Prices, expenses, insufficient contributors... where is the AMO going?
17 June 2011
Read by 1618 persons
Negotiations on prices resume in a few days, but disagreements are deep. Expenses are increasing faster than income and the deficit threatens. The decision to switch insured persons from the private sector to the AMO has not yet been officially announced.
Suspended for several months, negotiations for the revision of the national reference pricing (TNR) of the mandatory health insurance (AMO) will finally resume in mid-June. Contrary to what several observers think, the project is not buried. Public authorities wish to finalize the file before the start of the electoral period. It should be noted that the memorandum signed by the public authorities and doctors set July 31 as the deadline to reach an agreement, otherwise specialist doctors have threatened to de-convention themselves again.
If the problem, which has lasted for more than a year, finds a solution, it will not be a luxury in the face of the many problems facing the AMO. Because, since its start, this new system has been plagued by disruptions that threaten its viability in the medium and long term. To the deficits that will occur faster than expected (see: www.lavieeco.com) have been added in recent months the problem of the TNR and the postponement of the entry into force of article 114 of law
65-00. This article stipulates that private companies that had taken out a contract with insurance companies had to switch to the National Social Security Fund (CNSS) within 5 years of the entry into force of the scheme. A necessary measure to broaden the contributor base.
Regarding the TNR, it should be recalled that the agreement signed in 2006, at the start of basic medical coverage, set the price at 150 DH, giving rise to reimbursement under the AMO, for a consultation with a specialist and at 80 DH with a general practitioner. Prices that remain insufficient in the eyes of doctors, general practitioners and specialists, who are increasingly numerous to not respect them. The revision of the TNR will not only concern the fees of practitioners, but also the cost of certain procedures, particularly in cardiology or resuscitation.
2011, the surplus regime but what about 2012, and beyond?
Regarding the latter service, which is a major point of contention between the two parties, doctors are demanding a fee of 5,000 DH per day, while the AMO managing bodies are based on a fee of 1,500 DH per day excluding medicines and exploratory tests.
We do not yet know the proposals of the Ministry of Health concerning pricing, but it should be noted that the public authorities have a double concern: on the one hand, to revise these prices in order to guarantee quality service to AMO insured persons, and, on the other hand, to preserve the financial balance of the system through expenditure control. And it is also in a concern for financial viability that the CNSS emphasizes that "the aim of the TNR discussions is not only to make adjustments but rather to obtain a commitment from doctors to respect prices in order to control expenditure. Today, doctors ignore the prices and overruns are blatant!" . This is why, at the National Agency for Health Insurance (ANAM), it is important to specify that the good management of the AMO is not only dependent on the revaluation of prices but also and above all on the control of expenditure. In the light of the statistics of the managing bodies, we observe a rapid increase in expenditure during the period 2006-2010. This is, of course, due to the expansion of the population having used the system but also, it is said, to the behavior of doctors (overcharging and non-compliance with the agreement) and to the nomadism of patients who unfortunately do not benefit from any medical follow-up.
According to figures from the National Fund for Social Welfare Organizations (CNOPS), reimbursements for illness files, for the benefit of civil servants, increased from 2 billion DH in 2006 to 3.2 billion in 2010 and resources from 3.2 to 3.6 billion. The CNOPS has a cumulative surplus of 4 billion DH, but which can quickly disappear if expenditure is not controlled. The CNSS, the second manager of AMO for employees in the private sector, is experiencing the same situation. But it should be noted that this fund, having never managed health insurance before, its insured persons do not have the same medical consumption habits as those of the CNOPS. This explains the slower evolution of expenditure since the start of the AMO. Thus, in 2006, the CNSS reimbursed a total of 130 MDH in benefits compared to 1.2 billion in 2010. The extension to outpatient care in February 2010 partly explains the surge in expenditure. At the same time, its resources increased from 1.6 to 2.8 billion DH. The CNSS currently has a surplus cushion of 8 billion DH that the public authorities are keen to preserve for the viability of the system. But for how long? According to simulations carried out by the ANAM, a little over a year ago, the CNSS and CNOPS will accumulate a deficit of 720 MDH in 2012 and then 1.6 billion DH in 2013.
