Disinvestment and Value-Based Purchasing Strategies for Pharmaceuticals: An International Review

Challenges and countermeasures for China's centralised volume-based procurement policy in healthcare

To reduce the cost of healthcare expenditures in China, the government has developed a centralised volume-based procurement (CVBP) policy for medicines and medical consumables. Based on tracking the development history of centralised procurement in China, this study explores China's CVBP model. By comparing the centralised procurement models and healthcare expenditure data among China, the United States (U.S), the United Kingdom (UK), and Singapore, we find that China still faces many challenges in implementing the CVBP policy. The main challenges are as follows. First, the policy cannot be guaranteed the effectiveness of implementation without a well-coordinated regulatory mechanism. Second, the CVBP rules and quality evaluation standards are imperfect. Third, the interests of healthcare companies cannot be guaranteed. Fourth, the policy affects the benefits of medical institutions, and the government has not built a compensation mechanism for medical institutions. Fifth, it poses a challenge to the operational capacity and innovation level of Chinese companies. Therefore, this paper posits a three-stage strategy and nine measures that could benefit China's progress in implementing the CVBP policy.

The cost of total hip arthroplasty: compare the hospitalization costs of national centralized procurement and national volume-based procurement

Background

With the increasing demand for joint replacement surgery in China, the government has successively issued the policies of national centralized procurement (NCP) and national volume-based procurement (NVBP) of artificial joints. The purpose of this study is to evaluate the impact of NCP and NVBP policies on hospitalization cost, rehospitalization and reoperation rate of total hip arthroplasty (THA).

Methods

In total, 347 patients who underwent THA from January 2019 to September 2022 were retrospectively analyzed. According to the implementation of NCP and NVBP, patients were divided into three groups: control group (n = 147), NCP group (n = 130), and NVBP group (n = 70). Patient-level data on the total hospitalization costs, rehospitalization rate, THA reoperation rate and inpatient component costs were collected before and after the implementation of the policies and Consumer Price Index was used to standardize the cost.

Results

After the implementation of NCP and NVBP, the total cost of hospitalization decreased by $817.41 and $3950.60 (p < 0.01), respectively. The implantation costs decreased from $5264.29 to $4185.53 and then rapidly to $1143.49 (p < 0.01), contributing to increased total cost savings. However, the cost of surgery and rehabilitation increased after NCP and NVBP implementation (p < 0.01). The proportion of implants decreased from 66.76 to 59.22% and then to 29.07%, whereas that of drugs increased from 7.98 to 10.11% and then to 12.06%. The proportion of operating expenses rose from 4.86 to 8.01% and then to 18.47%. Univariate linear regression analysis showed that hospital stay, NCP and NVBP were correlated with total hospitalization cost (p < 0.01). Multivariate analysis showed that hospital stay, NCP and NVBP were independent predictors of total hospitalization cost (p < 0.01).

Conclusion

In this study, hospital stay, NCP, and NVBP were independent predictors of total inpatient costs. After the implementation of NVBP policy, the cost of implants and hospitalization has decreased significantly, and the technical labor value of medical staff has increased, but a multifaceted method is still needed to solve the problem of increasing costs of other consumables. Limitations of the study suggest the need for further and more comprehensive evaluation in the future.

Impact of National Centralized Drug Procurement policy on chemical pharmaceutical enterprises' R&D investment: a difference-in-differences analysis in China

Objective

This study aimed to evaluate the impact of the National Centralized Drug Procurement (NCDP) policy on chemical pharmaceutical enterprises' R&D investment and provide references for improving NCDP policy design and encouraging innovation in the pharmaceutical industry.

Methods

Using the panel data of 102 Shanghai and Shenzhen A-share listed enterprises from 2016 to 2022 under the chemical pharmaceutical classification of Shenwan in Wind database as the research sample, this study developed difference-in-differences (DID) models on bid-winning and bid-non-winning enterprises, respectively, to evaluate the impact of NCDP policy on their R&D investment. In addition, this study tested the heterogeneity of bid-winning enterprises based on the bid success rate, the decline of drug price, and enterprise size.

Results

The NCDP policy could encourage chemical pharmaceutical companies to increase R&D investment, but the low bid success rate and excessive drug price reduction would reduce their R&D enthusiasm, especially for small- and medium-sized enterprises.

Discussion

It is suggested that the NCDP policy should be further improved: first, revise the bidding rule of the NCDP policy and increase the bid success rate so that more enterprises can win bids, and second, to solve the problem of excessive drug price reduction, evaluate the rationality of bid-winning prices, and introduce a two-way selection mechanism between medical institutions and supply enterprises. Integrate pharmacoeconomic evaluation into the NCDP rules to form a benign competition among enterprises. Third, attention should be paid to supporting policies for small- and medium-sized enterprises. By increasing procurement volume, shortening payment time limits, and increasing the proportion of advance payments, enterprises' cash flow shortages can be alleviated, thus achieving fairness and inclusiveness in the implementation of the NCDP policy.

Utilization of innovative medical technologies in German inpatient care: does evidence matter?

BACKGROUND

The reimbursement of new technologies in inpatient care is not always linked to a requirement for evidence-based evaluation of patient benefit. In Germany, every new technology approved for market was until recently eligible for reimbursement in inpatient care unless explicitly excluded. The aim of this work was (1) to investigate the type of evidence that was available at the time of introduction of 25 innovative technologies and how this evidence evolved over time, and (2) to explore the relationship between clinical evidence and utilization for these technologies in German inpatient care.

METHODS

This study combined different methods. A systematic search for evidence published between 2003 and 2017 was conducted in four bibliographic databases, clinical trial registries, resources for clinical guidelines, and health technology assessment-databases. Information was also collected on funding mechanisms and safety notices. Utilization was measured by hospital procedures captured in claims data. The body of evidence, funding and safety notices per technology were analyzed descriptively. The relationship between utilization and evidence was explored empirically using a multilevel regression analysis.

RESULTS

The number of included publications per technology ranges from two to 498. For all technologies, non-comparative studies form the bulk of the evidence. The number of randomized controlled clinical trials per technology ranges from zero to 19. Some technologies were utilized for several years without an adequate evidence base. A relationship between evidence and utilization could be shown for several but not all technologies.

CONCLUSIONS

This study reveals a mixed picture regarding the evidence available for new technologies, and the relationship between the development of evidence and the use of technologies over time. Although the influence of funding and safety notices requires further investigation, these results re-emphasize the need for strengthening market approval standards and HTA pathways as well as approaches such as coverage with evidence development.

Patients' attitudes towards switching to national volume-based procurement (NVBP) Drugs-a qualitative investigation in Wuhan, China

BACKGROUND

The implementation of the NVBP policy has generated considerable reductions in drug procurement prices and an increase in the market share of the NVBP drugs.This study aimed to investigate patients' attitudes towards switching to drugs of national volume-based procurement (NVBP) and identify their underlying influencing factors in Wuhan, China.

METHODS

A total of 21 eligible patients from the Wuhan Union Hospital who were switched to NVBP drugs between January 2022 and May 2022 were included in our study. Semi-structured face-to-face interviews were conducted to collect interview information and the interview data was analyzed by the Colaizzi seven-step method.

RESULTS

Twenty-one semi-structured face-to-face interviews were conducted. The duration of each interview was 25-35 min and three themes related to patients' attitudes and their influencing factors were extracted, including (1) Patients' perception of the NVBP drugs; (2) Family and social influence to patients; (3) Medication habits of patients. This study found: 1) 71.4% patients (15/21) showed a positive attitude towards switching to NVBP medicines; 2)80.9% patients (17/21) have felt a significant reduction in their medication cost after the implementation of the NVBP policy; 3)Advices from healthcare professionals and health insurance reimbursement policies showed great impacts on patients' attitude towards switching to NVBP drugs; 4)Attitudes towards switching to NVBP drugs varied considerably among patients with different severities of disease.

CONCLUSION

The implementation of the NVBP policy has significantly reduced the cost of healthcare for patients and has been supported by71.4% (15 of 21) patients. However, some issues have been identified in the implementation of the policy in this study. Health professionals in general need to contribute more efforts to improve patients' preconceptions about the NVBP drugs and boost their confidence in the NVBP drugs.

Antiviral treatment in outpatients with herps zoster in six major areas of China, 2010–2019

Objective

The objective of this study was to assess the status and trends of antiviral treatment in outpatients with herpes zoster in China.

