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Litvinova Y, Merkur S, Allin S, Angulo-Pueyo E, Behmane D, Bernal-Delgado E, Dalmas M, De Belvis A, Edwards N, Estupiñán-Romero F, Gaal P, Gerkens S, Jamieson M, Morsella A, Picecchi D, Røshol H, Saunes IS, Sullivan T, Szécsényi-Nagy B, Vijver IVD, Walter R, Panteli D. Availability and financing of CAR-T cell therapies: A cross-country comparative analysis. Health Policy 2024; 149:105153. [PMID: 39270403 DOI: 10.1016/j.healthpol.2024.105153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/12/2024] [Accepted: 08/28/2024] [Indexed: 09/15/2024]
Abstract
Chimeric antigen receptor T-cell therapies (CAR-T therapies) are a type of advanced therapy medicinal product (ATMP) that belong to a new generation of personalised cancer immunotherapies. This paper compares the approval, availability and financing of CAR-T cell therapies in ten countries. It also examines the implementation of this type of ATMP within the health care system, describing the organizational elements of CAR-T therapy delivery and the challenges of ensuring equitable access to all those in need, taking a more systems-oriented view. It finds that the availability of CAR-T therapies varies across countries, reflecting the heterogeneity in the organization and financing of specialised care, particularly oncology care. Countries have been cautious in designing reimbursement models for CAR-T cell therapies, establishing limited managed entry arrangements under public payers, either based on outcomes or as an evidence development scheme to allow for the study of real-world therapeutic efficacy. The delivery model of CAR-T therapies is concentrated around existing experienced cancer centres and highlights the need for high networking and referral capacity. Some countries have transparent and systematic eligibility criteria to help ensure more equitable access to therapies. Overall, as with other pharmaceuticals, there is limited transparency in pricing, eligibility criteria and budgeting decisions in this therapeutic area.
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Affiliation(s)
- Yulia Litvinova
- Department of Health Care Management, Berlin University of Technology, Str. des 17. Juni 135, H80, 10623 Berlin, Germany.
| | - Sherry Merkur
- European Observatory on Health Systems and Policies, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK.
| | - Sara Allin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Toronto, ON M5T 3M6, Canada.
| | - Ester Angulo-Pueyo
- Data Science for Health Services and Policy Research Group, Institute for Health Sciences, IACS, San Juan Bosco 13 50009 Zaragoza, Spain.
| | - Daiga Behmane
- Institute of Public, Riga Stradins University, 26a Anniņmuižas bulvāris, Rīga, Latvia.
| | - Enrique Bernal-Delgado
- Data Science for Health Services and Policy Research Group, Institute for Health Sciences, IACS, San Juan Bosco 13 50009 Zaragoza, Spain.
| | - Miriam Dalmas
- Office of the Chief Medical Officer, Department of Policy in Health, Ministry for Health, Palazzo Castellania, 15, Merchants str., Valletta, Malta VLT 1171.
| | - Antonio De Belvis
- Università Cattolica del Sacro Cuore, Largo F. Vito, 1 00168 Rome, Italy.
| | - Nigel Edwards
- Nuffield Trust, 59 New Cavendish Street, London, W1G 7LP, England UK.
| | - Francisco Estupiñán-Romero
- Data Science for Health Services and Policy Research Group, Institute for Health Sciences, IACS, San Juan Bosco 13 50009 Zaragoza, Spain.
| | - Peter Gaal
- Health Services Management Training Centre, Semmelweis University, Kútvölgyi út 2., 1125 Budapest, Hungary.
| | - Sophie Gerkens
- Belgian Health Care Knowledge Centre (KCE), Boulevard du Jardin Botanique 55, 1000 Brussels, Belgium.
| | - Margaret Jamieson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Toronto, ON M5T 3M6, Canada.
| | - Alisha Morsella
- Università Cattolica del Sacro Cuore, Largo F. Vito, 1 00168 Rome, Italy.
| | - Dario Picecchi
- Faculty of Law, University of Luezern, Frohburgstrasse 3, 6002 Lucerne Switzerland
| | - Hilde Røshol
- Norwegian Medicines Agency, Grensesvingen 26, 0663 Oslo, Norway.
| | - Ingrid Sperre Saunes
- Division for Health Services, Norwegian Institute of Public Health, PO Box 222 Skøyen, N-0213 Oslo, Norway.
| | - Terry Sullivan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Toronto, ON M5T 3M6, Canada.
| | - Balázs Szécsényi-Nagy
- Health Services Management Training Centre, Semmelweis University, Kútvölgyi út 2., 1125 Budapest, Hungary.
| | - Inneke Van De Vijver
- National Institute for Health and Disability Insurance (RIZIV-INAMI), Directorate Pharmaceutical Policy - Health Care Department, Galileelaan 5/01, 1210 Brussels, Belgium.
| | - Ricciardi Walter
- Università Cattolica del Sacro Cuore, Largo F. Vito, 1 00168 Rome, Italy.
| | - Dimitra Panteli
- European Observatory on Health Systems and Policies, Eurostation (Office 07C024), Place Victor Horta/Victor Hortaplein, 40/30, 1060 Brussels, Belgium.
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García-Parra B, Guiu JM, Povedano MÓ, Modamio P. A scoping review of the role of managed entry agreements in upcoming drugs for amyotrophic lateral sclerosis: learning from the case of spinal muscular atrophy. Amyotroph Lateral Scler Frontotemporal Degener 2024:1-10. [PMID: 39254482 DOI: 10.1080/21678421.2024.2400522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Revised: 08/24/2024] [Accepted: 08/30/2024] [Indexed: 09/11/2024]
Abstract
Introduction: The therapeutic options for spinal muscular atrophy (SMA) are encouraging. However, there is currently no cure for amyotrophic lateral sclerosis (ALS). The clinical and economic uncertainty surrounding innovative treatments for rare neurodegenerative diseases makes it necessary to understand managed entry agreements (MEAs). The aim of this study was to review whether models of MEAs in SMA could be extrapolated to ALS. Methods: We performed a scoping review with information on MEAs on SMA in Web of Science (WOS), PubMed, Lyfegen Library, the National Institute for Health and Care Excellence (NICE), and the Canadian Agency for Drugs and Technologies in Health (CADTH). Results: We found 45 results in WOS and PubMed. After an initial survey, 10 were reviewed to assess eligibility, and three were selected. We obtained 44 results from Lyfegen Library, and three results each from NICE and CADTH. Conclusion: The main objective of MEAs is to reduce uncertainty in the financing of drugs with a high budgetary impact and clinical concerns, as is the case with drugs for SMA and ALS. While the information available on MEAs in SMA is scarce, some conceptual models are publicly available. MEAs for long-term treatments for SMA could be used for the design of MEAs in ALS because of their similarities in economic and clinical uncertainty.
