Public funding of pharmaceuticals in The Netherlands: investigating the effect of evidence, process and context on CVZ decision-making

Under careful construction: combining findings, arguments, and values into robust health care coverage decisions

Background

Health care coverage decisions deal with health care technology provision or reimbursement at a national level. The coverage decision report, i.e., the publicly available document giving reasons for the decision, may contain various elements: quantitative calculations like cost and clinical effectiveness analyses and formalised and non-formalised qualitative considerations. We know little about the process of combining these heterogeneous elements into robust decisions.

Methods

This study describes a model for combining different elements in coverage decisions. We build on two qualitative cases of coverage appraisals at the Dutch National Health Care Institute, for which we analysed observations at committee meetings (n = 2, with field notes taken) and the corresponding audio files (n = 3), interviews with appraisal committee members (n = 10 in seven interviews) and with Institute employees (n = 5 in three interviews), and relevant documents (n = 4).

Results

We conceptualise decisions as combinations of elements, specifically (quantitative) findings and (qualitative) arguments and values. Our model contains three steps: 1) identifying elements; 2) designing the combinations of elements, which entails articulating links, broadening the scope of designed combinations, and black-boxing links; and 3) testing these combinations and choosing one as the final decision.

Conclusions

Based on the proposed model, we suggest actively identifying a wider variety of elements and stepping up in terms of engaging patients and the public, including facilitating appeals. Future research could explore how different actors perceive the robustness of decisions and how this relates to their perceived legitimacy.

National Investment Framework for Revitalizing the R&D Collaborative Ecosystem of Sustainable Smart Agriculture

Demographic, economic, and environmental issues, including climate change events, aging population, growing urban-rural disparity, and the COVID-19 pandemic, contribute to vulnerabilities in agricultural production and food systems. South Korea has designated smart agriculture as a national strategic investment, expanding investment in research and development (R&D) to develop and commercialize convergence technologies, thus extending sustainable smart agriculture and strengthening global competitiveness. Hence, this study probes the status of smart agricultural R&D investment from the perspectives of public funds, research areas, technologies, regions, organizations, and stakeholders. It examines 5646 public R&D projects worth USD 1408.5 million on smart agriculture in 17 regions and eight technology clusters from 2015 to 2021. Further, it proposes a pool of potential collaborative networks via a case study of strawberry, a representative veritable crop inspiring smart agriculture, to demonstrate the study framework’s usefulness in promoting smart agriculture and establishing a sustainable R&D collaboration ecosystem. The proposed framework, accordingly, allows stakeholders to understand and monitor the status of R&D investment from various perspectives. Moreover, given the insight into the tasks belonging to technical areas and regions that require sustainable cooperation in smart agriculture, central and local governments develop policies to reinforce sustainable smart-farming models.

Are Recently Evaluated Drugs More Likely to Receive Positive Reimbursement Recommendations in South Korea? 11-year Experience of the South Korean Positive List System

PURPOSE

The South Korean government in 2014 introduced various policies to enhance accessibility of pharmaceuticals. This study sought to examine whether positive reimbursement recommendations of pharmaceuticals have increased since 2014.

METHODS

Industry submissions evaluated from January 2007 to December 2018 were identified, and characteristics relevant to reimbursement recommendations were extracted. Logistic regression analyses with robust SEs were used to quantify the likelihood of positive recommendations for pharmaceuticals, after controlling for relevant factors influencing the recommendations.

FINDINGS

During the study period, 355 (72.9%) of 487 submissions were positively recommended; the drugs evaluated after 2014 (77.8%) were significantly more likely to receive positive reimbursement recommendations than the drugs evaluated before 2014 (69.5%). In the multivariable logistic regression analysis, several factors (labeled a noncancer drug, priced less than alternatives, considered clinically superior, and having budget impact >10 billion South Korean won) were significantly associated with positive recommendations (P < 0.05). When considering interaction effects between evaluation year and other variables, only the interaction between comparative clinical benefit and evaluation year was significant. Specifically, clinically noninferior drugs evaluated after 2014 had 2.85 times the odds of receiving positive recommendations compared with the clinically noninferior drugs evaluated earlier.

IMPLICATIONS

Recently evaluated drugs are more likely to receive positive reimbursement recommendations, especially those drugs whose comparative clinical benefits are noninferior.

Differences in Health Technology Assessment Recommendations Among European Jurisdictions: The Role of Practice Variations

BACKGROUND

Health technology assessment (HTA) plays an important role in reimbursement decision-making in many countries, but recommendations vary widely throughout jurisdictions, even for the same drug. This variation may be due to differences in the weighing of evidence or differences in the processes or procedures, which are known as HTA practices.