Methods

Prescription data on antiviral drugs were extracted from the database of the Hospital Prescription Analysis Program of China according to the inclusion criteria. Yearly prescriptions and costs were calculated, and trends were analyzed. The trends were further stratified by age, sex, and specific drug use. The distribution of defined daily costs (DDCs) of valaciclovir and famciclovir were analyzed, and trends in the median DDCs were identified.

Results

A total of 132,911 prescriptions from 49 hospitals located in six major areas of China were included in the analysis. The yearly prescriptions containing antivirals increased from 8,819 in 2010 to 16,361 in 2019. The percentage of prescriptions for patients aged 65 years and above also increased (27.7% in 2010 to 31.0% in 2019), and the number of prescriptions for females was higher than those for males (P < 0.001). The average cost of antivirals per prescription decreased; thus, the yearly cost showed no increasing trend. The main prescribed antivirals were valaciclovir and famciclovir, which progressively increased in prescriptions. The use of acyclovir decreased during the study period. Prescriptions containing topical formulations, acyclovir and penciclovir, both increased. The DDCs of valaciclovir and famciclovir decreased dramatically.

Conclusion

The use of antivirals has increased over the decade, while the cost has not. Antiviral treatments adhere well to recent recommendations, except for the use of topical antivirals. The findings of this study may benefit the healthcare source allocation and management of herpes zoster in China.

Withdrawing or withholding treatments in health care rationing: an interview study on ethical views and implications

Background

When rationing health care, a commonly held view among ethicists is that there is no ethical difference between withdrawing or withholding medical treatments. In reality, this view does not generally seem to be supported by practicians nor in legislation practices, by for example adding a ‘grandfather clause’ when rejecting a new treatment for lacking cost-effectiveness. Due to this discrepancy, our objective was to explore physicians’ and patient organization representatives’ experiences- and perceptions of withdrawing and withholding treatments in rationing situations of relative scarcity.

Methods

Fourteen semi-structured interviews were conducted in Sweden with physicians and patient organization representatives, thematic analysis was used.

Results

Participants commonly express internally inconsistent views regarding if withdrawing or withholding medical treatments should be deemed as ethically equivalent. Participants express that in terms of patients’ need for treatment (e.g., the treatment’s effectiveness and the patient’s medical condition) withholding and withdrawing should be deemed ethically equivalent. However, in terms of prognostic differences, and the patient-physician relation and communication, there is a clear discrepancy which carry a moral significance and ultimately makes withdrawing psychologically difficult for both physicians and patients, and politically difficult for policy makers.

Conclusions

We conclude that the distinction between withdrawing and withholding treatment as unified concepts is a simplification of a more complex situation, where different factors related differently to these two concepts. Following this, possible policy solutions are discussed for how to resolve this experienced moral difference by practitioners and ease withdrawing treatments due to health care rationing. Such solutions could be to have agreements between the physician and patient about potential future treatment withdrawals, to evaluate the treatment’s effect, and to provide guidelines on a national level.

Frequency and estimated costs of ten low-value practices in the Spanish Primary Care: a retrospective study

BACKGROUND

The frequency of low-value practices (LVPs) in the healthcare system is a worldwide challenge. Far less is known about the related extra cost. This study aimed to evaluate the LVPs trend in Spanish primary care (PC), its frequency in both sexes, and estimate its related extra cost.

METHODS

A multicentric, retrospective, and national research project was conducted. Ten LVPs highly frequent and potentially harmful for patients were analyzed. Algorithms were applied to collect the data from 28,872,851 episodes registered into national databases (2015-2017). Cost estimation was made.

RESULTS

LVPs registered a total of 7,160,952 (26.5%) episodes plus a total of 259,326 avoidable PSA screening tests. In adults, a high frequency was found for prescription of 1g paracetamol >3 days, antibiotics for acute bronchitis (unconfirmed comorbidity), and benzodiazepines in patients >65 years with insomnia. Women received more jeopardizing practices (p≤0.001). Pediatrics presented a downward of antibiotic and paracetamol-ibuprofen prescription combination. The estimated extra cost was close to €292 million (2.8% of the total cost in PC).

CONCLUSION

LVPs reduction during the analyzed period was moderate compared to studies following 'Choosing Wisely list' of LVPs and must improve to reduce patient risk and the extra related costs.

Will the Volume-Based Procurement Policy Promote Pharmaceutical Firms' R&D Investment in China? An Event Study Approach

Innovation is the key to the development of the pharmaceutical industry. The pilot program of China’s “4 + 7” volume-based procurement policy (“4 + 7” procurement policy) brings the drug price back to a reasonable level through trading procurement quantities for lower drug prices. The policy manages to reduce the burden of the health care system, improve efficiency, and push the pharmaceutical industry to transform and update from the era of high gross profit of generic drugs to innovative drugs. So far, few studies have investigated the influence of the volume-based procurement policy on the innovation of pharmaceutical firms. By combining the event study and Difference-in-Difference (DiD) methodology, this study finds that the abnormal return (AR) of firms with high R&D intensity is lower than that of firms with low R&D intensity during the event window period. Moreover, further analysis identifies the moderating effect of firm size and firm type. Specifically, the results show that the negative influence of high R&D intensity on abnormal return (AR) during the announcement of the “4 + 7” procurement policy is stronger in large firms and innovative pharmaceutical firms. Finally, we discuss the policy implications of our study.

Building a National Reassessment Process for Oncology Drugs: Lessons Learned by the Canadian Real-World Evidence for Value of Cancer Drugs (CanREValue) Collaboration through a Simulated Reassessment Exercise

The CanREValue Collaboration established the Reassessment & Uptake Working Group to develop a preliminary process to reassess funded cancer drugs in Canada. A simulated exercise was conducted to evaluate the proposed reassessment process using a real-world case. We invited 32 attendees including representatives from Health Canada and Health Technology Assessment (HTA) agencies, along with payers, clinicians, academics, and patient representatives. A case was developed using a real-world study on a publicly funded cancer drug. In facilitated group sessions, participants were asked to deliberate upon the evidence presented in the case to issue reassessment recommendations. Several themes were identified through the deliberation discussions. While the generalizability of real-world evidence (RWE) is perceived as a strength, trust in the RWE depends largely on the source of the real-world data. The attendees suggested several improvements to the proposed reassessment process including evidence requirement for reassessment, recommendation categories, and a priori study protocols. This exercise generated important insights on the evidence required for conducting reassessment and considerations for improvements of the proposed reassessment process. Building upon lessons from this exercise, future work would continue to refine the reassessment process as part of the overall CanREValue framework.

The economic impact of a clinical pharmacist's involvement in the hospital medicines policy in a rural area

AIM

The evidence of the value of pharmaceutical care continues to grow, however, data on its effect in rural areas are still scarce. The aim of this article was to evaluate the economic impact of a clinical pharmacist's involvement in the hospital medicines policy design in a rural area, through the drug and therapeutics committee (DTC) and public procurement for medicines.

METHODS

An economic evaluation was conducted in the General Hospital Bjelovar which covers the Bjelovarsko-Bilogorska County in Croatia. It included costs from denial and approval decisions of the drug and therapeutics committee, during a 1-year period between June 1, 2019 and June 1, 2020, and costs for medicines in 2018 and 2019 that were intended for public procurement. The cost-benefit analysis and cost-minimisation analyses for the DTC and public procurement data have been conducted for the evaluation of the economic impact of a clinical pharmacist.

RESULTS

The involvement of a clinical pharmacist in the hospital medicines policy design through the DTC and public procurement for medicines provides an economic benefit. This resulted in a cost-benefit ratio of 14.18:1 and 18.31% and 17.58% savings through the DTC and public procurement process, respectively. To put in a different perspective, around 14 yearly gross salaries can be paid out from savings achieved by the clinical pharmacist through a 1-year period.

CONCLUSION

The involvement of a clinical pharmacist in the hospital medicines policy in a rural area hospital results with an optimisation of investment in medicines and leads to substantial cost savings for the healthcare system.

Influence of Chinese National Centralized Drug Procurement on the price of policy-related drugs: an interrupted time series analysis

BACKGROUND

The Chinese government implemented the first round of National Centralized Drug Procurement (NCDP) pilot (so-called "4 + 7" policy) in mainland China in 2019. This study aims to examine the impact of "4 + 7" policy on the price of policy-related drugs.

