EH 5_2015

Copyright:Shutterstock/Poznyakov EUROPEAN HOSPITAL  Vol 24 Issue 5/15 2 NEWS & MANAGEMENT Where pain relief is a matter of luck A question of cross-border healthcare Western Europe can choose from a variety of opioid preparations Hungary should re-join the competition for patients willing and able to pay for services, Dr Attila Bodnár believes Report: Michael Krassnitzer Access to pain relieving medication varies greatly within Europe. ‘The availability and reimbursement of certain pain relieving medications for patients depends less on medi- cal criteria than luck – living in the right country,’ declared Professor Hans Georg Kress, past president of the European Pain Federation EFIC, speaking in Vienna this September at the 9th EFIC Congress. A new EFIC study, first presented at the congress, examined the gap in supply of pain-relieving medica- tions in Europe, using oral opioid analgesics as an example. According to the study, the number of differ- ent opioid preparations available to pain patients is – as a rule – higher in Western Europe than in Eastern Europe. Germany heads the list with 47 approved oral opioid analgesics, the costs of which are assumed entire- ly by health insurers. Italy lies second with 42 approved and reimbursed opioids, followed by Denmark, with 37 on the market, of which only 22 are reimbursed and Sweden with 35 approved and paid medications. Medical tourism within Europe is not a new phenomenon, 2006 onward saw a surge in European medical tourism, largely involving patients for dentistry. For example, patients from the United Kingdom who struggle with availability in their home country can eas- ily access dental services in the Central-eastern European countries, and save up to 70% on treatment costs. The Directive 2011/24/EU on patients’ rights in cross-border healthcare has been regarded by many as a major achievement of the ‘patient empowerment’ policy pro- moted by the European Institutions, granting European citizens the right to access healthcare services in a different member state. Designed to address the obsta- cles deriving from the diversity of healthcare systems, such as the reimbursement rules and delivery of healthcare services, the ‘Cross- Border Healthcare Directive’ has established a general legal frame- work aimed at maintaining the sus- tainability of health systems while protecting patients’ right to seek treatment outside their home country. Currently, cross-border healthcare accounts for approximately 1% of the over- all EU public health spending – around €10 billion per year. In Hungary this number reaches 1.2% related to the total expenditure of public financed healthcare. Patients want to access cross-border health services when treatment is not avail- able in their home country, when it is better managed elsewhere, or, as is the case in many border areas, when the nearest available care is in another Member State. According to the World Health Organisation’s report on ‘Cross- Border Healthcare in Europe’ the volume of patient mobility with- in the EU remains relatively low because people are often unwilling to travel to other countries for care. The Eurobarometer pointed out that ‘only 5% of people living in the EU had received medical treatment in another EU country. In the majority of cases, the medi- cal treatment had not been planned: 3% just happened to have received treatment in another country, and only 2% of patients had treatment abroad because they had actually planned to do so.’ On the other hand, where patient mobility exists, this has raised issues related to its impact for patients, health profes- sionals and health systems. These aspects have provoked calls for better coordination of health systems and policies across the EU, resulting in the implementa- tion of the ‘Cross-Border Healthcare Directive’. However, the Directive appears to leave uncertainties for cross-border patients, such as effec- tive cooperation between national healthcare systems, some of which struggle to provide care within the same timeframe and of the same quality as is available in other EU countries - including cost reasons. Other uncertainties include the reimbursement rules of the Directive for patients seeking care abroad as well as the inability for some patients to look for care that is not covered under their domestic ben- efit package. Therefore, the impact of the Directive made established functions in each Member State to handle these kinds of problems. On the healthcare market there is worldwide competition for patients, while in Central Eastern Europe a market repartition process is hap- pening. The Hungarian central gov- ernment faces the same challenge as other governments: total public annual expenditure on the health- care system is very low in terms of GDP. However, thanks to seri- ous EU funding, the infrastructure and equipment in most state-owned medical institutions and even pri- vate sector providers has revived. Actually, Hungary’s power to strug- gle for a bigger market share of the healthcare market may also be strengthened by the of public sector institutions, because better condi- tions enable them to provide such The tail end includes Kosovo (four