedicines.ThislimitedfallinthepricelevelisinkeepingwiththetrendinrecentyearsinwhichthepricecutsdictatedbytheWGPwerelowerinthespringthanintheautumn.

1.8 Price development of prescription medicines based on the SFK price index (January 1996 = 100), weighted average of sales


100%Introduction of the Medicines Pricing Act

Introduction of clawback

Start of industry agreement period

Transition Agreement

Temporary introduction of the ‘De Geus’ measure

(Individual) preference policies

Increased clawbackMinistry of Health-KNMP agreement

90%

80%

70%

60%

50%

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

SFKdeterminesthedevelopmentofthepricelevelofmedicinesbycomparingthetotalcostofmedicinesdispensedbycommunitypharma-cistsonemonthwiththetotalcostofthesamequantityofthesamemedicinesdispensedbycommunitypharmaciststhenextmonth.Hencechangesinthenumberandnatureofthedis-pensedmedicinesdonotaffectthepricelevel

Preference policiesAtthebeginningof2008severalinsurers (Menzis,UVIT,CZandAgis)announcedtheirintentiontoexpandtheimplementationofthepreferencepolicyfrom1July2008.TheAssociationofDutchHealthInsurers(ZN)hadbeenexperimentingwiththepreferencepolicyforseveralyears,butithadnothadmuchimpactatanationallevel.Thepreferencepolicymeansthataninsurerindicatesthatonlyoneorcertainproductswithinaspecificgroupofmedicineswillbecoveredbytheirbasichealthinsurance.Medicinesproducedbysuppliers(labels)notcoveredbytheinsurerarenotreimbursed.Contrarytothepatientcontribu-tionregulationsoftheDrugReimbursementSystem,thismeansthatpatientshavetopayforanyalternativesentirelyoutoftheirownpocket.Theinsurers’national‘callfortenders’

inJune2008sparkedarealpricewarbetweensuppliersofgenericmedicines.Thepricesofthemostimportantgenericmedicinesfellby90%.Inadditiontothepreferencepolicy,theinsurersalsomadelowest-priceagreements(theinsurerpaysthepharmacythepriceofthecheapestalternativetoaparticularmedicineirrespectiveofwhetherthepharmacydispensesthemedicineinquestion)orso-called‘bandwithagreements’(theinsureronlycoversmedicinesthatareupto3to5%moreexpensivethanthecheapestalternative),whichforcedallsuppliersofgenericmedicinestoreducetheirpricestothelowestleveltoavoidpricingthemselvesoutofthemarket.Throughoutthecourseoftheyearthepricewarledtocostsreductionsof €355million.Earlierthesameyearthepricesofgenericmedicineshadalreadybeenreducedby€125millionasaresultofthePharmaceuti-calCareTransitionAgreementthatMinister AbKlinkhadsignedwiththepharmacyindustry.Henceturnoverderivedfromthesaleofgenericmedicineshalvedinjustundersixmonths.

concealed price policy TheDutchMinistryofHealth‘cashedin’ontheeffectsofthepricecutsbyreducingtheinsurers’medicinesbudgetsaccordingly.Dissatisfiedwith

1.6 Development of medicine prices

Medicinepriceshavehalvedinthelast15yearsThe combined effects of the Medicines Pricing Act and voluntary price cuts, both in the context of the industry agreements on medicine pricing and in response to health insurers’ preference policies, have meant that the prices of prescription medicines have almost halved from 1996 to 2010.


millionin2009.Thiswaslargelydueto thepricecutsforcedbythehealthinsurers’preferencepolicies.Thecostshareofgenericmedicinesfellfrom15.3%in2008to11.7%in2009.Thecostsharewashalfofwhatitwasin2007.

Parallel imports laggingParallel-importedmedicinesarebrandnamemedicinesthatareimportedoutsidethemanufacturer’sofficialdistributionchannelfromcountrieswithintheEuropeanUnionwherethepricelevelislowerthanintheNetherlands.In2009pharmacistsdispensedaparallel-importedmedicine12.8milliontimes(anincreaseof4.8%inrelationtothepreviousyear).Theincreaseinthenumber ofparallel-importedmedicinesdispensed bypharmaciststhereforelaggedwellbehindthenumberofgenericmedicinesandnon-parallel-importedbrandnamemedicines. Oneofthereasonsforthiswasthefactthatthesemedicinesweredifficulttoobtainorcouldnotbeobtainedonaregularbasis,becauseseveralmanufacturersnowlimitthesupplyofproductspercountry.Expenditureonparallel-importedmedicinesfellby1.8% in2009.Asignificantportionofthisreduc-tioninexpenditurewasaccountedforbytheexpiryofthepatentonpantoprazole(Pantozol)inMay2009.Fromthenontherewasapowerfulshiftfromparallel-importstogenericversionsofpantoprazole.In2008pantoprazolewasstilltopofthelistofparal-lel-importedmedicineswithboththehighestnumberofpharmacy-dispensedprescriptionsandthehighestexpenditure.Atorvastatinisnowtheparallel-importedmedicinethatgeneratesthehighestexpenditure.

increase in pharmacy-prepared medicinesTheSFKcategoryof‘pharmacy-prepared medicinesandotherproducts’includes medicinespreparedinaccordancewithanationalWINApprotocol(whichgenerallyhaveanationalidentificationnumber)andproductsnotlistedwithanationalidentifica-tionnumberintheG-StandardoftheZ-Index.Thislastcategoryalsoincludesmedicinesthatarepreparedinaccordancewiththepharma-cy’sownprotocoloralocalprotocol.Thecostshareofpharmacy-preparedmedicinesandotherproductsincreasedfrom0.9%in2008 to1.2%in2009.Thereisatechnicalreasonforthisrelativelylargeincrease:fromJuly2008SFKincorporatedimprovedrecordsofthecostsofmedicinesnotlistedintheG-Standard.ThisgivestheimpressionthattherewasasignificantincreaseinthesaleoftheseproductsfromJuly2008onwards.Basiccreamsandointmentsusedtotreatskinconditionssuch aseczema,itching,haemorrhoidsorseverelydryskinwerethemostfrequentlydispensedpharmacy-preparedmedicines.Ifnecessary,medicinessuchaslidocaine(alocalanaesthetic)canbeaddedtothesecreams.Pharmaciesalsoregularlyprepareandsupplysodiumfluoridemouthwash,acideardropsusedtotreatouterearinfections,eyedropsandeyeointments.

Agenericmedicineisacarboncopyof abrandnamemedicinewhosepatenthasexpired.Agenericmedicinedoesnothaveabrandnamebutisknownbythenameoftheactiveingredient.Thenameofthemanu-facturerisusuallylinkedtothenameofthegenericmedicine.Asinpreviousyears,Dutchpharmacistscontinuedtodispensemore genericmedicines.In200997millionphar-macy-dispensedprescriptionsweredispensedasgenericproducts(anincreaseof10.3%).Thismeantthattheshareofprescriptionsdispensedasgenericmedicinesincreased to57%,asopposedto56.2%in2008.

More prescriptions dispensed as generic medicines Theincreaseinthemarketshareofgenericmedicinesisinkeepingwithatrendthatstartedseveralyearsago.Forthelasttenyearstheshareofgenericmedicineshasincreasedbyanaverageof3.7%peryear. Theincreaseintheshareofpharmacy- dispensedgenericmedicinesisconsistent

withtheundertakingmadebypharmacists intheindustryagreementswiththegovern-menttopromotetheuseof(cheaper)genericmedicines.Thehealthinsurers’preferencepoliciesclearlyplayedanimportantroleintheincreaseinthenumberofgenericmedi-cinesdispensedbypharmacists,giventhat thelawallowshealthinsurerstorestrictreimbursementtomedicinestheychoose tocoverinaccordancewiththeirprefer-encepolicy.Thepatientisonlyentitledtoreimbursementofnon-preferredmedicinesifthereisamedicalnecessity,inwhichcasethedoctorwhoprescribesthemedicinemustnotethisontheprescription.Healthinsurersusuallyrestrictreimbursementtogenericmedicines,unlessitistotheirfinancialadvan-tagetorestrictreimbursementtoabrandnamemedicine(concealedpricemodel).Despitethefactthatpharmacistsdispensedanincreasingnumberofprescriptionsasgenericmedicines,thecostsofgenericpre-scriptionmedicinesreimbursedbystatutoryhealthinsurancefellby26.3%to€421

1.7 Market shares per product group

Shareofprescriptionsdispensed asgenericmedicinescontinues to increaseThe share of prescriptions dispensed as generic medicines increased to 57% in 2009. The significant shifts in the market shares of the various suppliers of generic products were mainly due to the health insurers’ preference policies. The cost share of generic medicines fell to 12%.


TheDrugReimbursementSystem(GVS) introducedon1July1991meansthatthe DutchMinistryofHealthdetermineswhether amedicinewillbereimbursedand,ifso, towhatextent.MedicinesthattheMinistry regardsasinterchangeablearegroupedtogetherasacluster,withthemaximum reimbursementbeingdefinedforeachcluster.Ifapatientusesamedicinethatcostsmorethanthemaximumreimbursementlimitforthecluster,thepatienthastopaythedifference.TheDutchMinistryofHealthlastadjustedthevariousreimbursementlimitsinFebruary1999.ThecurrentreimbursementlimitsarebasedonthepricelevelthatappliedinOctober1998.ThecombinedeffectsoftheMedicinesPricingAct(WGP),industryagreementsonmedicinepricingandhealthinsurers’preferencepoliciesmeanthatthepricesofmostmedicinesarenowconsiderablylowerthanthereimbursementlimitsestablishedinthedistantpast.TheGVSisexpectedtoberevitalised.Newrecalculatedreimbursementlimitsbasedoncurrentpriceswillapplyfrom1January2011.Ifprescriptionandsupplypatternsremainthesame,thesenewreimbursementlimitscouldhavesignificantconsequencesforpatientcontributions.Topre-venttheintroductionofpatientcontributions

forparamedicalcareandsecondlinementalhealthcare,justbeforetheparliamentaryrecessin2010,theLowerHouseoftheDutchParlia-mentpassedamotionaskingthegovernmenttoreassesstheGVS.ThesamemotionaskedtheMinistertotakestepstoensurethatamaximumannualpatientcontributionwasestablished forindividualcitizens.Themaximumannual contributionisexpectedtobe€200perperson.

Patient contributionsIn2009Dutchpharmacistsdispenseda prescriptionmedicinethatrequiredapatientcontribution(orsupplementarypayment)threemilliontimes.Patientcontributionsamountedtoatotalof€46.5million,asopposedto€46.2millionin2008.Unlikepreviousyears,thisisarelativelysmalldifference.MedicinesthatrequireapatientcontributionarelistedintheDrugReimbursementSystem(GVS),buttheofficialpharmacypurchasepriceishigherthantheestablishedreimbursementlimit.Thelimitisestablishedonthebasisoftheprinciplethatagroupofinterchangeablemedicinesmustalwaysincludeamedicinethatdoesnotrequireapatientcontribution.Theextenttowhichthepatientcontributionisactuallypaidbythemedicineusersisunknown.Healthinsurers

1.8 The Drug Reimbursement System

LullbeforethestormsurroundingpatientcontributionsIn 2009 patient contributions towards the cost of prescription medicines dispensed by Dutch pharmacists amounted to a total of € 46.5 million. If the Dutch Labour (PvdA), Liberal (VVD) and GreenLeft parties have any say, patient contributions will increase considerably over the next year.

1.9 Use of medicines per product group: prescriptions 2009


1.10 Use of medicines per product group: cost of medicines 2009


Cardiovascular medicines

Gastric medicines

Medicines for the central nervous system

Medicines for the respiratory system

Other medicines

Parallel import

Generic medicine

Pharmacy-prepared medicines and other products

Parallel import

Generic medicine


668Oncolytica

Established/Managing pharmacist

Second pharmacists

Pharmacy assistants

Other staff

Specialité

Specialité

57.0%

1,482

877

668

635

559

525

2.6%

32.8%

7.5%

71.2%

15.9%

11.7%1.2%

5.67

0.45

11.77


Gastric medicines



Other medicines

Parallel import

Generic medicine


Parallel import

Generic medicine


668Oncolytica


Second pharmacists

Pharmacy assistants

Other staff

Specialité

Specialité

57.0%

1,482

877

668

635

559

525

2.6%

32.8%

7.5%

71.2%

15.9%

11.7%1.2%

5.67

0.45

11.77


Theaverageper-capitacostofmedicinesintheNetherlandsalsoincludesthecostsinvolvedinsupplyingexpensivemedicines(anaverageof€52perperson).SFKdefinesexpensivemedicinesasmedicinesthatcostmorethan€500perprescription.Theseproductsareoftendistributedviaselectedpharmacies.Withtherapidincreaseintheuseofexpensivemedicines,whichinsomecountriesareonlyavailableviahospitals,theNetherlandsisedgingclosertotheWesternEuropeanaverage.However,thehealthinsu-rers’preferencepolicieshaveledtoasharpfallinthepricesofgenericmedicinesintheNetherlandssinceJune2008.Asaresult,ratherthanincreasing,theper-capitaspendremainedlevelat€335.

neighbouring countriesMedicineconsumptionis18to68%higher inneighbouringcountries.Theper-capitaspendinBelgium,GermanyandFranceis €395,€458and€564respectively.There isnocurrentdatafortheUKasawhole,sotheSFKcanonlyreportonmedicinecon-sumptioninEngland,wheretheper-capitaspendamountedto€224in2008.ThisputsEnglandrightatthebottomofthelist.