METHODS

This study used drug purchasing order data from the Centralized Drug Procurement Survey in Shenzhen 2019, covering 24 months from January 2018 to December 2019. "4 + 7" policy-related drugs were selected as study samples, including 25 drugs in the "4 + 7" procurement list and 57 alternative drugs that have an alternative relationship with "4 + 7" List drugs in clinical use. "4 + 7" List drugs were then divided into bid-winning and bid-non-winning products according to the bidding results. Single-group Interruption Time Series (ITS) analysis was adopted to examine the change of Drug Price Index (DPI) for policy-related drugs.

RESULTS

The ITS analysis showed that the DPI of winning (- 0.183 per month, p < 0.0001) and non-winning (- 0.034 per month, p = 0.046) products significantly decreased after the implementation of "4 + 7" policy. No significant difference was found for the immediate change of DPI for alternative drugs (p = 0.537), while a significant decrease in change trend was detected in the post-"4 + 7" policy period (- 0.003 per month, p = 0.014). The DPI of the overall policy-related drugs significantly decreased (- 0.261 per month, p < 0.0001) after "4 + 7" policy.

CONCLUSIONS

These findings indicate that the price behavior of pharmaceutical enterprises changed under NCDP policy, while the price linkage effect is still limited. It is necessary to further expand the scope of centralized purchased drugs and strengthen the monitoring of related drugs regarding price change and consumption structure.

Evidence-based public policy making for medicines across countries: findings and implications for the future

Aim: Global expenditure on medicines is rising up to 6% per year driven by increasing prevalence of non-communicable diseases (NCDs) and new premium priced medicines for cancer, orphan diseases and other complex areas. This is difficult to sustain without reforms. Methods: Extensive narrative review of published papers and contextualizing the findings to provide future guidance. Results: New models are being introduced to improve the managed entry of new medicines including managed entry agreements, fair pricing approaches and monitoring prescribing against agreed guidance. Multiple measures have also successfully been introduced to improve the prescribing of established medicines. This includes encouraging greater prescribing of generics and biosimilars versus originators and patented medicines in a class to conserve resources without compromising care. In addition, reducing inappropriate antibiotic utilization. Typically, multiple measures are the most effective. Conclusion: Multiple measures will be needed to attain and retain universal healthcare.

Healthcare Funding Decisions and Real-World Benefits: Reducing Bias by Matching Untreated Patients

Governments and health insurers often make funding decisions based on health gains from randomised controlled trials. These decisions are inherently uncertain because health gains in trials may not translate to practice owing to differences in the population, treatment use and setting. Post-market analysis of real-world data can provide additional evidence but estimates from standard matching methods may be biased when unobserved characteristics explain whether a patient is treated and their outcomes. We propose a new untreated matching approach that can reduce this bias. Our approach utilises the outcomes of contemporaneous untreated patients to improve the matching of treated and historical control patients. We assess the performance of this new approach compared to standard matching using a simulation study and demonstrate the steps required using a funding decision for prostate cancer treatments in Australia. Our simulation study shows that our new matching approach eliminates nearly all bias when unobserved treatment selection is related to outcomes, and outperforms standard matching in most scenarios. In our empirical example, standard matching overestimated survival by 15% (95% confidence interval 2-34) compared to our untreated matching approach. The health gains estimated using our approach were slightly lower than expected based on the trial evidence, but we also found evidence that in practice prescribers ceased prior therapies earlier, treated a more vulnerable population and continued treatment for longer. Our untreated matching approach offers researchers a new tool for reducing uncertainty in healthcare funding decisions using real-world data.

Leveraging the Similarities Between Cost-Effectiveness Analysis and Value-Based Healthcare

OBJECTIVES

This article aims to explore overlaps and differences between the emerging concept of value-based healthcare (VBHC) and the established field of cost-effectiveness analysis (CEA), as well as the feasibility of integrating them together. Interest in VBHC has grown significantly in developed countries that seek to preserve the sustainability of their healthcare systems. Consequently, it is likely that VBHC will soon play a meaningful role in health economic policy and decision making. Because VBHC and CEA share many similarities, academics have pointed out that integration could lead to opportunities for improvements in both fields.

METHODS

An exploration of overlapping topics in VBHC and CEA literature was performed to establish initial links between them. A new methodologic approach is described to consolidate key value frameworks from the respective fields.

RESULTS

Several key themes emerged in which these 2 concepts can reinforce each other: interpretation of value, sensitivity to outcome changes, scientific credibility, methodology and measurement, and usability in decision making. Subsequently, an initial method is described of how the VBHC framework for value could be integrated into CEA through a so-called value-based healthcare quality-adjusted life year (VBHC-QALY).

CONCLUSION

This article introduces the existing VBHC value framework to the cornerstone of modern CEA and substantiates the presumption of health economists that valuable synergies arise from consolidating the individual strengths of CEA and VBHC. Through integration CEA can help establish robust methods for VBHC implementation, while the latter can complement the former with a new viewpoint and conceptual toolbox for patient centricity and the definition of value.

What influences the outcome of active disinvestment processes in healthcare? A qualitative interview study on five recent cases of active disinvestment

BACKGROUND

Recent attempts of active disinvestment (i.e. withdrawal of reimbursement by means of a policy decision) of reimbursed healthcare interventions in the Netherlands have differed in their outcome: some attempts were successful, with interventions actually being disinvested. Other attempts were terminated at some point, implying unsuccessful disinvestment. This study aimed to obtain insight into recent active disinvestment processes, and to explore what aspects affect their outcome.

METHODS

Semi-structured interviews were conducted from January to December 2018 with stakeholders (e.g. patients, policymakers, physicians) who were involved in the policy process of five cases for which the full or partial withdrawal of reimbursement was considered in the Netherlands between 2007 and 2017: benzodiazepines, medication for Fabry disease, quit smoking programme, psychoanalytic therapy and maternity care assistance. These cases covered both interventions that were eventually disinvested and interventions for which reimbursement was maintained after consideration. Interviews were transcribed verbatim, double coded and analyzed using thematic analysis.

RESULTS

The 37 interviews showed that support for disinvestment from stakeholders, especially from healthcare providers and policymakers, strongly affected the outcome of the disinvestment process. Furthermore, the institutional role of stakeholders as legitimized by the Dutch health insurance system, their financial interests in maintaining or discontinuing reimbursement, and the possibility to relieve the consequences of disinvestment for current patients affected the outcome of the disinvestment process as well. A poor organization of patient groups may make it difficult for patients to exert pressure, which may contribute to successful disinvestment. No evidence was found of a consistent role of the formal Dutch package criteria (i.e. effectiveness, cost-effectiveness, necessity and feasibility) in active disinvestment processes.

CONCLUSIONS

Contextual factors as well as the possibility to relieve the consequences of disinvestment for current patients are important determinants of the outcome of active disinvestment processes. These results provide insight into active disinvestment processes and their determinants, and provide guidance to policymakers for a potentially more successful approach for future active disinvestment processes.

[Reduction of social coverage for symptomatic slow-acting drugs for osteoarthritis: a disinvestment initiative in Argentina, 2015-2017]

In April 2016, the National Institute of Social Services for Retirees and Pensioners discontinued its policy of 100% coverage for 159 drugs (the "social subsidy"), including symptomatic slow-acting drugs for osteoarthritis (SYSADOAs), due to insufficient evidence of significant clinical benefit. We evaluated the effect of this measure on the use of SYSADOAs as well as non-steroidal anti-inflammatory drugs (NSAIDs), which were unaffected by this policy change. We compared outpatient dispensations of SYSADOAs and NSAIDs from 2015 to 2017, measuring dispensed units, retail price, and out-of-pocket expenses for beneficiaries each month. After the change in coverage, there was a 61.6% total decrease in SYSADOA units dispensed, and a 63.4% decrease in the final sales price to the public, measured in constant values. Dispensation was not reoriented towards NSAIDs, which fell by 6.1%. The incidence of new treatments decreased (from 6.4 to 3.3 treatments per 1,000 beneficiaries per month), as did their continuity. Beneficiaries' out-of-pocket spending on SYSADOAs increased by 75.8% (at constant values). Disinvestment in interventions with questionable therapeutic value is an important tool in working toward the sustainability of health systems.