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Affiliation(s)
- Beliu García-Parra
- Clinical Neurophysiology Section - Neurology Service, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Josep M Guiu
- Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry, Faculty of Pharmacy and Food Sciences, Clinical Pharmacy and Pharmaceutical Care Unit, University of Barcelona, Barcelona, Spain, and
| | - MÓnica Povedano
- Clinical Neurophysiology Section - Neurology Service, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
- Motor Neuron Diseases Unit, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Pilar Modamio
- Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry, Faculty of Pharmacy and Food Sciences, Clinical Pharmacy and Pharmaceutical Care Unit, University of Barcelona, Barcelona, Spain, and
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Visacri MB, Ribeiro MC, Komoda DS, Duarte BKL, Correa CRS, Maia FDOM, Alves DFDS. Lenalidomide or Thalidomide for Transplant-Ineligible Patients With Newly Diagnosed Multiple Myeloma? An Overview of Systematic Reviews. Value Health Reg Issues 2024; 43:100998. [PMID: 38718736 DOI: 10.1016/j.vhri.2024.100998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 08/28/2024]
Abstract
OBJECTIVES To present an overview of evidence of efficacy, safety, and health-related quality of life of lenalidomide or thalidomide for transplant-ineligible multiple myeloma. METHODS A literature search was performed in 5 databases until July 2022. We included systematic reviews with network meta-analyses of randomized controlled trials on the use of lenalidomide compared with thalidomide for transplant-ineligible multiple myeloma. The A Measurement Tool to Assess Systematic Reviews 2 was used to appraise the quality of included reviews. The results were focused on the lenalidomide + dexamethasone until disease progression (RDc) versus thalidomide + dexamethasone until disease progression (TDc) and induction with melphalan + prednisone + lenalidomide, followed by maintenance with lenalidomide (MPR-R) versus induction with melphalan + prednisone + thalidomide, followed by maintenance with thalidomide (MPT-T) regimens. RESULTS Nine studies were included. Only 1 study did not show any weakness in critical domains of A Measurement Tool to Assess Systematic Reviews 2. For overall survival, RDc proved to be superior to TDc; however, no study showed significant difference between MPR-R and MPT-T. For progression-free survival, 2 of 3 studies showed that RDc is better than TDc; however, no difference between MPR-R and MPT-T was found. Regarding safety, these lenalidomide-based regimens had a lower risk for neurologic adverse events, with an increased risk of hematologic adverse events. No health-related quality of life meta-analyses were found. CONCLUSIONS These findings suggest that, in terms of efficacy and safety, lenalidomide-based regimen is a good option for treatment of transplant-ineligible multiple myeloma in the public health system of Brazil, especially for those patients who develop severe neuropathy with thalidomide.
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Towse A, Fenwick E. It Takes 2 to Tango. Setting Out the Conditions in Which Performance-Based Risk-Sharing Arrangements Work for Both Parties. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:1058-1065. [PMID: 38615938 DOI: 10.1016/j.jval.2024.03.2196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVES Faster regulatory approval processes often fail to achieve faster patient access. We seek an approach, using performance-based risk-sharing arrangements, to address uncertainty for payers regarding the relative effectiveness and value for money of products launched through accelerated approval schemes. One important reason for risk sharing is to resolve differences of opinion between innovators and payers about a technology's underlying value. To date, there has been no formal attempt to set out the circumstances in which risk sharing can address these differences. METHODS We use a value of information framework to understand what a performance-based risk-sharing arrangements can, in principle, add to a reimbursement scheme, separating payer perspectives on cost-effectiveness and the value of research from those of the innovator. We find 16 scenarios, developing 5 rules to analyze these 16 scenarios, identifying cases in which risk sharing adds value for both parties. RESULTS We find that risk sharing provides an improved solution in 9 out of 16 combinations of payer and innovator expectations about treatment outcome and the value of further research. Among our assumptions, who pays for research and scheme administration costs are key. CONCLUSIONS Steps should be undertaken to make risk sharing more practical, ensuring that payers consider it an option. This requires additional costs to the health system falling on the innovator in an efficient way that aligns incentives for product development for global markets. Health systems benefits are earlier patient access to cost-effective treatments and payers with higher confidence of not wasting money. Innovators get greater returns while conducting research.
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Affiliation(s)
- Adrian Towse
- Senior Visiting Fellow, Office of Health Economics, London, UK.
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5
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Gagnon MA. Commentary: Which Principles Should Apply for a National Strategy on Rare Diseases? Healthc Policy 2024; 19:27-31. [PMID: 39229660 PMCID: PMC11411644 DOI: 10.12927/hcpol.2024.27353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024] Open
Abstract
Lexchin and Sirrs (2024) proposed five relevant principles to guide the use of federal funding for expensive drugs for rare diseases, including funding of outcomes-based risk-sharing agreements (OBRSAs) and proactive commitment and participation in the generation of high-quality evidence in a transparent way. This rejoinder, however, questions whether the federal funding should be used only to buy new drugs or whether it could be used to develop new drugs as well. It also examines what OBRSAs would require in terms of institutional capacities to allow the collection of real-world evidence.
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Affiliation(s)
- Marc-AndrÉ Gagnon
- Associate Professor, School of Public Policy and Administration, Carleton University, Ottawa, ON
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6
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Callenbach MHE, Schoenmakers D, Vreman RA, Vijgen S, Timmers L, Hollak CEM, Mantel-Teeuwisse AK, Goettsch WG. Illustrating the Financial Consequences of Outcome-Based Payment Models From a Payers Perspective: The Case of Autologous Gene Therapy Atidarsagene Autotemcel (Libmeldy®). VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:1046-1057. [PMID: 38795960 DOI: 10.1016/j.jval.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 04/12/2024] [Accepted: 05/04/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVES To illustrate the financial consequences of implementing different managed entry agreements (managed entry agreements for the Dutch healthcare system for autologous gene therapy atidarsagene autotemcel [Libmeldy]), while also providing a first systematic guidance on how to construct managed entry agreements to aid future reimbursement decision making and create patient access to high-cost, one-off potentially curative therapies. METHODS Three payment models were compared: (1) an arbitrary 60% price discount, (2) an outcome-based spread payment with discounts, and (3) an outcome-based spread payment linked to a willingness to pay model with discounts. Financial consequences were estimated for full responders (A), patients responding according to the predicted clinical pathway presented in health technology assessment reports (B), and unstable responders (C). The associated costs for an average patient during the time frame of the payment agreement, the total budget impact, and associated benefits expressed in quality-adjusted life-years of the patient population were calculated. RESULTS When patients responded according to the predicted clinical pathway presented in health technology assessment reports (scenario B), implementing outcome-based reimbursement models (models 2 and 3) had lower associated budget impacts while gaining similar benefits compared with the discount (scenario 1, €8.9 million to €6.6 million vs €9.2 million). In the case of unstable responders (scenario C), costs for payers are lower in the outcome-based scenarios (€4.1 million and €3.0 million, scenario 2C and 3C, respectively) compared with implementing the discount (€9.2 million, scenario 1C). CONCLUSIONS Outcome-based models can mitigate the financial risk of reimbursing atidarsagene autotemcel. This can be considerably beneficial over simple discounts when clinical performance was similar to or worse than predicted.
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Affiliation(s)
- Marcelien H E Callenbach
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Daphne Schoenmakers
- Department of Child Neurology, Expertise Center Amsterdam Leukodystrophy Center, including lead of MLDi registry, Emma's Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands; Medicine for Society, Platform at Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Rick A Vreman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands; National Health Care Institute (ZIN), Diemen, The Netherlands
| | - Sylvia Vijgen
- National Health Care Institute (ZIN), Diemen, The Netherlands
| | - Lonneke Timmers
- National Health Care Institute (ZIN), Diemen, The Netherlands
| | - Carla E M Hollak
- Medicine for Society, Platform at Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Department of Endocrinology and Metabolism, Expertise Center for Inborn Errors of Metabolism, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Wim G Goettsch
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands; National Health Care Institute (ZIN), Diemen, The Netherlands.
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Wiedmann LA, Cairns JA, Nolte E. Evidence Quality and Health Technology Assessment Outcomes in Reappraisals of Drugs for Rare Diseases in Germany. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024:S1098-3015(24)02795-5. [PMID: 39094688 DOI: 10.1016/j.jval.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 06/08/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES Evidence on reappraisals of health technologies in Germany is limited, and for rare disease treatments (RDTs), the Federal Joint Committee follows different processes (limited or regular), depending on whether an annual revenue threshold has been exceeded. Our objective is to better understand (re)appraisal processes and their outcomes for RDTs in Germany. METHODS We analyzed appraisal documents of 55 RDT indications for which an initial appraisal and a reappraisal were conducted between 2011 and 2023. We extracted information for the type of evidence, the risk of bias, the availability of additional evidence, and the change in the maturity of survival data as proxies for evidence quality. Specifically, we reviewed the reasons for conducting reappraisals, examined how evidence quality and the clinical benefit rating (CBR) differed between initial appraisals and reappraisals, and explored the association between evidence quality and (1) the CBR and (2) the change in the CBR after reappraisal. RESULTS Most reappraisals were conducted because the annual revenue threshold was exceeded or the initial appraisal resolution was time limited. Almost all initial appraisals used the limited process, whereas the majority of reappraisals used the regular process. The CBR increased in only 9 and decreased in 21 of 55 reappraisals. There was some evidence that reappraisals with an accepted randomized controlled trial were significantly more likely to achieve a higher CBR. CONCLUSIONS Findings confirmed that reasons and processes for conducting reappraisals of RDTs in Germany differ. Further, high CBRs in reappraisals were not common and evidence quality in initial appraisals and reappraisals was limited.
