- The future of Local Health Units (ΤΟΜΥ)
- How could the Family Doctor institution be promoted?
- Application of anti-smoking law
- Policy on reducing smoking-related harm
- Measures and policies for promotion of vaccination
- Population screening programs
ROUND TABLE I
Prevention and Primary Healthcare
Primary Healthcare is the core of every organized health system. Unfortunately, despite the laws that have been passed in the last 30 years, the organization and operation of primary healthcare services are still lacking.
The government of SYRIZA attempted to create a network of Primary Healthcare Services (in Greek: ΠΦΥ) around the Local Healthcare Units (in Greek: ΤοΜΥ). Until today, more that 100 units have started operating, while the overall plan included 250 units, with the aim to meet with the population’s needs in urban centers.
However, the government was severely criticized for promoting a state-centered model and leaving freelance doctors out of it. As a result, the medical community cold-shouldered the whole endeavor. In addition, the government was accused of disregarding the existing health centers in semi-urban and agricultural areas.
New Democracy, on the other hand, has announced its intention to abolish the Local Healthcare Units (ΤοΜΥ), which would be absorbed by health centers, and focus on prevention with the objective to:
- reduce by 30% the number of smokers and obese children in the next decade
- reduce by 24% cancer cases related to smoking, bad nutrition and obesity within the next 10 years
- diagnose 75% of cancer cases in early stages (1 or 2) in the next decade
- reduce by 30% complications due to diabetes and cardiovascular diseases (heart attacks and strokes) in the next 5 years.
To this end, New Democracy has expressed its determination to apply the anti-smoking law and is planning a campaign to keep citizens informed on health issues and encourage them to exercise, quit smoking, follow a healthy diet low in fat and sugar, reduce alcohol consumption and control their weight.
Furthermore, ND is promoting special educational programs in schools as well as the creation of a national information platform not only for citizens but also for health professionals. Finally, the party’s plans include free preventive screening tests for all Greeks.
ROUND TABLE I
The progress of the various changes that the government is promoting in the Primary Healthcare system is not unhindered. About 100 Local Healthcare Units (ToMY) have been established so far, while the Ministry of Health aims to open 50 more by the end of the year.
The initial plan included a total of 250 units which were supposed to be put into operation until the summer of 2018; however, this goal was hindered mostly by the fact that very few general practitioners and pathologists responded to the State’s call for expression of interest.
Self-employed doctors’ interest in signing contracts with EOPYY (the Greek National Healthcare Services Provider) is markedly faint. According to medical associations the cause are the low fees, despite the government’s – delayed – efforts to improve the framework regarding new contracts and medical fees.
The family doctor system was put into effect on August 1st but it is not yet viable due to the inadequate number of medics. Indicatively, so far only 600 doctors have agreements with EOPYY, while there are approximately 1,700 general practitioners, pathologists and pediatricians according to updated records.
Therefore, the lack of available doctors is the main hindrance in the implementation of the new – greatly disputed by medical associations – system where the family doctor refers patients to other services of the Hellenic National Health System or to specialized doctors who have agreements with EOPYY.
The government maintains that this system will be put into effect gradually starting on January 1st 2019, until there are enough family doctors to cover the whole population of Greece. This means that, until then, the insured will be entitled to visit EOPYY’S doctors of all specialties free of charge and without previous reference by a general practitioner.
- Assessment of the implementation of changes in Primary Healthcare
- Incentives and counter-incentives for medical professionals
- Hurdles and challenges in the operation of Local Healthcare Units (ToMY)
- Services provided to citizens by Local Healthcare Units
ROUND TABLE II
Pharmaceutical policy and pharmaceutical expenditure check
All signs show that the control of pharmaceutical expenditure is a minefield which the new government will have to cross, given that, despite the application of Memorandums and strict interventions in pricing, the consumption of medicines in Greece is constantly rising.
Public pharmaceutical expenditure is artificially under control, as in the last 3 years the closed budget on medicinal products remains stuck (at approximately 2 billion euro). Pharmaceutical companies are constantly called to cover cost overruns through clawbacks and rebates.
Numbers prove that the medical care system is not viable:
- In 2018, pharmaceutical companies paid 560 million euro in clawbacks and 430 million euro in rebates.
- In the first trimester of 2019, overruns increased by 43% compared to the same trimester of the previous year.