However,expensivemedicinesareconfinedtohospitalsettingsintheUK,soexpenditureonexpensivemedicinesfallsoutsidetheextramuralarena.Theper-capitaspendin theNetherlandsismorethan25%higherthantheaverageper-capitaspendoftheever-frugalDanes.TheinhabitantsofSou-thernEuropeancountriesalsotraditionallyspendrelativelylittleonmedicines.In2008theaveragespendinNetherlandswasmorethaninItaly(€318),butlessthaninPortugal(€346)andSpain(€347).

share of care costs less than 10%Whenpublicexpenditureonpharmaceu-ticalsisrelatedtothetotalcostofhealthcare,theNetherlandscontinuestooccupyamodestpositioninthemiddleofthelistofotherWesternEuropeancountries.In2008expenditureonpharmacy-dispensed(bene-fit-packageandnon-benefitpackage)medi-cinesaccountedfor9.8%ofthetotalcarecostsintheNetherlands.Thelowerpricesofgenericmedicinesandariseinothercarecostscausedexpenditureonmedicinesto falltosuchanextentthat,asashareofthetotalcarecosts,itwasalmostapercentagepointlowerthanin2007,despitethefact

1.9 Medicine use in Western Europe

AveragespendintheNetherlandsremainsthesameLess than 10% of the total expenditure on care in the Netherlands is spent on medicines. This makes the Netherlands one of the lowest countries on the list in Western Europe. On average the Dutch spend € 335 on medicines, which is currently 17% below the Western European average (€ 403).

offeradditionalinsurancethatcoverspatientcontributions,eitherinfulloruptoacertainmaximumamountperyear.Manufacturersalsoreimbursethepatientcontributionsrequiredforsomemedicinesif,forstrategicreasons(fromaninternationalpointofview),theydonotwanttopricetheproductsinquestionbelowthereimbursementlimitortointroduce asupplementarypaymentforthepatient. Ifthisisthecase,thepatientpaysthepatientcontributionandsendsthereceiptforthepay-menttothemanufacturerforreimbursement,orthepharmacistreimbursesthepatientandisreimbursedbythemanufacturer.Amorerecentprocedureallowsthepharmacistnottochargethepatientcontributionbecausethemanufacturergivesthepharmacyanadditionaldiscountonthepurchasepricewhichcoversthepatientcontribution.WhethermanufacturerswillcontinuetoimplementthesemeasuresoncetheGVShasbeenreassessedremainstobeseen.Atthemomentpoliticiansfeelthatpatientcon-tributionsofupto€200peryearareacceptableandthereareplanstoprovideafinancialsafetynetforanythingabovethat.

aDHD medicines and the pillAlmosthalfofthetotalamountofpatientcontri-butionsin2009,€22million,wenttowardsthecostofpharmacy-dispensedADHDmedication.ThemeasureproposedbyVanderVeenmaybetotheadvantageoftheusersofADHDmedicationortheirparentsorcarers.In2009theaverageannualper-userpatientcontributionforatomo-xetine(Strattera)wasalmost€700:€500morethantheproposedfinancialsafetynet.Methyl-phenidateisthedrugmostcommonlyusedtotreatADHD.In2009approximatelyhalfofthemethylphenidateprescribedwasusedinaformthatdidnotrequireapatientcontribution,whiletheotherhalfwasusedinaslow-releaseformthatdidrequireapatientcontribution,whichaveragedatalmost€250peruserperyear. Thesafetynetmayleadmorepatientstouseslow-releaseformsofmethylphenidateiftheyknowthatthepatientcontributionissubjectto amaximumlimit.In2009womenusingacontra-ceptivepillhadtoforkoutmorethan€12millioninpatientcontributions.Thetop25productsthatrequiredapatientcontributionincludedsevenmedicinesforwhichthereareknowntobereim-bursementarrangements.Thereimbursementsprovidedinaccordancewiththesearrangementsamountedtoatotalof€7.8million.

1.11 Total GVS patient contributions paid via community pharmacists (1 = 1 million euros)


50

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

20 18 18 20 15 16 23 34 46 47

40

30

20

10

0


Inmostothercountries,includingBelgium,France,Spain,Italy,AustriaandSwitzerland,thepercentagerangesfrom10to20%.

However, the conservative prescription and medicine-taking patterns that have become typical in the Netherlands in recent years are the main reason for the relatively low expen-diture on medicines.

Thepricecutspromptedbythehealthinsurers’preferencepoliciesfrommid2008onwardsarethesecondmostimportantreasonforthelowmedicineconsumptionintheNetherlands.

1.13 Expenditure on pharmacy-dispensed pharmaceuticals as a share of the total expenditure on health care in 2008

Expenditure on medicines accounts for less than 10% of the total expenditure on care in the Netherlands. This makes the Netherlands one of the lowest countries on the list in Western Europe.


SPAIN

PORTUGAL

FRANCE

FINLAND

GERMANY

IRELAND

ITALY

BELGIUM

SWEDEN

AUSTRIA

SWITZERLAND

NETHERLANDS

ENGLAND

DENMARK

22.0%

21.5%

16.2%

16.1%

15.4%

14.3%

13.6%

11.9%

11.8%

11.0%

10.1%

9.8%

7.7%

7.3%

0% 5% 10% 15% 20% 25%

thatexpenditureonexpensiveproductsincreasedby23%duringthesameperiod.Generallyspeaking,theshareofexpenditureonpharmaceuticalsisgreaterincountriesthataresituatedfurthersouth,withFinlandbeinganexception.

reasonsThedifferencesinmedicineconsumptionarepartlyaccountedforbypopulationageing. IntheNetherlands14.8%ofthepopulation

isinthe65-plusagegroup.InFrance,BelgiumandGermanythepercentageofseniorcitizensisconsiderablyhigherat16.5%,17.1%and20.1%respectively.IntheNetherlandsseniorcitizensusethreetimesasmuchmedicationastheaverageuser.AnotherreasonfortherelativelylowexpenditureintheNetherlandsistheuseofgenericmedicines.Dutchpharma-cistsnowfill57%ofprescriptionswithgenericequivalents.Thisisasimilarsituationin countriessuchasGermanyandtheUK.

1.12 Per-capita spend on medicines dispensed by pharmacies in 2008

Spending on medicines in the Netherlands is on a par with the low level of expenditure on medicines in the traditionally frugal Southern European countries and Denmark. England has the lowest expenditure per capita, but this does not include expensive medicines.


500

564 510 458 389512 471 395 347 346 335 323 318 264 224

400

600

300

200

100

0

FRAN

CE

IREL

AND

SWIT

ZER

LAN

D

FIN

LAN

D

GER

MAN

Y

BEL

GIU

M

AUST

RIA

SPAI

N

PO

RTU

GAL

NETHERLANDS

SWED

EN

ITAL

Y

DEN

MAR

K

ENG

LAN

D

Western European average


In2009communitypharmacistsdispensed€4,789millionworthofmedicinesthatareincludedinthebasichealthservicespackagecoveredbystatutoryhealthinsurance. Thefollowinggraphshowstheexpenditure onfirst-levelATCgroups.

Highest expenditures2009wasthefirstyearsince2004thatthecholesterol-loweringmedicineatorvastatin(Lipitor)wasnotatthetopofthelistofthetoptenmedicinesthatgeneratedthehighestexpenditures.

Medicines2.1 Expenditure on medicines

RheumatoidarthritismedicinestoptheexpenditurelistFrom 2004 to 2008 the cholesterol-lowering medicine atorvastatin generated the highest expenditure in community pharmacies. In 2009 adalimumab, which is prescribed for rheumatoid arthritis, took over the position at the top of the list. Adalimumab also accounted for the highest increase in expenditure, followed by etanercept, another rheumatoid arthritis medicine.

2.1 Expenditure per group of medicines

Twenty percent of this expenditure, the same share as in previous years, is accounted for by the top ten medicines that generate the highest expenditures.



Gastric medicines



Other medicines

Parallel import

Generic medicine


Parallel import

Generic medicine


668Oncolytica


Second pharmacists

Pharmacy assistants

Other staff

Specialité

Specialité

57.0%

1,482

877

668

635

559

525

2.6%

32.8%

7.5%

71.2%

15.9%

11.7%1.2%

5.67

0.45

11.77

2


2.2 Top 10 medicine expenditures in 2009

actiVe ingreDient (ranKing in 2008) BranD naMe useD tO treat exPenDiture (MiLLiOn €)

1 Adalimumab (5) Humira rheumatoid arthritis 148 (+37%)

2 Atorvastatin (1) Lipitor High cholesterol 146 (-12%)

3 Etanercept (4) enbrel rheumatoid arthritis 129 (+17%)

4 Salmeterol with fluticasone (2) seretide respiratory conditions 122 (-1%)

5 Pantoprazole (3) Pantozol excessive gastric acid production

80 (-31%)

6 Tiotropium bromide (6) spiriva respiratory conditions 76 (+11%)

7 Esomeprazole (9) nexium excessive gastric acid production

70 (+11%)

8 Metropolol (8) selokeen,Lopresor

angina pectoris, high bloodpressure and heart failure

66 (+5%)

9 Formoterol with budesonide (10) symbicort respiratory conditions 64 (+5%)

10 Somatropin (-) several growth hormone deficiencies 58 (+7%)

As in 2008, respiratory medicines were well represented in the Top 10 in 2009, with tiotropium in 6th place and the combination preparations salmeterol and fluticasone in 4th place and formoterol and budesonide in 9th place.


Therewasan11.6%fallinturnoverderivedfromsalesofatorvastatin.Thefallinexpendi-tureonatorvastatinwaslargelyduetoafallinboththevolumeofsales(-4.6%)andprice(-6.3%).A37%increaseinexpenditureontheTNF-alphainhibitoradalimumab(Humira), amedicineprescribedforrheumatoidarthritis,putitatthetopofthelist.However,turnoverderivedfromsalesofadalimumab(€148 million)wereonlymarginally(€2million)higherthanturnoverderivedfromsalesofatorvastatin(€146million).Thirdonthelistwasetanercept(Enbrel),thesecondrheuma-toidarthritismedicineamongthetop10.Expenditureonetanerceptincreasedby 17%to€129million.

AdalimumabandetanerceptaretwooftheTNF-alphainhibitorsusedtotreatsevereformsofrheumatoidarthritisamongotherconditions.Expenditureonthesemedicinesincreasedby€40and€19millionrespectivelyin2009,makingthemthemedicinesthatsawthehighestexpenditureincreasesin2009.However,almostallofthisincreasebypassesregularpharmacies:adalimumabandetaner-ceptbothfindtheirwaytothepatientvia so-calledselectiveorexclusivesupply. Thisselectivedistributionmeansthatthesemedicinesarenotsuppliedbyeverycommu-nitypharmacy.Thereisonlyonenational pharmacychainthatsuppliesadalimumab. In2009morethantwo-thirdsoftheexpendi-tureonetanerceptwaschannelledviaasinglenationalpharmacychain.Revenuesderivedfromsalesofetanerceptviaregularcommu-nitypharmaciesincreasedfrom€35millionto€38.6millionin2009.InJuly2010MinisterAbKlinkannouncedplanstotransfertheTNF-alphainhibitorsfromtheDrugReimbursementSystem(GVS)tothehospitalbudgetfrom

1January2011.In2009twoofthesemedicines(adalimumabandetanercept)wereamongboththetoptenmedicinesthatgeneratedthehighestexpendituresandthetoptenmedicinesthatsawthehighestexpenditureincreases. Iftheseplansgoahead,adalimumabandetanerceptwilldisappearfromthetop10.

falls in expenditureThe€19millionfallinexpenditureonatorvas-tatinwasexceededbythefallinexpenditure ongastricacidsuppressantpantoprazole (Pantozol).In2008revenuesderivedfromsalesofpantoprazoleincreasedby10%.Yetin2009itsawthesharpestfallinexpenditureamongthetoptenmedicines,bothinmone-taryterms(€36million)andasapercentage(-31%).Thiscausedpantoprazoletofallfromthirdtofifthplaceonthelistofthetop10 medicinesthatgeneratedthehighestexpen-ditures.ThisfallinexpenditureisduetotheexpiryofthepatentonpantoprazoleinMay2009andthesubsequentpricecutsforced bythepreferencepolicies.Intermsofdefineddailydoses(DDDs),therewasactuallyan 11%increaseinsalesofpantoprazole,butthiswasnotenoughtomitigatethesharpfallinexpenditure.

Thehealthinsurers’preferencepolicieshadfurtherrepercussionsonthetop10medicinesthatgeneratedthehighestexpendituresin2009.Pricecutscausedthecholesterol-loweringmedicinesimvastatintodisappearfromthelistin2008andgastricacidsuppressantomepra-zolefollowedsuitin2009.Despitetheincreaseinsales(+18%intermsofDDDs)expenditureonomeprazolefellby€17million,infavourofesomeprazole(Nexium)whichsawa€70millionincreaseinexpenditure.

44

In2009communitypharmacistsintheNether-landssuppliedamedicineincludedinthebasicbenefitpackagecoveredbystatutoryhealthinsurance177milliontimes.21%ofthetotalnumberofprescriptions(37milliondispensings)wereforoneofthetoptenmostfrequentlydispensedmedicines.

In2004theDutchCollegeofGeneralPracti-tioners(NHG)recommendedthatmetoprololbeusedinplaceofatenololtotreathighbloodpressure,anginapectorisandheartfailure iftheconditionneededtobetreatedwith aselectivebetablocker.Metoprolol(Lopre-sor,Selokeen)hasbeentopofthelistofthetenmostfrequentlydispensedmedicines coveredbystatutoryhealthinsuranceeversince(2005).Inthemeantimethenumber ofprescriptionsdispensedbycommunitypharmacistshasmorethandoubled,from 2.4millionin2004to5.5millionin2009 (1.1millionmorethanin2008).Thesubstan-tialincreasesinthenumberofpharmacy- dispensedprescriptionsin2008and2009(19%and+25%respectively)wereduetothehigherfrequencyofclaimsformedicines

issuedinweeklydosepacksfollowingtheintroductionofdifferentiatedfeesinJuly2008.Hencetheincreaseinthenumberofdefineddailydoses(DDD)isamoreobjectiveindicatoroftheincreaseinsales.Formetoprololtheincreasewas6%in2009,virtuallythesame asin2008.

Therewasnochangeinthetop3most frequentlydispensedproductsinrelation to2008.Thedifferencebetweenthefront runner,metoprolol,andtheprotonpumpinhibitoromeprazoleinsecondplacewassmallerin2009thanin2008.Thisphenom-enonhasoccurredforthelastthreeyears andifthistrendcontinuesomeprazolemaywellreplacemetoprololatthetopofthelist in2010.ThispictureisconfirmedbythehigherpercentageincreaseinthenumberofDDDs ofomeprazoledispensedbypharmacists.

From1January2009theDutchMinisterofHealthrestrictedthereimbursementofbenzo-diazepinestoanumberofspecificindications(seeparagraph2.5.2).Asaresult,thesedativeoxazepam(4thplacein2008)andthesleep-

facts anD figures 2010 45

2.2 Prescriptions

Sleep-inducingmedicationdropsoutoftheTop10For years metoprolol has been the most prescribed medication in the basic benefit package covered by statutory health insurance. With the introduction of reimbursement conditions for sleep-inducing medication and sedatives, oxazepam and temazepam are no longer among the top ten most commonly prescribed medicines. The cholesterol-lowering medicine simvastatin saw the greatest increase in the absolute number of prescriptions.

2.3 Top 10 medicine expenditure increases in 2009

actiVe ingreDient (ranKing in 2008) BranD naMe useD tO treat exPenDiture in-

crease (MiLLiOn €)

1 Adalimumab (1) Humira rheumatoid arthritis 40,3

2Emtricitabine, tenofovir disoproxil and efavirenz (-) atripla HiV infection 22,8

3 Etanercept (2) enbrel rheumatoid arthritis 19,2

4 Tiotropium bromide (10) spiriva respiratory conditions 7,4

5 Insulin aspart (-) novorapid Diabetes mellitus 7,1

6 Esomeprazole (9) nexiumexcessive gastric acid production 6,9

7 Lenalidomide (4) revlimid Kahler’s disease 5,4

8 Calcium with vitamin D (-) several Bone loss 4,6

9 Macrogol, combinations (-) Movicolon constipation 4,5

10 Somatropin (-) several growth hormone deficiencies 3,9

In 2009 the rheumatoid arthritis medicines adalimumab and etanercept saw the highest increase in expenditure. The medicine in 2nd place on the list – a combination preparation prescribed to treat HIV infections – is a notable newcomer. Most of the expenditure on these medicines bypasses regular pharmacies.