OBJECTIVE

To provide insight into the effects of differences in practices on interpretation of intercountry differences in HTA recommendations for conditionally approved drugs.

METHODS

HTA recommendations for conditionally approved drugs (N = 27) up until June 2017 from England/Wales, France, Germany, the Netherlands, and Scotland were included. Recommendations and practice characteristics were extracted from these five jurisdictions and this data was validated. The effect of nonsubmissions, resubmissions, and reassessments; cost-effectiveness assessments; and price negotiations on changes in the percentage of negative recommendations and the interpretation of intercountry differences in HTA outcomes were analyzed using Fisher exact tests.

RESULTS

The inclusion of cost-effectiveness assessments led to significant increases in the proportion of negative recommendations in England/Wales (from 4% to 50%, P<.01) and Scotland (from 21% to 71%, P<.01). The subsequent inclusion of price negotiations led to significant reductions in the proportion of negative recommendations in England/Wales (from 50% to 14%, P<.01), France (from 31% to 3%, P=.012), and Germany (from 34% to 0%, P<.01). Results indicated that the inclusion of nonsubmissions and resubmissions might affect Scottish negative HTA recommendations (from 7% to 21%), but this effect was not significant. No significant effects were observed in the Netherlands, possibly owing to sample size.

CONCLUSION

Variations in HTA practices between international jurisdictions can have a substantial and significant impact on conclusions about recommendations by HTA bodies, as exemplified in this cohort of conditionally approved products. Studies comparing international HTA recommendations should carefully consider possible practice variations between jurisdictions.

Revealed and Stated Preferences of Decision Makers for Priority Setting in Health Technology Assessment: A Systematic Review

BACKGROUND

There is much interest from stakeholders in understanding how health technology assessment (HTA) committees make national funding decisions for health technologies. A growing literature has analysed past decisions by committees (revealed preference, RP studies) and hypothetical decisions by committee members (stated preference, SP studies) to identify factors influencing decisions and assess their importance.

OBJECTIVES

A systematic review of the literature was undertaken to provide insight into committee preferences for these factors (after controlling for other factors) and the methods used to elicit them.

METHODS

Ovid Medline, Embase, Econlit and Web of Science were searched from inception to 11 May 2017. Included studies had to have investigated factors considered by HTA committees and to have conducted multivariate analysis to identify the effect of each factor on funding decisions. Factors were classified as being important based on statistical significance, and their impact on decisions was compared using marginal effects.

RESULTS

Twenty-three RP and four SP studies (containing 42 analyses) of 14 HTA committees met the inclusion criteria. Although factors were defined differently, the SP literature generally found clinical efficacy, cost-effectiveness and equity factors (such as disease severity) were each important to the Pharmaceutical Benefits Advisory Committee (PBAC), the National Institute for Health and Care Excellence (NICE) and the All Wales Medicines Strategy Group. These findings were supported by the RP studies of the PBAC, but not the other committees, which found funding decisions by these and other committees were mostly influenced by the acceptance of the clinical evidence and, where applicable, cost-effectiveness. Trust in the evidence was very important for decision makers, equivalent to reducing the incremental cost-effectiveness ratio (cost per quality-adjusted life-year) by A$38,000 (Australian dollars) for the PBAC and £15,000 for NICE.

CONCLUSIONS

This review found trust in the clinical evidence and, where applicable, cost-effectiveness were important for decision makers. Many methodological differences likely contributed to the diversity in some of the other findings across studies of the same committee. Further work is needed to better understand how competing factors are valued by different HTA committees.

The bare necessities? A realist review of necessity argumentations used in health care coverage decisions

CONTEXT

Policy makers and insurance companies decide on coverage of care by both calculating (cost-) effectiveness and assessing the necessity of coverage.

AIM

To investigate argumentations pertaining to necessity used in coverage decisions made by policy makers and insurance companies, as well as those argumentations used by patients, authors, the public and the media.

METHODS

This study is designed as a realist review, adhering to the RAMESES quality standards. Embase, Medline and Web of Science were searched and 98 articles were included that detailed necessity-based argumentations.

RESULTS

We identified twenty necessity-based argumentation types. Seven are only used to argue in favour of coverage, five solely for arguing against coverage, and eight are used to argue both ways. A positive decision appears to be facilitated when patients or the public set the decision on the agenda. Moreover, half the argumentation types are only used by patients, authors, the public and the media, whereas the other half is also used by policy makers and insurance companies. The latter group is more accepted and used in more different countries.

