For patients and pharmacists in financially stricken Greece, even finding Aspirin has turned into a headache.
Mina Mavrou, who runs a pharmacy in a middle-class Athens suburb, spends hours each day pleading with drugmakers, wholesalers and colleagues to hunt down medicines for clients. Life-saving drugs such as Sanofi’s blood-thinner Clexane and GlaxoSmithKline Plc’s asthma inhaler Flixotide often appear as lines of crimson data on pharmacists’ computer screens, meaning the products aren’t in stock or that pharmacists can’t order as many units as they need.
“When we see red, we want to cry,” Mavrou said. “The situation is worsening day by day.”
The 12,000 pharmacies that dot almost every street corner in Greek cities are the damaged capillaries of a complex system for getting treatment to patients. The Panhellenic Association of Pharmacists reports shortages of almost half the country’s 500 most-used medicines. Even when drugs are available, pharmacists often must foot the bill up front, or patients simply do without.
The financial crisis is brewing a “Greek tragedy” of slowing access to medical care and worsening outcomes for patients, Martin McKee, a professor of European public health at the London School of Hygiene and Tropical Medicine, wrote in an October article in The Lancet.
The Greek Ministry of Health didn’t respond to repeated requests for comment.
“It would be unrealistic to deny that there are many difficulties regarding all public services due to the financial crisis,” Nicolaos Polyzos, secretary general of the Ministry of Health, wrote in a response to McKee’s article posted on the ministry’s website. “However, this cannot justify characterizing the current picture of (the) health sector in Greece as a ‘tragedy.’”
The reasons for the shortages are complex. One major cause is the Greek government, which sets prices for medicines. As part of an effort to cut its own costs, Greece has mandated lower drug prices in the past year. That has fed a secondary market, drug manufacturers contend, as wholesalers sell their shipments outside the country at higher prices than they can get within Greece.
Strained government finances only make matters worse. Wholesalers and pharmacists say the system suffers from a lack of liquidity, as public insurers delay payments to pharmacies, which in turn can’t pay suppliers on time.
“Wholesalers simply do not have the money anymore to play bank to the pharmacies,” Heinz Kobelt, secretary general of the European Association of Euro-Pharmaceutical Companies, said in a telephone interview.
330 Million Euros
Public insurers owe pharmacists some 330 million euros ($422.1 million) for drugs bought since April, Dimitris Karageorgiou, vice-chairman of the pharmacists’ association, said in an interview last month. Payment can take three months to up to a year, pharmacists said. Some are turning to patients to pay up front.
“They’re saying you pay me now, and then you’ll get the money from your social security fund,” said Ioannis Theodorakis, chairman of the Association of Persons with Multiple Sclerosis.
Theodorakis said he already knows a few patients who can’t afford to pay and aren’t on treatment. If non-payment by public insurers continues, more will discontinue treatment, he said in an interview in his office in Athens, a few steps from where protesters lob Molotov cocktails and pelt police with rocks at Syntagma Square.
“The whole system is dysfunctional,” said Aggeliki Matsouki, who opened her first pharmacy in Athens in 1981.
Chain-smoking in her tiny back office, Matsouki described calling other pharmacies to track down London-based Glaxo’s oral herpes drug Famvir. “If I can’t find a prescription drug, I try to borrow it from colleagues. We exchange medicines.”
Austerity measures imposed to address the financial crisis may paradoxically be making matters worse. Greek wholesalers now have more incentive than ever to sell drugs outside the country after Greece implemented a law last year further reducing prices. The law sets prices of medicines according to the average of the three lowest charges in 22 European Union countries, part of an effort to trim a health bill that in 2010 totaled more than 13 billion euros, or about 5 percent of GDP.
Parallel imports peaked in 2004, then flattened out about two years ago once drugmakers imposed quotas of the maximum amount of medicines they think the Greek market will need, said Kobelt, whose Brussels-based association represents companies engaged in the trade. Still, if pharmacies can’t pay, it makes economic sense to ship the drugs back out again rather than let them languish on wholesalers’ shelves, he said.
Kobelt said he’s seen boxes of Bayer AG’s Aspirin in Poland that originated in Greece, suggesting that the medicine fetches higher prices in eastern Europe.
“Even Polish people pay more than Greeks for Aspirin,” he said. “That is the recipe for parallel trade, I’m sorry to say.”
Novo Nordisk A/S, based in Bagsvaerd, Denmark, is a case in point.
“We are competing with our own products,” said Mike Rulis, a spokesman for the company.
Novo stopped selling some of its higher-priced insulins in Greece for about a month in 2010 after the government cut prices by about 25 percent. The drugmaker now ships in the same volume as before the cuts, yet pharmacists are running short of insulin, Rulis said in a telephone interview.
“There are cases where pharmacies will call our Greek affiliate and say, ‘We are out of stock, can you help us,’” he said. “Then we will call the wholesaler to make a special delivery.”
Reimbursement fraud compounds the drain on the country’s health resources, Richard Bergstrom, director-general of European Federation of Pharmaceutical Industries and Associations, said in an interview. Drugs shipped elsewhere yet submitted for reimbursement to public insurers as if they had been prescribed to patients cost Greece more than 500 million euros a year, Bergstrom said, citing figures he said he got from the Ministry of Health.
In a later e-mail, Bergstrom said he had personally seen packs of drugs with Greek reimbursement stickers on the market outside of Greece, suggesting that exporters were reimbursed and able to ship the packs abroad.
“If the pack is exported, the exporter is obliged to ’cancel’ the code, a bar code, by using a black pen,” Bergstrom wrote. “But this is not monitored.”
Not all pharmacists can afford to pay up-front for costly drugs in the hope of being reimbursed by insurers.
An invoice provided to Bloomberg News shows Roche Holding AG requesting a 926-euro payment in advance from a pharmacy for NeoRecormon, a medicine used to treat anemia in chemotherapy and chronic kidney disease patients.
The Swiss drugmaker switched to a payment-on-delivery policy for hospitals with a history of nonpayment last year after accepting 400 million Swiss francs ($426.7 million) in Greek government bonds for unpaid hospital debts. The Greek government announced in December 2010 it would issue more than 5 billion euros of non-interest paying bonds to hospital suppliers for unpaid bills from 2007 to 2009.
Roche extends a credit to pharmacies and in some cases has extended credit limits to ensure patients can get drugs, Daniel Grotzky, a company spokesman, said in a telephone interview. “This might be a pharmacy which has used up its credit line,” he said.
A year ago, the Health Ministry advised MS patients to buy medicine through state hospitals, Theodorakis said. Those hospitals often don’t have enough drugs, so patients go to pharmacies instead, he said.
Theodorakis stopped taking Merck KGaA’s Rebif in 2006 because he wasn’t satisfied the drug’s benefits outweighed its side effects in his particular case. The frustrating process of obtaining medicine contributed to his decision not to start taking another drug, said Theodorakis, who uses a wheelchair and has an assistant to type his e-mails.
“It’s a difficult decision to make because you can’t play dice with your health,” Theodorakis said.
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