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Driscoll D, Farnia S, Kefalas P, Maziarz RT. Concise Review: The High Cost of High Tech Medicine: Planning Ahead for Market Access. Stem Cells Transl Med 2019; 6:1723-1729. [PMID: 28749065 PMCID: PMC5689744 DOI: 10.1002/sctm.16-0487] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 05/30/2017] [Indexed: 11/24/2022] Open
Abstract
Cellular therapies and other regenerative medicines are emerging as potentially transformative additions to modern medicine, but likely at a staggering financial cost. Public health care systems’ budgets are already strained by growing and aging populations, and many private insurer's budgets are equally stretched. The current systems that most payers employ to manage their cash flow are not structured to absorb a sudden onslaught of very expensive prescriptions for a large portion of their covered population. Despite this, developers of new regenerative medicines tend to focus on the demands of regulators, not payers, in order to be compliant throughout the clinical trials phases, and to develop a product that ultimately will be approvable. It is not advisable to assume that an approved product will automatically become a reimbursed product, as examples from current practice in hematopoietic stem cell transplantation in the U.S. demonstrate; similarly, in Europe numerous Advanced‐therapy Medicinal Products achieved market authorization but failed to secure reimbursement (e.g., Glybera, Provenge, ChondroCelect, MACI). There are however strategies and approaches that developers can employ throughout clinical development, in order to generate clinical and health economic data which will be necessary to demonstrate the value proposition of the new product and help ensure market access for patients; furthermore, performance based managed entry agreements coupled with post‐launch evidence generation can help overcome challenges around product uncertainty at launch and reduce market access delays. Stem Cells Translational Medicine2017;6:1723–1729
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Affiliation(s)
- Dawn Driscoll
- DCi Biotech Inc. and DCi Biotech Pty Ltd., Perth, Australia
| | - Stephanie Farnia
- American Society for Blood and Marrow Transplantation, Arlington Heights, Illinois, USA
| | - Panos Kefalas
- Cell and Gene Therapy Catapult Limited, London, United Kingdom
| | - Richard T Maziarz
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
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Hornberger J. Assigning value to medical algorithms: implications for personalized medicine. Per Med 2013; 10:577-588. [PMID: 29776198 DOI: 10.2217/pme.13.55] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Genomic algorithms are typically multiple variable, mathematical equations that assign a score or probability to an event of clinical interest. Debate about the valuation of multianalyte algorithm assays highlights the gaps in best practices for valuing technologies. Decisions about valuation are partly about resolving scientific uncertainty, but also involve issues of social norms and political processes. More transparent discussion and understanding of beliefs about the valuation of algorithms would help reduce uncertainty and drive optimal investment in development and adoption of algorithms that improve social welfare; that is, affordably improving population health. Techniques have been evolving for greater public participation and engagement in such deliberations, which are to be encouraged in determining the valuation of genomic algorithms.
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Affiliation(s)
- John Hornberger
- Cedar Associates, 3715 Haven Avenue, Menlo Park, CA 94025, USA and Department of Medicine, School of Medicine, Stanford University, Stanford, CA 94305, USA.
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Relative effectiveness assessment of listed drugs (REAL): a new method for an early comparison of the effectiveness of approved health technologies. Int J Technol Assess Health Care 2010; 26:124-30. [PMID: 20059790 DOI: 10.1017/s0266462309990821] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Post-listing assessment of pharmaceuticals depends on national habits. In England, the assessment is based on estimates of cost per quality-adjusted life-year. These are made some considerable time after listing (negative list). In France, effectiveness, and then efficiency, is assessed immediately after listing (positive list). We propose a new formal method--the REAL method--that can help make early comparisons of the effectiveness of medical treatments. METHODS Relative efficacies are first obtained from randomized controlled trials (RCTs). Members of the Transparency Committee (French National Authority for Health) are then consulted by questionnaire on the transposability of these results to real life. The RCT results and experts' ratings are entered into an effect model to obtain estimates of relative effectiveness, using unidimensional scaling, and bootstrap procedures. RESULTS Application of the REAL method to the example of a new drug to treat Parkinson's disease and three comparators used in the same indication provided graphs of the distributions of their relative efficacy and relative effectiveness. The new drug was found to provide no added value. CONCLUSIONS The REAL method is a rational, transparent, and practical procedure for comparing the effectiveness of pharmaceuticals in an immediate post-listing setting.