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Affiliation(s)
- Lea A Wiedmann
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England, UK.
| | - John A Cairns
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England, UK
| | - Ellen Nolte
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England, UK
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Callenbach MHE, Goettsch WG, Mantel-Teeuwisse AK, Trusheim M. Creating win-win-win situations with managed entry agreements? Prioritizing gene and cell therapies within the window of opportunity. Drug Discov Today 2024; 29:104048. [PMID: 38830504 DOI: 10.1016/j.drudis.2024.104048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/06/2024] [Accepted: 05/29/2024] [Indexed: 06/05/2024]
Abstract
Outcome-based reimbursement models are gaining attention for managing the clinical uncertainties and financial impact of gene and cell therapies. Little guidance exists on how such models can create win-win-win situations, benefiting health-care payers, health-technology developers and patients. Our innovative approach prospectively prioritizes therapies for which a 'window of opportunity' might occur through the analysis of health-technology assessments and product characteristics. Within this window, one size does not fit all, and depending on the extent of clinical uncertainty and potential added benefit levels, different win-win-win situations exist in the United States, the United Kingdom and the Netherlands. Dutch Horizon scanning data prioritized etranacogene dezaparvovec (Hemgenix) and mozafancogene autotemcel for their potential to benefit from outcome-based reimbursement models. These insights extend beyond gene and cell therapies, and could help to provide sustainable health care and patient access to innovative therapies.
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Affiliation(s)
- Marcelien H E Callenbach
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Wim G Goettsch
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands; National Health Care Institute (ZIN), Diemen, the Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
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Grand TS, Ren S, Hall J, Åström DO, Regnier S, Thokala P. Issues, Challenges and Opportunities for Economic Evaluations of Orphan Drugs in Rare Diseases: An Umbrella Review. PHARMACOECONOMICS 2024; 42:619-631. [PMID: 38616217 PMCID: PMC11126517 DOI: 10.1007/s40273-024-01370-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/03/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND AND OBJECTIVES There are significant challenges when obtaining clinical and economic evidence for health technology assessments of rare diseases. Many of them have been highlighted in previous systematic reviews but they have not been summarised in a comprehensive manner. For all stakeholders working with rare diseases, it is important to be aware and understand these issues. The objective of this review is to identify the main challenges for the economic evaluation of orphan drugs in rare diseases. METHODS An umbrella review of systematic reviews of economic studies concerned with orphan and ultra-orphan drugs was conducted. Studies that were not systematic reviews, or on advanced therapeutic medicinal products, personalised medicines or other interventions that were not considered orphan drugs were excluded. The database searches included publications from 2010 to 2023, and were conducted in MEDLINE, EMBASE and the Cochrane library using filters for systematic reviews, and economic evaluations and models. These filters were combined with search terms for rare diseases and orphan drugs. A hand search supplemented the literature searches. The findings were reported by a compliant Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. RESULTS Two hundred and eighty-two records were identified from the literature searches, of which 64 were duplicates, whereas five reviews were identified from the hand search. A total of 36 reviews were included after screening against inclusion/exclusion criteria, 35 from literature searches and one from hand searching. Of those studies 1, 27 and 8 were low, moderate and high quality, respectively. The reviews highlight the scarcity of evidence for health economic parameters, for example, clinical effectiveness, costs, quality of life and the natural history of disease. Health economic evaluations such as cost-effectiveness and budget-impact analyses were scarce, and generally low-to-moderate quality. The causes were limited health economic parameters, together with publications bias, especially for cost-effectiveness analyses. CONCLUSIONS The results highlighted issues around a considerable paucity of evidence for economic evaluations and few cost-effectiveness analyses, supporting the notion that a paucity of evidence makes economic evaluations of rare diseases more challenging compared with more prevalent diseases. Furthermore, we provide recommendations for more sustainable approaches in economic evaluations of rare diseases.
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Affiliation(s)
- Tobias Sydendal Grand
- Sheffield Centre for Health and Related Research (SCHARR), University of Sheffield, 30 Regent Street, Sheffield, S1 4DA, UK.
- Lundbeck A/S, Copenhagen, Denmark.
| | - Shijie Ren
- Sheffield Centre for Health and Related Research (SCHARR), University of Sheffield, 30 Regent Street, Sheffield, S1 4DA, UK
| | - James Hall
- Institute of Applied Health Research, Health Economics Unit, University of Birmingham, Edgbaston, Birmingham, UK
| | | | | | - Praveen Thokala
- Sheffield Centre for Health and Related Research (SCHARR), University of Sheffield, 30 Regent Street, Sheffield, S1 4DA, UK
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Fernandez J, Babin C, Thomassin C, Pelon F, Kelley S, Cochat P, Galbraith M, Berdaï D, Pariente A, Salvo F, Vanier A. Can requests for real-world evidence by the French HTA body be planned? An exhaustive retrospective case-control study of medicinal products appraisals from 2016 to 2021. Int J Technol Assess Health Care 2024; 40:e33. [PMID: 38757153 DOI: 10.1017/s0266462324000291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
OBJECTIVES In France, decisions for pricing and reimbursement for medicinal products are based on appraisals performed by the National authority for health (Haute Autorité de Santé (HAS)). During the appraisal process, additional real-world evidence can be requested as "Post-Registration Studies" (PRS) when there are uncertainties in evidence that could be resolved by additional data collection. To facilitate PRS planning, a retrospective exploratory analysis was conducted to identify the characteristics of medicinal products associated with a PRS request. METHODS This analysis encompassed all appraisals finalized between January 1, 2016 and December 31, 2021 and compared products for which the appraisal led to a PRS request with those that did not. RESULTS Six hundred positive opinions for reimbursement were identified, with a PRS request present in 17 percent (n = 103) of cases. The independent characteristics associated with a PRS request were a mild or moderate clinical benefit score, a major to moderate or minor clinical added value score, previous availability under an early access program, and certain therapeutic areas (neurology, pulmonology, and endocrinology). These findings suggest two different profiles of PRS requests: (i) products for which there is uncertainty in the size of the clinical benefit and (ii) innovative products for which a substantial benefit is expected but uncertainties persist. CONCLUSIONS These results will assist health technology developers to better anticipate data generation to promptly address uncertainties identified by HAS. It may also help HAS and other assessment agencies to work together to improve postlaunch evidence generation according to the characteristics of the medicinal products.