Internal barriers to efficiency: why disinvestments are so difficult. Identifying and addressing internal barriers to disinvestment of health technologies

Although efficiency is a core concept in health economics, its impact on health care practice still is modest. Despite an increased pressure on resource allocation, a widespread use of low-value care is identified. Nonetheless, disinvestments are rare. Why is this so? This is the key question of this paper: why are disinvestments not more prevalent and improving the efficiency of the health care system, given their sound foundation in health economics, their morally important rationale, the significant evidence for a long list of low-value care and available alternatives? Although several external barriers to disinvestments have been identified, this paper looks inside us for mental mechanisms that hamper rational assessment, implementation, use and disinvestment of health technologies. Critically identifying and assessing internal inclinations, such as cognitive biases, affective biases and imperatives, is the first step toward a more rational handling of health technologies. In order to provide accountable and efficient care we must engage in the quest against the figments of our minds; to disinvest in low-value care in order to provide high-value health care.

Societal views in the Netherlands on active disinvestment of publicly funded healthcare interventions

OBJECTIVES

To obtain public support for the active disinvestment (i.e. policy decision to stop reimbursement) of healthcare interventions, it is important to have insight in what the public thinks about disinvestment and which considerations they find relevant in this context. Currently, evidence on relevant considerations in the disinvestment context is limited. Therefore, this study aimed to explore the societal views in the Netherlands on the active disinvestment of healthcare interventions and obtain insight into the considerations that are relevant for those holding the different views.

METHODS

A Q-methodology study was conducted among a purposively selected sample of citizens (n = 43). Data were collected in June and July 2019. Participants individually ranked a set of 43 statements broadly covering the issues that participants could consider relevant in the disinvestment context, from 'least agree' to 'most agree'. Qualitative feedback on the statement ranking was collected from each participant using a questionnaire. Principal component analysis followed by oblimin rotation was used to identify clusters of participants with similar statement rankings. These clusters/factors were interpreted as distinct viewpoints using the factor arrays and qualitative questionnaire responses of participants.

RESULTS

Four viewpoints were identified. People holding viewpoint I believe that reimbursement of necessary healthcare should be maintained, irrespective of its costs. People holding viewpoint II agree with viewpoint I, although they believe that necessity should be objectively determined. People holding viewpoint III think that unnecessary, ineffective and inefficient healthcare should be disinvested. People holding viewpoint IV, consider it most important that disinvestment decision-making processes are transparent and consistent.

CONCLUSION

Insight in the distinct viewpoints identified in this study contributes to a better understanding of why it has been considered difficult to obtain public support for disinvestment of healthcare interventions, and can help policymakers to change their approach to disinvestment to increase public support.

The Impacts of National Centralized Drug Procurement Policy on Drug Utilization and Drug Expenditures: The Case of Shenzhen, China

In 2019, the Chinese government implemented the first round of the National Centralized Drug Procurement (NCDP) pilot (so-called “4 + 7” policy) in mainland China, in which 25 drugs were included. We conducted this study to examine the impacts of NCDP policy on drug utilization and expenditures, and to clarify the main factors contributing to drug expenditure changes. This study used drug purchasing order data from the Centralized Drug Procurement Survey in Shenzhen 2019. Drugs related to the “4 + 7” policy were selected as study samples, including 23 “4 + 7” policy-related varieties and 15 basic alternative drugs. Driving factors for drug expenditures changes were analyzed using A.M. index system analysis (Addis A. & Magrini N.’ method). After the implementation of the NCDP policy, the volume of “4 + 7” policy-related varieties increased by 73.8%, among which winning products jumped by 1638.2% and non-winning products dropped by 70.8%; the expenditures of “4 + 7” policy-related varieties decreased by 36.9%. Structure effects (0.47) and price effects (0.78) negatively contributed to the increase in drug expenditures of “4 + 7” policy-related varieties, while volume effects (1.73) had positive influence. NCDP policy successfully decreased drug expenditures of “4 + 7” policy-related varieties with structure effects playing a leading role. However, total drug expenditures were not effectively controlled due to the increasing use of alternative drugs.

Formulary Management Activities and Practice Implications Among Public Sector Hospital Pharmaceutical and Therapeutics Committees in a South African Province

Introduction

The World Health Organization identified Pharmaceutical and Therapeutics Committees (PTCs) at district and hospital levels as one of the pivotal models to promote rational use of medicines (RUM). This is endorsed by the Government in South Africa. Formulary development and management is one of the main functions of PTCs. This study aimed to describe the formulary management activities among PTCs in public hospitals in Gauteng Province, South Africa, following initiatives to promote RUM in South Africa.

Methods

Qualitative, nonparticipatory, observational study, observing 26 PTC meetings. Data were coded and categorized using NVivo9^® qualitative data analysis software. Themes and sub-themes were developed. The themes and sub-themes on formulary management are the principal focus of this paper.

Results

More than half of the observed PTCs reviewed their formulary lists. There was variation in the review process among institutions providing different levels of care. Various aspects were considered for formulary management especially requests for medicines to be added. These included cost considerations (mainly focusing on acquisition costs), evidence-based evaluation of clinical trials, patient safety, clinical experience and changes in the National Essential Medicines List (NEML). The tertiary PTCs mostly dealt with applications for new non-EML medicines, while PTCs in the other hospitals mainly requested removal or addition of EML medicines to the list.

Conclusion

This is the first study from Gauteng Province, South Africa, reporting on how decisions are actually taken to include or exclude medicines onto formularies within public sector hospitals providing different levels of care. Various approaches are adopted at different levels of care when adding to- or removing medicines from the formulary lists. Future programs should strengthen PTCs in specialized aspects of formulary management. A more structured approach to formulary review at the local PTC level should be encouraged in line with the national approach when reviewing possible additions to the NEML.

Mapping of Current Obstacles for Rationalizing Use of Medicines (CORUM) in Europe: Current Situation and Potential Solutions

Introduction

There are increasing concerns regarding the inappropriate use of medicines with expenditure continuing to grow driven by increasing sales in oncology and orphan diseases, enhanced by their emotive nature. As a result, even high income countries are struggling to fund new premium priced medicines. These concerns have resulted in initiatives to better manage the entry of new medicines and enhance the rational use of medicines (RUM). However, there is a need to ascertain the current situation. We sought to address this by developing the Current Obstacles for Rationalizing Use of Medicines in Europe (CORUM) mapping tool to qualitatively investigate the current situation and provide analysis of current views on RUM and interventions among key European payers and their advisers. The findings will be used to provide future guidance.

Methodology

Descriptive study exploring and identifying perceived gaps to achieving optimal RUM. The CORUM tool was based on the WHO 12 key interventions to promote RUM.

Results

62 participants took part with most respondents believing their country could improve RUM capacity. This included educational initiatives on the use of clinical guidelines (90%) and the inclusion of problem-based pharmacotherapy in undergraduate curricula and for Continued Professional Development. Key challenges included a lack of regular updates of guidelines, exacerbated by limited funding and a lack of follow-up to monitor adherence to agreed guidelines. RUM could also be enhanced by the development of regional formularies as well as implementing Drug and Therapeutic Committees where these are currently limited. There also needs to be greater co-ordination between RUM and Health Technology Assessment activities, with countries learning from each other.

Conclusion

There is an urgent need to improve RUM through improved educational and other activities among European countries, with countries learning from each other. This will involve addressing current challenges and we will be following this up.

Formulating an Ethics of Pharmaceutical Disinvestment

There is growing interest among pharmaceutical policymakers in how to "disinvest" from subsidized medicines. This is due to both the rapidly rising costs of healthcare and the increasing use of accelerated and conditional reimbursement pathways which mean that medicines are being subsidized on the basis of less robust evidence of safety and efficacy. It is crucial that disinvestment decisions are morally sound and socially legitimate, but there is currently no framework to facilitate this. We therefore reviewed the bioethics literature in order to identify ethical principles and concepts that might be relevant to pharmaceutical disinvestment decisions. This revealed a number of key ethical considerations-both procedural and substantive-that need to be considered when making pharmaceutical disinvestment decisions. These principles do not, however, provide practical guidance so we present a framework outlining how they might be applied to different types of disinvestment decisions. We also argue that, in this context, even the most rigorous ethical reasoning is likely to be overridden by moral intuitions and psychological biases and that disinvestment decisions will need to strike the right balance between respecting justifiable moral intuitions and overriding unjustifiable psychological impulses.

