Interface policies bridging outpatient and hospital sectors in Europe: can cross-sectorial collaboration in reimbursement and procurement improve access to affordable medicines?

ABSTRACT

Introduction

Pharmaceutical systems are frequently characterized by fragmentation, and competences for outpatient and inpatient sectors sit with different authorities, payers, and purchasers. This fragmentation of responsibilities can incentivize shifting expensive therapies and thus patients from one sector to the other.

Areas covered

Reimbursement and procurement policies in Europe addressing unwanted consequences of this fragmentation were identified through literature reviews and surveys with policy-makers. Good practice examples include cross-sectorial reimbursement lists managed by committees with representatives from the outpatient and hospital sectors, specific funding mechanisms, joint procurement involving purchasers from both sectors, actions against procurement contracts prohibiting generic competition, and an extension of Health Technology Assessment to the hospital sector.

Expert opinion

Recognizing fragmentation as a major challenge for pharmaceutical systems, policy-makers in some countries reacted by implementing policies to support cross-sectorial collaboration. However, only a handful of good practice examples exist for reimbursement and procurement policies in Europe. Though robust evaluations are lacking, there are indications that pharmaceutical policies which ensure collaboration at the interface of the outpatient and inpatient sectors would likely result in efficiency gains and better use of public budgets and may serve as lever to improve access to medicines.

Plain Language Summary

In several European countries, the decision which medicines are funded by public money (reimbursement) and purchased by public institutions (public procurement) is taken independently for the outpatient sector and the hospital sector. There are different payers and procurers per sector, and even within a sector. Patients may be transferred between the sectors for financial reasons because one payer aims to shift the financial burden for the medication to the other sector.

Policy-makers have understood the importance of better collaboration between the sectors, and some European countries introduced policies addressing the issue.

The article presents examples of how reimbursement and procurement policies can be designed to improve the collaboration between the outpatient and hospital sectors. Committees that decide whether or not a medicine should be covered may contain representatives from both sectors; they may be mandated to take decisions that apply to medicines for outpatient use and administered in hospitals. Purchasers of both sectors may procure jointly a medicine. Supporting tools, such as the assessment of a medicine to support the decision on coverage and the price, may be used in both sectors. Financing solutions can reduce the incentive for one sector to shift a medicine to the other sector.

These measures can help that patients gain improved access to affordable medicines. However, despite the introduction of such interface policies in some countries, policy-makers still need to continue working on overcoming the fragmentation in the pharmaceutical system.

KEYWORDS:

• Cross-sector collaboration
• funding
• interface
• hospital
• outpatient
• pharmaceutical policy
• procurement
• reimbursement

Article highlights

• Interface policies serve to bridge gaps due to fragmentation between outpatient and inpatient sectors.

• Interface policies target both novel medicines with high budget impacts, which might be transferred from one sector to the other for economic reasons, as well as medicines with therapeutic alternatives, where initiation of a therapy in one sector can have implications for follow-up prescribing in the other sector.

• Reimbursement and public procurement of medicines can play a role in bridging gaps between the two sectors, if these policies target both outpatient and inpatient sectors and do not apply to only one sector.

• Communication and involvement of experts of both sectors are supportive to increasing awareness about the other sector.

• There is need for evaluations of interface policies which investigate the impact of these policy measures whose progress have mainly been demonstrated on an anecdotal basis.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

The authors are grateful to experts of several European countries who provided input on interface policy matters in their countries and to their colleagues Margit Gombocz, Valentin Kandler, Peter Schneider and Nina Zimmermann of the Austrian National Public Health Institute, who surveyed country information for the “Study on Best Practices in the Public Procurement of Medicines”.

Additional information

Funding

This perspective article draws from several pieces of research conducted over the last 15 years. In particular, it was informed by a review and survey done in the 2022 “Study on Best Practices in the Public Procurement of Medicines” commissioned by the European Health and Digital Executive Agency (HaDEA) as contracting authority under the mandate of the European Commission through the Framework contract SANTE/2016/a1/039 concerning the provision of services in the area of evaluation, impact assessment, monitoring and implementation and of other relevant services, in relation to the health and food policies (LOT 1) with reopening of competition. No funding was received for conducting the analysis for this review and writing the article.