EFPIA opinion on the Country Reports 2017
The reports highlight that several EU countries still have under-funded healthcare systems, which lead to poor healthcare coverage, limited access to healthcare services and pharmaceuticals and overall health outcomes that are below EU average. According to the reports, most Central and Eastern European countries, including Bulgaria, the Czech Republic, Croatia, Latvia, Hungary, Malta, Romania, Slovenia and Slovakia, have healthcare expenditure below or much below the EU average. Several countries are also highlighted as having poor health outcomes (Bulgaria, Czech Republic, Estonia, Croatia, Latvia, Lithuania, Hungary, Poland and Romania). Some reports also rightly notes that high proportion of out-of-pocket expenditure can be a barrier to access to healthcare and medicines in many cases, and lead to inequalities, including in Lithuania, Latvia and Bulgaria. For these countries, it remains an imperative to invest further in the healthcare system in order to increase coverage and equality.
For other countries, the focus is more on increasing the efficiency of healthcare. A common problem is related to over-use of hospital and specialist care, sometimes due to structural problems of the healthcare system (such as in the Czech Republic), or because lack of care coordination leads to unnecessary hospitalization (such as in Estonia), or lack of incentives to provide comprehensive care (such as in Hungary). Measures that need to be taken include strengthening primary care, increasing care coordination and aligning financial incentives to health outcomes rather than unnecessary procedures, which is an important issue across European health systems.
In this context, EFPIA would like to refer to the recent report from the OECD, “Tackling Wasteful Spending on Health”, which concludes that around one fifth of health expenditure in OECD countries makes no or only marginal contribution to health outcomes. According to the report, around 10% of hospital expenditure is spent on treating preventable medical errors and adverse events, and that even more is spend on “low-value care”, for example unnecessary clinical procedures or interventions that produce a sub-optimal result compared to an alternative intervention. Substantial benefits could therefore be made through resource re-allocation within the system and the report notes that efforts to reduce waste and low-value care is an important step in overall structural reforms, as opposed to mere cost-containment measures which can prove to be unsustainable and even detrimental to health outcomes. One example quoted by the report is a Dutch study that concluded that 20% of the budget for acute care could be saved by reducing overutilization and increase the integration of care.
EFPIA welcomes the focus in some of the reports on measures to increase value-for-money in health systems, including through using health technology assessment (HTA). EFPIA notes, however, that the rigorous assessment of value and/or cost-efficiency that HTA entails is often limited to medicines, whereas the goal to increase the value of healthcare overall and reduce waste throughout the system would require that all items of healthcare expenditure are assessed with regard to the value they bring to patients, to the overall system efficiency and to societies.
Several of the reports rightly reflects that many Member States have taken different measures to contain pharmaceutical expenditure, including through collaborative approaches with the pharmaceutical industry. EFPIA notes however that expenditure on and use of pharmaceuticals is consistently referred to as a cost only, without any reflection on the value they bring to patients, healthcare systems and societies. Not only do innovative pharmaceuticals bring benefits to patients in terms of increased survival and quality of life, they can also increase the efficiency of healthcare systems through reducing hospitalization or use of other healthcare interventions, and bring benefits to societies in terms of reducing sick leave and burden on social security systems. For example, use of influenza vaccination saves 250-330 million euro annually in Europe due to reduced need for GP visits and hospitalization, and medicines introduced for cardiovascular diseases during the last decades has brought savings on hospitalisation in OECD countries close to $90 per capita. However, in many countries the full benefit of innovative pharmaceuticals for patients and the larger system is difficult to realize because of short-term cost-containment measures and silo budgeting.
The focus of the European Semester is still mainly on fiscal sustainability, and it is important to recognize the limits this brings to the assessment of healthcare systems. A health system can, in theory, provide low and unequal access to healthcare, with poor health outcomes as a result, and still be financially sustainable. This conflict can constitute a challenge for countries that today spend less on healthcare than the European average and produce sub-optimal health outcomes and at the same time is deemed to be long-term fiscally unsustainable. The solution for these countries cannot be cost-containment, but to increase health expenditure on interventions that brings the most value for money, and implement more effective and comprehensive resource allocation. One illustrative example is the country report of Romania, which states that “continuous overspending of the budget on pharmaceuticals constrains the introduction of innovative medicines.” The problem here is clearly not that Romania spends too much on pharmaceuticals, but that the pharmaceutical budget is underfunded, which impedes the introduction of innovative medicines which could bring substantial value for patients and the broader health system. Therefore, broader structural reforms of healthcare systems is necessary in several countries in order to achieve what the ECOFIN Council in its conclusions of 8 November 2016 calls “the twin aim of ensuring fiscal sustainability and access to good quality health care services for all”.
In this context it should be noted that the country reports still to a large extent build on various fiscal, structural and process indicators (such as access to healthcare), whereas data on health outcomes are limited to a few macro-level indicators (such as overall life expectancy and preventable mortality). More granular and disease-specific health outcomes data, linked to particular interventions within the healthcare system, are needed in order to identify potential inefficiencies and analyse which interventions that bring the most value to patients. In this regard, EFPIA welcomes the ambition of the European Commission to analyse EU health systems purely from a health perspective, in the “State of Health in the EU” cycle, and look forward to taking part in that discussion together with all stakeholders. EFPIA furthermore welcomes the new mandate of the OECD to collect more data on patient-reported outcomes, which could bring more depth to the analysis of health system performance at the European level.
EFPIA calls on the Commission to recommend that all Member States implement systems for Health Systems Performance Assessment, with a strong focus on health outcomes measurements. Data show that there are substantial differences in health outcomes also within countries, which cannot be explained due to differences in funding levels, but rather in terms of what the money is spent on and sometimes sub-optimal treatment methods and pathways. Comprehensive and interlinked health information systems, including electronic health records and registries, for collecting real world evidence on health outcomes throughout the health system, have for this reason an important role to play. Such data will allow health systems to optimize patient pathways, make informed decisions on resource allocation and incentivize practices that bring the best health outcomes for patients. EFPIA would further call on the Commission and the Member States to consider how to best continue to utilize available EU funds and financial instruments for this purpose, including the European Fund for Strategic Investments, the European Structural and Investment Funds and the Connecting Europe Facility.
 Hospital expenditure per capita would have been $89 higher per capita in 2004 were it not for medicines introduced 1995-2004.