An evidence-based framework for identifying technologies of no or low-added value (NLVT)

OBJECTIVE

To synthetize the state of the art of methods for identifying candidate technologies for disinvestment and propose an evidence-based framework for executing this task.

METHODS

An interpretative review was conducted. A systematic literature search was performed to identify secondary or tertiary research related to disinvestment initiatives and/or any type of research that specifically described one or more methods for identifying potential candidates technologies, services, or practices for disinvestment. An iterative and critical analysis of the methods described alongside the disinvestment initiatives was performed.

RESULTS

Seventeen systematic reviews on disinvestment or related terms (health technology reassessment or medical reversal) were retrieved and methods of 45 disinvestment initiatives were compared. On the basis of this evidence, we proposed a new framework for identifying these technologies based on the wide definition of evidence provided by Lomas et al. The framework comprises seven basic approaches, eleven triggers and thirteen methods for applying these triggers, which were grouped in embedded and ad hoc methods.

CONCLUSIONS

Although identification methods have been described in the literature and tested in different contexts, the proliferation of terms and concepts used to describe this process creates considerable confusion. The proposed framework is a rigorous and flexible tool that could guide the implementation of strategies for identifying potential candidates for disinvestment.

Health Technology Assessment as Part of a Broader Process for Priority Setting and Resource Allocation

Over the last two decades, economic evaluation of health technologies has developed enormously, affirming its importance within the pursuit of efficiency in the management of health care systems. One concern that has been raised with health technology assessment (HTA) has been its operationalization within the realm of decision making. Here, we suggest a mechanism by which HTA can be understood as an input into a broader framework for priority setting and resource allocation. When HTA is seen in this light, topics that at times have had some lack of clarity, such as public engagement and disinvestment, simply become steps in the overall decision-making process.

Collective constructions of 'waste': epistemic practices for disinvestment in the context of Dutch social health insurance

Background

Faced with growing budget pressure, policymakers worldwide recognize the necessity of strategic disinvestment from ineffective, inefficient or harmful medical practices. However, disinvestment programs face substantial social, political and cultural challenges: mistrust, struggles for clinical autonomy or stakeholders’ reluctance to engage in what can be perceived as ‘rationing’. Academic literature says little about effective strategies to address these challenges. This paper provides insights on this matter. We analyzed the epistemic work of a group of policymakers at the National Health Care Institute on what was initially a disinvestment initiative within the context of the Dutch basic benefits package: the ‘Appropriate Care’ program. The Institute developed a strategy using national administrative data to identify and tackle low-value care covered from public funds as well as potential underuse, and achieve savings through improved organization of efficiency and quality in health care delivery. How did the Institute deal with the socio-political sensitivities associated with disinvestment by means of their epistemic work?

Method

We conducted ethnographic research into the National Health Care Institute’s epistemic practices. Research entailed document analysis, non-participant observation, in-depth conversations, and interviews with key-informants.

Results

The Institute dealt with the socio-political sensitivities associated with disinvestment by democratizing the epistemic practices to identify low-value care, by warranting data analysis by clinical experts, by creating an epistemic safe space for health care professionals who were the object of research into low-value care, and by de-emphasizing the economization measure. Ultimately, this epistemic work facilitated a collaborative construction of problems relating to low-value care practices and their solutions.

Conclusions

This case shows that – apart from the right data and adequate expertise – disinvestment requires clinical leadership and political will on the part of stakeholders. Our analysis of the Institute’s Appropriate Care program shows how the epistemic effort to identify low-value care became a co-construction between policymakers, care providers, patients and insurers of problems of ‘waste’ in Dutch social health insurance. This collective epistemic work gave cognitive, moral and political standing to the idea of ‘waste’ in public health expenditure.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4434-1) contains supplementary material, which is available to authorized users.

Evolution of Average European Medicine Prices: Implications for the Methodology of External Price Referencing

BACKGROUND

There are indications of staggered market entry of medicines in the national markets, with medicines being marketed first in countries with high prices. This study aimed to analyse the availability and evolution of medicine prices in the European Union (EU).

METHODS

This research was performed for an illustrative sample of five medicines (abiraterone, emtricitabine/rilpivirine/tenofovir disoproxil, fingolimod, linagliptin and sofosbuvir) in 27 EU Member States. Price data at 6, 12, 18, 36 and 60 months after marketing authorisation were retrieved from national administrative price databases and registers accessible through the Pharma Price Information service.

RESULTS

In the first year after marketing authorisation, price data for the selected medicines were only available in a small number of EU Member States-usually high-income countries. Availability increased over time. However, some countries, for instance Central and Eastern Europe, had price data available only several years after marketing authorisation. The average European price of the surveyed medicines decreased by at least 7.1% between 6 months and 3 years and at least 9.5% between 6 months and 5 years after marketing authorisation. Price data availability in lower-income countries at later stages, and price decreases in some countries, appear to be major reasons for the reductions in average prices.

CONCLUSIONS

If policymakers aim to apply the pricing policy of external price referencing (i.e. price setting based on prices in other countries) for cost-containment purposes, they are recommended to undertake continuous price revisions over the years.

Assessing value in health care: using an interpretive classification system to understand existing practices based on a systematic review

BACKGROUND

Implementing adequate strategies to assess the value of health services plays a central role in the effort to deal with the financial pressures faced by health care systems worldwide. This study aimed to understand which approaches to value assessment have been used in developed countries.

METHODS

We conducted a rapid review and a gray literature search to identify value assessment frameworks. A two-stage screening process was utilized to identify existing approaches and cluster similar frameworks. In addition, we developed an interpretive classification system to make sense of existing approaches.

RESULTS

One thousand one hundred seventy-six references were identified and 38 papers were selected for full-review. Among these 38 articles, 22 distinct approaches to assess value of health care interventions were identified and classified according to four points: 1) use of single or multiple considerations to base value estimates; 2) use of disease-specific or generic criteria; 3) reliance on process-based or outcomes-based consideration; and 4) type of input and evidence considered.

CONCLUSIONS

The contextual nature of value assessment in health care becomes evident with the diversity of existing approaches. Despite the predominance of cases relying on the Incremental cost-effectiveness ratio as the measure of value, this approach has not been sufficient to meet the needs of decision-makers. The use of multiple criteria has become more and more important, as well as the consideration of patient-reported measures. Considerations of costs are not always explicit and consistent.

Health technology reassessment in the Brazilian public health system: Analysis of the current status

BACKGROUND

The reassessment of technologies and services offered by healthcare systems is recent initiative and still without a widely adopted and evaluated method. To a better understanding of this process in Brazil, we have described the health technology reassessment (HTR) performed by the National Committee for Health Technology Incorporation (Conitec) into Brazilian public health system (SUS).

METHODS

A documental, exploratory, descriptive, retrospective study with qualitative-quantitative approach regarding the HTR performed by Conitec from January 2012 to November 2017.

RESULTS

After applying the criteria of inclusion and exclusion, we selected 47 technologies for this study. The vast majority of the demands (41 demands) came from the public sector, and only six from the private sector. Most of the requests referred to the exclusion of specific indication; followed by extension of use, withdraw of the technology from SUS, maintenance, and restriction of use. The dimensions of analysis found in the recommendation reports were scientific evidence on efficacy, effectiveness and safety, disease-related issues, issues related to the use of technology, costs, and social participation. However, these dimensions were not included in all analysis, and a standardized structure of the reports has not been observed. The most relevant decision factors considered for decision-making were efficacy, safety and use of the technology.

CONCLUSION

During a six-year period of Conitec actuation, we could find some reassessments of technologies that are available in SUS. We observed that these activities had enabled progress, however, they are still not yet structured, with gaps in the selection process, and the assessment since no methodology and criteria for proper conduct were established.

Public perspectives on disinvestments in drug funding: results from a Canadian deliberative public engagement event on cancer drugs

Background

Decisions relating to the funding of new drugs are becoming increasingly challenging due to a combination of aging populations, rapidly increasing list prices, and greater numbers of drug-indication pairs being brought to market. This is especially true in cancer, where rapid list price inflation is coupled with steeply rising numbers of incident cancer cases. Within a publicly funded health care system, there is increasing recognition that resource allocation decisions should consider the reassessment of, and potential disinvestment from, currently funded interventions alongside new investments. Public input into the decision-making process can help legitimize the outcomes and ensure priority-setting processes are aligned with public priorities.

