Health insurance companies win a dispute against pharmaceutical company

Million dispute about cholesterol-lowering: Health insurance prevail before the Federal Social Court

01/03/2011

The Federal Social Court (BSG) has supported the position of the statutory health insurance funds and confirmed that for the blood lipid lowering drug Sortis of the pharmaceutical manufacturer Pfizer in the future only the fixed amount far below the actual selling price of the preparations must be reimbursed. The rest pay the patients of the statutory health insurance out of pocket.

The US pharmaceutical company Pfizer is not impressed by the judgment of the BSG and stated that it wants to stick to its price strategy for the cholesterol-lowering drug Sortis (atorvastatin). Price reductions are not provided, because the Group is still convinced that Sortis should not be tied to the fixed amount as a therapeutic innovation, a Pfizer spokesman said following the verdict of the SPA in Kassel (Az: B 1 KR 7/10 R and B 1 KR 10/10 R).

Fixed amounts for cholesterol lowering Sortis rightfully
The health insurances had included the cholesterol-lowering drug Sortis because of lack of therapeutic superiority over other statins in the fixed amount of HMG-CoA reductase inhibitors and reimbursed a correspondingly low fixed amount for the preparations. Thus, cash patients who insisted on a treatment with Sortis, had to pay heavily. Between 28.30 euros (10 milligrams, 30 pieces) and 158.55 (40 milligrams, 100 pieces) per pack were to be raised by the patient out of pocket. The BSG has now confirmed this position and classified the classification or the reimbursement according to the fixed amounts of the HMG-CoA reductase inhibitor group as legal. For the health insurance companies a facilitating judgment, they threatened but additional billions with a higher remuneration for Sortis. However, these costs will continue to be borne by patients in the future as Pfizer does not appear to be willing to cut costs. Certain patient groups could benefit more from Sortis than from other statins, which illustrates the innovative performance of the drug and justifies the far higher price, the spokesman said following the verdict.

Pharmaceutical companies and insureds sue through all instances
The pharmaceutical company, together with a legally insured person, who relies on Sortis in his own estimation, went to court against the determination of the fixed amount of the statutory health insurance funds. Now, as the last instance, the BSG in Kassel has rejected the claim of the insured and the pharmaceutical company and confirmed the classification of the cholesterol-lowering agent by the health insurance companies. On the basis of the current findings, none of the plaintiffs can demand the abolition of the fixed amounts, according to the verdict of the BSG. If a study situation were available, which justifies important therapeutic advices, regulation restrictions or exclusions for group formation, the verdict could have been different, explained the BSG. However, such a study situation had not been available to the first Senate of the BSG for the formation of judgment, so that the argumentation of the plaintiff was not to follow. The established fixed-income group does not limit the possibilities of therapy and there are sufficient medically necessary prescription alternatives available, emphasized the BSG.

Pfizer requires higher prices for many products
At Pfizer, pharmaceutical prices far beyond the fixed amounts determined by the health insurances, are not uncommon. For example, insured patients have to pay for the Pfizer products Accupro (Quinapril), Accucide (Hydrochlorothiazide, Quinapril) and Selectol (Celiprolol).

The drug Sortis (atorvastatin) is a cholesterol synthesis inhibitor, also known as CSE inhibitors. The drug is used in conventional medicine for lowering cholesterol LDL prescription. The health insurance companies are of the opinion that the cholesterol-lowering drug Sortis is not reimbursed for lack of therapeutic superiority over other means at a fixed price. According to this judgment, patients who still insist on the treatment of Atorvastatin must continue to pay high additional payments. (Fp)

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Picture: Andrea Damm