More generics, fewer consultations with specialists
This explains the need, according to the ANAM, to implement three regulatory measures: the prescription of generic drugs instead of brand-name drugs (they represent 74% of prescriptions at the CNSS), the introduction of mandatory medical follow-up and the coordination of care within the framework of therapeutic protocols in order to avoid overconsumption of medical care. These three points are also on the agenda of the negotiations that will begin next week and must be the subject of an agreement between the parties. Otherwise, it is the sustainability of the basic medical coverage system that will be compromised.
According to a source close to the file, negotiations on these measures are likely to be stormy, particularly regarding the prescription of generics and the mandatory visit to the general practitioner. Regarding generics, doctors have, since the start of the AMO, refused to prescribe them because they doubt the quality and efficacy of this type of drug and, in the same vein, demand the bioequivalence test of generics. This procedure, it should be recalled, makes it possible to ensure that the copies have the same therapeutic effects as the brand-name drugs. The decree making the test mandatory is finalized, but has not yet been introduced into the adoption process. Moreover, it is important to emphasize that, even adopted, this decree cannot be applied before the adoption of the draft law on biomedical research, which has been in the government's General Secretariat for several months. For medical follow-up, the idea is, to avoid the nomadism of patients and an abuse of consumption of care, to direct them first to a general practitioner, which specialists consider as directing patients.
Article 114 becomes a legal void
But what could further undermine the system is the lack of expansion of its contributor base as initially planned. Thus, on the issue of the switch of companies that have not yet done so to the AMO (article 114), nothing has yet been done and 400,000 employees, currently insured with the private sector, are escaping the health insurance system. The government decided, during the summer of 2010, to set the entry into force of the switch to January 2013. The decision was announced verbally by the Prime Minister, but was not supported by a regulatory text. In fact, private companies are currently in an illegal situation. In addition, there is the reluctance of the CGEM which, in the face of the projected deficits of the system, requests state guarantees so that companies do not find themselves paying higher contribution rates.
Published June 14, 2011
Posted online June 17, 2011
Lavieeco.com
Suspended for several months, negotiations for the revision of the national reference pricing (TNR) of the mandatory health insurance (AMO) will finally resume in mid-June. Contrary to what several observers think, the project is not buried. Public authorities wish to finalize the file before the start of the electoral period. It should be noted that the memorandum signed by the public authorities and doctors set July 31 as the deadline to reach an agreement, otherwise specialist doctors have threatened to de-convention themselves again.
If the problem, which has lasted for more than a year, finds a solution, it will not be a luxury in the face of the many problems facing the AMO. Because, since its start, this new system has been plagued by disruptions that threaten its viability in the medium and long term. To the deficits that will occur faster than expected (see: www.lavieeco.com) have been added in recent months the problem of the TNR and the postponement of the entry into force of article 114 of law
65-00. This article stipulates that private companies that had taken out a contract with insurance companies had to switch to the National Social Security Fund (CNSS) within 5 years of the entry into force of the scheme. A necessary measure to broaden the contributor base.
Regarding the TNR, it should be recalled that the agreement signed in 2006, at the start of basic medical coverage, set the price at 150 DH, giving rise to reimbursement under the AMO, for a consultation with a specialist and at 80 DH with a general practitioner. Prices that remain insufficient in the eyes of doctors, general practitioners and specialists, who are increasingly numerous to not respect them. The revision of the TNR will not only concern the fees of practitioners, but also the cost of certain procedures, particularly in cardiology or resuscitation.
2011, the surplus regime but what about 2012, and beyond?
Regarding the latter service, which is a major point of contention between the two parties, doctors are demanding a fee of 5,000 DH per day, while the AMO managing bodies are based on a fee of 1,500 DH per day excluding medicines and exploratory tests.
