Medicines benefits management
policies and programs: updates
Emanuel Kwesi Eghan
Center for Pharmaceutical Management
Emmanuel Kwesi Eghan
Management Sciences for Health ( MSH)
Center for Pharmaceutical
Management (CPM)
keghan@msh.org
Management Sciences for Health
Outline
• An overview of MSHs user guide
• Results of assessment in Namibia
• Status of pilot assessments in South Africa and
Ghana
Universal Health Coverage
• “Achieving access to key promotive,
preventive, curative and rehabilitative health
interventions for all at an affordable cost;
thereby achieving equity in access” (WHO,
2012)
Medicines – A key component of UHC
Policies and Programs
• Medicines are a key component of preventive, curative and
rehabilitative health interventions
• Medicines are also responsible for a large proportion of
total health care expenditures in low and middle income
countries (LMIC) and often account for nearly half of all
out-of-pocket costs paid by consumers in those countries
• Complex inter-linkages between Pharmaceutical and
Insurance Systems that needs to be explored and
understood
Ghana – expanding coverage, rising total
claims, substantially increasing drug costs
Drug Costs as a Percent of
Total National Health Insurance Claims Costs
A complex inter-linkage between Pharm
Sector and Insurance systems
MSH Stakeholder Conference on Medicines and UHC:
starting a dialogue, June 2013, Washington DC
Medicines Benefits Management Policies
and Programs– Tool Kit
1. A Manual – Management of Medicines Benefits Policies
and Programs – Critical Elements and Key Considerations
2. An Assessment Guide on Medicines Benefits Management
Policies and Programs in Low to Middle Income Countries
•Both the manual and assessment tool are work in progress and will be
revised periodically with feedback from colleagues and experiences
gained in supporting medicines benefits management across countries
A Manual – Management of Medicines Benefits Policies and Programs
– Critical Elements and Key Considerations
(currently in draft)
 a technical document to guide the key pharmaceutical management
considerations in a UHC program.
 defines the role of the different pharmaceutical functions within
Universal Health Coverage and address policies, strategies,
approaches and regulatory requirements for the development of
equitable and transparent systems.
 seeks to assist policy makers and national program managers to
better understand what elements of their pharmaceutical system
need to be strengthened in order to support the expansion of
their UHC program
 provides a common understanding of which elements of a medicines
benefits program are truly essential and which options or design
elements should be considered when implementing or revising an
MBP
A Manual – Management of Medicines Benefits Policies and Programs
– Critical Elements and Key Considerations
(currently in draft)
The manual is not prescriptive and recognizes that each countries political;
legal and regulatory context is different -it provides :
a) Overview of essential components related to insurance and medicines
benefits programs and components needed for a sustainable medicines
program no matter size or scope
b) Key factors involved in the design or revision of benefits package
- management and governance structures; claims processing systems;
information technology and operational requirements; beneficiary or
client services; provider contracts and medicines delivery systems
c) Performance monitoring, utilization reviews and measuring impact of
medicines benefit programs with examples of M & E indicators
Medicines Benefit Program
Assessment Tool for UHC Programs
• MSH/Center for Pharmaceutical Management in
collaboration with Accenture Development Partners
developed an assessment guide and tool to assess the
status of medicines benefit management in middle- to
low-income countries.
• The assessment guide is modular with the following
sections: Stakeholder Analysis; Laws and Regulations;
Healthcare Programs Manufacturer/Distributor; and
Information Technology and Operations ; Performance
monitoring -Utilization review
Medicines Benefit Program
Assessment Tool for UHC Programs
• Stakeholder Analysis
- Understanding who the political and participating
Stakeholders are and mapping of political power groups
•Laws and regulations
• - mapping the laws, polices and regulations as well as
current policy reforms in health care; consumer interest;
insurance/medical aid and pharmaceutical sector;
provisions for accreditation health facilities ; provisions
governing licenses for prescribing dispensing pricing
including regulatory oversight
Medicines Benefit Program
Assessment Tool for UHC Programs
• Health Care programs
- Administration and Management governance
policies; in house versus contracted out MBPs
- Enrollment and eligibility
- Formulary – open, closed, tiered
- In patient and out patient coverage
- Contracting; payment mechanisms
- Utilization and Medicines Benefits Program
Performance Management
Medicines Benefit Program
Assessment Tool for UHC Programs
• Manufacturers, Distributor; Retailers and Dispensing prescribers
- Assessing the distribution of channels for pharmaceutical products and
services as part of a national coverage mapping
- Options for improved geographical access to all intended beneficiaries
•Information Technology and Operations
- Minimum and additional level of infrastructure available – variations in
the private and public sector
- Medicines ( product) data base ; provider Data bases; beneficiary data
bases
- Are there systems in place to assigning separate identifiers for each
unique medicine variation and providers
- Level of internet connectivity; texting and data management capability
Medicines Benefit Program
Assessment Tool for UHC Programs
- Level of adjudication functionality – manual or automated ; pre
authorization ? Level of authorization and links to therapies ; are there
quantity limits etc
•Management Systems
- Are accounts payable, accounts receivable and general ledger systems
generally available for coordinated medicines benefit management
- Are there opportunity of electronic payments? And right HR Level to
support the medicines management programs be it in house or contracted
out
- Turn around time for payment of benefits claims – Monthly or yearly
volumes
- Primary Server, application computing capabilities hat levels of consumer
cost sharing exist?