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Abstract
Many countries encourage immigration, yet almost without exception they impose medical conditions on the admissibility of prospective immigrants. This paper examines the ethical defensibility of this practice. It argues that the neighbourhood principle, which states that we owe a greater duty to neighbours than to strangers, when properly understood, extends to all human beings, that economic and safety considerations play only a limited role in ethically underwriting an exclusionary policy, and that medical immigration criteria should be harmonized with treatment eligibility criteria for citizens of the relevant countries themselves.
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Kluge EHW, Tomasson K. Health care resource allocation: complicating ethical factors at the macro-allocation level. HEALTH CARE ANALYSIS 2002; 10:209-20. [PMID: 12216746 DOI: 10.1023/a:1016531100046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
It is generally assumed that allocation problems in a socialized health care system result from limited resources and too much demand. Attempts at solutions have therefore centered in increasing efficiency, using evidence-based decision-making and on developing ways of balancing competing demands within the existing resource limitation. This article suggests that some of the difficulties in macro-allocation decision-making may result from the use of conflicting ethical perspectives by decision-makers. It presents evidence from a preliminary Canadian study to this effect.
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Abstract
This paper presents the case for re-examining the most commonly adopted basis of resource allocation in health care, i.e. need. The key problems identified with most needs approaches are (a) defining its precise meaning, (b) that the community is seldom consulted as to first what constitute needs for health care or second what relative weights are to be attached to health gains aimed at addressing different needs and (c) more generally, proceeding without knowing what the community wants the objectives of health care to be. It is suggested that John Broome's notion of "claims", especially what this paper calls "communitarian claims", may be helpful in providing a better basis for allocating health care resources. Such "communitarian claims" allow inter alia for the community to be involved in setting the social choice rules with respect to the governance of health care and for determining what it is that it (the community) wants from its health service. The links to rights are also identified and the advantages of communitarian claims over both a simple concept of need and rights are set out, without arguing that either needs (or rights) ought necessarily to be abandoned as bases for resource allocation in health care.
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Affiliation(s)
- G Mooney
- Department of Public Health and Community Medicine and Centre for Values, Ethics and the Law in Medicine, University of Sydney, NSW, Australia
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Affiliation(s)
- P M Mullen
- Health Services Management Centre, University of Birmingham, UK
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Waller J, Angbratt M, Blomberg C, Kronhed AC, Larsson L, Löfman O, Möller M, Toss G, Foldevi M, Trell E. Logics and logistics of community intervention against osteoporosis: an evidence basis. J Med Syst 1997; 21:33-47. [PMID: 9172068 DOI: 10.1023/a:1022839308196] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Under designations like small areas action research and intervention, directed 'ground-up' health promotion and prevention in the population form an important part of the ongoing medical systems development. There is recent evidence of the success of community intervention against cardiovascular disease. In osteoporosis, however, there is still a lack of conclusive data on both the logics and logistics of such an approach. Since 1988, a county health policy program has been formulated and implemented in Ostergötland, Sweden, following the principles and guidelines of the WHO HFA 2000 declaration. Vadstena (n approximately 7,600) was chosen for a local and generalizable osteoporosis prevention project mediated by the primary care organization by means of health promotion and education in the community. In the present report we emphasize that community intervention is an important new advancement of the medical systems, where the basic research questions include operational and management aspects as equally vital and measurable requisites and results as other performance and outcome variables. We found that a community intervention trial against osteoporosis is both motivated and feasible and in this report wish to provide evidence on these crucial issues of logics and logistics.