We do not yet know the proposals of the Ministry of Health concerning pricing, but it should be noted that the public authorities have a double concern: on the one hand, to revise these prices in order to guarantee quality service to AMO insured persons, and, on the other hand, to preserve the financial balance of the system through expenditure control. And it is also in a concern for financial viability that the CNSS emphasizes that "the aim of the TNR discussions is not only to make adjustments but rather to obtain a commitment from doctors to respect prices in order to control expenditure. Today, doctors ignore the prices and overruns are blatant!" . This is why, at the National Agency for Health Insurance (ANAM), it is important to specify that the good management of the AMO is not only dependent on the revaluation of prices but also and above all on the control of expenditure. In the light of the statistics of the managing bodies, we observe a rapid increase in expenditure during the period 2006-2010. This is, of course, due to the expansion of the population having used the system but also, it is said, to the behavior of doctors (overcharging and non-compliance with the agreement) and to the nomadism of patients who unfortunately do not benefit from any medical follow-up.
According to figures from the National Fund for Social Welfare Organizations (CNOPS), reimbursements for illness files, for the benefit of civil servants, increased from 2 billion DH in 2006 to 3.2 billion in 2010 and resources from 3.2 to 3.6 billion. The CNOPS has a cumulative surplus of 4 billion DH, but which can quickly disappear if expenditure is not controlled. The CNSS, the second manager of AMO for employees in the private sector, is experiencing the same situation. But it should be noted that this fund, having never managed health insurance before, its insured persons do not have the same medical consumption habits as those of the CNOPS. This explains the slower evolution of expenditure since the start of the AMO. Thus, in 2006, the CNSS reimbursed a total of 130 MDH in benefits compared to 1.2 billion in 2010. The extension to outpatient care in February 2010 partly explains the surge in expenditure. At the same time, its resources increased from 1.6 to 2.8 billion DH. The CNSS currently has a surplus cushion of 8 billion DH that the public authorities are keen to preserve for the viability of the system. But for how long? According to simulations carried out by the ANAM, a little over a year ago, the CNSS and CNOPS will accumulate a deficit of 720 MDH in 2012 and then 1.6 billion DH in 2013.
More generics, fewer consultations with specialists
This explains the need, according to the ANAM, to implement three regulatory measures: the prescription of generic drugs instead of brand-name drugs (they represent 74% of prescriptions at the CNSS), the introduction of mandatory medical follow-up and the coordination of care within the framework of therapeutic protocols in order to avoid overconsumption of medical care. These three points are also on the agenda of the negotiations that will begin next week and must be the subject of an agreement between the parties. Otherwise, it is the sustainability of the basic medical coverage system that will be compromised.
According to a source close to the file, negotiations on these measures are likely to be stormy, particularly regarding the prescription of generics and the mandatory visit to the general practitioner. Regarding generics, doctors have, since the start of the AMO, refused to prescribe them because they doubt the quality and efficacy of this type of drug and, in the same vein, demand the bioequivalence test of generics. This procedure, it should be recalled, makes it possible to ensure that the copies have the same therapeutic effects as the brand-name drugs. The decree making the test mandatory is finalized, but has not yet been introduced into the adoption process. Moreover, it is important to emphasize that, even adopted, this decree cannot be applied before the adoption of the draft law on biomedical research, which has been in the government's General Secretariat for several months. For medical follow-up, the idea is, to avoid the nomadism of patients and an abuse of consumption of care, to direct them first to a general practitioner, which specialists consider as directing patients.
Article 114 becomes a legal void
But what could further undermine the system is the lack of expansion of its contributor base as initially planned. Thus, on the issue of the switch of companies that have not yet done so to the AMO (article 114), nothing has yet been done and 400,000 employees, currently insured with the private sector, are escaping the health insurance system. The government decided, during the summer of 2010, to set the entry into force of the switch to January 2013. The decision was announced verbally by the Prime Minister, but was not supported by a regulatory text. In fact, private companies are currently in an illegal situation. In addition, there is the reluctance of the CGEM which, in the face of the projected deficits of the system, requests state guarantees so that companies do not find themselves paying higher contribution rates.
Published June 14, 2011
Posted online June 17, 2011
Lavieeco.com