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Affiliation(s)
- Judith Fernandez
- HTA Department, Haute Autorité de Santé, La Plaine Saint-Denis, France
| | - Céleste Babin
- HTA Department, Haute Autorité de Santé, La Plaine Saint-Denis, France
| | - Camille Thomassin
- HTA Department, Haute Autorité de Santé, La Plaine Saint-Denis, France
| | - Floriane Pelon
- HTA Department, Haute Autorité de Santé, La Plaine Saint-Denis, France
| | - Sophie Kelley
- HTA Department, Haute Autorité de Santé, La Plaine Saint-Denis, France
| | - Pierre Cochat
- Scientific Board and Chairman of the Transparency Committee, Haute Autorité de Santé, La Plaine Saint-Denis, France
| | | | - Driss Berdaï
- CHU de Bordeaux, Pharmacoepidemiology and Appropriate use of Medicine Team, Public Health Department, Clinical Pharmacology Unit Bordeaux, Nouvelle-Aquitaine, France
| | - Antoine Pariente
- CHU de Bordeaux, Pharmacoepidemiology and Appropriate use of Medicine Team, Public Health Department, Clinical Pharmacology Unit Bordeaux, Nouvelle-Aquitaine, France
- University of Bordeaux, INSERM, BPH, U1219, Team AHeaD Talence, Aquitaine, France
| | - Francesco Salvo
- University of Bordeaux, INSERM, BPH, U1219, Team AHeaD Talence, Aquitaine, France
- CHU de Bordeaux, Regional center for pharmacovigilance Public Health Department, Clinical Pharmacology Unit Bordeaux, Nouvelle-Aquitaine, France
| | - Antoine Vanier
- HTA Department, Haute Autorité de Santé, La Plaine Saint-Denis, France
- Université de Tours, UMR U1246 Sphere, Inserm Tours, Centre-Val de Loire, France
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Douglas CMW, Grunebaum S. Lessons learned from the Canadian Fabry Disease Initiative for future risk-sharing and managed access agreements for pharmaceutical and advanced therapies in Canada. Health Policy 2024; 143:105044. [PMID: 38508062 DOI: 10.1016/j.healthpol.2024.105044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/05/2023] [Accepted: 03/12/2024] [Indexed: 03/22/2024]
Abstract
Risk sharing agreements (RSAs) and managed access agreements have emerged as tools to overcome evidentiary uncertainty and contain costs of pharmaceuticals; however, Canada has relatively little experience with these health policy instruments. This article describes one of the few examples of national RSAs. Enzyme replacement therapies (ERT) were introduced in Canada to treat Fabry disease in the early 2000s through an RSA. Based on qualitative interviews with key participating actors, this article explains how this RSA ensured continuity of treatment for patients already on ERT, and collected robust real-world evidence to secure treatment for future Fabry patients. We show the importance of partnerships, collaborations, and active patient communities in establishing RSAs, as well as the critical role of robust registries for the collection, storage, and use of that real-world data. In doing so, this paper points to reasons that explain the relative dearth of RSAs in Canada, which can be resource (both human and finance) intensive and are difficult to broker in a federalist health system. Through these findings, policy lessons are developed concerning the need for technological and governance platforms on how RSA in Canada can be more effectively supported going forward in a broader move towards "social pharmaceutical innovation".
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Affiliation(s)
- Conor M W Douglas
- Department of Science, Technology & Society, Faculty of Sciences, York University, 307 Bethune College, 4700 Keele St., Toronto ON, Canada M3J 1P3.
| | - Shir Grunebaum
- Department of Science, Technology & Society, Faculty of Sciences, York University, 307 Bethune College, 4700 Keele St., Toronto ON, Canada M3J 1P3
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Wills A, Mitha A. Financial Characteristics of Outcomes-Based Agreements: What Do Canadian Public Payers and Pharmaceutical Manufacturers Prefer? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:340-346. [PMID: 38154595 DOI: 10.1016/j.jval.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVES This study sought to gain insight into the financial characteristics of outcomes-based agreements (OBAs) considered most suitable to Canadian public payers and pharmaceutical manufacturers, and the rationale for their preferences. METHODS A total of 17 public payers and pharmaceutical manufacturers participated in semistructured qualitative interviews, which assessed their knowledge of OBAs and their preferred financial characteristics. RESULTS Payers identified 5 OBA financial models that they considered both acceptable and feasible, in no preferential order: (1) discontinuation of therapy, (2) rebates for nonresponders, (3) free trial period, (4) adjustable pricing, and (5) blended rebate. Payers had a clear preference for short-term OBAs (<1 year), whereas both payers and manufacturers agreed OBAs with longer durations (up to 5 years) would be manageable if appropriately designed. Six key success factors to design suitable and acceptable OBA financial models were identified, including the areas of interim reporting, easily measurable health outcomes, trusted data sources, engaging unbiased third-party data experts, harmonizing OBA billing methods, and the inclusion of budget caps. CONCLUSIONS Manufacturers and payers showed high level of interest in OBAs and a robust understanding of their potential role in supporting timely market access for patients in need, with the caveat that they need to be carefully designed to provide value. Further opportunities for discussion and engagement between public payers and manufacturers are needed to establish how to implement OBAs at a pan-Canadian level and how individual provinces and territories can incorporate them within their existing governance infrastructures.
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Dayer VW, Drummond MF, Dabbous O, Toumi M, Neumann P, Tunis S, Teich N, Saleh S, Persson U, von der Schulenburg JMG, Malone DC, Salimullah T, Sullivan SD. Real-world evidence for coverage determination of treatments for rare diseases. Orphanet J Rare Dis 2024; 19:47. [PMID: 38326894 PMCID: PMC10848432 DOI: 10.1186/s13023-024-03041-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/19/2024] [Indexed: 02/09/2024] Open
Abstract
Health technology assessment (HTA) decisions for pharmaceuticals are complex and evolving. New rare disease treatments are often approved more quickly through accelerated approval schemes, creating more uncertainties about clinical evidence and budget impact at the time of market entry. The use of real-world evidence (RWE), including early coverage with evidence development, has been suggested as a means to support HTA decisions for rare disease treatments. However, the collection and use of RWE poses substantial challenges. These challenges are compounded when considered in the context of treatments for rare diseases. In this paper, we describe the methodological challenges to developing and using prospective and retrospective RWE for HTA decisions, for rare diseases in particular. We focus attention on key elements of study design and analyses, including patient selection and recruitment, appropriate adjustment for confounding and other sources of bias, outcome selection, and data quality monitoring. We conclude by offering suggestions to help address some of the most vexing challenges. The role of RWE in coverage and pricing determination will grow. It is, therefore, necessary for researchers, manufacturers, HTA agencies, and payers to ensure that rigorous and appropriate scientific principles are followed when using RWE as part of decision-making.
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Affiliation(s)
- Victoria W Dayer
- CHOICE Institute, School of Pharmacy, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
| | | | - Omar Dabbous
- Novartis Gene Therapies, Inc., Bannockburn, IL, USA
| | - Mondher Toumi
- Faculty of Medicine, Public Health Department, Aix-Marseille University, Marseille, France
| | | | | | | | - Shadi Saleh
- American University of Beirut, Beirut, Lebanon
| | - Ulf Persson
- The Swedish Institute for Health Economics, Lund, Sweden
| | | | - Daniel C Malone
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | | | - Sean D Sullivan
- CHOICE Institute, School of Pharmacy, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
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Gladwell D, Ciani O, Parnaby A, Palmer S. Surrogacy and the Valuation of ATMPs: Taking Our Place in the Evidence Generation/Assessment Continuum. PHARMACOECONOMICS 2024; 42:137-144. [PMID: 37991631 DOI: 10.1007/s40273-023-01334-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 11/23/2023]
Abstract
Medical technology is advancing rapidly, but established methods for health technology assessment are struggling to keep up. This challenge is particularly stark for the assessment of advanced therapy medicinal products-therapies often launched on the basis of single-arm studies powered to a surrogate primary endpoint. The most robust surrogacy methods investigate trial-level correlations between the treatment effect on the surrogate and the outcome of ultimate interest. However, these methods are often impossible with the evidence usually available for advanced therapy medicinal products at the time of the launch (randomized controlled trials are necessary for these advanced methods). Additionally, these surrogacy relationships are usually considered to be technology specific, adding uncertainty for any approach that primarily relies on historic data to estimate the surrogacy relationship for novel interventions such as advanced therapy medicinal products. The literature has already highlighted the need for early dialogue, staged assessment processes, and pricing arrangements that responsibly share the risk between the manufacturer and payer. However, it is our view that in addition to these critical developments, the modeling methods employed could also improve. Currently, health technology assessment practitioners typically either ignore the surrogate and simply extrapolate the endpoint of greatest patient relevance irrespective of the degree of maturity or assume historic surrogate relationships apply to the novel technology. In this opinion piece, we outline an additional avenue. By drawing on the understanding of the mechanism of action and insights generated earlier in the evidence generation/assessment continuum, cost-effectiveness modelers can make better use of the wider data available. These efforts are expected to reduce uncertainty at the time of the initial launch of pharmaceutical products and increase the value of subsequent data collection efforts.