The committee for the control of pharmaceutical expenditure has considered several measures and options, but decision-making procedures are painfully slow. Everything shows that the possibility to offset clawback dues by spending on clinical research and development as well as productive investments will be legislated in the near future.
The new government will have to make crucial decisions on a series of proposals that have been submitted, such as:
- Exclusion of expenditure on vaccines from the closed budget
- Exclusion of expenditure on uninsured citizens from the closed budget by creating a separate fund with the participation of the industrial sector and the state
- Shared financial responsibility for the state and the industrial sector, as was recently legislated in Cyprus.
- Distortions that remain unresolved
- Why are expenses still out of control?
- How could the re-adjustment of the closed budget on pharmaceutical expenditure be achieved?
- Link of clawback calculation with investments on clinical trials
- Incentives for generic medicines
- Health Technology Assessment
- Pharmaceutical coverage of uninsured citizens
- How could public-private partnership (PPP) be achieved in the healthcare sector?
- Criteria for the selection of new hospital administrators
- Application of DRGs system in the public and private sector
- Mergers of facilities and re-organization of healthcare units
- Personnel hiring
ROUND TABLE III
Organization, administration and funding of the Hellenic Healthcare System
Despite the application of a series of Memorandums, in the last 10 years there have been very few substantial interventions on the organization, administration and funding of the Hellenic Healthcare System. All experts agree that the existing system is outdated while the financing methods ineffective and counterproductive.
In recent years, there have been intense discussions regarding the merger of various structures and services and the re-definition of their activities in order to cut costs and improve efficiency. Despite these efforts, little has been achieved on a practical level, as, for example, the shutdown of the Social Insurance Institute (IKA) hospitals and their incorporation into the Hellenic Healthcare System (ESY) or the conversion of the IKA multi-clinics into healthcare centers. However, these few changes were made without planning nor proper assessment of the problems, therefore brought poor results.
The SYRIZA government did not address issues such the assessment, reorganization and merging of various services. In addition, it lost valuable time in the implementation of the DRGs (diagnosis-related groups) financing system in hospitals, despite the fact that significant steps had already been taken by the previous government.
The new government, which will take over after the elections of July 7th, will be called to take crucial decisions related to healthcare. For example, the criteria for the selection of hospital managers and directors of other health services, such as Health Districts (YPE), the Hellenic Healthcare Services Organization (EOPYY), the National Organization for Medicines (EOF), Educational and Counseling Support Centers (KESY) etc.
Given that New Democracy is the clear front-runner of the elections, it is extremely important to know its members’ plans regarding the healthcare sector. Its campaign program does not include merging of healthcare units or re-determination of medical services, but refers to assessment of their efficacy. Moreover, its representatives have clearly stated their intention to promote public-private partnership, thus it remains to be seen which legal steps will be taken to make this possible and which sectors they will be applied in.
ROUND TABLE III
Most of memorandum measures were applied in the pharmaceutical sector. This was not unfair, given that in the period 2004-2009 there was an uncontrollable increase in pharmaceutical expenditure by the Greek NHS as well as private organizations.
Despite a series of measures that have been taken since then, pharmaceutical spending is still out of control. At the same time, EOPYY’s budget is “closed”, meaning that there is an increase in the amounts that the pharmaceutical companies are called to return, which has rendered the medical care system non-viable.
It is estimated that in 2018 pharmaceutical industries will return approximately 1.1 billion euros, while EOPYY’s budget amounts to 2 billion and another 700 million correspond to costs incurred by patients. This means that Greece’s annual pharmaceutical spending is worth about 3.8 billion euros, of which the State covers just 2 billion!
The current government recognizes that the 2-billion-euro budget is totally inefficient to cover existing needs, therefore it has decided to increase it gradually following economic development rates. In addition, two important initiatives are being promoted:
– The creation of the Health Technology Assessment Committee
– The cross-party Committee on pharmaceutical policies
However, this action is the target of severe criticism due to the fact that decisions are taken without necessary deliberations and consultation with patients, which would allow the latter to participate in the decision-making process.
• Budget ceilings related to in-patient and out-patient healthcare
• Pharmaceutical expenditure check
• Health Technology Assessment – Negotiations
• Incentives for generic medicinal products
• Coverage of uninsured citizens