Press release of the Czech Society for Oncology on reimbursement of biological therapy. Oncologists are under real threat of criminal prosecution or n

Press release

Prague, 11 November 2010 The Czech Society for Oncology of the Czech Medical Association of JEP (CSO) regrets to inform the public and political representation of the Czech Republic that amendments for the year 2010 to the special contracts entered into between the Comprehensive Cancer Centres and healthcare payers have not yet been signed by the health insurance companies even though it is already as late as the middle of November. Oncologists in the Centres now faced with Sophie’s choice – “They can choose: Either not to prescribe modern effective treatment to suitable patients and risk law suits against themselves and the healthcare facility where they are employed, because they will knowingly hurt patients, or they can prescribe biological therapy to patients and expose their employers to the risk of indebtedness. The management of the indebted hospital where the Comprehensive Cancer Centre (CCC) is located, may accuse the responsible doctor of causing the financial situation, and as a result the doctor may receive notice of termination of employment”, explained Prof. Dr. Jiří Vorlíček, CSc., President of the Czech Society for Oncology.

Oncologists refuse to bear the social responsibility for this situation, although they bear responsibility towards their patients in legal terms. The Czech Society for Oncology requests continuation of the system established during the years 2007-2009, which was transparent, predictable for all, and ensured the provision of specialised and costly care to all patients who needed it. CCC had a document signed by the healthcare payers (insurers) providing written records to what extent the treatment would be reimbursed by the health insurance company. The number of patients treated was based on demographic and epidemiologic data, according to which the CSO is able to precisely estimate the numbers of patients who will need expensive care in the given year. This data is indisputable and doctors were certain up until this year that the health insurance company would pay for any treatment correctly indicated to the patient.

However, the situation changed in the year 2010 and health insurance companies, in contrast to the previous agreements, changed their attitudes towards the financing of care and stopped paying for treatment provided to specific individual patients. In this way, the healthcare payers/insurers cancelled the system in which treatment costs followed the individual patients. Instead of the currently existing, agreed, and functional system, health insurance companies proposed to limit the number of patients who could be entitled to receive optimal care. Setting upper limits on the number of patients according to “treatment sites” was rejected by most healthcare facilities and this year the centres have treated and will treat patients without certainty as to if and when they will receive reimbursement for the treatment provided. “For example, the management of VZP (General Health Insurance Company) publicly promised that the costs of biological therapy will follow the patients and that doctors can treat all patients who need this treatment. The regional branches of health insurance companies, which are responsible for the preparation of amendments, insisted on the establishment of upper limits on costs. Therefore, many hospital directors instructed the oncologists to limit targeted treatment as was proposed by the health insurance companies. In practical terms, this decision means that biological therapy will not be provided to the patient until another patient stops therapy or dies”, explained Professor Vorlíček. This procedure is contrary to the legal entitlement of patients who are entitled to receive instant care and if they don’t receive it, they can file a lawsuit and it can be expected they would win such a legal case.

Based on precise data that is available from carefully held registers of biological therapy, the CSO prepared methodology for the calculation of annual costs for modern cancer treatment administered to patients in the Czech Republic. The 12-month costs for the most modern cancer treatments in our country are approximately CZK 2.2 billion. If there is no under-treatment and biological therapy is prescribed to all patients for whom it is indicated and who would undoubtedly benefit from it based on their diagnosis, the annual costs would be almost CZK 6 billion. “These numbers clearly prove that biological therapy is not administered to every patient and its prescription is strictly selective”, added Prof. Vorlíček.

In addition to the interest for cancer patients, the CSO takes care of the stability of resources in the health insurance schemes. The dismal situation can be solved by the return to the biological therapy reimbursement system that had functioned properly until the year 2009, when reimbursement of care followed specific patients. Based on information sources of the Institute of Health Information and Statistics of the Czech Republic* (ÚZIS), it is quite obvious that the total sales of the pharmacies for medicinal products were CZK 42.769 billion in the year 2008, and CZK 47.434 billion in the year 2009. Biologicals, including those that are used in other medical disciplines, are among a large group of pharmaceuticals that are available subject to a special request form. In the period between the years 2008 (CZK 11.538 billion) and 2009 (CZK 12.249 billion), the sales of all drugs subject to a special request form increased by CZK 711 million according to ÚZIS. Total costs for drugs subject to a special request form constituted only one fourth of the overall costs for all drugs. These facts clearly demonstrate that the system, when the reimbursement of care followed the specific patient, created a burden on the insurance system. This fact is also supported by statements of the healthcare representatives from May 2010** “Cost savings ensuing from an effective spending of resources in the public health insurance schemes will enable an increase in the availability of modern more expensive care to a higher number of patients.”

Another possibility is that the health insurance companies clearly and publicly declare which treatment they will not pay to their clients and why. Each client of the health insurance company would have a contract and know precisely what his/her entitlements are for his/her premiums. There is no doubt money savings are possible in the area of patient motivation during outpatient treatment, otherwise it could not happen that almost 1/4 of the drugs prescribed an on outpatient basis *** (CZK 9 billion per year) are not used by the patients and finally end up in the garbage.

Chairman of the Czech Society for Oncology

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