46

Thechangeinthereimbursementstatusofcommonlyusedbenzodiazepinesmeantthatthemedicinesinthisgroupsawthegreatestfallinthenumberofprescriptionsformedicinescoveredbystatutoryhealthinsurancein2009.However,thisfallinthenumberofprescriptionsformedicinesincludedinhealthinsurancebenefitpackageisalsoatheoreticalfallgiventhatthereductioninactualusewasfarsmaller.


2.5 Top 10 prescription increases in 2009

actiVe ingreDient (ranKing in 2008) BranD naMe useD tO treat

increase in PrescriPtiOns

1 Simvastatin (8) Zocor High cholesterol 1,447,000 (48%)

2 Acetylsalicylic acid (3) aspirine Blood platelet aggregation 1,192,000 (34%)

3 Omeprazole (2) Losec excessive gastric acid production 1,186,000 (31%)

4 Metoprolol (4) selokeenLopresor

angina pectoris, high blood pressure and heart failure

1,090,000 (25%)

5 Metformin (7) glucophage Diabetes mellitus 808,000 (30%)

6 Furosemide (6) Lasix Diuretic 762,000 (34%)

7 Pantoprazole (5) Pantozol excessive gastric acid production 630,000 (26%)

8 Hydrochlorothiazide (9) several Diuretic 501,000 (23%)

9 Calcium, combination with other drugs (-) several calcium deficiency 450,000 (48%)

10 Amlodipine (-) norvasc angina pectoris, high blood pressure and heart failure

447,000 (28%)

source: foundation for Pharmaceutical statisticsinducingdrugtemazepam(6thplacein2008)droppedoutofthelistofthetop10mostfrequentlydispensedmedicinesinthebasichealthservicespackagecoveredbystatutoryhealthinsurance.Thebenzodiazepineswerereplacedbytwonewcomerstothetop10:thediuretichydrochlorothiazidein8thplace,whichisusedtolowerbloodpressure,and thethyroidmedicationlevothyroxinewhichwasdispensedtoapproximately350,000 usersin2009.

fastest riserThecholesterol-loweringmedicinesimvastatinwasthefastestriserintermsofbothDDDs(+33%)andprescriptionsdispensedbyphar-macists(+48%).Thissharpincrease,whichonlyoccurredforsimvastatin,wasduetogovernmentattemptstorestrictentitlementtoreimbursementofstatinstothegenericver-sionssimvastatinorpravastatininthe

firstinstance.ThenumberofdispensedDDDsofotherstatinsfellbyanaverageof3%.Withthecontraceptivepillbeingreadmittedtothehealthinsurancebenefitpackagein2008,therewasasudden(theoretical)sharpincreaseinthenumberofprescriptions. Henceitwastobeexpectedthattheseproductswouldnolongerbeamongthetop10in2009.Aspirinwasinsecondplaceinthetop10in2009,withanevenhigherincreaseinthenumberofprescriptionsthanin2008.Thirdplacewasoccupiedbyomeprazole,which isalwayshighupthelist.

Withthechangeinthewayclaimsaresubmit-tedformedicinesissuedinweeklydosepacksin2008,thelistofthetoptenincreasesinthenumberofprescriptionsin2009isactuallylargelytheoretical.Inotherwords,thefollow-ingtablehasnotbeencorrectedtoallowforthechangeinthewayclaimsaresubmitted.

2.4 Top 10 medicine prescriptions in 2009

actiVe ingreDient (ranKing in 2008) BranD naMe useD tO treat PrescriPtiOns

1 Metoprolol (1) selokeenLopresor

angina pectoris, high blood pressure and heart failure

5,500,000

2 Omeprazole (2) Losec excessive gastric acid production 5,000,000

3 Acetylsalicylic acid (3) aspirine Blood platelet aggregation 4,700,000

4 Simvastatin (5) Zocor High cholesterol 4,500,000

5 Metformin (7) glucophage Diabetes mellitus 3,500,000

6 Pantoprazole (9) Pantozol excessive gastric acid production 3,000,000

7 Furosemide (10) Lasix Diuretic 3,000,000

8 Hydrochlorothiazide (11) several Diuretic 2,700,000

9 Diclofenac (8) Voltaren Painkiller 2,600,000

10 Levothyroxine (13) several thyroid disorders 2,600,000



yearsforthestructuralmarketpositionofanewmedicinetobecomeapparent.Thecombinationpreparationemtricitabinewithtenofovirandefavirenz(Atripla)istopofthelistofnewmedicinesthatgeneratethehigh-estexpenditures.In2009thecostofthisHIVmedicineamountedto€5.9million.Emtri-citabineandtenofovirhavebeenavailableontheinternationalmarketasseparatefor-mulationssince2003and2001respectively.Efavirenzhasbeenavailableonthe(inter-national)marketsince1998.Thefixed-dosecombinationpreparationregisteredin2007hasbeenavailableonprescriptionsinceJune2008.Developingamedicineisanexpensive

business.Newmedicinesgenerallycomewithahighpricetag.In2009theaveragecostofanewmedicineperprescriptionwas€618.Thiswasmorethan30timeshigherthantheaveragepriceofallprescriptionmedicines.Sevenofthetwelverecentlyintroduced medicinesthatgeneraterevenuesinexcess of€1millioncostmorethan€500per prescription.

2.6 Cost of new medicines as a percentage of the total cost of medicines from 2000 to 2009

In 2009 the cost share of new medicines fell to the lowest percentage in ten years.


10%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

9.0% 6.6% 7.1% 7.6% 8.3% 6.3% 5.0% 3.4% 1.3%2.9%

8%

6%

4%

2%

0%

TheDutchgovernmentdeterminesitspolicyontheadditionofnewmedicinestothebasichealthservicespackagecoveredbystatutoryhealthinsuranceontheadviceoftheDutchHealthCareInsuranceBoard(CVZ).Medi-cinesthattheDutchMinistryofHealthjudgestobetherapeuticallyuniqueareaddedtotheso-called‘Appendix1B’,whichlistsallnewandinnovativemedicinesthatarefully reimbursedbyhealthinsurers.

Forinnovatorpharmaceuticalfirmssuccess-fulintroductionsofnewactivepharmaceuticalingredients,alsoknownasnewchemicalentities(NCEs),arecruciallyimportant. Newmedicinesalsoexistintheformofcom-binationpreparations.However,althoughcombinationpreparationsareofficiallynew,theyareessentiallyanewcombinationofknownsubstances.SFKdefinesamedicineasanewmedicineiftheactivepharmaceuticalingredient,orcombinationofactivepharma-ceuticalingredients,was/werefirstregis-teredwiththeMedicinesEvaluationBoard(CBG)intheNetherlandsortheEuropeanMedicinesAgency(EMEA)nomorethanfouryearsagoandiftheMinisterofHealthhasaddedthemedicinetothebasichealth

insurancebenefitpackageontheadvice oftheDutchHealthCareInsuranceBoard.

In2009communitypharmacistsdispensedmorethan€3.6billionworthofmedicinescoveredbystatutoryhealthinsurance. €46.2millionofthiswasaccountedforbynewmedicinesintroducedfrom2006onwards.Thesenewmedicinestherefore represented1.3%ofthetotalcostofmedi-cines.Thispercentagewaslowerthanin2008(2.9%)and,asin2008,itwasthe lowestpercentageintenyears.Attheendoftheninetiesnewmedicineswerestillaccountingforapproximately9to10% ofthetotalcostofmedicines.Followingtheturnofthemillenniumthecostshareof newmedicinesfelltojustabove6%asfewernewmedicineswereavailable.Andthiswas atrendthatcontinued.

new medicines that generate revenues in excess of € 1 millionIn2009justoveroneinthefiveofthemedi-cinesintroducedfrom2006onwardsgeneratedrevenuesinexcessof€1million.Thisinanindicatorthatgenerallysignalsasuccessfulintroduction,butitusuallytakesfivetosix

2.3 New medicines

NewmedicinesaccountforalowershareofthecostsThe cost share of new medicines fell to 1.3% in 2009: the lowest percentage in ten years. Seven of the twelve recently introduced medicines that generate revenues of more than € 1 million cost more than € 500 per prescription.


willqualifyforintegralfinancingonthisbasis.Wehavethereforecalculatedestimatesbasedonmedicineuse.Togivearoughideaofthenumberofpatientswhoqualifyforintegralfinancing,SFKhasmadeaselectionbasedontheATCclassifications.TheselectionincludesallpatientswhousemedicinesinthefollowingATCgroups:A10(Drugsusedindiabetes),B01(Antithromboticagents)andC(Cardiovascularsystem)andR03(Drugsforobstructiveairwaydiseases(asthmaandCOPD)).

complex medication profiles

It is anticipated that integral financing will apply to approximately one third of all community pharmacy patients.

In2009thesepatientsusedoneormoremedi-cinesintheselectedATCgroups.However,thetotalmedicineuseofthesepatientsextendsfarbeyondmedicationfordiabetes,COPD,heartfailureandCVRM.Intotalthesemedicineusersaccountforapproximatelythree-quartersofallmedicinesdispensedbycommunityphar-macies.Inotherwords,thesepatientsusuallyhavecomplexmedicationprofiles.

2.4.1 Drugs for cardiovascular risk management

Cardiovascularriskmanagement(CVRM)involvestwogroupsofpatients:patientswhoareknowntohavedevelopedcardiovasculardiseaseandpatientswhohaveanincreasedriskofdevelopingthedisease,suchaspeoplewithhighbloodpressure.Anginapectoris,myocardialinfarction,cerebralinfarctionandtransientischaemicattack(TIA)areallexamplesofcardiovasculardisease.Treatment

withmedicinesispartofcardiovascularriskmanagement.Adviceonlifestylemodificationandmonitoringofpatientswithincreasedriskofaninitialorsubsequentmanifestationofcardiovasculardisease,aorticaneurysmandperipheralarterialvasculardiseasesallfallwithincardiovascularriskmanagement.

2.4.1.1 Primary approach: cholesterol- lowering medicinesAsaprimaryapproachtheobjectiveofthe CardiovascularRiskManagementGuidelinesissuedbytheDutchCollegeofGeneralPracti-tioners(NHG)istooptimisetheprescriptionofcholesterol-loweringstatinsasameansofpreventingcardiovasculardisease.Thetotalexpenditureoncholesterol-loweringmedicinesfellfrom€325millionin2008to€282millionin2009.In2008therewasaslightfallinthenumberofDDDsinrelationto2007.In2009thenumberofdispensedDDDsincreasedagaintoatotalof533million.93%ofthemorethanninemillionprescriptionsforcholesterol-loweringmedicineswereforstatins.Thetotalnumberofstatinusersincreasedfrom1.4millioninthesecondhalfof2008to1.5millioninthesecondhalfof2009.(Onceapersonstartsusingacholesterol-loweringmedicine,theygenerallycontinueusingitfortherestoftheirlife.)Againin2009atorvastatin(Lipitor)wasthecholesterol-loweringmedicinethataccountedforthehighestexpenditure.Itwasalsothesecondmostcommonlyprescribedstatin(withsimvastatininfirstplace).Nevertheless,revenuesderivedfromsalesofatorvastatinfellfrom€166millionto€147millionin2009.The4%fallinthenumberofDDDsand11%fallinrevenuespointstoafallintheaveragepriceperDDD.Theincreasinguseofstatinswaslargelyduetotheincreasinguseofsimvastatinand,toalesserextent,theuse

In2009stepsweretakentochangethewaythatchronicdiseasecareisfinanced.Ratherthantherebeingaseparatepaymentforeachpartofthetreatment,agroupofcareproviderscanagreetoofferapackageofcareforasinglesetfee.Careprovidersthenagreeamongthem-selveshowtheamountistobedividedbetweenthem.Integralfinancinghasbeenanoptionforthetreatmentofdiabetesmellitustype2andvascularriskmanagementsince1January2010.ItwasalsointroducedasanoptionforthecareforCOPDpatientsfrom1July2010.Althoughintegralfinancinghasonlybeenoutlinedatthisstage,thesystemofDiagnosisTreatmentCombi-nationsusedinhospitalsisanobviouscompari-son.Withintegralfinancingthearrangementoffinancingiscompletelydifferenttotheexistingsysteminwhichcareisfinancedpercarepro-vider.Whoprovidesthecarewillprovetobelessimportant.Atthemomentitlooksasifintegralfinancingwillbeusedprimarilyforpharmaceu-ticalcare,withthecostofthemedicinesbeingincorporatedatalaterstage.FollowingthefalloftheCabinetin2010,theinclusionofpharmaceu-ticalcareinintegralfinancingwasdeclaredcon-troversial.Whetherthemedicinesthemselves

willalsobeincludedinintegralfinancingisstillasubjectofdiscussionthroughouttheindustry.

Generalpractitionersdeterminewhetherinte-grallyfinancedcarecanbeprovidedforpatientswithaconditionforwhichintegralfinancingis apossibility.Theexactdiagnosisisnotrevealedtothepharmacist.Medicinesarenotalwaysexclusivelyintendedtotreatconditionsforwhichintegralfinancingisanoption.Hencethefigurespresentedforthemedicinescoveredinthisreportcannotbetakenasanaccuraterepre-sentationofthecostsofthesemedicinesiftheywereincorporatedwithinintegralfinancing.

from condition to medicationInlightoftheprospectofintegralfinancing,thissectionofthereportdiscussesthegroupsmedicinesthatareprescribedforconditionsforwhichintegralfinancingisapossibility.Themedicinesusedtotreattheseconditionsrepresentasignificantportionoftherangeofmedicinessuppliedbypharmacies.BecauseSFKisnotawareofthereasonwhyaparticu-larmedicineisprescribed,itisnotpossibletodeterminethesizeofthepopulationthat

2.4 Integral financing for chronic conditions

Integralfinancinglikelytohave amajorimpactChanges in the way that the care of diabetes mellitus type 2, COPD and heart failure patients and cardiovascular risk management are financed are likely to affect pharmacists. This new form of financing will apply to almost one third of community pharmacy customers. This group of patients accounts for almost three-quarters of all medicines dispensed by pharmacies.

52

generalpractitionerswereactivelyinvolvedswitchingpatientsfromsingle-sourcestatinstomulti-sourcestatins.Thesameeffectoccurredatthebeginningof2010.