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Affiliation(s)
| | | | | | - Stephen Palmer
- Centre for Health Economics (CHE), University of York, York, UK
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15
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Peasah SK, Huang Y, Venditto J, Brekosky R, Belletti D, Campbell V, Manolis C, Good CB. Ticagrelor versus clopidogrel for recurrent myocardial infarction: An outcomes-based agreement. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 12:100347. [PMID: 37920750 PMCID: PMC10618484 DOI: 10.1016/j.rcsop.2023.100347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 09/13/2023] [Accepted: 10/10/2023] [Indexed: 11/04/2023] Open
Abstract
Background Outcomes-based agreements (OBA) are performance-based risk-sharing agreements between manufacturers and payers which provide the opportunity for collection and evaluation of real-world outcomes to supplement clinical trials. Objectives To describe an OBA comparing ticagrelor to clopidogrel in patients admitted with acute coronary syndrome (ACS) and proportion of recurrent myocardial infarction (MI) in a real-world setting. Methods Commercial (CM) and Medicare (MC) insurance patients of a large regional health plan, who presented with ACS and were prescribed either ticagrelor or clopidogrel were prospectively analyzed. The cohort consisted of adults (18-85 years) discharged between January 1, 2019, and December 31, 2020, who were adherent to the study medications, within the confines of the OBA. The primary outcome of interest was the proportion of recurrent MI hospitalizations within one year of discharge. Results There were 500 patients who met inclusion criteria in the ticagrelor cohort and 648 in the clopidogrel cohort. The mean age of patients in the ticagrelor cohort was 61.5 ± 10.5 years old and 66.5 ± 10.2 years in the clopidogrel cohort. The proportion of patients with type 2 diabetes, hypertension, or a history of congestive heart failure at baseline in the ticagrelor cohort was 31%, 85%, 14% respectively, and 43%, 90%, and 32% respectively in the clopidogrel cohort. The overall proportion of hospitalization for recurrent MI was 1.00% in the ticagrelor and 3.13% in the clopidogrel cohorts. In the follow-up propensity-matched analysis, although recurrent MI hospitalization was higher in the clopidogrel cohort (1.69% vs 1.21%) it was not statistically significant (p-value 0.5242). Conclusion Patients presenting with ACS and treated with ticagrelor had a lower rate of hospitalization for recurrent MI compared to patients treated with clopidogrel cohort within the confines of an OBA in a real-world setting.
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Affiliation(s)
- Samuel K. Peasah
- Value-Based Pharmacy Initiatives, Center for High Value HealthCare, UPMC Health Plan, India
| | - Yan Huang
- Value-Based Pharmacy Initiatives, Center for High Value HealthCare, UPMC Health Plan, India
| | | | | | | | | | | | - Chester B. Good
- Value-Based Pharmacy Initiatives, Center for High Value HealthCare, UPMC Health Plan, India
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Rejon-Parrilla JC, Espin J, Garner S, Kniazkov S, Epstein D. Pricing and reimbursement mechanisms for advanced therapy medicinal products in 20 countries. Front Pharmacol 2023; 14:1199500. [PMID: 38089054 PMCID: PMC10715052 DOI: 10.3389/fphar.2023.1199500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/06/2023] [Indexed: 02/12/2024] Open
Abstract
Introduction: Advanced Therapy Medicinal Products are a type of therapies that, in some cases, hold great potential for patients without an effective current therapeutic approach but they also present multiple challenges to payers. While there are many theoretical papers on pricing and reimbursement (P&R) options, original empirical research is very scarce. This paper aims to provide a comprehensive international review of regulatory and P&R decisions taken for all ATMPs with centralized European marketing authorization in March 2022. Methods: A survey was distributed in July 2022 to representatives of 46 countries. Results: Responses were received from 20 countries out of 46 (43.5%). 14 countries reimbursed at least one ATMP. Six countries in this survey reimbursed no ATMPs. Conclusion: Access to ATMPs is uneven across the countries included in this study. This arises from regulatory differences, commercial decisions by marketing authorization holders, and the divergent assessment processes and criteria applied by payers. Moving towards greater equality of access will require cooperation between countries and stakeholders, for example, through the WHO Regional Office for Europe's Access to Novel Medicines Platform.
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Affiliation(s)
- Juan Carlos Rejon-Parrilla
- Health Technology Assessment Area (AETSA), Andalusian Public Foundation Progress and Health (FPS), Seville, Spain
| | - Jaime Espin
- Andalusian School of Public Health, Granada, Spain
- Instituto de Investigación Biosanitaria ibs, Granada, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Cátedra de Economía de la Salud y Dirección de Organizaciones Sanitarias (Esalud2), Granada, Spain
| | - Sarah Garner
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Stanislav Kniazkov
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - David Epstein
- Department of Applied Economics, University of Granada, Granada, Spain
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Horrow C, Kesselheim AS. Confronting High Costs And Clinical Uncertainty: Innovative Payment Models For Gene Therapies. Health Aff (Millwood) 2023; 42:1532-1540. [PMID: 37931198 DOI: 10.1377/hlthaff.2023.00527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Gene therapies offer potentially life-changing benefits for patients, but their unprecedented high prices exacerbate challenges for reimbursement. Payers must confront high budgetary impacts, as a large up-front payment for each patient makes it difficult to predict and absorb costs. Payers also face considerable clinical uncertainty, as evidence for efficacy and durability is limited at approval. Alternative payment models may address these reimbursement problems and ensure equitable patient access. We developed a taxonomy of possible payment mechanisms for gene therapies, including installments, risk pools, reinsurance, price-volume agreements, expenditure caps, subscriptions, outcomes-based payments and rebates, warranties, population outcomes-based agreements, and coverage with evidence development. We illustrate how these payment models take three main approaches: amortization, which mitigates initial budget impact by spreading payments over time; risk spreading, which makes budgets more predictable by pooling costs with other payers or capping costs based on expected volume; and performance-based payment, which addresses clinical uncertainty by tying prices to patient- or population-level outcomes. We discuss each payment model, its advantages and challenges, and considerations for US payers.
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Affiliation(s)
- Caroline Horrow
- Caroline Horrow, Brigham and Women's Hospital, Boston, Massachusetts
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18
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Farmer C, Barnish MS, Trigg LA, Hayward S, Shaw N, Crathorne L, Strong T, Groves B, Spoors J, Melendez Torres GJ. An evaluation of managed access agreements in England based on stakeholder experience. Int J Technol Assess Health Care 2023; 39:e55. [PMID: 37497570 DOI: 10.1017/s0266462323000478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVES The objective of this research was to evaluate managed access policy in England, drawing upon the expertise of a range of stakeholders involved in its implementation. METHODS Seven focus groups were conducted with payer and health technology assessment representatives, clinicians, and representatives from industry and patient/carer organizations within England. Transcripts were analyzed using framework analysis to identify stakeholders' views on the successes and challenges of managed access policy. RESULTS Stakeholders discussed the many aims of managed access within the National Health Service in England, and how competing aims had affected decision making. While stakeholders highlighted a number of priorities within eligibility criteria for managed access agreements (MAAs), stakeholders agreed that strict eligibility criteria would be challenging to implement due to the highly variable nature of innovative technologies and their indications. Participants highlighted challenges faced with implementing MAAs, including evidence generation, supporting patients during and after the end of MAAs, and agreeing and reinforcing contractual agreements with industry. CONCLUSIONS Managed access is one strategy that can be used by payers to resolve uncertainty for innovative technologies that present challenges for reimbursement and can also deliver earlier access to promising technologies for patients. However, participants cautioned that managed access is not a "silver bullet," and there is a need for greater clarity about the aims of managed access and how these should be prioritized in decision making. Discussions between key stakeholders involved in managed access identified challenges with implementing MAAs and these experiences should be used to inform future managed access policy.