Methods

In September 2014, a public deliberation event was held in Vancouver, Canada, to obtain public input on the topic of cancer drug funding. Twenty-four members of the general public were tasked with making collective recommendations for policy-makers about the principles that should guide funding decisions for cancer drugs in the province of British Columbia. Deliberative questions and decision aids were used to elicit individuals’ willingness to make trade-offs between expenditures and health outcomes.

Results

Participants discussed the implications of disinvestment decisions from cancer drugs in terms of its impact on patient choice, fairness and quality of life. Their discussions indicate that in order for a decision to disinvest from currently-funded cancer drugs to be acceptable, it must align with three main principles: the decision must be accompanied by significant gains, described both in terms of cost savings and opportunities to re-invest elsewhere in the health care system; those who are currently prescribed a cancer drug should be allowed to continue their course of treatment (referred to as a continuance clause, or “grandfathering” approach); and it must consider how access to care for specialized populations is impacted.

Conclusions

The results from this deliberation event provide insight into what is acceptable to British Columbians with respect to disinvestment decisions for cancer drugs. These recommendations can be considered within wider health system decision-making frameworks for funding decisions relating to all drugs, as well as for cancer drugs.

Development and pilot of a multicriteria decision analysis (MCDA) tool for health services administrators

INTRODUCTION

Health administration is complex and serves many masters. Value, quality, infrastructure and reimbursement are just a sample of the competing interests influencing executive decision-making. This creates a need for decision processes that are rational and holistic.

METHODS

We created a multicriteria decision analysis tool to evaluate six fields of healthcare provision: return on investment, capacity, outcomes, safety, training and risk. The tool was designed for prospective use, at the beginning of each funding round for competing projects. Administrators were asked to rank their criteria in order of preference. Each field was assigned a representative weight determined from the rankings. Project data were then entered into the tool for each of the six fields. The score for each field was scaled as a proportion of the highest scoring project, then weighted by preference. We then plotted findings on a cost-effectiveness plane. The project was piloted and developed over successive uses by the hospital's executive board.

RESULTS

Twelve projects competing for funding at the Royal Brisbane and Women's Hospital were scored by the tool. It created a priority ranking for each initiative based on the weights assigned to each field by the executive board. Projects were plotted on a cost-effectiveness plane with score as the x-axis and cost of implementation as the y-axis. Projects to the bottom right were considered dominant over projects above and to the left, indicating that they provided greater benefit at a lower cost. Projects below the x-axis were cost-saving and recommended provided they did not harm patients. All remaining projects above the x-axis were then recommended in order of lowest to highest cost-per-point scored.

CONCLUSION

This tool provides a transparent, objective method of decision analysis using accessible software. It would serve health services delivery organisations that seek to achieve value in healthcare.

Clinical and Financial Implications of Medicine Consumption Patterns at a Leading Referral Hospital in Kenya to Guide Future Planning of Care

Background: Medicines can constitute up to 70% of total health care budgets in developing countries as well as considerable expenditure in hospitals. Inventory management techniques can assist with managing resources efficiently. In Kenyatta National Hospital (KNH), a leading hospital in Kenya, over 30% of expenditure is currently allocated to medicines, and this needs to be optimally managed.

Objective: To investigate drug consumption patterns, their costs and morbidity patterns at KNH in recent years.

Methodology: Cross-sectional retrospective record review. Inventory control techniques, ABC (Always, Better, and Control), VEN (Vital, Essential, and Non-essential) and ABC-VEN matrix analyses were used to study drug expenditure patterns. Morbidity data was extracted from the Medical Records.

Results: Out of an average of 811 medicine types procured annually (ATC 5), 80% were formulary drugs and 20% were non-formulary. Class A medicines constituted 13.2–14.2% of different medicines procured each year but accounted for an average of 80% of total annual drug expenditure. Class B medicines constituted 15.9–17% of all the drugs procured yearly but accounted for 15% of the annual expenditure, whilst Class C medicines constituted 70% of total medicines procured but only 5% of the total expenditure. Vital and Essential medicines consumed the highest percentage of drug expenditure. ABC-VEN categorization showed that an average of 31% of medicine types consumed an average of 85% of total drug expenditure. Therapeutic category and Morbidity patterns analysis showed a mismatch between drug expenditure and morbidity patterns in over 85% of the categories.

Conclusion: Class A medicines are few but consume the largest proportion of hospital drug expenditure. Vital and essential items account for the highest drug expenditure, and need to be carefully managed. ABC-VEN categorization identified medicines where major savings could potentially be made helped by Therapeutic category and Morbidity pattern analysis. There was a high percentage of non-formulary items, which needs to be addressed. Inventory control techniques should be applied routinely to optimize medicine use within available budgets especially in low and middle income countries.

Barriers for Access to New Medicines: Searching for the Balance Between Rising Costs and Limited Budgets

Introduction: There is continued unmet medical need for new medicines across countries especially for cancer, immunological diseases, and orphan diseases. However, there are growing challenges with funding new medicines at ever increasing prices along with funding increased medicine volumes with the growth in both infectious diseases and non-communicable diseases across countries. This has resulted in the development of new models to better manage the entry of new medicines, new financial models being postulated to finance new medicines as well as strategies to improve prescribing efficiency. However, more needs to be done. Consequently, the primary aim of this paper is to consider potential ways to optimize the use of new medicines balancing rising costs with increasing budgetary pressures to stimulate debate especially from a payer perspective. Methods: A narrative review of pharmaceutical policies and implications, as well as possible developments, based on key publications and initiatives known to the co-authors principally from a health authority perspective. Results: A number of initiatives and approaches have been identified including new models to better manage the entry of new medicines based on three pillars (pre-, peri-, and post-launch activities). Within this, we see the growing role of horizon scanning activities starting up to 36 months before launch, managed entry agreements and post launch follow-up. It is also likely there will be greater scrutiny over the effectiveness and value of new cancer medicines given ever increasing prices. This could include establishing minimum effectiveness targets for premium pricing along with re-evaluating prices as more medicines for cancer lose their patent. There will also be a greater involvement of patients especially with orphan diseases. New initiatives could include a greater role of multicriteria decision analysis, as well as looking at the potential for de-linking research and development from commercial activities to enhance affordability. Conclusion: There are a number of ongoing activities across countries to try and fund new valued medicines whilst attaining or maintaining universal healthcare. Such activities will grow with increasing resource pressures and continued unmet need.

Measuring Health-Related Quality of Life in Adolescent Populations: An Empirical Comparison of the CHU9D and the PedsQLTM 4.0 Short Form 15

OBJECTIVE

The aim was to conduct an empirical assessment of the measurement properties of the preference-based Child Health Utility 9D (CHU9D) versus the non-preference-based Pediatric Quality of Life Inventory (PedsQL)™ 4.0 Short Form 15 Generic Core Scales (referred to as 'PedsQL') in an Australian community-based sample of adolescents.

METHODS

An online survey including the CHU9D, the PedsQL, a self-reported general health question, and socio-demographic questions was administered to adolescents (aged 15-17 years). Descriptive summary statistics and psychometric analyses were conducted to assess levels of agreement and convergent validity between the instruments.

RESULTS

A total of 775 adolescents (mean ± SD age 15.8 ± 0.8 years) completed the survey. The mean ± SD scores of the CHU9D and the PedsQL were 0.72 ± 0.22 and 72.86 ± 16.56, respectively. For both instruments, there were significant differences in health-related quality of life scores according to self-reported health status and socio-economic status. Overall, both the Spearman's correlation (r = 0.63) and the intraclass correlation coefficient (0.77) suggested a high level of agreement.

CONCLUSIONS

The findings indicate good levels of agreement overall between the CHU9D and PedsQL and provide further support for the validity of the application of the CHU9D in the economic evaluation of adolescent health care treatment and service programmes.

Dealing with the spiralling price of medicines: issues and solutions

Escalating cost of medicines is rapidly becoming a serious threat to patients and health systems. This trend has been documented to impact patient outcomes adversely. As clinicians and tax payers, it is our responsibility to be aware of the potential detrimental effects spiralling costs have on our patients, our community and our health system and to mitigate these effects by exposing this issue to our respective professional societies, representatives of the pharmaceutical companies that we interact with, government regulatory bodies and to patients who we are caring for. Only through understanding and constructive actions will we be able to provide the best quality of care to our patients and continue to enjoy universal healthcare in our country.

