"They will not be
considered as compensation in kind for the purposes of article 44.2. of the tax
law, the studies arranged by institutions, companies or employers and financed
directly or indirectly by them for the updating, training or retraining of
their personnel "... (1).
On December 30, the BOE
published a modification of Article 44 of the Personal Income Tax Regulation,
which considers that the payments made by pharmaceutical companies to
physicians and other professionals to attend congresses and training activities are exempt from taxation. They are not considered payments in kind, they
are not considered additional income. They are considered training expenses of
the company in which they work, that is, of the Health Service. But why?
Because, according to this regulation, these are expenses financed by employers.
These are expenses financed indirectly by the Health Service, by the State,
even though they are paid through a pharmaceutical company. It is
the State that is financing, because it gives the pharmaceutical company the
possibility of collecting a very important "indirect tax", the
surcharge that it puts on medicines thanks to the monopoly of patents and the exclusivity
of data. With this surcharge, the laboratories finance the training expenses of
the health professionals, finance research expenses, but they are left with
much more money for doing these tasks. It is a perverse and inefficient system.
In this model, pharmaceutical
companies "invite", decide which doctor goes to Congress, which
doctor goes to this or that course of research. Doctors should ask the
laboratory for the favor of inviting them or their residents to the courses and
congresses. The State, health services, taxpayers, ultimately, pay. But the
doctor feels grateful to the laboratory, which is the one that has invited her
or him. The doctor is not even aware that it is his health center, his Health
Service, which is paying. Now the RD 1074/2017 clarifies it.
It is a perverse system,
because the employer, the Health Service loses the ability to direct the
training process, the priorities, the contents... In fact, it is the
laboratories that condition or decide programs and speakers. In addition, the
professional does not feel well treated by his Health Service, his employer,
and believes that it is the laboratory that cares about him. And when one
receives a favor, tends to be grateful, tends to prescribe the products of who
invited him, even if unconsciously. In this way, hyper-prescription of more
expensive drugs which may not be indicated is encouraged. On the other hand,
many professionals do not accept that the laboratory invites them, considering
it contrary to their professional ethics, and can not access the training
activities they need, because their employer has "delegated" to these
companies. The industry captures in this way a strategic dimension of the
health organizations, the continuous training of its personnel, and conditions
the behavior of professionals and managers.
But the system is not only
perverse. It is enormously inefficient. The state, governments, health systems,
give pharmaceutical companies the ability to collect the "tax" of the
over-price that patents allow, supposedly to pay for the research and training
of their professionals. But companies spend much less than we give them and the
rest goes to profit. Indeed, in Spain, in 2016, the total sales of medicines at
laboratory prices were €15.59 billion (2). Following the criteria of Dean
Baker, Co-Director of the Center for Economic and Policy Research (3), we can
estimate that, if the drugs were paid at the price of generic, we would have
spent 30%, €4.68 billion. It means that the "over-price" we pay is
€10.91 billion. But the companies only spent 908 million euros in research (4), and 501 million euros in training and financing of scientific
societies and associations of patients (5). It is a lot of money, but
pharmaceutical companies still profit much more, €9.50 billion, which could go
to more training, more research, or other very necessary purposes of Health
Services (adequate staffing, adequate remuneration, appropriate technology ,
health promotion programs, social services, etc.). *
Would it not be reasonable to
change this model for another in which prices are paid based on effective
market competition, without the monopoly of patents (generic price), and R
& D and training spending will be paid directly by Health Services? I think the answer is yes. The way out of the current spiral of excessive prices is "delinkage" (to delink prices and financing of research). (6)
Thus, the research would
address the health priorities of patients and populations, and not the
commercial interests of the laboratories. The research would be cooperative and
open. And the results of the research would be used without monopoly, with
which the prices of medicines would not be exorbitant and would not put at risk
the accessibility and stability of health systems.
In the same way, the training
would be managed by the teaching committees of the health centers and the
Health Services, according to the needs of the patients and the health
institutions, without interference from the commercial interests of the
industry.
The change of model will not
be easy nor from one day to the next. It will be a process in which the first
step is to become aware of the problem (high prices cause thousands of patients
can not access the medication they need and, at the same time, exorbitant
prices jeopardize the viability of health systems) and of a possible
alternative. From there, regional and national governments, as well as the EU
authorities, must take measures to change the situation. Health professionals
can also decisively influence with their opinion and attitudes in changing the
model. The UN Secretary-General’s High Level Panel on Access to Medicines
Report (7) has showed interesting steps to move forward.
Current expenditure on drugs in Spain (2016), and alternative model (in million euros)
|
Current Model, with indirect
financing of training and R&D
|
Alternative Model, with direct
financing of training and R&D
("delinkage")
|
Expenditure on drugs, at Ex Factory
Price, paid by Health Services and Patients
|
15,595
|
|
Sale price if there is free
competition (generics)
|
|
4,678
|
Over-price (indirect tax through the
Patente Monopolies
|
10,917
|
0
|
Expenditure on R&D
Expenditure in payment of courses,
congresses, scientific societies
|
908
501
|
908
501
|
|
|
|
Profits for laboratories
|
9,508
|
|
Savings for the Health System (for
contracting more professionals, adequate working conditions, R & D,
health promotion, etc.)
|
|
9,508
|
*In
the EU-28 savings will be more than €70 billion, and in the US more than $183
billion, annualy.
