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Full text of the opinion published on the website of the Ministry of Health of the Czech Republic:

Opinion of the Ministry of Health of the Czech Republic on the Selection of a Medicinal Product Intended for the Treatment of a Rare Disease with Reimbursement Granted under Section 39da as a Comparator in Cost-Effectiveness Assessment in Proceedings for the Determination or Modification of Reimbursement in the So-Called Permanent Reimbursement Regime Conducted under Section 39g or Section 39i of Act No. 48/1997 Coll., on Public Health Insurance and on Amendments to Certain Related Acts, as Amended

Cost-effectiveness assessment, as part of evaluating the appropriateness of a therapeutic intervention, is a necessary element of administrative proceedings for the determination or modification of the amount and conditions of reimbursement of a medicinal product conducted under Section 39g or 39i of Act No. 48/1997 Coll., on Public Health Insurance and on Amendments to Certain Related Acts, as amended (hereinafter referred to as "Act No. 48/1997 Coll." or the "Public Health Insurance Act"), in cases enumerated in Section 15(9) of this Act. Fulfilment of the condition of an appropriate therapeutic intervention is one of the basic conditions for granting reimbursement for a medicinal product for a given indication (regardless of whether this indication is defined by a specific formulation of the reimbursement restriction or by the summary of product characteristics), as Section 15(6)(d) of Act No. 48/1997 Coll. stipulates that "The Institute shall not grant reimbursement for medicinal products and foods for special medical purposes that do not meet the conditions of an appropriate therapeutic intervention."

According to the second sentence of Section 15(7) of Act No. 48/1997 Coll., "An appropriate therapeutic intervention shall mean healthcare services provided for the prevention or treatment of disease with the aim of achieving the most effective and safest treatment while maintaining cost-effectiveness." Thus, cost-effectiveness is one of the cumulative conditions of an appropriate therapeutic intervention within the meaning of Section 15(7).

However, the definition of an appropriate therapeutic intervention for a medicinal product intended for the treatment of a rare disease (hereinafter also referred to as "LPVO") with reimbursement granted under Section 39da differs from the definition applicable to a medicinal product in the so-called permanent reimbursement regime, i.e., with reimbursement from public health insurance granted in proceedings conducted under Section 39g or Section 39i of Act No. 48/1997 Coll. According to the third sentence of Section 15(7) of Act No. 48/1997 Coll., "In the case of medicinal products intended for the treatment of a rare disease under Section 39da, an appropriate therapeutic intervention shall mean healthcare services provided for the prevention or treatment of a rare disease with the aim of achieving the most effective and safest treatment, provided that the pharmacotherapeutic impact of this disease has a societal significance and the financial impact on the health insurance system (hereinafter the 'budget impact') is in accordance with the public interest pursuant to Section 17(2)."

This different approach to the requirement of appropriate therapeutic intervention in proceedings for the determination or modification of reimbursement for LPVOs under Section 39da as compared to medicinal products in the so-called permanent reimbursement regime is further expressed in Section 39da(3)(i) of Act No. 48/1997 Coll., which states that "In the proceedings for determining the amount and conditions of reimbursement of a medicinal product intended for the treatment of a rare disease, the following shall be assessed..., (i) cost-effectiveness analysis, however, without taking into account its result in the form of the incremental cost-effectiveness ratio..."

A medicinal product intended for the treatment of a rare disease for which reimbursement has been granted under Section 39da of the Public Health Insurance Act thus does not necessarily meet the condition of an appropriate therapeutic intervention as defined by the requirements of the law for medicinal products under the so-called permanent reimbursement regime. An LPVO reimbursed under Section 39da does not have to meet the condition of maintaining cost-effectiveness and therefore may not qualify as an appropriate therapeutic intervention within the meaning of the second sentence of Section 15(7) of the Act (although it does qualify under the third sentence of Section 15(7)). The anticipated inability of LPVOs to demonstrate their cost-effectiveness as required in proceedings under Section 39g is one of the reasons why LPVOs are granted a different procedure for determining reimbursement under Section 39da.

For the above reasons, when proving the appropriate therapeutic intervention of a medicinal product entering the so-called permanent reimbursement system under Section 39g, or in proceedings for modifying reimbursement under Section 39i of the Act, it is not possible to rely on the appropriate therapeutic intervention demonstrated by an LPVO that entered the reimbursement system under Section 39da. These are two different types of appropriate therapeutic intervention, requiring the demonstration of different circumstances and applicable in different types of proceedings. Therefore, it is not valid to equate them or assume that if an LPVO reimbursed under Section 39da meets the condition of appropriate therapeutic intervention pursuant to the third sentence of Section 15(7) of the Act, it also meets the condition pursuant to the second sentence of that same provision.

