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CSS Insurance

Medication

The market for medication is very tightly regulated. CSS Insurance measures additional regulations by their ability to allow for mechanisms that are as close to market mechanisms as possible. However, when it comes to the pricing of medicine today, there are still various false incentives and unclear regulations (e.g. strict margin rules, arbitrary innovation supplement, unclear application of the foreign price comparison (APV) and therapeutic cross-comparison (QTV), lack of pricing momentum, no annual review of prices by the FOPH etc.): The lack of incentives and false incentives mean that medication in Switzerland is expensive compared with medication abroad and that fewer generic medicines are dispensed, among other things.

That is why CSS supports political efforts to introduce market-related mechanisms to the pricing of medicine in the mandatory basic insurance system and to inject more competitive momentum into prices on the medicine market.

The amount of generic medicine prescribed in Switzerland is particularly low. CSS supports the Federal Council's efforts to introduce the fixed-price system for medicines whose patents have expired. In the basic insurance system (OKP), a fixed price should be determined for substitutable medicines whose patents have expired. Patients asking for a different medication with the same active ingredient, whose price exceeds the fixed price, should pay the difference themselves if there are no medical reasons for prescribing the more expensive preparation. This measure would make generic medicine more attractive and eliminate the advantage accorded original preparations.

CSS is conducting negotiations with the service providers to establish fair compensation of the distribution margin for each distribution channel. Doctors, for example, have a restricted range of medicine on offer and thus lower storage costs. The logistic costs and capital expenditure for hospital pharmacies, on the other hand, are already included in the flat rates paid for hospital inpatient services. These differences could best be reflected in tariffs with the aid of contracts between the service providers and health insurers. At the same time, contract-based solutions have the advantage that additional services provided when dispensing medication can be compensated in accordance with their added value. An example of this kind of additional service is the dispensing of generic medicine at the start of treatment. CSS is working towards such a solution by taking part in the negotiations on service-based remuneration (SBR).

The current approval and pricing process for medicinal products is based purely on the documentation submitted by the applicant. Recommendations of the Federal Medicines Commission are not binding in the current setting. In addition, the Federal Office of Public Health (BAG) is not required to account for its decisions. At present, only the company which submitted the application can appeal a BAG decision. This means that, as cost bearers, the health insurers cannot react in the interests of their clients when a medication is admitted to the catalogue of benefits in spite of doubts regarding its WZW criteria or if it is given a price that is too high to be considered justified. CSS therefore advocates introducing to the pricing system a right of appeal for the stakeholders concerned (insurers, consumers/patients).

You can find further information on the topic of medication in our publication on health policies "im dialog" 1/2016 (in german).