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Affiliation(s)
- J Waller
- Vadstena Primary Health Care Center, Sweden
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Rosner F, Kark P, Packer S. Oregon's health care rationing plan. Committee on Bioethical Issues of the Medical Society of the State of New York. J Gen Intern Med 1996; 11:104-8. [PMID: 8833018 DOI: 10.1007/bf02599586] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- F Rosner
- Mount Sinai Services at the Queens Hospital Center, Jamaica, NY 11432
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Affiliation(s)
- L Doyal
- St Bartholomew's and The London Hospital Medical Colleges, University of London, UK
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Pollock AM. Rationing health care: from needs to markets? The politics of destruction: rationing in the UK health care market. HEALTH CARE ANALYSIS 1995; 3:299-308; discussion 309-14. [PMID: 10156208 DOI: 10.1007/bf02197076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Rationing health care is not new. As governments world wide struggle to contain the costs of health care, health policy analysts debate how rationing should be done. However, they too often neglect how the mechanisms for funding and allocating health care resources are themselves vehicles for rationing treatment. In the UK, where health care rationing debates currently abound, there has been no formal evaluation of the role of the market in allocating scarce health care resources. The market in health care has increased administration, fragmented services, eroded local accountability, and decreased choice. This fragmentation, and the associated competition between purchasers and providers, means that resource allocation can no longer be monitored and evaluated in a national context. The loss of a population focus has left a vacuum in planning. Services cannot be planned rationally, and so are not able consistently to avoid duplication or to respond cogently to estimates of need. The loss of accountability means that decisions about the allocation of health care resources are no longer open to scrutiny by local people. Increasingly, especially in social and long term care the cost of care is being transferred to the individual. The new mechanisms for resource allocation are distributing resources unfairly: away from the poor, the sick and the elderly. The great myth of the market is that it has enabled decision-making to become explicit. This is not the case. To make health care resource allocation appear rational and acceptable to the public, health authorities have resorted to exercises in consumer consultation, and value laden guidelines where clinical cloaks are used to disguise political decisions on funding. In the UK, until the true role of the internal market is acknowledged, myths and subterfuge will conceal the winners and losers in the new system of rationing health care.
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Affiliation(s)
- A M Pollock
- Merton, Sutton and Wandsworth Health Authority, London, England
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12
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van der Wilt GJ. Cost-effectiveness analysis of health care services, and concepts of distributive justice. HEALTH CARE ANALYSIS 1994; 2:296-305. [PMID: 10139421 DOI: 10.1007/bf02251075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Two answers to the question 'how can we allocate health care resources fairly?' are introduced and discussed. Both utilitarian and egalitarian approaches are found relevant, but both exhibit considerable theoretical and practical difficulties. Neither seems capable of solving the problem on its own. It is suggested that, for practical purposes, a version of Rawls' famous thought experiment might provide at least some enlightenment about which theoretical approach should be used to address the question.
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Affiliation(s)
- G J van der Wilt
- Faculty of Medical Sciences, University of Nijmegen, The Netherlands
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13
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Seedhouse D. Real government required. HEALTH CARE ANALYSIS 1994; 2:1-4. [PMID: 10134365 DOI: 10.1007/bf02251328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Bury M, Moran G, Cribb A, Sheaff R. The commentaries. HEALTH CARE ANALYSIS 1994. [DOI: 10.1007/bf02251330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Baker R. Visibility and the just allocation of health care: a study of age-rationing in the British National Health Service. HEALTH CARE ANALYSIS 1993; 1:139-50. [PMID: 10135591 DOI: 10.1007/bf02197107] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to 'universalize the best'. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalize care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the 'done thing' without explicit policy directives and in a manner largely invisible to patients, to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories.
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Affiliation(s)
- R Baker
- Humanities Center, Union College, Schenectady, NY 12308
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