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Affiliation(s)
- Caroline Farmer
- Peninsula Technology Assessment Group (PenTAG), Department of Public Health and Sport Sciences, University of Exeter Medical School, Exeter, UK
| | - Maxwell S Barnish
- Peninsula Technology Assessment Group (PenTAG), Department of Public Health and Sport Sciences, University of Exeter Medical School, Exeter, UK
| | - Laura A Trigg
- Peninsula Technology Assessment Group (PenTAG), Department of Public Health and Sport Sciences, University of Exeter Medical School, Exeter, UK
| | - Samuel Hayward
- Health and Care Public Health Team, North Somerset Council
| | - Naomi Shaw
- Peninsula Technology Assessment Group (PenTAG), Department of Public Health and Sport Sciences, University of Exeter Medical School, Exeter, UK
| | - Louise Crathorne
- Peninsula Technology Assessment Group (PenTAG), Department of Public Health and Sport Sciences, University of Exeter Medical School, Exeter, UK
| | - Thomas Strong
- Managed Access Team, National Institute for Health and Care Excellence (NICE), London, UK
| | - Brad Groves
- Managed Access Team, National Institute for Health and Care Excellence (NICE), London, UK
| | - John Spoors
- Medicines Value and Access Unit, NHS England, London, UK
| | - G J Melendez Torres
- Peninsula Technology Assessment Group (PenTAG), Department of Public Health and Sport Sciences, University of Exeter Medical School, Exeter, UK
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Iglesias-López C, Agustí A, Vallano A, Obach M. Financing and Reimbursement of Approved Advanced Therapies in Several European Countries. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:841-853. [PMID: 36646280 DOI: 10.1016/j.jval.2022.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 12/01/2022] [Accepted: 12/27/2022] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The uncertainty in the cost-benefit of advanced therapy medicinal products (ATMPs) is a current challenge for their reimbursement in health systems. This study aimed to provide a comparative analysis of the National Health Authorities (NHAs) reimbursement recommendations issued in different European countries. METHODS The NHA reimbursement recommendations for the approved ATMPs were compared among 8 European Union (EU) Countries (EU8: Ireland, England/Wales, Scotland, The Netherlands, France, Germany, Spain, and Italy). The search was carried out until December 31, 2021. RESULTS A total of 19 approved ATMPs and 76 appraisal reports were analyzed. The majority of the ATMPs were reimbursed, although with uncertainty in added therapeutic value. No relationship between the type of the European Medicines Agency approval and reimbursement was found. Managed entry agreements, such as payment by results, were necessary to ensure market access. The main issue during the evaluation was to base the cost-effectiveness analyses on assumptions because of the limited long-term data. The estimated incremental cost-effectiveness ratio among countries reveals high variability. Overall, the median time to NHA recommendation for the EU8 is in the range of 9 to 17 months. CONCLUSIONS Transparent, harmonized, and systematic assessments across the EU NHAs in terms of cost-effectiveness, added therapeutic value, and grade of innovativeness are needed. This could lead to a more aligned access, increasing the EU market attractiveness and raising public fairness in terms of patient access and pricing.
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Affiliation(s)
- Carolina Iglesias-López
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antònia Agustí
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain; Clinical Pharmacology Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Antoni Vallano
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain; Medicines Department, Catalan Healthcare Service, Barcelona, Spain.
| | - Mercè Obach
- Healthcare Planning Department, Catalan Healthcare Service, Barcelona, Spain
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20
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Drummond M, Ciani O, Fornaro G, Jommi C, Dietrich ES, Espin J, Mossman J, de Pouvourville G. How are health technology assessment bodies responding to the assessment challenges posed by cell and gene therapy? BMC Health Serv Res 2023; 23:484. [PMID: 37179322 PMCID: PMC10182681 DOI: 10.1186/s12913-023-09494-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The aims of this research were to provide a better understanding of the specific evidence needs for assessment of clinical and cost-effectiveness of cell and gene therapies, and to explore the extent that the relevant categories of evidence are considered in health technology assessment (HTA) processes. METHODS A targeted literature review was conducted to identify the specific categories of evidence relevant to the assessment of these therapies. Forty-six HTA reports for 9 products in 10 cell and gene therapy indications across 8 jurisdictions were analysed to determine the extent to which various items of evidence were considered. RESULTS The items to which the HTA bodies reacted positively were: treatment was for a rare disease or serious condition, lack of alternative therapies, evidence indicating substantial health gains, and when alternative payment models could be agreed. The items to which they reacted negatively were: use of unvalidated surrogate endpoints, single arm trials without an adequately matched alternative therapy, inadequate reporting of adverse consequences and risks, short length of follow-up in clinical trials, extrapolating to long-term outcomes, and uncertainty around the economic estimates. CONCLUSIONS The consideration by HTA bodies of evidence relating to the particular features of cell and gene therapies is variable. Several suggestions are made for addressing the assessment challenges posed by these therapies. Jurisdictions conducting HTAs of these therapies can consider whether these suggestions could be incorporated within their existing approach through strengthening deliberative decision-making or performing additional analyses.
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Affiliation(s)
- Michael Drummond
- Centre for Health Economics, University of York, York, UK.
- CERGAS, SDA Bocconi School of Management, Milan, Italy.
| | - Oriana Ciani
- CERGAS, SDA Bocconi School of Management, Milan, Italy
| | | | - Claudio Jommi
- CERGAS, SDA Bocconi School of Management, Milan, Italy
| | | | - Jaime Espin
- Andalusian School of Public Health, Andalusia, Spain
| | - Jean Mossman
- Patient Representative and Visiting Senior Research Associate in the Medical Technology Research Group, LSE Health, London School of Economics, London, UK
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Peasah SK, Huang Y, Palli SR, Swart EC, Donato BM, Pimple P, Bovier J, Manolis C, Good CB. Real-world impact of empagliflozin on total cost of care in adults with type 2 diabetes: Results from an outcomes-based agreement. J Manag Care Spec Pharm 2023; 29:152-160. [PMID: 36705285 PMCID: PMC10387982 DOI: 10.18553/jmcp.2023.29.2.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND: Value-based health care is expanding through payment models such as outcomes-based agreements between manufacturers and payers. OBJECTIVE: To describe the total-cost-of-care outcomes of an outcomes-based agreement evaluating the real-world impact of empagliflozin vs other type 2 diabetes mellitus (T2DM) drugs among all patients with T2DM, with and without cardiovascular disease (within and beyond the requirement of the agreement). METHODS: In this prospective real-world analysis, members from the health plan of an integrated health care delivery system from the commercial and Medicare Advantage lines of business, who qualify under the confines of the contract, were included for analysis. Thus, members aged 18 years and older who were continuously enrolled in the identification (January 1, 2018, to December 31, 2018) and measurement periods (≤1 year post-index) with a T2DM diagnosis were retained. Patients using empagliflozin and empagliflozin-combination drugs constituted the empagliflozin group; those using all other antihyperglycemics, the nonempagliflozin group. Patients with type 1 diabetes, or those using metformin or insulin monotherapy, at index were excluded. Eligible members were followed for up to the earliest occurrence of disenrollment date, discontinuation (60-day medication fill gap allowed) of empagliflozin (or nonempagliflozin containing) medication, or the end of the measurement period. We compared, using Student's t-test and summary statistics (for reporting the outcomes agreement) and a propensity-matched difference-in-difference model (for the followup evaluation beyond the requirement of the agreement), the mean all-cause total cost of care (pharmacy plus medical) per patient per month (PPPM) between the 2 groups, including a subgroup of members with a baseline cardiovascular disease diagnosis. RESULTS: There were 4,577 (3,069 and 1,508 in the commercial and Medicare) and 33,712 (15,571 and 18,141 in the commercial and Medicare) in the empagliflozin and nonempagliflozin groups, respectively. The difference in mean total cost PPPM was $75 lower for empagliflozin vs nonempagliflozin groups, driven mainly by lower medical costs in the empagliflozin group (-$465 PPPM). However, the difference was not statistically significant in the propensity score-matched model. CONCLUSIONS: Although empagliflozin had higher pharmacy costs, the total cost of care for patients with T2DM and with established cardiovascular disease were comparable to the group of patients with all other T2DM, driven mainly by lower medical costs. DISCLOSURES: The authors report no conflicts of interest beyond being employees of the 2 organizations involved in this outcomes-based agreement. Ms. Palli is a former employee of Boehringer Ingelheim Pharmaceuticals, Inc., who was affiliated at the time of study conduct.
