German Pharmacists Prepare Legal Challenge Over Prescription Pricing Dispute
The German Pharmacists’ Association (DAV) is escalating its fight against health insurance companies over the valuation of prescriptions, announcing plans for legal action in collaboration with state pharmacists’ associations. This move signals a deepening conflict that has seen multiple lawsuits filed and reflects years of disagreement over fair reimbursement practices.
The core of the dispute centers on whether pharmacies should be reimbursed for the full cost of a medication package, even if only a portion is used, or solely for the quantity of the drug actually dispensed. Health insurance companies favor reimbursement of partial quantities, arguing it aligns with cost efficiency. Pharmacies, however, contend they should be able to bill for the entire pack, as an opened package cannot typically be resold. Currently, pharmacies operating under the latter practice can expect retaxation – a reduction in reimbursement – at least for the time being.
The disagreement stems from differing interpretations of the current version of the Medicines Price Ordinance (AMPreisV). Previously, the auxiliary tax served as a basis for estimating prescription costs, but this is no longer the case. Recently, the Federal Ministry of Health (BMG) attempted to intervene by adding the word “proportionate” to a crucial paragraph, aligning with the health insurance companies’ position.
However, the Federal Social Court (BSG) overturned this change, ruling that pharmacies are permitted to bill for the entire package, even with partial usage. The court determined that the economic efficiency requirement of the Social Security Code (SGB) does not supersede this right. “Don’t just reimburse partial quantities, take the entire package into account when estimating the prescription,” the ruling effectively stated.
This decision followed a lawsuit initiated by a pharmacy in Westphalia-Lippe against AOK NordWest, triggered by the health insurance company’s attempt to reduce reimbursement for a fully billed package. The pharmacy’s position was upheld based on the current AMPreisV.
The BMG has indicated it will review ongoing drafts for pharmacy reform in light of the BSG’s judgment, a development the DAV views as a positive step. This has emboldened the association to pursue further legal challenges.
With its upcoming legal steps, the DAV aims to clarify how similar billing cases should be assessed, particularly those involving health insurance companies claiming bill reductions. The focus is now shifting from finished medicines to billing for active ingredients. According to the DAV, health insurers are seeking to only refund the pro rata price of partial quantities, leading to repeated partial reimbursements.
While the financial impact of these disputes may seem minor, the DAV emphasizes the broader implications. “It’s about attention, it’s about the long-term resolution of a dispute that has been going on for years,” a senior official stated. The association is urging the BMG to revise the AMPreisV to eliminate ambiguity and establish clear guidelines for prescription valuation.
The stakes are high, as the viability of individual prescription compounding is at risk. Pharmacies fear that continued threats of retaxations will make this practice unprofitable and unsustainable. Ultimately, the dispute impacts the ability to secure supplies and relieve pressure on the healthcare system. Health insurance companies should be relieved of the burden, but not at the expense of pharmacies.
Source: Pharmaceutical newspaper
