Number of applications for individual reimbursement of medicines in 2010

Reimbursement for the chronically ill
Increased reimbursement
single reimbursement
Groups of medicines generating the highest number of single reimbursement applications
Electronic applications

In 2010, we reached decisions in a total of 144,324 individual reimbursement applications against 138,714 in 2009, corresponding to an increase of 4 %.

The figure breaks down to approx. 96,000 applications for single reimbursement (about 3 % fewer than in 2009), approx. 34,000 applications for reimbursement for the chronically ill (about 30 % more than in 2009), approx. 12,000 applications for reimbursement for the terminally ill (about 7 % more than in 2009) and approx. 2,800 applications for increased reimbursement (about 14 % more than in 2009), cf. table 1 below.

Table 1. Number of applications for individual reimbursement, 2006-2010

Reimbursement for the chronically ill

In 2010, the number of applications for reimbursement for the chronically ill continued to increase, despite that potentially fewer people could benefit from reimbursement for the chronically ill as a result of an adjustment of the reimbursement threshold for the chronically ill. On 1 January 2010, the reimbursement threshold for adults was increased from DKK 15,577 to DKK 16,131.

Increased reimbursement

Table 2. Distribution of the number of applications for increased reimbursement, 2009-2010, by the medicines most frequently applied for

While the total number of applications for increased reimbursement increased by 14 % in 2010, from 2,515 in 2009 to 2,874 in 2010, the number of persons on behalf of which increased reimbursement has been applied for fell slightly. This means that per person, several different strengths and packages have been applied for. The acceptance rate for all applications is almost unchanged from 2009 (67.6 %) to 2010 (67.2 %).

2010 saw a large increase in the number of applications for medicines containing clopidogrel, losartan, topiramate, citalopram and escitalopram. For clopidogrel, losartan and topiramate the increase was ascribable to patent expiry at the end of 2009 or in 2010 and the marketing of inexpensive generics, by which the reimbursement price fell significantly.

Within the group of antidepressants (N06), a total of 889 applications for 302 different patients were reviewed. Of these, 549 (62 %) applications for 69 (23 %) different patients were submitted by the same doctor.

Single reimbursement

The number of single reimbursement applications was 3 % less than in 2009. The fall is attributable to medicines that have been granted general reimbursement, which means that single reimbursement should no longer be applied for (Table 1).

In 2010, 8 % (7,716 of 96,232) of single reimbursement applications were refused. The refusal rate has been approx. 6 % over the preceding 3 years. The increase in application refusals results mostly from new groups of medicines entitled to single reimbursement in ATC groups A02 (drugs for acid related disorders), C09 (agents acting on the renin-angiotensin system) as well as C01BD (amiodarone) and N03AX16 (pregabalin for treatment of pain). The large increase of refusals in the group N03AX16 in 2010 is ascribable to the change of single reimbursement criteria for medicines in this group, at end-2009.

The Danish regions' expenditure on reimbursement granted under the single reimbursement scheme amounted to DKK 896 million or 12.5 % of the Danish regions' total medicine expenditure in 2010. The corresponding figure for 2009 was 12.6 %.

Groups of medicines generating the highest number of single reimbursement applications

Table 3 below shows the groups of medicines that generated the highest number of single reimbursement applications in 2010.

Table 3. Groups of medicines that generate many single reimbursement applications, 2009-2010. Total number of applications as well as number of granted applications and number of refused applications

N06D Anti-dementia drugs (e.g. donepezil, rivastigmine, galantamine and memantine)

The number of single reimbursement applications continued to increase (9.9 %). In 2010, the increase was larger than the increase in 2009 compared to 2008 (3.6 %).

N06BA Centrally acting sympathomimetics (e.g. methylphenidate, atomoxetine and modafinil)

In 2010, the number of single reimbursement applications increased by 28.2 %. ADHD (FD90.0) is the indication based on which most applications are submitted. The increase is due to an increase in the number of patients diagnosed with ADHD and who start medical treatment. We see quite many applications for adults who are primarily treated with methylphenidate.