Piloting
of medicines
benefits
Piloting
of medicines
benefits
assessment tool
assessment tool
Country
Population Covered
Participating Medical Aid
Schemes
Namibia
16-18% (2.1 million)
16 Medical Aid Schemes
South Africa
18% (54 million)
About 117 medical Aid
schemes
Ghana
35% (23 million)
Single payer scheme with a
number of small private
schemes
Assessment of Medicines Benefit Programs
in Namibia: Methodology
•
Desk Reviews; Interview with Principal officers and Administrators of Medical Schemes;
MoHSS; Social Security Commission; Medicines Regulatory Council; Wholesaler and
Distributors; Prescribers; Pharmaceutical Society of Namibia; University of Namibia ;
Pharmacies; NAMAF;
Name
Mr. Gabriel Mbapaha
Title
Chief Executive Officer
Mr. Callie Schaefer
Mr. Uahatjiri Banda Ngaujake
Chief Executive Officer
Manager, Research and Development
Organization
Namibia Association of Medical Aid
Funds
Prosperity Health Administrator
Social Security Commission
Mr. Tiaan Serfontein
Mr. Johannes Gaeseb
Dr. Philemon Nakangombe
Mr. A. Ben
Mr. Gabriel Achiawo
Dr. Kondjeni Kafidi
Dr. H. L. Musweu
Dr. Ebong Akpabio
Mr. Mark Schimdbauer
Mr. Ben Kumhalo
Prof Peter Nyarango
Chief Executive Officer
Registrar
Acting Medical Director
Accountant
Oshana Administrator
Pharmacists/Manager
Private Medical Practitioner
Consultant
Marketing Manager
President
Dean
MedScheme Administrators
Medicine Control Council
Oshakati Government Hospital
Oshakati Government Hospital
MetHealth
PAMA pharmacy
Kapia Health Centre
Independent
Newmed Wholesale
Pharmaceutical Society of Namibia
University of Namibia Medical School
Results
of Assessment
of Medicines
Results
of Assessment
of Medicines
Benefits
programs
in Namibia
Benefits
program
in Namibia
Stakeholder Analysis ; Legal
and Regulatory context
Remark
s
Is there a multi stakeholder platform to
address MBP ?
No
Who are the various stakeholders
A new committee UHCAN had just been launched to
address the new UHC policy intent
≥ 10
Public private players MoHSS, Social Security
Commission; NAMIFISA; NAMAF; MCC: PSN
Presence a law guiding health insurance
or Medical aid schemes
Yes
Do (es) Scheme(s) specify which users
are eligible for benefits
Yes
Are exemptions allowed to policies such
as cost sharing to increase access for the
poor or consumers with priority health
problems
No
A couple schemes have low cost
sharing for HIV and AIDS
Are there price controls on medicines
inherent to health insurance
single exit pricing
systems
Yes
program
Namibia Benefit
ResultsBenefits
of assessment
of in
Medicines
Health Care Programs
Programs in Namibia
Administration and management
Is the medicines Benefit management plan managed in house or contracted out
contracted out
Is the administration of medicines benefits done by Government or separate autonomous or semi
autonomous agency Who are the various stakeholders
N/A
Are there PBM operating in the country
Enrollment and Eligibility
Yes
Does the benefit program allow exceptions to allow access to excluded or restricted services or
medicines or to override any caps on numbers of prescription or quantities dispensed
No
Are the member identification systems electronic or paper based
electronic
Are process for managing reviews; granting or denial approval
Scope of Coverage
Yes
Is the enrollment mechanism voluntary or mandatory
Benefit Scope and design
voluntary
What type of formulary or medicines list is in place - closed? Open? Or Tiered
How often are list reviewed
Is generic substitution allowed
Closed ; tiered
what incentives are used to encourage generic substitution
Yes
tiered pricing and
dispensing fees
Results of assessment of Medicines Benefit Programs in Namibia
Health Care Programs
Financing
Finding
What if any , are the existing gaps for financing health insurance and or
MBP coverage from a UHC perspective
Do cost share vary by medicines type or medicines prices
Do the medicine benefits programs cover both in-patient and out
patients
If in -patient cover is available are medicines billed separately or as
part of total treatment cost
Yes
Remarks
Copay range from 3-20%
depending on scheme and
price of medicine
Yes
Billed separately
Public sector
reimbursement slow; paid
at gazette rates; sometime
Are both private and public sector facilities utilized
Yes
not paid at all
However when patient use
out of network provider
Is the method of payment for prescription based on reimbursement to predominantly by claims they can submit claims for
individuals or claims submitted by accredited provider?
submitted by provider
reimbursement.
