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The case of little Martin, for whose treatment the Czechs donated almost 150 million crowns in an incredibly short time until Wednesday, rightly evokes pride and even emotion as a demonstration of solidarity. But it shouldn’t stop there.
If public collections are not to become a standard part of the Czech healthcare system, it is absolutely necessary for the system to clarify how it wants to deal with what we could call really expensive medicines. In the professional debate, they are called a little differently. Usually center drugs (according to the fact that they are administered in specialized medical centers) or orphans (from orphan drugs, i.e. solitary or “orphan” drugs).
These are (as in the case of little Martin) either drugs for very rare diseases with several dozen “target” patients, or highly innovative and modern preparations for the treatment of more “common” diagnoses, such as blood or oncological diseases. What they all have in common is that they are very expensive indeed. The price of treatment is calculated in tens of millions of crowns.
Despite the impression of a specific case that has attracted public attention in recent days, health insurance companies very often cover these drugs. Since 2013, the largest insurance company VZP has regularly published the costs from the previous year for its “most expensive” clients (in anonymized form). A fundamental shift can be seen in these tables as well. In 2012, VZP paid for the most expensive treatment worth around six million crowns. In 2022, VZP’s “most expensive client” was a two-year-old girl suffering from spinal atrophy, who received medicine for 63 million crowns.
A few years ago, patients with blood diseases and metabolic disorders occupied the top positions of these charts. In recent years, after the advent of innovative biological and genetic drugs, it has been possible to help patients with various forms of so-called spinal muscular atrophy. And the top places in the list of “most expensive clients” belong to them. Specifically, in 2022, patients with this diagnosis occupied the first nine ranks at the VZP, and the treatment bill for all of them exceeded 55 million crowns.
What is, on the one hand, a miracle of state-of-the-art medicine and hope for patients who, just a few years ago, would not have had a chance of survival or a full life, is, on the other hand, a real problem for the spending part of the healthcare system. The overall cost of center drugs is rising rapidly. While in 2011 insurance companies spent less than seven billion crowns on these drugs (3.2 percent of total costs), in 2022 it was 27.4 billion crowns (6.5 percent of total costs). In the last five years alone, these expenses have increased by 80 percent, and there is no prospect of any significant slowdown in growth in the coming years.
Last year, more money from the public health insurance went to central medicines than, for example, to all the care provided by all general practitioners.
Of course, such a development raises unpleasant questions. Any system that grows a brand new and large expense item within a few years needs to think about changes. It’s like a whole new big ministry suddenly appearing in the national budget. Not a small office intended for the formal satisfaction of coalition partners, but a truly large institution whose budget chapter would rank among the five largest. Let’s give it a new ministry the size of defense or interior.
In that case, the first question will of course be whether these new expenses are necessary and wouldn’t it be better to get rid of them and leave everything as before. Certainly a legitimate consideration in the case of a hypothetical new ministry. In the case of expenses for center drugs, however, it can hardly stand up. We can expect a broad social consensus that we should pay for very expensive treatment with good prospects for improving life for patients (often children) with serious and rare diseases.
In addition to simple humanity, the fact that the Czech Constitution gives its citizens a very broad right to free (paid) care will necessarily push us to this consideration. And if the letter of this law has any “spirit”, then it undoubtedly aims primarily at care for which there is no chance that the patient would ever be able to pay for it out of his own money.
Then other considerations must come into play. The first leads to an increase in the income of the entire system. However, both higher insurance premiums and higher co-payments are practically impossible paths in Czech conditions. Of course, the reasoning arises that if we want to help thousands of patients with very expensive treatment, we could stop paying millions of patients for very cheap treatment, for which most of them can find money in their own pockets. But this idea is both politically impassable and socially and technically very tricky.
So what remains is internal savings, reduction of some costs and the search for efficiency. There are still quite a few reserves here and they are talked about quite openly. However, the key item for our consideration must be prevention. According to some estimates, up to 80 percent of all expenses of health insurance companies today cover the treatment of diseases that can be prevented mainly by a healthier lifestyle.
Of course, these “preventable” or “civilization” diseases – led by many cardiovascular problems, type 2 diabetes and some types of cancer – will never be completely eradicated. But their occurrence can be reduced – on the one hand by smart programs of preventive inspections (we can do this in the Czech Republic and we have something to develop) and on the other hand by education and motivation towards a healthier lifestyle (on the contrary, we really cannot do that in the Czech Republic).
The author of this text is certainly not an advertisement for a healthy lifestyle. Nevertheless, it is necessary to admit and realize that every step that reduces the risk of our future civilizational diseases increases the chances for patients like little Martin and dozens of children and adults with a similar fate. And conversely. That’s how inexorable and simple those numbers are in the environment of super-expensive biological and genetic drugs.