The Reimbursement and Funding of Inpatient Medicines

Introduction: With the introduction of prospective payment systems based on case-mix the compensation for drug costs is built into patient-classification systems or so called DRGs. Since these systems are constructed not very flexible, the inflexibility may cause a delay in the drug’s uptake in the hospital practice as well as a lack of appropriate funding. In order to compensate for that inflexibility supplementary and alternative funding measures for drugs were established in Germany, England and France. These funding measures as well as patient classification systems are assumed to be determined by the influence of particular priorities which are displayed in diverging regulations and decision outcomes. The funding and reimbursement processes as well as corresponding decisions and regulations are more or less arbitrary and priority-driven among Germany, England and France. Methodology: An explorative research design was chosen. To collect information in total 14 experts have been recruited who have an insight into the clinical practice in the examined countries. Semi-structured expert interviews, documents and scientific articles provided insights with regard to an initial concept of inpatient-drug reimbursement-barriers and the actual practice in German, British and French hospitals. Stern’s and Holder’s (1999) appraisal framework for regulatory systems was used to assess the institutional design and regulatory processes. Results: The analysis revealed different qualities of regulation depending on the level of decision-making, the involved stakeholders and their competencies as well as the domain decisions and regulations are made for or in. Thereby, drugs reimbursed as part of activity-based hospital budgets do not face significant barriers to be administered and funded. Although the regulatory setting is not very transparent in all three of the countries, decisions can be retraced, are predictable and not very arbitrary. Differently the situation turned out with respect to supplementary and alternative funding of drugs. Thereby major regulatory deficits occurred in particular with regard to the granting of funding for innovative drugs in Germany and in England in general. Conclusion: The qualitative ranking from A to E was applied to indicate supporting and constraining features and characteristics of the different hospital remuneration. In terms of the most favorable conditions a ranking of A was given. An E-ranking in contrast implies that the level’s specific regulatory setting causes a highly unfavorable and uncertain situation for the new drug’s uptake in the daily hospital practice and its secured funding. Regulatory and decision-making systems turned out to be comparable well in all three of the countries. Thereby, France turned out to be the most favorable country in terms of providing patients in need quickly with drugs and allowing manufacturers to earn a reasonable rate of return. Except for the granting of supplementary innovation remuneration, which turned out to be quite arbitrary, also Germany has a good regulatory framework in place which is acceptable to all involved stakeholders. The most urgent need for improvement in the regulatory system was discovered in England. There, highly unfavorable conditions, with regard to alternative and supplementary funding endanger the universal and equal access to care for patients in need and do not allow pharmaceutical manufacturers and hospitals for an acceptable extend of predictability concerning a drug’s funding.