Risk-Sharing Agreements in the EU: A Systematic Review of Major Trends

OBJECTIVE

Our objectives were to explore the changes in the level of interest in risk-sharing agreements (RSAs) in the EU during the last 15 years and the underlying reasons for these changes.

METHODS

A systematic literature review was conducted using PubMed, Scopus, Web of Science, and Embase. Articles identified were divided into 'quantitative articles' used to establish the level of interest and 'qualitative articles' used to identify the underlying trends in RSAs.

RESULTS

The literature search retrieved 2144 scientific articles. Data were extracted from 238 articles. Of these, 100 contained quantitative data and 138 contained qualitative data. The pace of articles being published about RSAs grew significantly in 2015, which related to the increase in interest in and knowledge about RSAs. The underlying reasons for the fluctuations were condensed into four overall themes: (1) push for value-based pricing, (2) economic crisis and further push to contain costs, (3) criticism of RSAs in the real world, and (4) diversification of RSAs to fit the purpose.

CONCLUSION

The overall level of interest in RSAs in the EU has been increasing since 2000; therefore, articles reporting the number of RSAs implemented and case studies have been steadily growing as evidence is becoming more readily available. The number of qualitative articles reporting and discussing the underlying reasons for these changes in interest has largely fluctuated over the last 15 years. Despite these fluctuations, interest in RSAs remains high.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 11: reporting outcomes of an evidence-driven approach to disinvestment in a local healthcare setting

Background

This is the final paper in a thematic series reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE Program was established to explore a systematic, integrated, evidence-based organisation-wide approach to disinvestment in a large Australian health service network. This paper summarises the findings, discusses the contribution of the SHARE Program to the body of knowledge and understanding of disinvestment in the local healthcare setting, and considers implications for policy, practice and research.

Discussion

The SHARE program was conducted in three phases. Phase One was undertaken to understand concepts and practices related to disinvestment and the implications for a local health service and, based on this information, to identify potential settings and methods for decision-making about disinvestment. The aim of Phase Two was to implement and evaluate the proposed methods to determine which were sustainable, effective and appropriate in a local health service. A review of the current literature incorporating the SHARE findings was conducted in Phase Three to contribute to the understanding of systematic approaches to disinvestment in the local healthcare context.

SHARE differed from many other published examples of disinvestment in several ways: by seeking to identify and implement disinvestment opportunities within organisational infrastructure rather than as standalone projects; considering disinvestment in the context of all resource allocation decisions rather than in isolation; including allocation of non-monetary resources as well as financial decisions; and focusing on effective use of limited resources to optimise healthcare outcomes.

Conclusion

The SHARE findings provide a rich source of new information about local health service decision-making, in a level of detail not previously reported, to inform others in similar situations. Multiple innovations related to disinvestment were found to be acceptable and feasible in the local setting. Factors influencing decision-making, implementation processes and final outcomes were identified; and methods for further exploration, or avoidance, in attempting disinvestment in this context are proposed based on these findings. The settings, frameworks, models, methods and tools arising from the SHARE findings have potential to enhance health care and patient outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3172-0) contains supplementary material, which is available to authorized users.

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 Assessment for Disinvestment of Intramuscular Interferon Beta for Relapsing-Remitting Multiple Sclerosis in Brazil

In Brazil, inclusion and exclusion of health technologies within the Unified Health System (SUS) is the responsibility of the National Committee for Health Technology Incorporation (CONITEC). A recent Cochrane systematic review demonstrated that intramuscular interferon beta 1a (IFN-β-1a-IM) was inferior to the other beta interferons (IFN-βs) for multiple sclerosis (MS). As a result, CONITEC commissioned an analysis to review possible disinvestment within SUS. The objective of this paper is to describe the disinvestment process for IFN-β-1a-IM in Brazil. The first assessment comprised a literature review and mixed treatment comparison meta-analysis. The outcome of interest was the proportion of relapse-free patients in 2 years. This analysis confirmed the inferiority of IFN-β-1a-IM. Following this, CONITEC recommended disinvestment, with the decision sent for public consultation. More than 3000 contributions were made on CONITEC's webpage, most of them against the preliminary decision. As a result, CONITEC commissioned a study to assess the effectiveness of IFN-β-1a-IM among Brazilian patients in routine clinical care. The second assessment involved an 11-year follow-up of a non-concurrent cohort of 12,154 MS patients developed by deterministic-probabilistic linkage of SUS administrative databases. The real-world assessment further demonstrated that IFN-β-1a-IM users had a statistically higher risk of treatment failure, defined as treatment switching or relapse treatment or death, with the assessment showing that IFN-β-1a-IM was inferior to the other IFN-βs and to glatiramer acetate in both direct and indirect analysis. In the drug ranking with 40,000 simulations, IFN-β-1a-IM was the worst option, with a success rate of only 152/40,000. Following this, CONITEC decided to exclude the intramuscular presentation of IFN-β from the current MS treatment guidelines, giving patients who are currently on this treatment the option of continuing until treatment failure. In conclusion, we believe this is the first example of this new disinvestment process in action, providing an exemplar for other treatments in Brazil as well as other countries.

Patient Access, Unmet Medical Need, Expected Benefits, and Concerns Related to the Utilisation of Biosimilars in Eastern European Countries: A Survey of Experts

This policy research aims to map patient access barriers to biologic treatments, to explore how increased uptake of biosimilars may lower these hurdles and to identify factors limiting the increased utilisation of biosimilars. A policy survey was developed to review these questions in 10 Central and Eastern European (CEE) and Commonwealth of Independent States (CIS) countries. Two experts (one public and one private sector representative) from each country completed the survey. Questions were related to patient access, purchasing, clinical practice, and real-world data collection on both original biologics and biosimilars. Restrictions on the number of patients that can be treated and related waiting lists were reported as key patient access barriers. According to respondents, for both clinicians and payers the primary benefit of switching patients to biosimilars would be to treat more patients. However, concerns with therapeutic equivalence and fear of immunogenicity may reduce utilisation of biosimilars. Similar limitations in patient access to both original biologics and biosimilars raise concerns about the appropriateness and success of current biosimilar policies in CEE and CIS countries. The conceptual framework for additional real-world data collection exists in all countries which may provide a basis for future risk-management activities including vigorous pharmacovigilance data collection.

Ongoing Initiatives to Improve the Quality and Efficiency of Medicine Use within the Public Healthcare System in South Africa; A Preliminary Study

Introduction: South Africa has an appreciable burden of both communicable and non-communicable diseases as well as high maternal, neonatal, and child morbidity. In recent years there have been significant strides with improving the public health system, and addressing current inequalities, with the right to health a constitutional provision in South Africa. Initiatives include the introduction of National Health Insurance, programmes to enhance access to medicines for patients with chronic diseases, as well as activities to improve care in hospitals, including improving pharmacovigilance. Consequently, the objective of this paper is to review ongoing initiatives within the public healthcare sector in South Africa and their influence to provide future direction.

Method: Principally a structured review of current and planned activities.

Results: There have been a number of major activities and initiatives surrounding the availability and access to medicines in the public system in recent years in South Africa. This includes a National Surveillance Centre and an innovative early warning system for the supply of medicines as well as the development of a National Health Care Pricing Authority and initiatives to improve contracting. There have also been developments to improve the supply chain including instigating Medicine Procurement Units in the provinces and enhancing forecasting capabilities. Access to medicines is improving though the instigation of stable chronic disease management initiatives to increase the number of external pick-up points for medicines. There are also ongoing programmes to enhance adherence to medicines as well as enhance adherence to the Standard Treatment Guidelines and the Essential Medicines List with their increasing availability. In addition, there is a movement to enhance the role of health technology assessment in future decision making. Hospital initiatives include increased focus on reducing antimicrobial resistance through instigating stewardship programmes as well as improving adverse drug reaction reporting and associated activities.

Conclusion: Overall, there are an appreciable number of ongoing activities within the public healthcare system in South Africa attempting to ensure and sustain universal healthcare. It is too early to assess their impact, which will be the subject of future research.