ThefactthattheDutchGeneralPractitionersAssociation(LHV)advisedgeneralpractitio-nerstosendrepeatprescriptionsbacktothespecialistappearstohavehadrelativelylittleeffectwhenitcomestostatins.InDecember2009specialistswereresponsiblefor14.7%ofrepeatprescriptionsformulti-sourcestatinsintermsofDDDs.ByApril2010thishadgraduallyincreasedto18.6%.Henceatthatpointgeneralpractitionerswereclearlycontinuingtowriterepeatprescriptionsformulti-sourcestatins. 2.4.1.2 Secondary approach:

antithrombotics and anti-hypertensive medicines

Asasecondaryapproachcardiovascularriskmanagementseekstooptimisetheuseofmedicationsuchasantithromboticsand antihypertensivemedicinestoprevent cardiovasculardisease,topromotetherapycomplianceandtooptimisepolicyforexistingpatientswithcardiovasculardiseaseordia-betesmellitustype2.Patientsarealsogivenadviceonlifestylemodification,whichis consideredtobeveryimportant.

antithromboticsIn2009thenumberofantithromboticusersincreasedby3%to1.7million.Actualuseincreasedby5%in2009to465millionDDDs.Acetylsalicylicacidwasthemostcommonlyprescribedmedicinewithuseincreasingby5%.Thesecondmostcommonlyprescribedmedicinewascarbasalatecalcium,whichwasoftenprescribedintheformofaneffervescenttablet.Oneofthereasonsfortheincrease

intheuseofacetylsalicylicacidmaybethefactthattheguidelinesissuedbytheDutchInstituteforHealthcareImprovement(CBO)andtheguidelinesissuedbytheDutchCol-legeofGeneralPractitioners(NHG)bothrecommendedthatallpatientswithanginapectorisbetreatedwiththeplateletaggre-gationinhibitor.Attheendof200985%ofpatientswithanginapectoriswereprescribedanantithrombotic,suchasacetylsalicylicacid,asco-medication.Althoughthisdoesnotyetincludeallpatientswithanginapectoris,theshareisclearlyhigherthanpreviously.In2005and2008thepercentageswere81%and83%respectively.70%ofpatientswithanginapec-torisweredispensedacholesterol-loweringmedicine.Likesecondarypreventionwithanantithrombotic,thispercentagehasalsoriseninrecentyears.In2005and2008respectively55%and67%ofpatientswithanginapectoriswereprescribedastatin.

antihypertensive medicinesAntihypertensivemedicinesbelongtovarious groups(diuretics,betablockers,calciumantagonistsandRAASinhibitors).Notallofthemedicinesinthesegroupsareusedtotreathighbloodpressure.Andtheproductsthatareusedtotreathighbloodpressureoftenhaveotheruses.Becausethereasonforaprescrip-tionisnotdisclosedtoSFK,antihypertensivemedicinesaregroupedsomewhatarbitrarilyonthebasisofATC-codes.1

1 Thiazides and related diuretics (C03A and C03B), diuretics and potassium-sparing agents in combination) (C03E), selective beta-blocking agents (C07AB), beta-blocking agents and other diuretics (C07B and C07C), dihydropyridine derivatives (C08CA) and agents acting on the renin-angiotensin system including combinations (C09).


ofpravastatin,bothpromptedbythechangeinthereimbursementstatusofstatins.SinceJanuary2009theuseofstatinsisonlycoveredbybasichealthinsuranceiftheinsuredhasanincreasedriskofdevelopingacardiovascularcondition,suchthattreatmentwithstatinsisindicated.Yetthemeasurefailedtohavethedesiredeffectbecausethedoctorsprescribingthestatinsdeclaredenmassethattheywereoftheopinionthatthewritingofaprescriptionwasequivalenttoamedicalcertificateandwasthereforesufficienttoconfirmthemedicalnecessityofthemoreexpensivemedication.

In2009theDutchMinisterofHealthannouncedthatprescribers’budgetswouldbereducedfrom2011iftheydidnotassumeresponsibilityforcontrollingexpenditurebyprescribingcheaperunbrandedproductsratherthanexpensive(brand-name)medicinesin2010.Inresponse,generalpractitionersdeclaredthattheywerenolongerpreparedtoassumeresponsibilityforortoincurthecostsofrepeatprescriptionsfor(expensive)medicinesincaseswheretherapywasinitiallyinstitutedbyspecialists.InDecember2009theDutchGeneralPractitionersAssociation(LHV)advisedgeneralpractitionerstosendtheserepeatprescriptionsbacktothespecialist inquestion,sothat,fromthenon,thecostswouldbeattributedtothespecialists.

increasing preference for generic cholesterol-lowering medicinesSFKmonitoredtheeffectofthemeasuresdescribedaboveontheprescriptionofcho-lesterol-loweringstatins.DuringtheperiodfromJuly2008toApril2010theuseofstatinsincreasedbyapproximately19%,from36.5mil-lionto43.3milliondefineddailydoses(DDD)permonth.InJuly2008approximately50%of

DDDsweredispensedintheformofthegeneric(multi-source)statinsthenavailable(simvasta-tin,pravastatinandfluvastatin).ByApril2010thepercentagehadincreasedto62%.Duringthesameperiodtherewasbotharelativeandanabsolutereductionintheshareof(single-source)statins(atorvastatinandrosuvastatin)onlyavailableasabrandnamemedicine,from17.9millionDDDsto16.8millionDDDs.

First-timeprescriptionsareindicativeof shiftsinprescriptionpatterns.(Amedicineisconsideredtohavebeenprescribed/dispensedforthefirsttimeifithasnotbeenprescribed/dispensedtothepatientinquestioninthesamestrengthinthelast12months.)Duringtheperiodreferredtoabove,thenumberoffirst-timeprescriptionsforstatinsissuedbyspecialistsanddispensedbycommunitypharmacistsremainedmoreorlessconstantatapproximately12,000permonth.Inthesecondhalfof2008,beforetheintroductionofrestrictedreimbursement,54%ofthesefirst-timeprescriptionswereformulti-sourcesta-tins.InJanuary2009thissuddenlyincreasedto67%-apercentagethatremainedvirtuallyunchangeduntilAprilofthisyear.

Inthesecondhalfof200869%ofthefirst-timeprescriptionsforstatinsissuedbygeneralpractitionerswereformultisourcestatins.Duringthefirstfewmonthsof2009,followingtheintroductionofthereimbursementmea-sure,thepercentagewasinitiallyfarhigher(90%),buthashoveredatapproximately76%sinceJune2009.Thesharpincreaseatthebeginning2009wasaccountedfornotbythedispensingoffewerfirst-timeprescriptionsforsinglesourcestatins,butbyanincreaseinthenumberoffirst-timeprescriptionsformulti-sourcestatins.Thispointstothefactthat


2.4.2 Diabetes medicines

Diabetesmellitusisawidespreadcondition. In2009integralfinancingwasintroducedasanoptionforthetreatmentoftype2diabetes,inwhichthebodystillproducesinsulinbutfailstorespondtoit.Treatmentoftype1dia-betes,inwhichthebodynolongerproducesinsulin,suchthatdiabetespatientshavetoinjectthemselveswithinsulin,doesnotfallwithinthesystemofintegralfinancing.

Approximately788,000peopleweretakingdiabetesmedicationintheNetherlandsin2009,4%morethanin2008.Thetotalnumberofdefineddailydoses(DDDs)ofdiabetesmedicinesdispensedbyDutchpharmacistsamountedtoapproximately366millionin2009,anincreaseof3%.At€177million,thecostsassociatedwiththesemedicineswere3%lowerthanin2008,despitethefactthatthecostofinsulinsincreasedby3%(€4.5million).Unlikein2008,in2009theincreaseinthenumberofdispensedDDDswasgreaterthantheincreaseinthecosts.ThismeantthattheaveragecostperDDDfellby7%.In2009thediabetesmedicineexenatideshowedthehighestrelativeincrease,closelyfollowedbythemetforminandsitagliptincombinationpreparation.Inabsoluteterms,metforminwasthemostcommonlydispenseddiabetesmedicine:in2009pharmacistsprocessed3.5millionprescriptionsformetformin,dispens-ingatotalof123millionDDDsto560,000users.Metforministhefirststepifmedicinaltreatmentisrequired.Thesecondstepisthepossibleadditionofasulphonylureaderivative.Sulphonylureaderivativeswereprescribed2.1milliontimesin2009.Thenumberofdis-pensedDDDsremainedthesameasin2008.Thenumberofusers(300,000)wasalsomore

orlessthesameasin2008.TheguidelinesissuedbytheDutchCollegeofGeneralPrac-titioners(NHG)advisegeneralpractitionerstoaddpioglitazoneforpatientswithexistingcardiovasculardiseasewhodonotshowanysignsofincreasedriskofheartfailure.Useofpioglitazoneincreasedby4%in2009whileexpenditureremainedatthesamelevelasin2008(€7.5million).

Thelaststepinmedicinaltreatmentoftype2diabetesistheadditionofdifferentformsofinsulin.Thenumberofinsulinusersincreasedbyalmost9,000(+3%)to273,000in2009.MeasuredintermsofthenumberofDDDs, useincreasedby6%.

Withinthecontextofintegralfinancing,inthefuturepharmacistsmayhavetoagreeafixedpriceperpatient.Soitisimportantforpharmaciststogainaninsightintothenum-bersoftype2diabetespatientsforwhomtheirpharmacyprovidespharmaceuticalcare.Althoughtype1diabetespatientsdonotusemetformin,thereareasmallnumberoftype2diabetespatientswhodonot(ornolonger)usemetforminbutonlyuseinsulin.Henceitisimpossibleforpharmaciststomakecategori-calstatementsregardingthetypeofdiabetesmanifestedbytheirpatientsbasedpurelyontheirmedicationprofile.Thetaskofdetermin-inganintegralcostprice(onthebasisofthemedicationprofile)isfurthercomplicatedbythefactthatinsulinisseveraltimesmoreexpensivethantheregularmedicinesused bytype2diabetespatients.

Onaverage,useofantihypertensivemedicinesincreasedbyapproximately8.5%peryearfrom2002to2008.In2009Dutchpharmacistsdispensed1.5billiondefineddailydoses(DDD)ofthesemedicines.Thiswas6%morethanin2008.Theassociatedcosts,withoutincludingthefeeforservicesprovidedbythepharmacy,amountedto€315million:afallof10%.

combinationsAcombinationofantihypertensivemedicinesareoftenusedtotreathighbloodpressure.Somecombinationsareavailableasready-madecommercialpreparations.Variousantihyperten-sivemedicinesareoftentakentogether.54%ofpatientswhouseantihypertensivemedicinestakeacombinationofthesemedicines.Theremainingpatientsuseasinglemedicine.

DiureticsDiureticshelptoreducebloodpressurebydrainingwaterandmineralsfromthebody.Therearetwomaingroupsofdiuretics:thiazides(andrelateddiuretics)andloopdiuretics.Generallyspeaking,onlythefirstgroupofdiureticsareusedtotreathyper-tension.Loopdiureticstendtobeusedtotreatheartfailure.46%ofpatientswhouseantihypertensivemedicinestakediuretics.

Beta blockersBetablockershelptoreducehypertensionbyreducingtheforceandfrequencyoftheheartbeat.Onlyselectivebetablockersareincludedinthegroupofantihypertensivemedicinesmentionedhere.Betablockersarealsoused totreatanginapectoris.Manypatientswhouseantihypertensivemedicinestakeaselectivebetablocker.Approximatelyonemillionpeopleusemetoprolol,whichhasbeenthemost commonlydispensedprescriptionmedicine intheNetherlandsforyears.

DihydropyridinesOfthecalciumantagoniststhedihydropyrid-inesaremorefrequentlyusedtotreathyper-tensionthanthecalciumantagoniststhattendtobeprescribedforanginapectoris.Approxi-mately610,000peopleuseadihydropyridine.IntermsofthenumberofdispensedDDDs,thedihydropyridinesshowedthegreatestincreasein2009:morethan7%.Thesemedicinesweredispensed3.4milliontimes.

raas inhibitors40%ofthetotalnumberofprescriptionsforantihypertensivemedicineswerefortheso-calledRAASinhibitors.RAASinhibitorssup-presstherenin-angiotensin-aldosteronesystem,whichresultsinreducedbloodpressureviaacomplexmechanism.ThisgroupofmedicinescanbesubdividedintotheACEinhibitorswhichwereintroducedintheeightiesandangiotensin-IIantagonistswhichfollowedtenyearslater.Morethan1.8millionpeopletakeanRAASinhibitor.Ofthese,approximatelyonemillionuseanACEinhibitor,with15%usingitinafixedcombinationwithadiuretic.Theremainingpatientsuseanangiotensin-IIantagonist. ThetotaluseofRAASinhibitorsincreased byalmost7%in2009.


integral financing of cOPD IthasbeenpossibletomakeagreementsregardingtheintegralfinancingofthecareprovidedforaCOPDpatientsinceJuly2010.Againinthiscase,pharmaceuticalcareisnotincludedforthetimebeing.Ifanything,itisevenmoredifficultforapharmacisttogainaninsightintothenumberofCOPDpatientswhoobtainpharmaceuticalcarefromtheirpharmacy.COPDpatientsgenerallyusethesamemedicinesasasthmapatients,henceitisimpossibletomakeadistinctionbasedpurelyonthemedicationprofile.Ageisanimportantfactor,becauseCOPDusuallyaffectspeopleovertheageof40,butagainitisnotpossibletomakeastrictdistinction.

Ifintegralfinancinghasbeenagreed,itisimportantthatthedoctorprovidesthecareasdefinedintheguidelines.WhentreatingCOPD,ifmedicinaltreatmentisrequired, doctorsareadvisedtostartwithashort-actingbronchodilatorandthentodeterminewhichisthemosteffective.Overall,theshort-actingbronchodilators(ipratropium,salbuta-molandterbutaline),whichareadministeredbyinhalation,sawaslightfallinuse(-1%DDD)in2009.With52.6milliondispensedDDDs,salbutamolisbyfarthemostfrequentlydispensedshort-actingbronchodilator.

Ifashort-actingbronchodilatorfailstohavesufficienteffect,thedoctormaydecidetoprescribealong-actingbronchodilator. Overall,theuseofthelong-actingbroncho-dilators(tiotropium,formoterolandsal-meterol)increasedby8%.With1.4millionprescriptions,salmeterol,onitsownor incombinationwithotherasthma/COPD medication,wasthemostcommonly prescribedlong-actingbronchodilator.

Formoterol,possiblyincombination withotherasthma/COPDmedication, wasprescribed960,000times.With860,000prescriptions,tiotropiumwasprescribedapproximately100,000timesless.Interms ofDDDs,tiotropiumwasthefastestriseramongthegroupoflong-actingbroncho-dilators,withanincreaseof12%.

Bronchodilatorcombinationmedication generallyincludesaninhaledcorticosteroidwithbudesonideorfluticasone.

2.4.4 Antidepressants

In2009Dutchcommunitypharmacistsdis-pensedalmost242milliondefineddailydoses(DDDs)ofantidepressants,scarcelyonepercentmorethanin2008,whentherewasalsoverylittlegrowthinrelationtotheyearbefore.