CONCLUSION

The majority of necessity-based argumentation types is used for either favouring or opposing coverage, and not for both. Patients, authors, the public and the media use a broader repertoire of argumentation types than policy makers and insurance companies.

National reimbursement listing determinants of new cancer drugs: a retrospective analysis of 58 cancer treatment appraisals in 2007-2016 in South Korea

BACKGROUND

Since the positive-list system was introduced, concerns have been raised over restricting access to new cancer drugs in Korea. Policy changes in the decision-making process, such as risk-sharing agreement and the waiver of pharmacoeconomic data submission, were implemented to improve access to oncology medicines, and other factors are also involved in the reimbursement for cancer drugs. The aim of this study is to investigate the reimbursement listing determinants of new cancer drugs in Korea.

METHODS

All cancer treatment appraisals of Health Insurance Review and Assessment during 2007-2016 were analyzed based on 13 independent variables (comparative effectiveness, cost-effectiveness, drug-price comparison, oncology-specific policy, and innovation such as new mode of action). Univariate and multivariate logistic analyses were conducted.

RESULTS

Of 58 analyzed submissions, 40% were listed in the national reimbursement formulary. In univariate analysis, four variables were related to listing: comparative effectiveness, drug-price comparison, new mode of action, and risk-sharing agreement. In multivariate logistic analysis, three variables significantly increased the likelihood of listing: clinical improvement, below alternative's price, and risk-sharing arrangement. Cancer drug's listing increased from 17% to 47% after risk-sharing agreement implementation.

CONCLUSION

Clinical improvement, cost-effectiveness, and RSA application are critical to successful national reimbursement listing.

Using CART to Identify Thresholds and Hierarchies in the Determinants of Funding Decisions

There is much interest in understanding decision-making processes that determine funding outcomes for health interventions. We use classification and regression trees (CART) to identify cost-effectiveness thresholds and hierarchies in the determinants of funding decisions. The hierarchical structure of CART is suited to analyzing complex conditional and nonlinear relationships. Our analysis uncovered hierarchies where interventions were grouped according to their type and objective. Cost-effectiveness thresholds varied markedly depending on which group the intervention belonged to: lifestyle-type interventions with a prevention objective had an incremental cost-effectiveness threshold of $2356, suggesting that such interventions need to be close to cost saving or dominant to be funded. For lifestyle-type interventions with a treatment objective, the threshold was much higher at $37,024. Lower down the tree, intervention attributes such as the level of patient contribution and the eligibility for government reimbursement influenced the likelihood of funding within groups of similar interventions. Comparison between our CART models and previously published results demonstrated concurrence with standard regression techniques while providing additional insights regarding the role of the funding environment and the structure of decision-maker preferences.

Which factors enhance positive drug reimbursement recommendation in Scotland? A retrospective analysis 2006-2013

OBJECTIVES

To identify the factors that influence the Scottish Medicines Consortium (SMC) in deciding whether to accept pharmaceutical technologies for use within the Scottish health care system.

METHODS

A database of SMC submissions between 2006 and 2013 was created, containing a range of clinical, economic, and other factors extracted from published health technology assessment reports. A binomial outcome variable was used, defined as the decision to "accept for use" or "not recommend" a technology. Univariate and multivariate analyses were conducted to assess the impact by means of odds ratios (ORs) of the submitted evidence on the recommendation decision.

RESULTS

Out of 463 applications, 265 were accepted for use (57%) and 198 (43%) were not recommended for use within National Health Service Scotland. Univariate analyses showed that 13 variables significantly affected the SMC decision. Of these 13 variables, 7 variables were shown to have a meaningful impact in the multivariate analysis. Four of these concerned the outcome of cost-effectiveness analyses; the fact that a submission was supported by a cost-minimization analysis was the strongest positive variable (OR = 10.30) and a submission showing a product not being cost-effective (i.e., incremental cost-effectiveness ratio above £30,000/quality-adjusted life-year gained) was the strongest negative predictor (OR = 0.47). The other variables concerned whether the submission was related to a product indicated for a nervous system disease (OR = 0.41), whether it was indicated for nonchronic use (OR = 1.66), and whether the submission was performed by a big company (OR = 2.83).

CONCLUSIONS

This study demonstrated that the outcome of cost-effectiveness analyses is an important factor affecting the SMC's reimbursement recommendation decision.