Interface management

The starting treatment in hospitals, often with expensive medicines, has a major impact on the out-patient sector as it influences the further choice of medicines prescribed after dis-charge of the patient.

Due to the different remuneration systems in the in-patient and out-patient sector (cf. section 5.1) in several countries, expensive medicines tend to be shifted between the sectors. This was for example reported for Austria, Germany, Finland, the Netherlands and Sweden.

Several countries (e.g. BG, MT, FR) have expressed a need of implementing interface management which is defined as the mechanism of cooperation between the hospital and the out-patient sector (cf. PHIS 2009a). However, some of them have not implemented specific initiatives yet, while in other countries (in particular in the Nordic countries) several initiatives have been launched.

Box 8.1: European survey – Interface management Austria

In Austria coordination problems between the out-patient and in-patient sector are reported.

The separated financing system of the in-patient and out-patient sectors might lead to a shifting of expensive treatments to the other sector. The first use of a medicine is often realised in the in-patient sector whereas the follow-up prescription is done by out-patient doctors. At the time of first prescription of a medicine an extensive medical observation may be required which can only be offered in the in-patient sector.

The positive list in the out-patient sector, the Reimbursement Code, is also valid for the in-patient sector.

A starting point for interface management is that representatives of a sickness fund are members of the Pharmaceuticals and Therapeutic Committees in hospitals in some Aus-trian regions. But the degree of participation and the role of the out-patient sector represen-tatives within these committees differ among the Austrian provinces.

In the Austrian province Tyrol a pilot project (“Medicines at the interface”) initiated by the Tyrolean sickness fund is running which exactly deals with such shifts of expensive phar-maceutical treatments (oncologic and rheumatologic medicines) between the in-patient and out-patient sectors. One of the main aims is to realise an adequate financial approach for reimbursing these services in the sector where those medicines are applied.

Source: PHIS 2009c

In some countries (e.g. DK, ES, SE) Pharmaceutical and Therapeutic Committees (PTC) try to tackle this problem of transfer of patients and medical treatments between the sectors by coordinating hospital pharmaceutical formularies with the positive list for the out-patient sector. The aim is to avoid starting treatment with an expensive medicine in the hospital which might result in a continuation in the out-patient care although alternative treatments

are available. In the UK hospitals have been asked to take into account the impact of their prescribing on primary care and joint Pharmaceutical and Therapeutic Committees within primary care were established to support this. There are examples of hospitals switching and controlling specific medicines to support cost-effective prescribing in primary care.

The boxes in this sector describe country examples with regard to interface management problems or initiatives.

Box 8.2: European survey – Interface management Norway

Interface management between the in-patient and out-patient sector in Norway exists with regard to specific medicines as hospitals pay for medicines that patients need after dis-charge of the hospital. These medicines include tumor necrosis factor (TNF) medicines and medicines for the treatment of Multiple Sclerosis. The funding of these products was trans-ferred from the budget of the National Insurance Scheme (NIS) to hospital budgets in 2006 and 2008 respectively. This was mainly due to the fact that some products in this field were financed by the NIS and some products were financed by the hospital. This created the economic incentive for hospitals to prescribe products funded by NIS. Also it was an aim to achieve more competition in the area and lower prices.

The Pharmaceutical and Therapeutic Committee provides mandatory prescribing recom-mendations. For example for TNF medicines the first and second choice of medicine in 2008 switched places in 2009. This means that doctors follow the prescribing recommenda-tions on interface management.

Source: PHIS 2009o

In Latvia the interface idea is guaranteed by the Centre of Health Economics, which elabo-rates both the list of medicines used in out-patient care and the one in hospitals. Hospitals provide treatment recommendations for primary care and general practitioners usually follow those treatment recommendations.

In Finland improving cooperation between in-patient and out-patient sector continues to be a challenge. Currently there are many ongoing local development projects and experiments concerning municipal services (for example increasing cooperation between municipalities, between primary and secondary care services and between municipalities and the private sector). However, they are not well coordinated from the national level, probably leading to increasing regional diversities in structures.

Box 8.3: European survey – Interface management United Kingdom

Health economy prescribing committees (sometimes referred to as Area Prescribing and Medicines Management Committees (APCs)) whose “member” organisations are primary and secondary care commissioners (purchasers) and providers work together to ensure a consistent health community approach to medicines management. Many were established to manage more effectively the entry of new medicines into the NHS. Now, however, the functions and forms of many APCs go far beyond this original remit.

In particular, they can be used as forums to resolve issues around medicines safety and usage across the care interfaces, for example from primary to secondary care.

There are clear benefits to patients and organisations of having an effective and influential APC, for example, an APC can:

– promote co-operation and consistency of approach in the commissioning process – prevent duplication of professional and managerial effort by ensuring local joint working – ensure that robust standards and governance underpin community wide decision making – enable key stakeholders, working in the NHS locally, to exert an influence on the

prioriti-sation, improvement and development of healthcare delivery

– co-ordinate the safe and effective use of medicines across a health community.

Source: PHIS 2009t