Savings from reducing low-value general surgical interventions

Background

Finding opportunities for improving efficiency is important, given the pressure on national health budgets. Identifying and reducing low-value interventions that deliver little benefit is key. A systematic literature evaluation was done to identify low-value interventions in general surgery, with further assessment of their cost.

Methods

A multiplatform method of identifying low value interventions was undertaken, including a broad literature search, a targeted database search, and opportunistic sampling. The results were then stratified by impact, assessing both frequency and cost.

Results

Seventy-one low-value general surgical procedures were identified, of which five were of high frequency and high cost (highest impact), 22 were of high cost and low frequency, 23 were of low cost and high frequency, and 21 were of low cost and low frequency (lowest impact). Highest impact interventions included inguinal hernia repair in minimally symptomatic patients, inappropriate gastroscopy, interval cholecystectomy, CT to diagnose appendicitis and routine endoscopy in those who had CT-confirmed diverticulitis. Their estimated cost was €153 383 953.

Conclusion

Low-value services place a burden on health budgets. Stopping only five high-volume, high-cost general surgical procedures could save the National Health Service €153 million per annum.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 9: conceptualising disinvestment in the local healthcare setting

BACKGROUND

This is the ninth in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The disinvestment literature has broadened considerably over the past decade; however there is a significant gap regarding systematic, integrated, organisation-wide approaches. This debate paper presents a discussion of the conceptual aspects of disinvestment from the local perspective.

DISCUSSION

Four themes are discussed: Terminology and concepts, Motivation and purpose, Relationships with other healthcare improvement paradigms, and Challenges to disinvestment. There are multiple definitions for disinvestment, multiple concepts underpin the definitions and multiple alternative terms convey these concepts; some definitions overlap and some are mutually exclusive; and there are systematic discrepancies in use between the research and practice settings. Many authors suggest that the term 'disinvestment' should be avoided due to perceived negative connotations and propose that the concept be considered alongside investment in the context of all resource allocation decisions and approached from the perspective of optimising health care. This may provide motivation for change, reduce disincentives and avoid some of the ethical dilemmas inherent in other disinvestment approaches. The impetus and rationale for disinvestment activities are likely to affect all aspects of the process from identification and prioritisation through to implementation and evaluation but have not been widely discussed. A need for mechanisms, frameworks, methods and tools for disinvestment is reported. However there are several health improvement paradigms with mature frameworks and validated methods and tools that are widely-used and well-accepted in local health services that already undertake disinvestment-type activities and could be expanded and built upon. The nature of disinvestment brings some particular challenges for policy-makers, managers, health professionals and researchers. There is little evidence of successful implementation of 'disinvestment' projects in the local setting, however initiatives to remove or replace technologies and practices have been successfully achieved through evidence-based practice, quality and safety activities, and health service improvement programs.

CONCLUSIONS

These findings suggest that the construct of 'disinvestment' may be problematic at the local level. A new definition and two potential approaches to disinvestment are proposed to stimulate further research and discussion.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 10: operationalising disinvestment in a conceptual framework for resource allocation

Background

This is the tenth in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. After more than a decade of research, there is little published evidence of active and successful disinvestment. The paucity of frameworks, methods and tools is reported to be a factor in the lack of success. However there are clear and consistent messages in the literature that can be used to inform development of a framework for operationalising disinvestment. This paper, along with the conceptual review of disinvestment in Paper 9 of this series, aims to integrate the findings of the SHARE Program with the existing disinvestment literature to address the lack of information regarding systematic organisation-wide approaches to disinvestment at the local health service level.

Discussion

A framework for disinvestment in a local healthcare setting is proposed. Definitions for essential terms and key concepts underpinning the framework have been made explicit to address the lack of consistent terminology. Given the negative connotations of the word ‘disinvestment’ and the problems inherent in considering disinvestment in isolation, the basis for the proposed framework is ‘resource allocation’ to address the spectrum of decision-making from investment to disinvestment. The focus is positive: optimising healthcare, improving health outcomes, using resources effectively.

The framework is based on three components: a program for decision-making, projects to implement decisions and evaluate outcomes, and research to understand and improve the program and project activities. The program consists of principles for decision-making and settings that provide opportunities to introduce systematic prompts and triggers to initiate disinvestment. The projects follow the steps in the disinvestment process. Potential methods and tools are presented, however the framework does not stipulate project design or conduct; allowing application of any theories, methods or tools at each step. Barriers are discussed and examples illustrating constituent elements are provided.

Conclusions

The framework can be employed at network, institutional, departmental, ward or committee level. It is proposed as an organisation-wide application, embedded within existing systems and processes, which can be responsive to needs and priorities at the level of implementation. It can be used in policy, management or clinical contexts.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2506-7) contains supplementary material, which is available to authorized users.

Adaptive Pathways: Possible Next Steps for Payers in Preparation for Their Potential Implementation

Medicines receiving a conditional marketing authorization through Medicines Adaptive Pathways to Patients (MAPPs) will be a challenge for payers. The "introduction" of MAPPs is already seen by the European Medicines Agency (EMA) as a fait accompli, with payers not consulted or involved. However, once medicines are approved through MAPPs, they will be evaluated for funding by payers through different activities. These include Health Technology Assessment (HTA) with often immature clinical data and high uncertainty, financial considerations, and negotiations through different types of agreements, which can require monitoring post launch. Payers have experience with new medicines approved through conditional approval, and the fact that MAPPs present additional challenges is a concern from their perspective. There may be some activities where payers can collaborate. The final decisions on whether to reimburse a new medicine via MAPPs will have more variation than for medicines licensed via conventional processes. This is due not only to increasing uncertainty associated with medicines authorized through MAPPs but also differences in legal frameworks between member states. Moreover, if the financial and side-effect burden from the period of conditional approval until granting full marketing authorization is shifted to the post-authorization phase, payers may have to bear such burdens. Collection of robust data during routine clinical use is challenging along with high prices for new medicines during data collection. This paper presents the concept of MAPPs and possible challenges. Concerns and potential ways forward are discussed and a number of recommendations are presented from the perspective of payers.

Drug Pricing in South Korea

Between 2000 and 2013, spending on medicines in Korea increased by 275.3%. In order to curb this trend, several pricing policies and measures were introduced. This study reviews these policies and their implications based on pricing regulations as well as a literature review. New medicines now undergo both a reimbursement assessment and price negotiations. The reimbursement of new medicines is based on their cost effectiveness. The prices of new medicines are subsequently fixed through negotiations between the payer, the National Health Insurance Service, and the relevant manufacturer. Generic drugs are automatically priced via a new standard methodology. Repricing mechanisms were complicated and now redundant. Simple and efficient measures rather than complex and inefficient measures are needed to maintain the value-for-money principle for new medicines as well as achieve financial efficiency through price competition among generic drugs.

DRUG DISINVESTMENT FRAMEWORKS: COMPONENTS, CHALLENGES, AND SOLUTIONS

OBJECTIVES

Value assessments of marketed drug technologies have been developed through disinvestment frameworks. Components of these frameworks are varied and implementation challenges are prevalent. The objective of this systematic literature review was to describe disinvestment framework process components for drugs and to report on framework components, challenges, and solutions.

METHODS

A systematic literature search was conducted using the terms: reassessment, reallocation, reinvestment, disinvestment, delist, decommission or obsolescence in MEDLINE, EMBASE, NLM PubMed, the Cochrane Library, and CINAHL from January 1, 2000, until November 14, 2015. Additional citations were identified through a gray literature search of Health Technology Assessment international (HTAi) and the International Network of Agencies for Health Technology Assessment (INAHTA) member Web sites and from bibliographies of full-text reviewed manuscripts.

RESULTS

Sixty-three articles underwent full text review and forty were included in the qualitative analysis. Framework components including disinvestment terms and definitions, identification and prioritization criteria and methods, assessment processes, stakeholders and dissemination strategies, challenges, and solutions were compiled. This review finds that stakeholders lack the political, administrative, and clinical will to support disinvestment and that there is not one disinvestment framework that is considered best practice.

CONCLUSIONS

Drug technology disinvestment components and processes vary and challenges are numerous. Future research should focus on lessening value assessment challenges. This could include adopting more neutral framework terminology, setting fixed reassessment timelines, conducting therapeutic reviews, and modifying current qualitative decision-making assessment frameworks.