approved none reimbursed), Russia (4/4), Bosnia- Herzegovina (3/0) and the Ukraine where not a single oral opioid is available. In some European countries the health insurers or public purse reim- burses opioid costs automatically, if the medication is approved. In Eastern Europe, the cost of most approved products is reimbursed. However, in most countries the offi- cial approval process is distinct from the cost absorption by the health insurers. ‘In everyday reimbursement practice, access to important pain relievers is restricted although they are offi- cially approved and available from the chemist,’ Kress said. The pain physician at the Medical University of Vienna pointed out an example from Austria, the capsaicin bandage (8%) against neuropathic pain. Initial application must occur in a hospital. However, the health insurer will only assume the costs for the continued treatment if performed by a medical practitioner in the local practice. However, the physician cannot bill the health insurer for the application procedure that takes some one and a half hours and therefore must offer it free of charge. Result: practically no physician is willing to do this. ‘In this way the use of the approved and demonstrably effective medica- tion is indirectly prevented,’ Kress concluded. ‘In Austria, the provision of pain relief medicine has slid into a cri- sis in recent years,’ according to Dr Wolfgang Jaksch, President of the Austrian Pain Society (ÖSG). Outlining the situation in the alpine republic, he explained: ‘There is no legal mandate that hospitals perform out-patient pain treatment. Since per- sonnel and financial resources are being cut constantly, that is just where they are being reduced.’ Jaksch named two other countries, which, in his view, act as models of supplying patients with pain medi- cation. In 2010, Italy adopted a law (Legge 38) in which the foundation for a major structural improvement in pain medical care was laid. It grants citizens the right to palliative and pain medical care and oblig- es the Italian regions to provide a comprehensive selection of pain and palliative medical care. Among other things, a post-doctoral masters degree in pain therapy has also been introduced. In the course of a reform in Belgium, two and a half years ago, 34 specialised facilities, situated in hospitals, spread across the whole country, have been approved as ‘mul- ti-disciplinary pain centres’ through an accreditation process. Their job is to treat chronic – and in certain cases of sub-acute – pain both on an out-- and inpatient basis. In addi- tion to such highly specialised facili- ties, every Belgian hospital has been obliged to create interdisciplinary pain teams, which will be remuner- ated in the context of the regular hospital financing. Professor Hans Georg Kress heads the clinical department for special anaesthetics and pain therapy at the Allgemeine Hospital, Vienna. He is also a past president of the European Pain Federation EFIC Dr Wolfgang Jaksch DEAA is senior physician at Vienna’s Wilhelminen Hospital and president of the Austrian Pain Society (ÖSG) Photos(2):B&K/NicholasBettschart Dr Attila Bodnár is Director of the Bajcsy-Zsilinsky Hospital and Out- patient Clinic, Budapest, Hungary Treatments due to be removed from the CDF list, and thus no longer routinely funded by England’s NHS Albumin Bound Paclitaxel for advanced pancreatic cancer Bendamustine for Chronic Lymphocytic Leukaemia Bendamustine for relapsed mantle cell non-Hodgkin’s lym- phoma Bevacizumab for first line treatment of recurrent or meta- static cervical cancer Bevacizumab for advanced breast cancer Bevacizumab for second or third line treatment of advanced colorectal cancer Bosutinib for refractory chronic phase Chronic Myeloid Leukaemia Bosutinib for refractory accelerated phase Chronic Myeloid Leukaemia Bosutinib for accelerated phase Chronic Myeloid Leukaemia Brentuximab for refractory systemic anaplastic lymphoma Brentuximab for relapsed or refractory CD30+ Hodgkin¹s lymphoma Cetuximab for third or fourth line treatment of metastatic colorectal cancer Cetuximab for third or fourth line treatment of metastatic colorectal cancer (with response to previous Cetuximab) Dasatinib for treatment of chronic phase chronic myeloid leukaemia Everolimus for metastatic renal cell carcinoma Ibrutinib for treatment of relapsed/ refractory Chronic Lymphocytic Leukaemia Ibrutinib for treatment of relapsed/ refractory Mantle Cell Lymphoma Lenalidomide for second line treatment of multiple myeloma Panitumumab for third or fourth line treatment of meta- static colorectal cancer Panitumumab for third or fourth line treatment of metastat- ic colorectal cancer (with a response to previous Cetuximab) Pegylated Liposomal Doxorubicin for named sarcomas Peptide Receptor Radionucleotide Therapy (Lutetium177 Octreotate or Yttrium90 Octreotide/ Octreotate) for advanced neuroendocrine tumours Pomalidomide for relapsed and refractory multiple myeloma Radium-223 Dichloride for prostate cancer Trastuzumab Emtansine for breast cancer Continued from page 1 England‘s harsh slash at cancer drugs list Continued on page 6

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