Attheendoftheninetiesofthelastcentury,useofantidepressantswasincreasingby18%peryear.Atthebeginningofthiscenturytheincreasefelltoapproximately7%peryearandfrom2005theincreaseinuselevelledoff.Despitetheslightincreaseinusein2009,expenditureonantidepressantsfellby30%,from€121millionin2008to€84millionin2009,largelyasaresultofthehealthinsurers’preferencepolicies.Ifwediscountthecostofpharmacyservices,thecostofantidepressantsfellfrom€85millionin2008to€43millionin2009.Yetthenumberofprescriptionsforantidepressantsdispensedbypharmacistsin2009(almost2.1million)was13%higherthanin2008.Theincreaseislargelyduetotheintroductionofthenewsystemofseparateprescriptionsforweeklydosepacksfrom1July2008.Theshareofweeklydosepacksasa

2.4.3 Asthma/COPD medication

In2009communitypharmacistsdispensedaprescriptionmedicineforasthmaand/orCOPDsevenmilliontimes.Thesemedicineswereworthatotalof€394millionintermsofexpenditureandrepresented4.0%ofthetotalnumberofprescriptionsand8.2%ofthetotalexpenditureonprescriptionmedicines.ThetwomainmedicinesusedtotreatasthmaandCOPDarebronchodilatorsandanti-inflamma-tories(corticosteroids).In2009communitypharmacistsdispensedabronchodilator medicine3.5milliontimes.Thesemedicineswereworthatotalof€140millioninterms ofexpenditure.Anti-inflammatorieswere dispensed1.2milliontimesandwereworth atotalof€50millionintermsofexpenditure.Combinationpreparationsofthesetwotypesofmedicinesweredispensedbycommunitypharmacists2.0milliontimesandwereworth

atotalof€187millionintermsofexpendi-ture.Inotherwords,almosthalfofthetotalexpenditureonasthmaandCOPDmedicationwasaccountedforbycombinationprepara-tions.Intermsofthenumberofprescriptionsdispensedbypharmacists,thepercentagewasconsiderably(justover25%)lower.Expendi-tureonmedicinesusedtotreatasthmaandCOPDshowedastrongupwardtrendforseveralyearsupuntil2007.Since2008theincreasehasbeenfarlesspronounced.In2007expenditureincreasedby8%,butin2008and2009itincreasedbyjust1.7%and2.7%respectively.However,theabsenceofasharpfallinexpenditureduringthesaidperiodsug-geststhathealthinsurers’preferencepolicieshadlittleimpactonthisgroupofproductsas awhole.Duringthisperiodtheaverageannualincreaseinthenumberofprescriptionsdis-pensedbypharmacistswasmoreorlesson aparwiththeincreaseinexpenditure.

2.7 Expenditure on and pharmacy-dispensed prescriptions of asthma and COPD medication in 2009

astHMa anD cOPD MeDicatiOnexPenDiture

(MiLLiOn €)

cHange in reLatiOn

tO 2008

DisPenseD PrescriPtiOns

(MiLLiOn)

cHange in reLatiOn

tO 2008

Salmeterol with fluticason (Seretide) 122 - 1% 1.2 + 3%

Tiotropium (Spiriva) 76 + 11% 0.9 + 12%

Formoterol with budesonide (Symbicort) 65 + 5% 0.7 + 13%

Salbutamol 26 + 9% 1.7 + 5%

Other asthma and COPD medication 105 + 1% 2.5 + 1%

tOtaL 394 + 3% 7.0 + 5%

The top 4 medicines used to treat asthma and COPD account for 73% of the total expenditure and 65% of the total number of pharmacy-dispensed prescriptions for this group of medicines.



2.5.1 Non-reimbursed medicines

In2009pharmacistsdispensed1.2millionprescriptionsfornon-reimbursableprescrip-tionmedicinesworthatotalof€62.5million.Asarule,prescriptionmedicinesareeligibleforreimbursementbybasichealthinsuranceintheNetherlands.Medicinesavailablewithoutaprescriptionarenoteligibleforreimbursement.

Thereareexceptionstothisrule.Thingssuchasnon-prescriptionlaxatives,calciumtabletsandanti-allergymedicationmaybeeligibleforreimbursementifadoctorprescribesthemforapatientwhohastousethemonanongoingbasis.Medicinesusedtotreaterectiledysfunction,malariaprophylacticsandsmo-kingcessationmedicationareallexamplesofprescriptionmedicinesthatarenotcoveredbybasichealthinsurance.

erectile dysfunction medicinesIn2009Dutchpharmacistsdispenseda prescriptionmedicineforerectiledysfunction306,000timesto129,000men.Thesefiguresarealmostidenticalwiththefiguresfor2008.Sildenafil(Viagra)wasstillthefrontrunnerin

thegroupoferectiledysfunctionmedicines,withpharmacistsdispensing162,000prescriptionsin2009.Tadalafilwasinsecondplacewith116,000prescriptions.

Malaria prophylactics Doctor-prescribedmalariaprophylacticsarenoteligibleforreimbursementbybasichealthinsurance.Lastyearpharmacistsdispensedmalariaprophylactics153,000times,approxi-mately10%lessfrequentlythanin2008. In2006and2007malariaprophylacticsweredispensedalmost190,000times.ThereasonforthefallingtrendinthedispensingfiguresisunknowntoSFK.Malarone,acombinationpreparationwithproguanilandatovaquone,wasthemostfrequentlydispensedmalariapreventive,withalmost120,000prescriptions.

anti-smoking medication Smokingcessationaidsareanothergroup ofmedicinesnotcoveredbybasichealthinsu-rance.Thisappliesnotonlytonon-prescriptionnicotinereplacementproducts,butalsotoanti-smokingmedicationthatisonlyavailableonprescription.In2009thereweretwomedicinesthatdoctorscouldprescribetohelppeoplestop

2.5 Non- and conditionally reimbursed medicines

IncreaseinexpenditureoutsidebasichealthinsuranceIn 2009 Dutch pharmacists dispensed a prescription medicine not covered by basic health insurance 1.2 million times. Medicines used to treat erectile dysfunction were at the top of the list, with pharmacists dispensing more than 300,000 prescriptions.

percentagethetotalnumberofprescriptionsforantidepressantsdispensedbypharmacistsgraduallyincreasedfrom24.3%inthethirdquarterof2008to29.9%inthefourthquarterof2009.TheshareofDDDsdispensedintheformofweeklydosepacks,increasedfrom5.3%to6.6%duringthesameperiod.

In2009,intermsofthecostofmedicines,treatmentwithantidepressantsworkedout atanaverageof18eurocentsperdefineddailydoses(DDD).In2001itworkedoutatanaverageof79eurocents:morethanfourtimeshigher.Notallantidepressantshaveseenafallinprice.TheaveragefallinpriceisaccountedformainlybytheSSRIs(ATCN06AB).In2001theaveragecostofaDDDofanSSRIwas87eurocents;by2009thishadfallento11eurocents.Escitalopram,whichappearedonthemarketin2004,wastheonlyoneoftheSSRIsthatcostconsiderablymorein2009,averag-ingat63eurocentsperDDD.Atthebeginningof2009itlookedasiftheaveragecostofthismedicinewouldalsofallgiventhatgenericversionsofescitalopram(Lexapro)wereavail-able.However,theMedicinesEvaluationBoard(CBG)suspendedthetradinglicenceforthesegenericversionsattheendofApril.

Itisnotablethatthefallinpriceappearstohavebypassedthemoretraditionalantidepres-sants(thenon-selectivemonoaminereuptakeinhibitors(ATCN06AA)).TherehasonlybeenaslightfallinthecostperDDDinrecentyears.In2009theaveragecostperDDDwas22eurocents.Thismeantthatthisgroupofmedicines,whichwereonceconsideredtobecheap,arenowalmostthemostexpensive.Whenchoos-ingwhethertoprescribetraditionalantide-pressantsorSSRIs,aswellasconsideringthe

contraindications,thepotentialsideeffectsandearlierexperiencesarealsotakenintoaccount.In2009amitriptylinewasthemostcommonlyprescribedtraditionalantidepressantwith925,000prescriptions.However,thismedicineismainlyusedtotreatneuropathicpain. Insecondplacewasnortriptyline,which,at acostof41eurocentsperDDD,wasthemostexpensiveofthetraditionalantidepressants.

At32eurocents,theaveragecostperDDD ofthemedicinesintheATCgroup‘Otheranti-depressants’(N06AX)washigher,butthiswaslargelyduetothetwoantidepressantsthatrecentlyaddedtothisgroup:duloxetinein2005(Cymbalta)andbupropionin2007(Well-butrin).Bothofthesemedicinescostapproxi-mately€1.15perDDDin2009.Ifthesetwomedicinesarenotincluded,theaveragecost ofthemedicinesinthisgroupisapproximately24eurocentsperDDD.

TheSSRIparoxetine(Seroxat)hasbeenthemostcommonlyusedantidepressantintheNetherlandsforyears.Pharmacistsdispensed61millionDDDsofparoxetinein2009,4%lessthanin2008.InsecondplacewastheSSRIcitalopram,with39millionDDDs(+2.5%).In2009pharmacistsdispensed32.5millionDDDsofvenlafaxine(Efexor),whichbelongs tothegroupof‘otherantidepressants’. Thiswasthesameasin2008.

TheDutchCollegeofGeneralPractitioners(NHG)hasannouncedplanstotightentheguide-linesontheprescriptionofantidepressants.(TheguidelinesdatebacktoOctober2003.) In2010theDutchMinistryofHealthindicatedthatsavingsof€20millionmightbeachievedfrom2011onwardsbyrestrictingtheprescriptionofantidepressantsfor(very)milddepression.


2.5.2 Conditionally reimbursed medicines

Thelastcategoryisagroupofmedicines thatareonlyreimbursedbyhealthinsurers ifcertain(medical)conditionsaremet.TheseconditionsarestatutorilyestablishedpermedicineandarelistedinAppendix2oftheHealthInsuranceRegulations.Hencethesemedicinesareoftenreferredtoas‘Appendix2medicines’.Attheendof2009therewere91medicinesthatwereonlycoveredbybasichealthinsuranceundercertainconditions.

BenzodiazepinesBenzodiazepines,whichproduceacalmingeffect,wereaddedtothiscategoryin2009.Theyweredispensed10.4millionin2009 andwerereimbursablein30%ofcases; intheremaining70%ofcasestheywere notreimbursable.Thenumberofpharmacy- dispensedprescriptionsforthebenzodia-zepinesoxazepamandtemazepamthatwereeligibleforreimbursementfellby75%and79%to806,000and589,000respectively.

Ifallpharmacy-dispensedprescriptionsaretakenintoaccount,includingtheprescriptionspaidforbythepatient,thenumberofprescrip-tionsforoxazepamandtemazepamfellbyjust13%and11%respectivelyinrelationto2008.In2009oxazepamwouldhavebeeninninthplaceonalistofthetoptenprescriptionmedi-cinesirrespectiveofreimbursementstatus.

statinsAshasalreadybeenmentioned,fromJanuary2009statinswereonlyeligibleforreimburse-mentbybasichealthinsuranceiftheinsuredhadahigherriskofdevelopingcardiovascularcomplicationsandhadthereforebeenpre-scribedtreatmentwithstatins.Furthermore,thetreatmenthadtobeadministeredinaccordancewiththeguidelinesissuedbytheprofessionalgroupsinquestion.Theseguide-linesstipulatethatthetreatmentmustbeginwithsimvastatinandpravastatin.Themoreexpensivestatins,atorvastatinandrosuvastatin,areonlycoveredbythehealthinsurerifthedoctorissuesamedicalcertificate.

smoking:varenicline(Champix)andbupropion(Zyban).Togetherthesemedicinesaccountedformorethan120,000pharmacy-dispensedprescriptionsin2009,10%morethanthealmost110,000prescriptionsdispensedin2008.Thebanonsmokinginrestaurants,barsandcafeswasintroducedinJuly2008.In2007

pharmacistsdispensedoneorotherofthesesmokingcessationaidslessthan70,000times.Thesefiguresdonotincludepharmacy-dis-pensedprescriptionsforWellbutrin.Wellbutrinisalsobupropionbutisregisteredasanantide-pressant.Whenprescribedasanantidepressant(inahigherstrength)Wellbutrinisreimbursed.

OseltamivirThedispensingofoseltamivir(Tamiflu)wasaspecialphenomenonin2009.TheantiviraldrugwasusedduringthepandemicofinfluenzaA(H1N1),alsoknownasMexicanflu.Commer-ciallyavailableTamifluwasnotincludedinthebasichealthinsurancebenefitpackageandhadtobepaidforbythepatient.Thegovernmentassumedresponsibilitybypurchasingtheactiveingredient,oseltamivir,fromthemanufacturer,Roche,andarrangingforittobeputinsachets.Thesesachetsofoseltamivirwerethenmade

availablethroughpharmaciestopatientswhoweremedicallydiagnosedwithinfluenzaA.Thesachetsfromthegovernmentsupplyforapandemicwereissuedtopatientsfreeofcharge.Pharmacistsreceivedafeeof€7.00foreach prescriptiontheydispensed.In2009pharma-cistsdispensedatotalofmorethan33,500 prescriptionsfromthenationalsupplyand dispensedcommerciallyavailableTamiflu27,000times.In2008pharmacistsdispensedthesemedicines600times.

2.8 Prescription medicines excluded from reimbursement in 2009

MeDicine Or use actiVe ingreDientsPHarMacy-DisPenseD

PrescriPtiOns exPenDiture (€)

Erectile dysfunction sildenafil, vardenafil 306,000 19,000,000

Malaria prophylactics Proguanil, mefloquine 153,000 9,400,000

Smoking cessation Varenicline, bupropion 120,000 6,600,000

Vaccines seasonal flu and typhoid fever 97,000 3,800,000

Cough medicines Promethazine, oxomemazine 76,000 750,000

Nozinan for pain control Levomepromazine 61,000 425,000

Haemorrhoid cream with corticosteroids

Hydrocortisone, among others 59,000 750,000

Weight loss Orlistat, sibutramine 44,000 2,200,000

Hair loss Minoxidil, finasteride 34,000 2,900,000


62

Therecordnumberofpharmacyclosures in2008wasbeatenin2009.SFKrecorded 29pharmacyclosuresin2009,onemorethanin2008.Atleasttwelveofthesepharmaciescloseddownlessthantenyearsaftertheyopened. Theoldestpharmacythatcloseditsdoors permanentlyin2009hadexistedformorethanacentury.Therelaxationofthelegislativeandregulatoryrequirementsthatapplytopharma-cieshasledtotheestablishmentofanincreas-ingnumberofmorespecialistpharmaciesthatprovidespecificservices.Itwasnotablethatalargenumberofthe57newpharmaciesthatopenedin2009weresituatedeitherinorinthevicinityofahospital.Therewasalargeincreaseinthenumberofoutpatientpharmaciesin2009,with14newoutpatientpharmaciesopening.Tenpharmaciesopenedinhealthcentresin

2009andseveralpharmacistsdecidedtoofferout-of-hourspharmacyserviceseitherinde-pendentlyortogetherwithotherpharmacists.

Pharmacy chains and formulas see little growthThepercentageofcommunitypharmaciesownedbychainsfellfrom35%to32%in2009.Mediqhadtoreduceitspharmaciesfrom229to206in2009.YetMediqisstillthelargestpharmacychainintermsofthenumberofpharmaciesactuallyownedbythechain. Fifteenofthe206Mediqpharmaciesareownedbyindependentpharmacists,therestareownedbythechain.Lloydssawlimitedgrowthin2008butdidnotopenanynewpharma-ciesin2009.TheEscuraformulaownedbypharmaceuticalwholesalerBrocacefincludes


Pharmacies3.1 Independent pharmacies versus pharmacy chains

Slowergrowthinthenumber ofpharmaciesOn 1 January 2010 there were 1,976 community pharmacies in the Netherlands, 28 more than the year before. With this, there was a slower growth in the number of community pharmacies, with 29 pharmacies shutting up shop permanently in 2009. Nevertheless the number of community pharmacies has increased net due to the opening of new outpatient pharmacies and out-of-hours pharmacies. What is striking is that the percentage of community pharmacies owned by chains shrank from 35% to 32%.