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Affiliation(s)
- Samuel K Peasah
- Center for High-Value Health Care, UPMC Health Plan, Pittsburgh, PA
| | - Yan Huang
- Center for High-Value Health Care, UPMC Health Plan, Pittsburgh, PA
| | - Swetha R Palli
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT
| | | | | | - Pratik Pimple
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT
| | | | | | - Chester B Good
- Center for High-Value Health Care, UPMC Health Plan, Pittsburgh, PA
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Cheung WY, Cameron C, Mitha A, Wills A. Building infrastructure for outcomes-based agreements in Canada: can administrative health data be used to support an outcomes-based agreement in oncology? Support Care Cancer 2023; 31:5. [PMID: 36512133 PMCID: PMC9747826 DOI: 10.1007/s00520-022-07486-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Outcomes-based agreements (OBAs) have the potential to provide more timely patient access to novel therapies, although they are not suitable for every new medication or reimbursement scenario. The authors of this paper studied how to operationalize an OBA in oncology by leveraging existing real-world data (RWD) infrastructure in the province of Alberta. OBJECTIVE The main objectives were to (1) evaluate which health outcomes in oncology are suitable for OBAs and whether they can be tracked with existing infrastructure, and (2) determine how RWD in oncology can be used to implement an OBA and the expected timing for delivery. METHODS Using the Oncology Outcomes (O2) Group infrastructure and Alberta administrative data, a review of five key oncology outcomes was performed to determine suitability to support an OBA. RESULTS Overall survival and time-to-next-treatment were determined as potentially suitable oncology outcomes for OBAs; progression-free survival, patient-reported outcomes, and return to work were deemed inadequate for OBAs at the current time due to data limitations. CONCLUSIONS Results indicate that it is feasible to leverage RWD to support OBAs in oncology in Alberta, with minimal additional data, resources, and infrastructure. The operational processes and steps to collect and analyze RWD for OBAs were identified, starting with performing an RWD feasibility study. The expected timeframe to fulfill the real-world evidence (RWE) requirements for an OBA is approximately 3 years for cancers with short trajectories.
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Affiliation(s)
- Winson Y. Cheung
- University of Calgary, Cancer Care Alberta, Oncology Outcomes, Calgary, AB Canada
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Reimbursement and payment models in Central and Eastern European as well as Middle Eastern countries: A survey of their current use and future outlook. Drug Discov Today 2023; 28:103433. [PMID: 36372328 DOI: 10.1016/j.drudis.2022.103433] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/01/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Abstract
There is growing interest in innovative reimbursement and payment models in Central and Eastern European (CEE) and Middle Eastern (ME) countries. A questionnaire was sent to payers from CEE and ME countries regarding the current use of, future preferences for and perceived barriers with these models. Twenty-seven healthcare payers from 11 countries completed the survey. Results showed participants preferred using outcome-based reimbursement models and delayed payment models more often; however, currently they are rarely applied. Barriers hindering implementation were mostly related to IT and data infrastructure, measurement issues, transaction costs and the administrative burden. Given these barriers highlighted in our study, policymakers should focus on the development of an implementation framework with contract templates for the preferred reimbursement and payment schemes to aid the feasibility of a successful implementation.
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Callenbach MHE, Vreman RA, Mantel-Teeuwisse AK, Goettsch WG. When Reality Does Not Meet Expectations-Experiences and Perceived Attitudes of Dutch Stakeholders Regarding Payment and Reimbursement Models for High-Priced Hospital Drugs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:340. [PMID: 36612665 PMCID: PMC9819658 DOI: 10.3390/ijerph20010340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 06/17/2023]
Abstract
This study aimed to identify the current experiences with and future preferences for payment and reimbursement models for high-priced hospital therapies in the Netherlands, where the main barriers lie and assess how policy structures facilitate these models. A questionnaire was sent out to Dutch stakeholders (in)directly involved in payment and reimbursement agreements. The survey contained statements assessed with Likert scales, rankings and open questions. The results were analyzed using descriptive statistics. Thirty-nine stakeholders (out of 100) (in)directly involved with reimbursement decision-making completed the survey. Our inquiry showed that currently financial-based reimbursement models are applied most, especially discounts were perceived best due to their simplicity. For the future, outcome-based reimbursement models were preferred, particularly pay-for-outcome models. The main stated challenge for implementation was generating evidence in practice. According to the respondents, upfront payments are currently implemented most often, whereas delayed payment models are preferred to be applied more frequently in the future. Particularly payment-at-outcome-achieved models are preferred; however, they were stated as administratively challenging to arrange. The respondents were moderately satisfied with the payment and reimbursement system in the Netherlands, arguing that the transparency of the final agreements and mutual trust could be improved. These insights can provide stakeholders with future direction when negotiating and implementing innovative reimbursement and payment models. Attention should be paid to the main barriers that are currently perceived as hindering a more frequent implementation of the preferred models and how national policy structures can facilitate a successful implementation.
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Affiliation(s)
- Marcelien H. E. Callenbach
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, 3584 CG Utrecht, The Netherlands
| | - Rick A. Vreman
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, 3584 CG Utrecht, The Netherlands
- National Health Care Institute (ZIN), 1112 ZA Diemen, The Netherlands
| | - Aukje K. Mantel-Teeuwisse
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, 3584 CG Utrecht, The Netherlands
| | - Wim G. Goettsch
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, 3584 CG Utrecht, The Netherlands
- National Health Care Institute (ZIN), 1112 ZA Diemen, The Netherlands
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Cowie MR, Bozkurt B, Butler J, Briggs A, Kubin M, Jonas A, Adler AI, Patrick-Lake B, Zannad F. How can we optimise health technology assessment and reimbursement decisions to accelerate access to new cardiovascular medicines? Int J Cardiol 2022; 365:61-68. [PMID: 35905826 DOI: 10.1016/j.ijcard.2022.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/26/2022] [Accepted: 07/12/2022] [Indexed: 11/18/2022]
Abstract
Regulatory approvals of, and subsequent access to, innovative cardiovascular medications have declined. How much of this decline relates to the final step of gaining reimbursement for new treatments is unknown. Payers and health technology assessment (HTA) bodies look beyond efficacy and safety to assess whether a new drug improves patient outcomes, quality of life, or satisfaction at a cost that is affordable compared to existing treatments. HTA bodies work within a limited healthcare budget, and this is one of the reasons why only half of newly approved drugs are accepted for reimbursement, or receive restricted or "optimised" recommendations from HTA bodies. All stakeholders have the common goal of facilitating access to safe, effective, and affordable treatments to appropriate patients. An important strategy to expedite this is providing optimal data. This is demonstrably facilitated by early (and ongoing) discussions between all stakeholders. Many countries have formal programmes to provide collaborative regulatory and HTA advice to developers. Other strategies include aligning regulatory and HTA processes, increasing use of real-world evidence, formally defining the decision-making process, and educating stakeholders on the criteria for positive decision making. Industry should focus on developing treatments for unmet medical needs, seek early engagement with HTA and regulatory bodies, improve methodologies for optimal price setting, develop internal systems to collaborate with national and international stakeholders, and conduct post-approval studies. Patient involvement in all stages of development, including HTA, is critical to capture the lived experience and priorities of those whose lives will be impacted by new treatment approvals.
