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Health systems in transition
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Box 5.8
Evaluating efficiency in pharmaceutical care
Policy regarding pharmaceutical products had significant changes, namely a price cut in
medicines and promotion of generic drugs. Between 2011 and 2014, total pharmaceutical spending
on ambulatory care decreased by 12%. This decrease was the result of a notable price cut in
pharmaceuticals that counterbalanced the effect of increased consumption on total expenditure
and public expenditure with pharmaceuticals. Increased consumption occurred because the uptake
of pharmaceuticals already on the market increased, and also due to entry of new pharmaceuticals
to the market (Barros et al, 2015).
In 2014, NHS spending represented 62.5% of total spending with pharmaceutical sales in
ambulatory care, whereas NHS users co-payment accounted for 37.5%.
Between 2011 and 2014, the entry of new pharmaceuticals on the market was mostly comprised by
generics. Generics accounted for more than 70% of entries of new pharmaceuticals on the market
annually, in that period.
In 2015, the share of generic drugs was approximately 47%, generics being the main provider of
pharmaceuticals to the NHS, considering the number of units (around 47% in ambulatory care and
more than 67% in the hospital sector). By contrast, generics represent approximately 24.3% of NHS
spending with pharmaceuticals in ambulatory care and 22.5% in the hospital sector.
5.6.1 Pharmaceutical coinsurance
Prescribed drugs are subject to variable patient coinsurance based on effectiveness
criteria, with full payment required for those pharmaceuticals deemed to have
little or no clinical value or that are not cost-effective. Since 1992, there have
been four categories of NHS coinsurance, whose rates have been regularly
revised. Currently, pharmaceuticals in category A have a coinsurance rate of
10% (the NHS reimburses 90% of the costs); category B, 31%; category C, 63%;
and category D, 85% (Ordinance No.195-D/2015, of 30 June 2015). Decree-Law
No. 106-A/2010, of 1 October 2010 establishes two kinds of reimbursement
regimens. The special regimen (drugs dispensed both at hospital and in the
community pharmacy) applies to patients with particular conditions or groups
of patients. The general regimen establishes a co-insurance rate, according to
the categories mentioned above, if those medicines are not included in the list of
indispensable medicines in terms of life support. Also, Ordinance No. 1319/2010,
of 28 December 2010 establishes the reimbursement according to NHS users’
special conditions. This depends on the users’ income, being pensioners with
a maximum annual income of up to 14 times the national minimum monthly
wage eligible for a lower level of co-insurance on pharmaceuticals. These
pensioners have an additional reduction in co-insurance for the pharmaceuticals.
The Ministry of Health defines which pharmaceuticals fall into each category.