B01 Antithrombotic agents (e.g. clopidogrel)

2010 shows a fall of 44.3 % in the number of applications for single reimbursement of medicines for secondary prevention of blood clots (e.g. clopidogrel). The fall is the result of granting general reimbursement to medicines containing clopidogrel (75mg) in July 2010.

M05 Drugs for treatment of bone diseases

The number of single reimbursement applications within the group of bisphosphonates, raloxifene and strontium for preventive treatment of fractures once again decreased (31.5 %). The reason that the number of applications has dropped even further compared to 2009 could be that

• the generic products of bisphosphonates that have entered the market in recent years are still within a price range that does not prevent most patients from buying the product without a reimbursement grant
• fewer product switches between bisphosphonates and raloxifene and strontium have taken place, which has meant fewer single reimbursement applications for these products
• a rising number of patients are treated with parathyroid hormone (Forsteo® or Preotact®) rather than the other osteoporosis products. The number of single reimbursement applications for Forsteo® and Preotact® has thus increased (9.7 %) compared to 2009.

C09 Agents acting on the renin-angiotensin system

On 15 November 2010, a number of medicines for the treatment of hypertension and other cardiovascular diseases changed reimbursement from conditional reimbursement to having non. Apart form losartan, the medicines include all angiotensin II antagonists (including combinations) and the renin inhibitor aliskiren (including the combination with hydrochlorothiazide).

The vast majority of people in treatment with these medicines have therefore switched to other treatment with general reimbursement in the last part of 2010. In the last months of 2010, we received approx. 2,000 applications for single reimbursement of cardiovascular medicines which lost reimbursement and a little more than half were granted. The reason for refusal is usually that it has not been documented sufficiently in the application that the patient cannot be treated with less expensive and just as efficient medicines with general reimbursement.

Non-marketed medicines

2010 shows an increase of 25.4 % in the number of single reimbursement applications for medicines that are not marketed in Denmark, from 5,211 to 6,533. This is primarily because of recurring problems during the year with supplying various marketed medicines, which meant that patients who cannot be treated with alternative marketed medicines in some periods were granted a compassionate use permit and single reimbursement for these medicines. The medicines were e.g. colestyramine, Modiodal® and Gabitril®.

Magistral medicines

In special circumstances, single reimbursement is granted to magistral medicines prescribed by a doctor if the patient cannot be treated with authorised, marketed medicines. Problems with manufacture of marketed medicines have caused the increase of 31, 7 % in 2010, hence why it has been necessary to treat the patients with magistral medicines, in stead. These include e.g. Marplan® tablets from Medilink A/S and Atropine® ”PS” eye drops from Pharma-Skan ApS.

Electronic applications

Since 1 October 2006, doctors have been able to submit applications for individual reimbursement electronically via the Medicine Profile by means of a digital signature (medicin-it.dk). On 15 October 2010, the digital signature type "Doctors' assistant" provided the possibility to prepare applications for the doctor.

Table 4. Distribution of the number of electronic applications by type of reimbursement, 2007-2010

As can be seen from table 4, the number of electronic applications submitted to us electronically continues to increase.

Table 5. Distribution of the total number of applications and number of electronic applications by type of applicant, 2009-2010

Table 5 shows that while general practitioners are most active in submitting applications electronically, hospitals are less inclined to do so. Specialists account for the highest increase in the number of applications submitted electronically.

Table 6, Distribution of the total number of provider IDs that applied electronically by type of applicant, 2009-2010

Table 6 shows that we received electronic applications from a total of 1,501 different provider IDs/hospital departments in 2010. This is an increase of 20 % on the year before.

The fact that the hospital departments use electronic submission only very moderately makes it difficult for us to reach our goal of achieving greater increases in electronic applications. We hope that the new possibility that the doctors' assistants can prepare applications for the doctor will help us achieve this goal.