3


Theslowergrowthinthenumberofpharma-ciesintheNetherlandsmeantthattheaveragepatientpopulationofacommunitypharmacyfellto7,800persons.In2002pharmaciesservedanaverage9,000persons.In2009 theaveragecommunitypharmacydispensedamedicineincludedinthebasichealthinsurancebenefitpackage90,500times.Thiswas5,500prescriptionsmorethanin2008(anincreaseof6.5%).Theincreaseinthenumberofpre-scriptionswasmainlyduetotheintroductionofthenewfeestructureon1July2008.Fromthenonhealthinsuranceclaimsformedicinesissuedin(correspondinglylowerpriced)weeklydosepacksweresubmittedweeklyasopposedtoonceeverytwoorthreeweeks.

the average pharmacyTheaveragecommunitypharmacyearnedturnoverof€2,441,000fromthesaleofmedi-cinesincludedinthebasicbenefitpackagein2009.Thiswas€29,000lessthanin2008.Thecostofmaterialsforprescriptionmedicinesaccountedforthegreatestshareoftheturno-verandamountedto€1,830,000in2009,afallof€118,000(6%)inrelationto2008.Thefallwasduetotheloweringofthepricesofgeneric

medicines,aprocessthatwasstronglyinflu-encedbyhealthinsurers’preferencepoliciesfromJune2008onwards,andtherestrictedreimbursementofsleep-inducingmedicationandsedativesfrom1January2009.TheDutchHealthCareAuthority(NZa)increasedthemaximumfeesfortheprovisionofpharma-ceuticalcare,whichmeantthatearningsintheformofpharmacyfeesforthedispensingofprescriptionmedicinesincreasedby€86,000to€564,000in2009.Theincomeofaphar-macypracticeconsistsofthisfeeincomepluspurchasingadvantages(minustheclawback).Withthedeclineofmaterialcostspharmacistsalsosawasharpreductionintheirpurchas-ingadvantages.TheextentofthisreductionisunknowntoSFKhencetheimpactthatthishadontheoperatingresultoftheaveragephar-macyisalsounknown.

Longer established pharmaciesAttheendof2009therewere1,976commu-nitypharmaciesintheNetherlands.1,583ofthesepharmaciesweresetupmorethantenyearsago.Overthelasttenyearstherehasbeenaconsiderableincreaseinthenumberofspecialistpharmaciesthatprovidecertain

3.2 Community pharmacy turnover

RegularpharmaciesseeafurtherfallinturnoverFor the average pharmacy turnover derived from the sale of medicines covered by statutory health insurance fell by € 116,000 to € 2.4 million in 2009. This fall in turnover was partly offset by a € 86,000 increase in pharmacy fee income. Pharmacies set up more than ten years ago saw a greater fall in turnover than the average pharmacy.

bothindependentpharmaciesandpharmaciesownedbythewholesaler.Therewereapproxi-mately120Escurapharmaciesin2009. Ofthese,94wereownedbyBrocacef,threelessthanin2008.In2009AllianceHealthcareNederlandowned74pharmacies,fourlessthantheyearbefore.Thepharmaciesownedby Allianceandseveraloftheindependentpharma-ciesaffiliatedwithAlliancearerunasKring-apotheekpharmacies.Atotalof325pharma-ciesusetheKring-apotheekpharmacyformula. Inmid-2009Alliancealsostartedexperimen-tingwiththeinternationalBootstheChemistconceptintheNetherlands.Havinginitiallysetuptwopilotbranches,AlliancewentontoopenanotherthreebranchesofBootslaterintheyear.Andlastlytherewereapproximately200independentpharmaciesthatwereaffiliatedwiththeServiceApotheekformula.

independent pharmacies collaborateInadditiontothecollaborativealliancesreferredtoabove,anincreasingnumberofindependentpharmaciesjoinedforcesin2009.TheDutchPharmacists’Cooperation(Napco),whichpromotestheinterestsofindependentlyestablishedpharmacies,sawconsiderablegrowthin2009,withitsmembershipincreasingfrom340membersin2008to563inSeptember2010.ThisgrowthmaybeduetothecreationofaliquidationfundforaffiliatedpharmacistswhodonotwishtoindependentlybearthefinancialrisksassociatedwiththeAchmeaIDEAcontract.Anotherdevelopmentthat contributestothetrendtowardsincreasing collaboration,whichisnotincludedinthese figures,istheopeningofcentralprescription-fillingfacilitieswherepharmacistspreparerepeatmedication,oftenforseveralpharmacies.

3.1 Developments in the number of community pharmacies from 2002 to 2009

There was a smaller increase in the number of community pharmacies in 2009. The share of chain store pharmacies shrank. It was mainly specialist pharmacies, such as outpatient pharmacies, that accounted for the slight growth.


2,000

1,500

1,000

500

02002

15%

1654

2003

19%

1697

2005

30%

1784

2004

23%

1732

2006

35%

1825

2007

35%

1893

2008

35%

1948

2009

32%

1976

Owned by pharmacists Pharmacy chains


PharmacistsfinancetheirpracticecostsandderivealargeshareoftheirincomefromthedispensingfeesformedicinescoveredbytheWMG.UpuntilJanuary2009dispensingfeeswerebasedonthecostpatternoftheaveragepharmacy,whichwasdeterminedbyperio-dicauditsconductedbyNZaanditslegalpredecessors.ItnowseemsthatNZaisnolongerbasingitscalculationofcost-coveringdispensingfeesonthesameprinciples.Asaresult,variouspharmaciesarefindingthattheirfinancialcontinuityisatrisk,especiallynowthattheirpurchasingadvantageshavedwindledfollowingtheintroductionofhealthinsurers’preferencepolicies.However,NZapolicynolongerseekstoassurethefinancialcontinuityofindividualpharmacies.Infact,themedium-termvisionthatNZapublishedin2008openlyspeculatesonascenariothatinvolvestherationalizationof30%ofthe existingpharmacies.

Maximum and maximally increased feesAtthebeginningofDecember2009NZasetmaximumfeesforpharmaceuticalcarethatwouldapplyfrom1January2010.Thesefeesarebasedontheprinciplethattheaverage

maximumfeeshouldworkoutat€7.91. Thisisanincreaseof9%inrelationtothefeesthatappliedfromMay2009onwards. Inadditiontothemaximumfee,theNZafeesystemalsoallowsforamaximallyincreasedfee.Intheory,thismakesitpossiblefor pharmacistsandinsurerstoagreefeesupto amaximallyincreasedfeethatNZaconsiderssufficienttocoverthecosts.NZaintroducedthissystemasa‘flexiblefeesystem’,designedtostimulatenegotiationsbetweenpharmacistsandinsurers.Pharmacistscanonlychargeanincreasedfeeonthebasisofawrittenagree-menttothiseffectwiththeinsurer.Themaxi-mallyincreasedfeesare26%higherthanthemaximumfeeandworkoutatanaverageof€10.00.Thepotentialdifferencebetweenthemaximumfeeandthemaximallyincreasedfeehasthereforeincreasedfrom€0.64 to€2.09.NZagavenoexplanationforthisconsiderableincreaseand,unlikepreviousyears,itdid notdefinetheamountofacost-coveringfee. Asin2009,theamountoftheclawbackremainsnegotiable.However,althoughNZagiveshealthinsurersscopetonegotiate,itisdebatablewhetherpharmacistsareabletoderivefullbenefitfromthisarrangement.

3.3 Dispensing fees

FeesareinadequateforthemajorityofpharmacistsIn 2010 the Dutch Health Care Authority (NZa) increased the maximum pharmacy fees by 9%. The average fee is meant to work out at € 7.91. It is expected that approximately 63% of the pharmacies will not earn this intended average fee.

services,suchasout-of-hourspharmacies, outpatientpharmaciesandpharmaciesthatsupplyexpensivemedicinesforaspecificpatientpopulation.Thefiguresforthe‘ave-rage’pharmacyarebasedonallpharmacies: thelongerestablishedpharmacies,mostofwhichareregularpharmacies,andthenewerpharmaciesthatprovidespecificservices.Theemergenceofspecialistpharmacieshas aconsiderableimpactonthefigures,solongerestablishedregularpharmacieswillonlyrelatetothepictureoftheaveragepharmacytoalimitedextent.In2009thisgroupofregularpharmacistssawa10%fallinthecostofmate-rialsformedicinescoveredbytheHealthCareMarketRegulationAct(WMG).Thisdecreasewasfargreaterthanthe6%fallseenbythe‘average’pharmacy,becausethemajorityof theexpensivemedicinesaredispensedbyalimitednumberofnationalsuppliers,whereasturnoverderivedfromthesaleofthesemedi-cinesareincludedintheturnoverofthe ‘average’pharmacy.Bothgroupsofpharmaciessawasimilarreductioninfeeincome.

Over-the-counter medicinesInadditiontotheturnoverderivedfrom thesaleofprescriptionmedicines,pharmacies alsogeneraterevenuesbysupplying(over- the-counter)medicinesthatdonotcomeundertheHealthCareMarketRegulationAct(WMG).Thesedrugsareoftenalsoobtainableindrugstoresandsupermarkets.Someofthesenon-WMGmedicinesareeligibleforreimburse-mentunderhealthinsuranceiftheyarepre-scribedbyadoctorfortheuseonanongoingbasis.In2009theaveragepharmacydispensednon-WMGmedicinesthatwereincludedinthebasicbenefitpackageapproximately4,200times,withrevenuesamountingtoatotalof€65,000.Basedontherecommendedretailprice,€18,000ofthisshouldbeincome (margin)fortheaveragepharmacy.Inpractice,pharmacistsearnlessthanthisfordispensingthesemedicinesbecausepharmacistsandinsurersagreelowerprices.


Most pharmacies earn less than the intended average feeInpractice,mostpharmacieswillnotearntheaveragefeeof€7.91in2010.BasedontheprescriptionsdispensedbypharmacistsduringtheperiodfromJanuarytoJune2010,82%ofthepharmacieswillearnalowerfee.Thisaveragefeeiscalculatedbydividing theearningsderivedfromalloftheservicesidentifiedbyNZaatthemaximumfeesby thenumberofprescriptionsdispensedWMG-medicines.TocomparetheaveragefeeactuallyearnedbypharmacistswiththeaveragefeeenvisagedbyNZa,thetotalnumberofpre-scriptionsdispensedbypharmacistshastobeconvertedbacktothenumberofprescriptions

accordingtotheformerfeesystem.Ifthefiguresarecorrected,63%ofpharmaciesearnlessthantheintendedaveragefee1.Therearealsoconsiderabledifferencesinearningsfromonepharmacytoanother.Atoneendofthespectrumoneintenpharmaciesearnafeeofapproximately6.4%to10.2%lowerthantheintendedaveragefee,whileattheotherendofthespectrum,pharmacistsareearningafeethatisatleast8.1%higherthantheintendedaveragefee.Outpatientpharmaciesandout-of-hourspharmaciesinparticularcanearnany-thingfrom1.4to2.8timestheintendedaveragefee.Theconsiderabledifferencesinearningsraisethequestionastowhetherthefeesystemisfairgiventhedifferencesinpracticecosts.

1 SFK has not taken additional agreements regarding increased dispensing fees into account in these calculations.

3.3 Expected average fee earned by community pharmacists based on WMG prescriptions dispensed by pharmacists from January to June 2010

63% of pharmacists will not earn the maximum fee set by NZa.


€ 10

Average fee after correctionActual average fee

€ 8

€ 6

€ 4

0% 5% 10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Intended average fee

Differentiated feesInJuly2008NZaintroducedanewfeesystemforpharmacists.Forcommunitypharmaciststhisnewsystemmeansthatthereisnolongerasetfeeforeachitemdispensedaspartof aprescription.Thenewsystemmakesadis-tinctionbetweenbasicservicesandadditionalservicesandsetscorrespondingmaximumfees.FromJanuary2010thebasicreimburse-mentfeesforthedispensingofregularand

weeklyprescriptionsare€5.99and€3.29respectively.Thedispensingofthesepre-scriptionsmayalsoinvolvetheprovisionofoneormoreadditionalservicesifthepharma-cisthastopreparea(special)formula,iftheprescriptionisbeingdispensedforthefirsttime,duringtheevening,duringthenight oronaSunday.

3.2 Financing of services provided by NZa standard pharmacies from 1 January 2010 (maximum and maximally increased fees)

nO. MaxiMuM fee MaxiMuM

reiMBurseMent MaxiMaLLy

increaseD fee

MaxiMaLLy increaseD

reiMBurseMent

Basic service

standard dispensing 73,238 € 5.99 € 438,696 € 7.54 € 552,215

Weekly dispensing 23,332 € 3.29 € 76,762 € 4.15 € 96,828

Additional services

first time dispensing 18,839 € 5.99 € 112,846 € 7.54 € 142,046

Out of hours dispensing 954 € 11.97 € 11,419 € 15.08 € 14,386

special preparation 119 € 89.78 € 10,684 € 113.12 € 13,461

regular preparation 1805 € 11.97 € 21,606 € 15.08 € 27,219

tOtaL 96,570 € 6.96 € 672,013 € 8.76 € 846,155

tOtaL nZa accOunting units 84,904 € 7.91 € 672,013 € 10.00 € 846,155 source: foundation for Pharmaceutical statistics


originalprice),involvesjustasmanypracticecostsasthesaleofapacketofliquoricelozengeswhichalsocosts€2.00.AsacriterionNZaarguesthat,onaverage,pharmacistsmustearnmorethan€85,000inincomefromthesale ofmedicalaids(suchasincontinencepadsandstomacareproducts)and(over-the-

counter)productsthatarealsowidelyavailableelsewhere.Inpractice,theincomethattheaveragepharmacyearnsfromthesaleoftheseproductsisapproximately€20,000lower.Especiallysincetheleadinginsurershave dramaticallyreducedthereimbursementpricesformedicalaidsinrecentyears.