SEP + 50% ( margin) +15%
What are the standard basis for payment of pharmaceuticals
VAT
Are separate dispensing fees paid per product or per prescriptions ?
Yes
SEP + 30% ( margin) +
What are the criteria for different dispensing fee if the exist ?
15% VAT
Prescriber Dispensing
Do national or state laws and regulations address prescriber dispensing
?
Yes
Results of Assessments of medicines
benefits management in Namibia
Utilization Review and Program
Performance Management
Do the schemes have routine data to calculate following
indicators
Findings
Medicines expenditure as a proportions of scheme total expenditures
Yes
5/5
Monthly and annual cost of payments of medicines and disaggregation of high
volume and high cost medicines
Yes
5/5
Total expenditure per member per month
Yes
5/5
In patient spend per member per month
Yes
5/5
Out patient spend per member per month
Yes
5/5
Medicines expenditure per disease per month
Expenditure per New chemical entity per month
Medicine expenditure per category of provider
Medicines expenditure generic versus brand where applicable
Yes
Yes
Yes
Yes
5/5
5/5
5/5
5/5
Numbers and average cost per month and annual prescribers,pharmacy providers
and beneficiaries
Do schemes currently have procedures to address the issues around
Increasing use of generic medicines
Limiting use of high cost medicines
Improving patient adherance to chronic disease medicines
Yes
Yes
Yes
Yes
Yes
5/5
5/5
5/5
5/5
5/5
measuring patient or provider statisfaction as measure by number of complaints
received
Yes
5/5
Remarks
All schemes are able to generate
on a routine basis
Observations and recommendations
 A large uninsured population still exists in Namibia with limited access to
much needed services and medicines. Coverage needs to be extended to
large uninsured populations. Larger risk pools and risking pooling (high
versus low income) are needed.

Issues around medicines coverage need to be captured in the terms of
reference of UHCAN. Going forward, UHCAN will have to address or
make recommendation on several issues, including but not limited to :
Finalizing the cost-benefit package based on priority setting in the
context of Namibia; Developing a national reimbursable list based on the
benefit package
 Consensus on specific diseases, such as HIV and AIDS, and choice of
medications to be covered
 Strengthening brand and generic use as recommended in pharmacy law
 Developing approaches to address overuse and underuse of medicines
Observations and recommendations
 Improving medicines availability in rural areas (courier pharmacies,
chronic disease dispensing units, dispensing doctors, etc.)
 Pricing of medicines and the process for updating and/or reviewing
medicines
 Ascertaining the applicability of the single-exit-pricing ( SEP) single
exit-pricing system in the public sector
 The role of the national supply chain; how to utilize the potential
benefit of the national tendering system for medicines; and
rationalizations of pricing between the public and private sectors
under the upcoming universal health coverage program need to be
clarified
 Monitoring and evaluation systems need to be rolled out to measure
the extent to which access to much needed medicines and services is
improved under UHC
Observations and recommendations
 Government of Namibia needs to play a leading role to
adapt existing technology within medical aid plans into
the public sector.
 The absence of a standardized national coding system
for medicines. May require development (where
absent) and standardization (where present) of existing
coding for diseases, procedures, and medicines
nationwide during roll out of UHC. The medical aid
schemes NAPPI coding system could be standardized
and advocated for nationwide use
Status
additional using
pilot assessments
:
Anofassessment
a similar methodology
has been done in South Africa on medicines
An assessment
using
a
similar
methodology
has
been
done
SouthofAfrica
on medicines
benefits management in collaboration with
the in
NDOH
the medicines
- Draft
report to bewith
finalized
and shared
key stakeholders
benefits management
collaboration
the NDOH
of the with
medicines
- Draft report to be finalized
and shared with key stakeholders
Name
Title
Organisation
Dr Alban Pillay
Deputy Director General
Department of Health
Amos Masango & Vincent Tlala
COO & Registrar
South African Pharmacy Council
Debbie Parker
Supplier Relations Manager
Curasana Wholesaler
Prof. Di McInTyre
Director
Health Economics Unit, University of Cape Town
Antione Van Buren
CEO
Pharmacy Direct, SA
Christo Rademan
MD
Mediscor
Prof Fatima
Chairperson
Pricing Committee ,
Roger Wiseman
Health Policy and Clinical
Governance
Liberty Health
Fuad Salie
Hospital Manager
Netcare Parklands Hospital Durban
Princess M. Makhosazane
Director
Market Access MSD (Pty)Ltd;
Marquin Cotz
Hospital Manager
Mediclinic Worcester
Mr. Vivian Fritelli
Manager
National Association of Pharmaceutical Manufacturer
Tania Mathys
Pharmacist Manager
CDU
Humphrey Zokufa
Managing Director
Board of Health Care Funders
Representatives
Western Cape, DoH
Discovery Health
Next Steps
 Assessment in Ghana -MoU signed with NHIA
and planned assessments in Dec, 2014 /Jan
2105
 Reviewers needed for Manual and Tool
 Country Case studies needed
Thank You