Using an LPVO reimbursed under Section 39da as a comparator in the base-case scenario of a cost-effectiveness analysis in proceedings for the determination or modification of reimbursement in the so-called permanent reimbursement regime would lead to methodological inconsistencies in the cost-effectiveness assessment submitted by the applicant and subsequently to inequalities in the Institute's assessment compared to other medicinal products in the permanent reimbursement regime.

Based on the above, it is clear that an assessed intervention in proceedings for the determination or modification of reimbursement in the so-called permanent reimbursement regime cannot be considered to meet the condition of appropriate therapeutic intervention if a medicinal product reimbursed under Section 39da is used as a comparator in the base-case scenario of the cost-effectiveness analysis.

The Ministry is therefore convinced that the use of a medicinal product intended for the treatment of a rare disease reimbursed under Section 39da as a comparator in the base-case scenario of the cost-effectiveness assessment in proceedings for the determination or modification of reimbursement in the so-called permanent reimbursement regime cannot in any way prove that the assessed intervention meets the condition of appropriate therapeutic intervention within the meaning of the second sentence of Section 15(7) of Act No. 48/1997 Coll. Failure to demonstrate appropriate therapeutic intervention under the second sentence of Section 15(7) of Act No. 48/1997 Coll. in reimbursement proceedings under the so-called permanent reimbursement regime constitutes a legal reason for denying reimbursement pursuant to Section 15(6)(d) of the same Act.

This is an unofficial translation generated with the assistance of ChatGPT-4o. It is provided for informational purposes only and does not constitute an official or legally binding translation.

As part of a streamlined reimbursement review for cost-saving purposes (§ 39p(1)), the State Institute for Drug Control unified reimbursement conditions by removing the “A” symbol (indicating use in ambulatory care) for products that can be self-administered by patients after prior training.

The Institute argued that if all products in a given group serve the same purpose and can be administered by patients, there is no reason for them to be subject to different reimbursement conditions. Previously, some products required immediate administration by a physician (marked with the “A” symbol), while others—therapeutically interchangeable—were not subject to such restriction.

The appeal body agreed with this reasoning and described the previous arrangement as inefficient.

The Institute had already reached the same conclusion in 2022, stating that if the accompanying texts (SPC/PIL) allow for patient self-administration after proper training instead of administration in ambulatory care, the “A” prescription restriction (ZULP for ambulatory care) may be removed without requiring a pharmacoeconomic assessment, as no expansion in the number of treated patients occurs.

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Articles on decision-making practice are based on publicly available texts from the decisions of the Ministry of Health of the Czech Republic and the State Institute for Drug Control (SÚKL).

A continuously updated overview of decisions issued by SÚKL and the Ministry of Health in the field of pricing and reimbursement is available on the Pharmeca a.s. website.

The text was translated using ChatGPT 4o.  

The Ministry of Health annulled the decision of the State Institute for Drug Control (SÚKL) on the grounds that the Institute had failed to respect the Ministry’s previous binding legal opinion, as set out in its earlier decision — which we reported in our regular 2021 newsletter.

In 2021, the Association of Health Insurance Companies (Svaz ZP) appealed against the extension of reimbursement conditions for products containing inosine pranobex as part of a comprehensive reimbursement review. The Institute had approved the extension without assessing the cost-effectiveness and budget impact of the proposed change.

The Ministry stated that the removal of reimbursement conditions, such as prescription and indication restrictions, constitutes an expansion of reimbursement that leads to an increase in the number of treated patients. Following the change, all medical specialists could prescribe these products for reimbursement from public health insurance within the approved therapeutic indications listed in the SPC. However, the Ministry emphasized that the prevalence of the relevant conditions in the general Czech population was likely much higher than the number of patients covered under the prior reimbursement restrictions. The contested decision would thus logically lead to increased use and higher reimbursement costs.

By extending reimbursement without a proper assessment of cost-effectiveness and budget impact, the Institute acted unlawfully.

In the further course of the administrative proceedings, the Institute was not allowed to change the reimbursement conditions in a way that would increase the number of treated patients without the submission and assessment of the relevant pharmacoeconomic analyses from the parties to the proceedings. However, after the participants failed to provide the requested analyses, the Institute performed its own calculations and again extended the reimbursement conditions. This decision was again challenged — all payers filed an appeal.

Following further review, the Ministry of Health reiterated that the Institute may not create its own pharmacoeconomic analyses for the purpose of changing reimbursement conditions in the absence of such analyses submitted by the parties. The Institute is only authorized to perform corrective recalculations or similar adjustments within the scope of analyses provided by the parties.

For these reasons, the Ministry annulled the Institute’s decision once again.

Are you interested in reading regular commentaries on decisions by Pharmeca a.s.? Feel free to contact us.
At Pharmeca, we help you navigate the complex landscape of pharmaceutical and medical device information. We also offer flexible services that can be tailored to your needs at any time.
Our market position and experience allow us to support you whenever you need expert guidance.

