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Spotlight on Greece

Those wanting to bring products into this troubled market must understand and manage the country's rapid move from prescriber to payer

Greece flagFor many countries across the European Union, the shift in influence from prescriber to payer has been a slow, evolving process. This has allowed pharmaceutical companies in France, the UK and Germany to develop market access strategies gradually, taking time to identify the new influencers and create relevant messaging for each stage of the drug lifecycle.

However, as the reality of the ongoing economic turmoil combines with escalating health costs, other countries are looking at the changes that have been achieved in these countries and assessing options for imposing greater control over prescribing. The result is a rapid shift in prescribing decision maker.

In Greece today, doctors still have prescribing autonomy. However, this is set to change as, under legislation introduced in 2010, a tender process is to be introduced which will create a short 'white list' of drugs which doctors will be obliged to prescribe.

Within a matter of months, all clinician autonomy will be removed.

At the heart of this radical restructure is the need to overhaul accounting controls across the health service.

According to the Organisation for Economic Cooperation and Development (OECD), in 2007 Greece spent 2.4 per cent of gross domestic product (GDP) on pharmaceuticals, the highest of all its 34 member countries.

Indeed, one of the conditions set by the International Monetary Fund in 2010, when Greece accepted the €110bn ($145bn) bailout package, was to reform a public health system where hospitals and doctors ran up €5.4bn of unpaid bills to suppliers between 2007 and 2009.

Centralised system
Key to this process is the requirement for the Greek government to monitor spending in hospitals and centralise the system for buying drugs and equipment to negotiate lower prices.

To facilitate this new tender process, Greece has rapidly consolidated its primary and secondary care purchasing operations. The purchasing requirements of 120 hospitals are now handled by seven regional organisations, while the 200 public insurance agencies have been consolidated from 200 to just three. The government recently announced its intention to organise the health services by combining hospitals according to their proximity or specialisation (oncology, orthopaedics, paediatrics and so on).

This initiative is called Health Map and adds another level of complexity to addressing the right decision maker.

Under the tender process, which is scheduled to become fully operational in 2012, pharmaceutical companies will have to provide therapeutic information and disease indications, as well as proving a capacity to deliver in high volumes. The process, which is expected to take around six months for each tender, will result in the creation of a white list of around three products, the cheapest of which will head the list.

For pharmaceutical companies still focused on maximising field force effectiveness through visits to doctors, this shift to a tender process requires a major change in strategy. Companies are still waiting to discover the final details of the new tender regulations, including the level of detail the state will demand regarding the molecular component of products. However, in the interim there is a clear need to embark upon robust market access activity to determine how best to approach this new tender process.

Underpinning the strategy must be excellent information about the new influencers and stakeholders. The new regional organisations are in place, with clearly defined structures and roles; it will be essential to map the networks of influence between these Key Opinion Leaders (KOL), encompassing doctors, hospital pharmacists, purchasing officers, nurses, civil servants and insurance agency executives, to assess the way the tender process evolves over the next couple of years.

It is highly likely that distinct regional variations will develop. Indeed, while the government is keen to achieve a consistent countrywide model where possible, the expectation is that the tender processes, and decisionmaking, will vary between both insurance agencies and hospital procurement bodies. Therefore pharmaceutical companies need to understand the new procedures being adopted by each regional purchasing organisation to determine the right approach and messaging.

Armed with in-depth understanding of stakeholders and their influence networks, and insight into the tender processes in place in each organisation, pharmaceutical companies can then build the right market access strategy.

This must be underpinned by a broad range of skills, not only the technical and negotiation skills of Key Account Managers (KAM), but also including the associated expertise of research and development and medical experts within the company. It is the creation of a broad, multi-skilled team, able to share information effectively, that will be key to success in the tender process. The pharmaceutical companies also need to realise that the KAM is a completely different role compared to that of the medical rep, the specialist or even the medical scientific liaison or clinical research associates.

Too often, companies disregard these differences and 'promote' executives from the salesforce without ensuring they have adequate skills or offering the necessary training.

Importance of timing
Plus, timing is key. New tenders will come up every day, in different therapeutic areas, from different regional bodies.

Each tender has a specific cut-off date. If the tender or contract is missed, the company will be out of that market for two or three years. This is a massive change from the traditional detailing model, where a missed visit to a doctor one day can be made the following day. In this new environment, pharmaceutical companies need to put in place tools that not only enable information to be shared but also set alerts for tender deadlines to ensure the market access team is focused and cooperating on shared goals.

Of course, on top of this radical change to the purchasing process, pharmaceutical companies also need to address new processes for drug approval and reimbursement. The Greek government has a target to increase the prescription of generics from just 15 per cent today to around 50 per cent. Therefore, though the key influencers in the Ministry of Health, which is the government body operating Greece's National Health Care System, are already known, companies' market access strategies must embrace the key stakeholders within health technology assessment and pricing bodies too, to ensure drugs reach the market, and at the right price.

Without correctly addressing this aspect of the drug lifecycle, there will be no need to compete in the new tender process.

Conclusion
The good news for pharmaceutical companies is that the government insists this new health service structure will address the significant backlog in payment for goods already received and ensure such a problem does not occur again. Furthermore, for those that win tenders, sales will be guaranteed for two to three years, enabling attention to be focused on new opportunities.

However, this is a massive change, in a very short space of time, from an open market to one with a limited, clearly defined formulary. It is those companies that leverage both accurate stakeholder information and insight into the new regional procurement processes that will have a head start in understanding the new tendering model and developing the right, and most effective, market access strategy.

Theofilos Timiou Cegedim Relationship Management


The Author

Theofilos Timiou, CRM operations director, Cegedim Relationship Management, Greece.







22nd September 2011

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