3,4 Breakdown of maximum practice costs reimbursement and dispensing fees as of 1 January 2010*

Practice cOsts reiMBurseMent DisPensing fee

Personnel costs 348,064 4.1

accommodation costs 66,563 0.78

general costs 87,017 1.02

it costs 26,254 0.31

financial costs 21,191 0.25

transport and delivery costs 11,374 0.13

Pharmacist’s gross annual salary 80,000 0.94

additional income reimbursement 28,064 0.33

Total reimbursement / dispensing fee 668,527 7.87

retrospective adjustment of the dispensing fee for 2009 0.04

Weighted average dispensing fee 7.91

In addition to the gross annual salary, the standard income also includes things such as social security contributions and occupational disability and pension premiums,

*) Indicative estimate based on NZa data


Themaximumfeesarebasedonthereimburse-mentofthepracticecostsofastandardphar-macyasdefinedbyNZa.Asof1January2010NZahassetthereimbursementofpracticecostsat€597,693to€668,527tooffsetthereductioninpharmacyearningsasaresultofhealthinsurers’preferencepoliciesamongotherthings.NZabasesitscalculationsonannualproductionof84,904units.AunitisafactorusedbyNZatomaketheproduc-tionofthepharmacyusedinthecalculationscorrespondtothenumberofprescriptionsforWMGmedicinesthatwouldhavebeendispensedbythepharmacyunderthefeesystemthatappliedupuntil1July2008.Thepracticecostsincludethestandardincomeforapharmacist,whichissetat€108,064.ActingontheinstructionsoftheDutchMinisterofHealth,asaneconomymeasureNZadidnotindextheportionofthefeethatcorrespondstothepharmacist’sincomeinlinewiththeratesthatapplyforprofessionalcarepractitio-ners.Sothestandardincomeforapharmacistremainsthesameasin2009.Inadditiontothegrossannualsalary,thestandardincomealsoincludesthingssuchassocialsecuritycontri-butionsandoccupationaldisabilityandpensionpremiums.Thegrossannualsalaryforthe

pharmacistisalmost€80,000,whichamountstoagrossmonthlysalaryof€6,150.

Maximum dispensing fees still do not cover pharmacy costsDespitetheincreaseinthefeesfrom1January2010,themaximumdispensingfeesstilldonotcoverthecosts.KNMPisoftheopinionthattheNZacalculationsonwhichpharmacypracticecostsandreimbursementofthesecostsarebased,areincomplete.Forexample,NZadidnotbaseitscalculationsonthecostsofallofthedifferenttypesofpharmacies,suchasout-patientpharmaciesandchainstorepharma-cies.Furthermore,incalculatingthefeesNZadidnotallowforthefinancingcostsinvolved insettingupapharmacyandtakingoverapharmacy(start-uplossesandgoodwill),thecostsofinvestedequity(anaverageof€300,000perpharmacy)andinvestmentsinpremisesthathavebeenownedforsomeyears.KNMPhasalsocriticisedNZapolicyofallocatingpracticecoststotheissuingofnon-pharmaceuticals.AccordingtotheapproachadoptedbyNZa,thedispensingofagenericmedicinewhich,asaresultofpricecutsforcedbyhealthinsurers’preferencepolicies,nowcostsjust€2.00(approximately10%ofthe

3.4 Financing of practice costs

FeesstilldonotcovercostsAccording to the Royal Dutch Association for the Advancement of Pharmacy (KNMP) the newly increased fees that applied from 1 January 2010 still do not cover the practice costs of a community pharmacy. This is because NZa calculations fail to allow for different kinds of pharmacies and exclude costs that NZa ascribes to the commercial risk of independent pharmacy owners.


Since1January2009insurershavehadthepossibilityofagreeingwithpharmacistsfeesthatrangefromthemaximumfeetothemaxi-mallyincreasedfeeestablishedbyNZa.Theamountofclawbackisalsonegotiable.Forapharmacisttobeeligibleforahigherfeetheremustbeawrittencontract.Thesecontractsusuallycontainagreementsregardingqualityandefficiency,buttheymayalsostipulaterequirementsthatmustbemetwhensubmit-tingaclaimtotheinsurerforexample.On 1April2009NZawasawareof26contractsthatcontainedthesekindsofagreements.Attheendof2009insurersstartedoffe-ringmoregenericcontractsthatpromisedpharmacistshigherfeesiftheymetadditionalconditions.Attheendof2009theextenttowhichthesecontractswerebasedongenuinenegotiationswasoftendebatable.Variouspharmacistsexperiencedthenegotiations asa‘takeitorleaveitoption’whensigningastandardcontract.InitsExtramuralPharmacyMonitor2010,NZaclaimsthatapproximately350to400pharmacistshadsignedadditionalagreementsasof1April2010.

the achmea/agis ‘pack price contract’Attheendof2009thelargestinsuranceconcern,Achmea/Agis,broughtoutanewcontractthatallowedpharmaciststoclaimhigherfees(currently3.67%abovethemaximumfeeestablishedbyNZa).ThisIntegralEfficiencyContractforExcellentPharmacists(theso-calledIDEAcontract)isalsoreferredtoasthe‘packpricecontract’becausepharmacistsarepaidafixed‘pack’priceof€0.08perDDDirrespectiveoftheactualpurchasepriceofthemedicine.Theclawbackdoesnotapplyhere.Itisnoteasytooverseetheconsequencesofthecontractforindividualpharmacists.Itisdifficultifnotimpossibletoinfluenceexternalfactorssuchastheprescribingpatternsofdoc-torsandchangesinthepatientpopulation,yetfactorssuchasthesecanhaveahugeimpactonthefinancialresultsofthecontract.Andoncethereisacontracttheseexternalrisksshiftfromtheinsurertothepharmacy.Yetthepharmacisthaslimitedmeansofinfluen-cingtherisks.Allinallthismakesitextremelydifficulttodeveloparealisticfinancialfore-castforapharmacist.Thecontractappealstopharmacistsbecauseitallowsthemtodeter-minewhich(brandof)medicinetheydispensetothepatient.Achmeaofferedpharmacists

3.6 Health insurer contracts

LimitednumberofcontractsregardinghigherfeesNZa offers pharmacists and health insurers the possibility of making additional written agreements regarding fees that more accurately cover costs. In addition to financial agreements, under certain conditions some insurers agree to pay pharmacists for quality processes.

Intandemwiththis,thepreferencepoliciesintroducedbyseveralleadinghealthinsurersfromMay2008onwardsresultedintherapiddwindlingofpharmacypurchasingadvan-tagesonlargegroupsofpopulargenericmedicines.Becausetheauditsconducted byNZawerealwaysseveralstepsbehind theactualstateofaffairs,thepharmaceuticalsectorhadtosettlefortheuseofextrapo-lationsbasedonahistoricalsituationandassumptionstoarriveatanup-to-dateesti-mateofpharmacypracticecostsandearnings.HenceKNMPfeltthattherevisedfeesthatNZahadestablishedfor2009onthebasis ofthesaidauditswerealsoinadequate.KNMPsubmittedthemattertotheDutchTradeandIndustryAppealsTribunal(CBb).NZainformedthetribunalthatitintended toconductfurtherextensiveauditsof

pharmacists’accountsin2009.Shouldtheoutcomeofthisfourthsetofauditsindicatethatthefeesneededtoberevised,NZawouldrevisethefeeswithretroactiveeffectfrom 1July2009.ThecaseconcerningtherevisedfeesthatNZahadestablishedfor2009washeardbyCBbon24June2010.Thedisputecentredontheso-calleduncertaintymarginwhichhadbeenawronglydubbedsurplusprofitbyNZa.NZaarguedthatthisstillappliedtotheaveragepharmacywiththefeesthatithadestablishedfor2009,whileKNMPmaintainedtheviewthatthefeesthatNZahadestablishedforpharmacistsfor2009failedtocoverthecostsandledtopharma-cistsoperatingataloss,suchthattherewasnouncertaintymargin.Thetribunal’srulingonthiscaseisnotknownaswegotopress.

3.5 The consequences of the NZa audits

LitigationoverthefeesestablishedbyNZa2007 saw the beginning of a seemingly endless series of audits by NZa to determine pharmacy practice costs and purchasing advantages. These audits were meant to form the basis for the realistic reimbursement of pharmacy practice costs via pharmacy dispensing fees.


Theprocessingrate(thenumberofprescrip-tionsprocessedbyafull-timepharmacyassis-tantonanannualbasis)isanindicatoroftheproductivityofapharmacy.Italsosayssome-thingabouttherelationshipbetweenstaffinglevelsandtheworkloadinthepharmacy.How-ever,therearevariousotherfactorsthatalsoplayaroleinhowtheworkloadisexperienced.Theseincludetheextenttowhichpharmacistsreceiveelectronicallytransmittedprescrip-tionsfromprescribers,thewayeveningandweekendservicesareorganised,thepresenceorabsenceofrobotisationinthepharmacy,theextenttowhichthepharmacypreparesmedi-cines,theextenttowhichpharmacypersonnelotherthanpharmacyassistantsareemployedinthepharmacyandthefactthatinsurersarenowshiftingtheresponsibilityfortheimplementationofanincreasinglywiderangeofinsuranceregulations–suchaspreferencepolicies–ontopharmacies.ThesefactorshavehadanincreasingimpactontheprocessingrateasdeterminedbySFKinrecentyears,henceitisincreasinglylessreliableas anobjectivemeasureoftheworkload.

former calculation methodForyearsSFKhasbasedthecalculationoftheprocessingrateonthenumberofWMGandnon-WMGmedicinesdispensedbyapharmacy.

Thiswasirrespectiveofwhetherthemedicinesarereimbursedbythehealthinsurer,ornot.Medicalaidssuchasdiabetestestproducts,incontinencepads,dressingmaterialsandnon-pharmaceuticalsaswellarenotincludedinthecountwhencalculatingtheprocessingrate.Withtheintroductionofthenewfeesystemon1July2008,medicinesdispensedinweeklydosepacksareaccountedforeveryweek,ratherthaneverytwo,threeorfourweeks astheywerebefore.ThismeansthatsinceJuly2008thetotalnumberofprescriptionsdispensedbypharmacistshasbeenconsider-ablyhigherthaninpreviousyears.Thismakesitdifficulttomakeareliablecomparisonwithpreviousperiods.

In2009theaverageprocessingratewas18,700prescriptionsperfull-timepharmacyassistant. Ifthefiguresareadjustedtoallowforthemorefrequentclaimsformedicinesdispensedinweeklydosepackstofacilitateacomparisonwithpreviousyears,theprocessingratein2009worksoutatapproximately16,000prescrip-tions.Theincreasingprocessingrateispartlyduetothefactthatpharmacistshavebeenforcedtoreducetheirpersonnelcostsbecause oftheinadequatedispensingfees.KNMPisoftheopinionthattheescalatingworkloadinpharma-cieshasanadverseeffectonthequalityofcare.

3.7 Personnel and workload

ProcessingrateincreasesfurtherIn 2009 the processing rate increased to 18,700 prescriptions per full-time assistant. Although the average pharmacy employs the same number of assistants as the average pharmacy, the average pharmacy’s fee income is below average.

whochosenottosigntheIDEAcontract,theoptionofsigningamoreextensivepreferencecontract,iscompletelylimitedinfreedomofchoice.AccordingtotheNZaExtramuralPharmacyMonitor2010,morethanthree-quartersofthepharmacistswhohaveacon-tractwithAchmea/AgisoptedfortheIDEAcontractratherthanthemoreextensive preferencecontract.

Inadditiontothestandard(IDEAorprefe-rence)contractsomepharmacistswerealsoofferedtheoptionofenteringintoamoreintensivecontractualrelationshipwithAch-mea/Agiswhichallowedthemtoclaimhigherfees,withanadditional4%beingofferedasstandard.Toqualifyforthismoreintensivecontract,pharmacistshadtomeetadditionalconditions,suchasHKZcertification(issuedbytheFoundationforHarmonisationofQua-lityAssessmentinHealthCare)andcertainqualityrequirementsregardingmedicationsafetyand/ortherapycompliance.

ZorgenZekerheidintroducedasimilarinten-siveprocessin2010.Theso-calledTopZZorgmoduleofferspharmacistsabonusof€0.55 foreachdispenseditembeingpartofaprescrip-tion.Theprojectsinthemoduleareessentiallyconcernedwithincreasingpatientmedicationcomplianceandpatientmedicationsafety.

the uVit concealed price modelTheinsuranceconsortiumUVITdecidedtoexpanditspreferencepolicyand,incomparisonwith2008and2009,in2010itabandonedthelowestpriceagreements.UVITasksmedicinesupplierstomakeanunder-the-tableofferforallofitspolicyholders.UVITthendesignatesthesupplierwhooffersthebestconditions(orthelowestprice)asitspreferredsupplier.AlthoughUVITclaimsthatitpassesonthe

discountsnegotiatedinthismannertothepatientbynotchargingapolicyexcessfor preferredproducts,itisimpossibletomonitortheextenttowhichthisactuallyoccurs. Thisconcealedpricemodelinevitablyreducestransparencyinthemarket.

Menzis and cZInsurersMenzisandCZgenerallyoffercontractsbasedonanextensive(price)preferencepolicy.Onlythecheapestmedicineisreimbursed.CZallowsforamaximumdifferenceofupto5%andseekstorewardpharmacistsandgeneralpractitionersviaitsOptimalMedicineUseModule(MOG).CZanticipatesthatthiswillbringprescribinganddispensingpatternsmorecloselyintolinewiththeprofessionalguidelines.In2011Menzispromisestorewardpharmacistswithanadditional€0.10foreachbasicservicetheyprovideifthepharmacyscoresabovethenationalaverageforKNMPqualityindicatorson90%ofitemsin2010, orin2009,ifthesearethelatestfigures.

Generallyspeakinginsurersseektopromote(financial)efficiency,buttheygoaboutitin differentways.Manycontractsrefertothemaintenanceorimprovementofsubstitutionlevelsandsometimesimposefinancialcon-sequences.Thisisintendedtoensurethat,wherepossible,pharmacistsdispensethecheapestversionofamedicineifthereis achoiceofseveralmedicineswiththe sameactiveingredient.

It is striking that several large health insurance consortiums simply seek to control pharmacy costs, rather than implementing an active policy together with pharmacists with a view to introducing further improve-ments in the quality of patient care.


PersonnelAccordingtofiguresreleasedbythePharmacyPersonnelPensionFund(PMA)16,548personswereemployedaspharmacyassistantsincommunitypharmaciesasof1January2010.Thisisanincreaseof236persons(+1.4%) inrelationto2009.Mostpharmacyassistantsprefertoworkparttime.Thisispartlyrelatedtothefactthat,amongotherthings,therole ofpharmacyassistanttendstobeafemale

occupation(99%ofpharmacyassistantsarewoman).In2009theaverageworkingweekwas24.4hours,whichisconsiderablyshorterthanin2008(-4%).Thenumberofsupportstaffincommunitypharmaciesincreasedfrom6,436to6,657persons(+3.4%).Again,themajority(76%)oftheseemployeesarewomen.Supportstaffalsotendtoworkparttimewithanaverageworkingweekof19hours.

3.6 Number of people employed by an average pharmacy in 2009 (in full-time units)



Gastric medicines



Other medicines

Parallel import

Generic medicine


Parallel import

Generic medicine


668Oncolytica


Second pharmacists

Pharmacy assistants

Other staff

Specialité

Specialité

57.0%

1,482

877

668

635

559

525

2.6%

32.8%

7.5%

71.2%

15.9%

11.7%1.2%

5.67

0.45

11.77

3.5 Development of the processing rate in community pharmacies

*From July 2008 medicines dispensed in weekly dose packs count individually in the calculation of the processing rate. The dif-ference that this introduces in relation to previous years is shown in purple.

