Pharmeca.cz

On February 21, 2025, the Ministry of Health of the Czech Republic published the following opinion on the procedure for assessing the financial impact on the health insurance system when determining or changing the amount and conditions of reimbursement for a medicinal product or food for special medical purposes:

"The Department of Medicinal Products and Medical Devices of the Ministry of Health of the Czech Republic (hereinafter referred to as "the Ministry"), in view of the wording of the applicable Act No. 338/2024 Coll., amending Act No. 48/1997 Coll., on Public Health Insurance and on Amendments and Supplements to Certain Related Acts, as amended, Act No. 592/1992 Coll., on Insurance Contributions for Public Health Insurance, as amended, and Act No. 378/2007 Coll., on Medicinal Products and on Amendments to Certain Related Acts (the Medicinal Products Act), as amended, which, with effect from January 1, 2025, changes the principles in the area of monitoring limits of deductible co-payments for partially reimbursed medicinal products and foods for special medical purposes (the protective limit) and the subsequent reimbursement of deductible co-payments exceeding the protective limit under Act No. 48/1997 Coll., on Public Health Insurance and on Amendments and Supplements to Certain Related Acts, as amended (hereinafter referred to as "the Public Health Insurance Act"), hereby issues its opinion on the procedure for assessing the financial impact on the health insurance system when determining or changing the amount and conditions of reimbursement for medicinal products or foods for special medical purposes.

The method of assessing the financial impact on the health insurance system (hereinafter referred to as "budget impact") is expressed in the third and fourth sentences of Section 15(8) of the Public Health Insurance Act, which state that "The budget impact is determined as the difference between the costs of treating a given disease associated with the use of a medicinal product or food for special medical purposes that would be reimbursed from health insurance funds, and the costs of treatment using another medicinal product, food for special medical purposes, or treatment method that is already reimbursed from health insurance funds. The budget impact must be in accordance with the public interest pursuant to Section 17(2)."

If, under Section 15(9) of the Public Health Insurance Act, the anticipated budget impact associated with determining reimbursement for a medicinal product or food for special medical purposes shows an increase in expenditures from the health insurance system, the budget impact assessment must be conducted through a budget impact analysis submitted by the applicant, which the State Institute for Drug Control assesses during the proceedings [see Section 39b(2)(c) of the Public Health Insurance Act].

The requirements of the third and fourth sentences of Section 15(8) of the Public Health Insurance Act for the applicant-submitted budget impact analysis and the procedure of the State Institute for Drug Control in its assessment are elaborated in the methodology SP-CAU-27 (hereinafter referred to as "the methodology") as of the date of this opinion. For the purpose of quantifying the budget impact, the methodology allows only the perspective of health insurance expenditures (for completeness, it should be noted that this applies outside of proceedings conducted under Section 39da of the Public Health Insurance Act).

The Ministry is aware from its own official activities that the State Institute for Drug Control currently considers only direct costs (both pharmaceutical and non-pharmaceutical) demonstrably incurred from health insurance in connection with the therapy of the given disease as relevant costs in the budget impact assessment, whereby the State Institute for Drug Control considers only the costs at the level of reimbursement from health insurance, or costs corresponding to the maximum consumer price if this price is lower than the reimbursement amount, as direct pharmaceutical costs for both the evaluated intervention and the comparator.

However, as the Public Health Insurance Act stipulates that the budget impact is determined as the difference in treatment costs for the given disease (from the perspective of health insurance) associated with the use of medicinal products, the Ministry considers it necessary to include in the relevant direct costs for the evaluated intervention and the comparator also the amounts of deductible co-payments reimbursed by health insurance funds above the protective limit of the insured, which, in connection with the amendment to the Public Health Insurance Act, will be a direct expenditure of health insurance funds paid to pharmacy service providers related to the treatment of the given disease.

For this reason, it is necessary that the applicant, within the submitted application, consider the anticipated budget impact, taking into account any deductible co-payments for the evaluated and comparator intervention.

If, in the assessment of the anticipated budget impact under Section 39b(2)(j) of the Public Health Insurance Act in proceedings on determining or changing the amount and conditions of reimbursement for a medicinal product, it becomes apparent that this anticipated reimbursement impact on health insurance funds, taking into account the anticipated amount of deductible co-payments (representing the cost of treating the given disease), shows an increase in expenditures from the health insurance system, in such a case, the applicant must submit a budget impact analysis that also considers the amount of the anticipated deductible co-payment.

According to the Ministry, in order to fulfill the purpose of the aforementioned legal provisions concerning the new protective limit rules, it is necessary that, in the budget impact assessment by the applicant and the budget impact evaluation by the State Institute for Drug Control, the deductible co-payment amounts applied in practice are considered, rather than the highest possible deductible co-payment amounts calculated according to the second sentence of Section 16b(1) of the Public Health Insurance Act.

The Ministry further emphasizes that the deductible co-payments for partially reimbursed medicinal products and foods for special medical purposes, which count towards the insured person's protective limit, are known to the State Institute for Drug Control from its own official activities, as well as to health insurance funds, and marketing authorization holders can also determine the actually applied amounts of deductible co-payments from the publicly available data on the website of the State Institute for Drug Control at https://prehledy.sukl.cz/prehled_leciv.html#/ or calculate them from data on already reimbursed medicinal products (comparators) published at regular intervals on https://opendata.sukl.cz/?q=katalog/lek-13 (note: link valid as of the date of this opinion).

For practical implementation, the Ministry believes that the above-mentioned change in the procedure for budget impact assessment can be realized as follows. The budget impact analysis will, in addition to the currently expressed budget impact, also include a separately calculated budget impact incorporating the costs of deductible co-payments for partially reimbursed medicinal products and foods for special medical purposes that would arise for health insurance funds when exceeding the annual protective limit. However, presenting a separately calculated budget impact with applied deductible co-payments will not be entirely necessary (or would be redundant) in cases where no deductible co-payment arises in the determination or change of the reimbursement amount and conditions for the evaluated intervention.

In conclusion, the Ministry states that this opinion does not interfere with the current practice of assessing cost-effectiveness analyses."   

The original document is available on the website of the Ministry of Health of the Czech Republic.

The text of the opinion was translated using ChatGPT 4o.