Our knowledge, your opportunity.

Articles on decision-making practice are based on publicly available texts from the decisions of the Ministry of Health of the Czech Republic and the State Institute for Drug Control (SÚKL).

A continuously updated overview of decisions issued by SÚKL and the Ministry of Health in the field of pricing and reimbursement is available on the Pharmeca a.s. website.

The text was translated using ChatGPT 4o.  

In its decision, the Ministry of Health confirms the possibility of ensuring patients’ right to free (i.e., fully reimbursed) medicinal products from the groups listed in Annex No. 2 to Act No. 48/1997 Coll., even through products that are not available on the Czech market at the time of the SÚKL decision, as long as it is certain that such products will be available in sufficient quantities at the time the administrative decision becomes enforceable.

This typically applies to contractual arrangements between marketing authorization holders and health insurance companies, which include a binding commitment to ensure availability of the respective medicinal products.

On the other hand, the right to free medicinal products cannot be ensured through products that are not present on the Czech market or are available only in negligible quantities.

Furthermore, according to the Ministry of Health of the Czech Republic, SÚKL is not obliged to verify whether a product has been reported as temporarily unavailable on the domestic market, since such a temporary unavailability concerns only a transitional period, unlike permanent discontinuation of supply.

Articles on decision-making practice are based on publicly available texts from the decisions of the Ministry of Health of the Czech Republic and the State Institute for Drug Control (SÚKL).

A continuously updated overview of decisions issued by SÚKL and the Ministry of Health in the field of pricing and reimbursement is available on the Pharmeca a.s. website. 

The text was translated using ChatGPT 4o.  

Are you interested in reading regular commentaries on decisions by Pharmeca a.s.? Feel free to contact us.

At Pharmeca, we help you navigate the complex landscape of pharmaceutical and medical device information. We also offer flexible services that can be tailored to your needs at any time.

Our market position and experience allow us to support you whenever you need expert guidance.

Our knowledge, your opportunity.

According to the Ministry of Health (MZ), even a single health insurance company can demonstrate that the presented budget impact exceeds the current financial capacity of its fund, even if this applies only to that specific insurer.

Rejecting the statement of one insurance company solely because other insurers remain silent or their statements are less convincing (or not sufficiently substantiated) is, in the Ministry’s view, irrational. If the presented budget impact poses an economic risk to even one health insurance company, this is clearly a factor indicating the unacceptability of the proposed budget impact.

The requirement by SÚKL for statements from all health insurance companies regarding the acceptability of the budget impact has no legal basis, according to the Ministry of Health.

Articles on decision-making practice are based on publicly available texts from the decisions of the Ministry of Health of the Czech Republic and the State Institute for Drug Control (SÚKL).

A continuously updated overview of decisions issued by SÚKL and the Ministry of Health in the field of pricing and reimbursement is available on the Pharmeca a.s. website. 

The text was translated using ChatGPT 4o.  

Are you interested in reading regular commentaries on decisions by Pharmeca a.s.? Feel free to contact us.

At Pharmeca, we help you navigate the complex landscape of pharmaceutical and medical device information. We also offer flexible services that can be tailored to your needs at any time.

Our market position and experience allow us to support you whenever you need expert guidance.

Our knowledge, your opportunity.

The State Institute for Drug Control questioned the cost-effectiveness of the medicinal product from the group of drugs used for the treatment of functional gastrointestinal disorders, as presented in the administrative proceedings. The reason was significant uncertainties in the submitted analysis.

Upon reviewing the documentation, the Institute identified several problematic aspects. Pharmaceutical costs had increased compared to the originally submitted data. Uncertainties regarding dosage—the method of dose determination was unverifiable, and it was impossible to clearly establish the considered dosage for individual patients. Serious discrepancies in total cost presentation—different values appeared in various sections of the documentation.

All these inconsistencies prevented a proper assessment of cost-effectiveness.

Given these findings, the Institute concluded that the submitted analysis did not meet the minimum quality requirements, and therefore, the medicinal product could not be considered a cost-effective intervention.

Articles on decision-making practice are based on publicly available texts from the decisions of the Ministry of Health of the Czech Republic and the State Institute for Drug Control (SÚKL).

A continuously updated overview of decisions issued by SÚKL and the Ministry of Health in the field of pricing and reimbursement is available on the Pharmeca a.s. website. 

The text was translated using ChatGPT 4o.  

Are you interested in reading regular commentaries on decisions by Pharmeca a.s.? Feel free to contact us.

At Pharmeca, we help you navigate the complex landscape of pharmaceutical and medical device information. We also offer flexible services that can be tailored to your needs at any time.

Our market position and experience allow us to support you whenever you need expert guidance.

Our knowledge, your opportunity.