The more frequent claims for medicines dispensed in weekly dose packs affected the processing rate in 2009.


average pharmacyTomakemoreallowanceforthedifferenttypesofcommunitypharmaciesandthefactthatthesedifferencesaffecttheprocessingrate,SFKhasdeterminedtheprofileofanave-ragepharmacyin2009.TheprofileisbasedoneveryWMGmedicinedispensedaspartofaprescriptionandisexpressedaspercen-tagesofbasicversusweeklydispensingandNZa-definedservicesacrossallpharmacy-dispensedprescriptionsforWMGmedicines.Basedonthesecharacteristics,in2009theprofileoftheaveragepharmacywasasfollows:

77%standarddispensingversus23%weeklydispensing:19%firsttimedispensing,0.1%out-of-hoursdispensing,2%regularprepara-tionand0.1%specialpreparation.WhereasmeanpharmacistsfindthattheyearnlessthantheaveragedispensingfeeestablishedbyNZa,asimilarphenomenondoesnotapplytotheprocessingrate.Basedonaselectionofpharma-cistswhogenerallyconformtotheprofileoftheaveragepharmacy,thereisnosignificantdif-ferencebetweentheirprocessingrateandtheaverageprocessingrateforallpharmacists.

20,000

2000 2001 2002 2003 2004 2005 2006 2007 2008* 2009

13,932 14,454 14,374 14,424 14,115 14,090 14,221 14,500 18,71615,992

16,000

12,000

8,000

4,000

18,000

14,000

10,000

6,000

2,000

0


studyofpharmacyin2002,followingadipduringtheperiodfrom1999to2001.Manyrecentlyqualifiedpharmacistsbegantheirstudiesin2003,ayearinwhichinterestinpharmacycoursesbegantopickupwith anincreasingnumberoffirst-yearstudents.Andgiventhatpharmacycourseshavebeenincreasinglypopulareversince,weexpecttoseeafurtherinfluxofpharmacistsintothelabourmarketforthenextfewyears.

shrinking labour market Approximately70%(99people)ofthose whoqualifiedaspharmacistschooseto gointothecommunitypharmacy.In2009therewere2,877peopleworkingasmanagingandsecondpharmacists,35lessthanin 2008(-1.2%).Thismeansthattherewas afallinthenumberofworkingcommunitypharmacistsin2009.Allowingfortheinfluxofrecentlyqualifiedpharmacists,thismeansthat134communitypharmacistslefttheactiveprofessionin2009.Thenumberofpharmacistsleavingtheprofessionwas farhigherthaninpreviousyears.

3.7 Numbers of first-year pharmacy students and students qualifying as pharmacists (2000-2009)

The increasing number of first-year students since 2002 has resulted in an increase in the number of people qualifying as pharmacists since 2008. This is expected to continue for the next few years. In 2009 there was a fall in the number of first-year students for the first time since 2001.


600

500

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

198 / 192 182 / 155 278 / 256 343 / 227 383 / 222 443 / 173 448 / 141 507 / 117 516 / 130 494 / 142

400

300

200

100

0

Pharmacyandpharmaceuticalsciencecourseshavebeenincreasinglypopularsince2002.Attheendof2009therewereslightlyfewerfirst-yearstudentspursuingpharmaceuticalcoursesinUtrecht(228),Groningen(164)andLeiden(102)thanin2008.Nevertheless,494registeredstudentswasanotherhistorichigh.

registered studentsBasedonfiguresreleasedbytheuniversities,atthebeginningof2010therewere2,439studentsenrolledinthethreepharmaceuticalcoursesintheNetherlands.Thiswas43fewerstudentsthanin2009.In2009thenumberofstudentspursuingpharmaceuticalscienceinUtrechtfellfrom1,393to1,318persons,afallof5%.InGroningenthenumberofstudentsenrolledinthepharmaceuticalcoursefellfrom841to796,alsoafallof5%.Yettherewasaconsiderableincreaseinthenumberofstudentsstudyingbio-pharmaceuticalscienceinLeiden,withatotalof325peopleonthecourse,77morestudentsthanthepreviousyear(+30%).However,studentswhocompletethecoursedonotqualifyaspharmacists,butasscientificresearchersinthefieldofmedicine.

ratio of men to women Morewomenthanmenhavebeenstudyingpharmacyforsomeyears.In2008and200960%ofpharmacyandpharmaceuticalsciencestudentswerewomen.Yettherewasanevengreaterpreponderanceofwomenin2003,when63%ofallpharmacystudentswerewomen.Therehasbeenaslightshiftintheratiobetweenthesexesamongfirst-year students:in200662%offirst-yearstudentswerewomen,in2009thepercentageof femalefirst-yearstudentsfellto57%.

Popularity of pharmacy courses bears fruitThenumberofqualifiedpharmacistsemergingfromthepharmaceuticalfacultiesinUtrechtandGroningenhasbeenincreasingsince2008.In2008130pharmacistswereawardeddegreesbytheseuniversities.Andin2009therewasafurtherincrease,with142gra-duatesbeingawardedpharmacydegrees. Thenumberofgraduatesisnowconsiderablyhigherthanin2007,when117studentsquali-fiedaspharmacists.Theincreaseinnumbersistheresultofaresurgenceofinterestinthe

3.8 Pharmacists and the labour market

FewerjobsforcommunitypharmacistsAs in 2008, in 2009 there was an increase in the number of qualified pharmacists who entered the market. The popularity of pharmacy courses suggests that the number of new pharmacists will continue to increase for the next few years. Yet a relatively large number of pharmacists are also leaving community pharmacy. Hence in 2009 there were fewer working pharmacists than in previous years.


Forpharmacists2009wasmarkedbytheintroductionofindicatorsdesignedtoprovideapictureofthequalityofthepharmaceuticalaspectsofservicesprovidedbypharmacistsincombinationtheprescriptionhabitsofdoctors.

igZ / KnMP quality indicators for pharmacists2009wasthefirstyearthatIGZaskedpharma-ciststorevealtheresultsoftheirpharmaco-therapeuticcarebyprovidingdataon42indicators.TheseindicatorsweredevelopedbyIGZ,KNMP/WINApandSIRasthefirstBasicSetofQualityIndicatorsforPharmacists.Thedatainthisfirstbasicsetrelatedtothecalendaryear2008.In2010pharmacistswereagainaskedtoprovidesimilarinformationforthecalendaryear2009.SFKassistedpharma-cistsbyissuingtheKISSwebreport,whichpresentedtherequireddatafor24ofthe42indicatorsofmedicationsafetyandpharmaco-therapyinaready-to-useformatasfaraspos-sible.Toenablepharmaciststoimprovetheirresults,inthespringof2010SFKexpandedthewebreportwiththeadditionofsearchestotracepatientsonwhomtheindicatorswerebasedwhoreceivedlessthanoptimalservice.

Health insurersHealthinsurersarealsoincreasinglyusingindicatorstodeterminewhetherpharmacistsqualifyforhigherfees.HealthinsurerAch-mea/AgisusedtwooftheIGZ/KNMPqualityindicatorsfor2009todeterminewhetherpharmacistswereeligibleforamoreintensivecontractualrelationship,whichwouldmeanthattheycouldclaimhigherfees(seealsoparagraph3.6).Ifhealthinsurersstartmakingagreementswithpharmacistsregardingthequalityofpharmaceuticalservices,itistobeexpectedthatmoreinsurerswillincorporateindicatorsinadditionalcontractstomonitorcompliancewiththeseagreements.Althoughtheseindicatorsarenotadoptedasabasisforfinancialcontracts,insurersareclearlymakingmoreandmoreagreementswithpharmacistsbasedonperformanceindicators.In2010healthinsurerMenzisusedseveralofthe IGZ/KNMPqualityindicatorstoassessthe performanceofpharmacistswhowereeligibleforhigherfees.Healthinsurerssetstandardstoassesswhetherpharmacistsqualifyforhigherfees.Pharmacistshavetomeetorexceedthesestandardstobeabletoclaimhigherfees.SFK isnotinvolvedinestablishingthestandards.

3.9 Quality indicators

Tomeasureistoknow?In 2009 the quality indicators for pharmacists developed by the Dutch Health Care Inspectorate (IGZ) and KNMP marked the launch of a multi-year project designed to provide an insight into the quality of the pharmaceutical care. Health insurers are also increasingly using these indicators to assess pharmacy services linked to higher fees.

In2009therewerefewerworking(second)pharmacists.Thisisthefirsttimethatthishashappenedinsomeyears.Inpreviousyearsthetotalnumberofpharmacistsgrewbyanaverageof1.8%peryear.Thefallinthenumberofworkingpharmacistscoincidedwithincreasingdemandforcare.IntermsofdispensedDDDs,therehasbeenasteadyincreaseinthedemandforextramuralphar-maceuticalcare.In2009therewasa2.7%increaseinmedicineuseintermsofDDDs,

whichmeansthattheincreaseinthedemandforcareisgrowingfasterthanthepopulationisageing(0.4%)andfasterthantheincreaseinthenumberofcommunitypharmacies(1.4%).KNMPisoftheopinionthat,given theincreasingdemandforcare,thereis nowashortageofcommunitypharmacists. Thefallinthenumberofworkingcommunitypharmacistsin2009,despiteaconsiderableinfluxofrecentlyqualifiedpharmacists, isaworryingdevelopment.

3.8 Number of people employed in community pharmacies

2005 2006 2007 2008 2009

Pharmacies 1,784 1,825 1,893 1,948 1,976

Pharmacists 2,789 2,825 2,871 2,912 2,877

Pharmacy assistants 15,096 15,427 16,027 16,312 16,548

Other pharmacy staff 5,162 5,457 5,809 6,436 6,657

There are fewer jobs for second pharmacists in community pharmacies.



3.9 Some of the Quality Indicators for Pharmacists (Basic Set for 2009 in KISS)

nr. inDicatOr

4 Percentage of users of blood glucose lowering medicines with an established diabetes contraindication.

5 Percentage of patients >55 with an established heart failure contraindication

6 Percentage of patients on nsaiDs using loop diuretics and ras inhibitors.

7 Percentage of users of cOx-2 selective inhibitors with suspected cardiovascular conditions.

9 Percentage of patients with established penicillin intolerance.

12a number of patients using coumarins in combination with co-trimoxazole.

12b number of patients using coumarins in combination with (oral or vaginal) miconazole.

16 number of internally detected and recorded errors.

18a Percentage of patients dispensed inhalation medication for the first time given inhalation instructions.

18b Percentage of patients using inhaled corticosteroids with antimycotics.

19 Percentage of patients dispensed benzodiazepines for the first time informed of the effect on their responsiveness and driving performance.

20 Percentage of patients dispensed a repeat prescription for benzodiazepines informed of the risk of dependency.

21 Percentage of patients >65 using benzodiazepines on an ongoing basis.

22a Percentage of patients dispensed antidepressants for the first time informed that the medication would not take effect immediately.

22b Percentage of patients who stopped taking medication within 6 months (prescriptions dispensed for the first times in the first half of the year under review).

27 Percentage of patients who made complaints.

28 number of patients who reported side effects to the netherlands Pharmacovigilance centre (LareB).

36 Percentage of patients >70 using traditional nsaiDs with gastric protection.

37 Percentage of patients using nitrates and antithrombotics simultaneously.

38 Percentage of patients using opiates and laxatives.

39 Percentage of patients with excessive use of bronchodilators and inhaled corticosteroids.

40 Percentage of patients dispensed oral blood glucose lowering medicines for the first time supplied with metformin.

41 Percentage of patients using long-acting hypnotics on an ongoing basis.

42 Percentage of dispensed third-generation quinolones.

In addition to the indicators listed above, the KISS web report compiled by SFK also includes searches to trace patients who received less than optimal service.


(apparent) accuracySeveralaspectsoftheIGZ/KNMPqualityindicatorsmakethemmoreorlesssuitableascriteriathatcanbeusedforthepurposeofmonitoringandevaluatingcompliancewithagreements.Forexample,thenumberofpatientsonwhichanindicatorisbasedplaysaconsiderableroleindeterminingtheextenttowhichanindicatorissuitableandstableenoughtoserveasacriterion.Ifthereisarelativelysmallnumberofpatientsonwhichanindicatorisbased,afewmoreorfewerpatientscoulddeterminewhetherornotapharmacyisconsideredtohavemetthestandard.TheIGZ/KNMPqualityindicatorsweredevelopedtoprovideapictureofthequalityofpharmacotherapeuticcareprovidedbyaparticularpharmacy.Inthiscontext,thenumberofpatientsonwhichanindicatorisbased,servesmoretogiveanideaoftheinci-

denceofparticularsituationsforaparticularpharmacy,withoutfinancialagreementsbeinglinkedtotheoutcome.Anotheraspectisthefactthattheindicatorsaredeterminedperpharmacy:patientsarenotfollowedfromonepharmacytoanothertomonitortheirmedicineuse.Forexample,thismeansthatapatientwhoobtainsanNSAID(painkiller)fromapharmacyotherthantheirusualpharmacyandagastricprotectorfromtheirusualpharmacywillbeincorrectlyregisteredasapatientusinganNSAIDwithoutgastricprotection.Incasessuchasthese,thesitua-tioncanbeclarifiedwhenservingindividualpatientsbyreferringtoadditionalpatientinformationinthepharmacyinformationsys-tem.However,individualcasesandexceptionsarenottakenintoaccountwhenanindicatorisusedforthepurposeofmonitoringandevaluatingcompliancewithagreements.


Keyfigures2009 forpharmaceuticalsKeyfiguresforpharmaceuticalsincludedinthebasichealthinsurancebenefitpackagein2009

tHe netHerLanDsaVerage

Per PHarMacyaVerage

Per PersOn

Expenditure on pharmaceuticals € 4,789 million € 2,441,000 € 315

of which gVs contributions € 47 million € 24,000 € 3

Cost of medicines € 3,681 million € 1,877,000 € 242

WMg medicines € 3,589 million € 1,830,000 € 236

non-WMg medicines € 92 million € 47,000 € 6

Pharmacy fees € 1,108 million € 564,000 € 73

Dispensing fees € 1,073 million € 546,000 € 71

Margin on non-WMg medicines* € 35 million € 18,000 € 2

Prescriptions 178 million 90,500 11.7

WMg medicines 170 million 86,300 11.2

non-WMg medicines 8 million 4,200 0.5

Patients 15 million 7,800 -

* Margin on non-WMG medicines based on the recommended retail price listed in the G-Standard. In practice pharmacists and health insurers agree lower prices. This means that the actual margin is lower than the margin noted above.

4

C colophonfacts and figures 2010 is published by the foundation for Pharmaceutical statistics (stichting farmaceutische Kengetallen, sfK). reproduction of data contained in this report is permitted on the condition that the source is quoted in full as: foundation for Pharmaceutical statistics (stichting farmaceutische Kengetallen) february 2011.

Compiled and edited by a.M.g.f. griens (drs.)J.s. Lukaart (drs. ing.)r.J. van der Vaart

Design and printingBasement graphics, the Hague

Editorial addressfoundation for Pharmaceutical statisticsP.O. Box 304602500 gL the Haguethe netherlandst +31 (0)70 373 74 44f +31 (0)70 373 74 [email protected]

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