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Affiliation(s)
- Martin R Cowie
- Royal Brompton Hospital & School of Cardiovascular Medicine & Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Andrew Briggs
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Maria Kubin
- Department of Integrated Evidence Generation, Bayer AG, Wuppertal, Germany
| | - Adrian Jonas
- National Institute for Health and Care Excellence (NICE), London, UK
| | - Amanda I Adler
- Diabetes Trial Unit, Oxford Centre for Diabetes, Endocrinology, and Metabolism (OCDEM), Oxford, UK
| | - Bray Patrick-Lake
- Department of Strategic Partnerships, Evidation Health, San Mateo, CA, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm Clinical Investigation Center at Institut Lorrain du Coeur et des Vaisseaux, University Hospital of Nancy, Nancy, France
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Stafinski T, Glennie J, Young A, Menon D. HTA decision-making for drugs for rare diseases: comparison of processes across countries. Orphanet J Rare Dis 2022; 17:258. [PMID: 35804398 PMCID: PMC9264608 DOI: 10.1186/s13023-022-02397-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/11/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Drugs for rare diseases (DRDs) offer important health benefits, but challenge traditional health technology assessment, reimbursement, and pricing processes due to limited effectiveness evidence. Recently, modified processes to address these challenges while improving patient access have been proposed in Canada. This review examined processes in 12 jurisdictions to develop recommendations for consideration during formal government-led multi-sectoral discussions currently taking place in Canada.
Methods (i) A scoping review of DRD reimbursement processes, (ii) key informant interviews, (iii) a case study of evaluations for and the reimbursement status of a set of 7 DRDs, and (iv) a virtual, multi-stakeholder consultation retreat were conducted. Results Only NHS England has a process specifically for DRDs, while Italy, Scotland, and Australia have modified processes for eligible DRDs. Almost all consider economic evaluations, budget impact analyses, and patient-reported outcomes; but less than half accept surrogate measures. Disease severity, lack of alternatives, therapeutic value, quality of evidence, and value for money are factors used in all decision-making process; only NICE England uses a cost-effectiveness threshold. Budget impact is considered in all jurisdictions except Sweden. In Italy, France, Germany, Spain, and the United Kingdom, specific factors are considered for DRDs. However, in all jurisdictions opportunities for clinician/patient input are the same as those for other drugs. Of the 7 DRDs included in the case study, the number that received a positive reimbursement recommendation was highest in Germany and France, followed by Spain and Italy. No relationship between recommendation type and specific elements of the pricing and reimbursement process was found. Conclusions Based on the collective findings from all components of the project, seven recommendations for possible action in Canada are proposed. These focus on defining “appropriate access”, determining when a “full” HTA may not be needed, improving coordination among stakeholder groups, developing a Canadian framework for Managed Access Plans, creating a pan-Canadian DRD/rare disease data infrastructure, genuine and continued engagement of patient groups and clinicians, and further research on different decision and financing options, including MAPs. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02397-4.
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Affiliation(s)
- Tania Stafinski
- Health Technology and Policy Unit, School of Public Health, University of Alberta, Edmonton, T6G 1C9, Canada
| | - Judith Glennie
- J. L. Glennie Consulting Inc., Knowledge Broker Consultant, PRISM Research Collaborative, Aurora, Canada
| | - Andrea Young
- Health Technology and Policy Unit, School of Public Health, University of Alberta, Edmonton, T6G 1C9, Canada
| | - Devidas Menon
- Health Technology and Policy Unit, School of Public Health, University of Alberta, Edmonton, T6G 1C9, Canada.
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Xoxi E, Rumi F, Kanavos P, Dauben HP, Gutierrez-Ibarluzea I, Wong O, Rasi G, Cicchetti A. A Proposal for Value-Based Managed Entry Agreements in an Environment of Technological Change and Economic Challenge for Publicly Funded Healthcare Systems. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:888404. [PMID: 35782579 PMCID: PMC9245041 DOI: 10.3389/fmedt.2022.888404] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022] Open
Abstract
Managed entry agreements (MEA) represent one of the main topics of discussion between the European National Payers Authorities. Several initiatives on the subject have been organized over the past few years and the scientific literature is full of publications on the subject. There is currently little international sharing of information between payers, mainly as a result of the confidentiality issues. There are potential benefits from the mutual sharing of information, both about the existence of MEAs and on the outcomes and results. The importance of involving all the players in the decision-making process on market access for a medicinal product (MP) is that it may help to make new therapies available to patients in a shorter time. The aim of this project is to propose a new pathway of value-based MEA (VBMEA), based on the analysis of the current Italian pricing and reimbursement framework. This requires elaboration of a transparent appraisal and MEA details with at least a 24-month contract. The price of the MP is therefore valued based on the analysis of the VBMEA registries of the Italian Medicines Agency. Although the proposal focuses on the Italian context, a similar approach could also be adapted in other nations, considering the particularities of the single health technology assessment (HTA)/payer system.
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Affiliation(s)
- Entela Xoxi
- Postgraduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filippo Rumi
- Postgraduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
- *Correspondence: Filippo Rumi
| | - Panos Kanavos
- London School of Economics and Political Science, London, United Kingdom
| | - Hans-Peter Dauben
- Rheinische Fachhochschule Köln, University for Applied Science, Köln, Germany
| | - Iñaki Gutierrez-Ibarluzea
- BIOEF, Public Foundation of the Department of Health to Promote Innovation and Research in Euskadi, Bilbao, Spain
| | | | - Guido Rasi
- Clinical Trial Center, Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Americo Cicchetti
- Postgraduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
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Fontrier AM. Market access for medicines treating rare diseases: Association between specialised processes for orphan medicines and funding recommendations. Soc Sci Med 2022; 306:115119. [PMID: 35700552 DOI: 10.1016/j.socscimed.2022.115119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 06/03/2022] [Accepted: 06/07/2022] [Indexed: 11/25/2022]
Abstract
Access to medicines treating rare diseases ('orphan medicines') has proven challenging due to high prices and clinical uncertainty. To optimise market access to these medicines, some healthcare systems are implementing specialised pathways and/or processes during marketing authorisation (MA) and/or health technology assessment (HTA). Comparing one setting where these medicines are classed as "orphan" (Scotland) to another where they considered "non-orphan" (Canada), this study aims to explore whether the presence of specialised pathways and processes at MA and HTA levels is associated with more favourable funding recommendations and faster time to market access. A matched sample of 116 medicine-indication pairs with MA approval from 2001 to 2019 in Europe and Canada was identified, and publicly available sources were used for data extraction. Descriptive statistics were used for data analysis. All medicines were commercially marketed in both countries, except one instance in Scotland. In Scotland, more orphan medicines (68.1%) had a favourable HTA recommendation than in Canada (60.4%), while Canada issued more negative HTA recommendations (20.7%) than Scotland (15.5%). Low levels of agreement on HTA recommendations and the main reasons driving recommendations were found between settings. In both countries, medicines with specialised MA approval were less likely to receive negative HTA recommendations than medicines with standard MA. Time to market access was faster in Canada than Scotland, though medicines with specialised MA approval had slower timelines than medicines with standard MA approval in both countries. However, it is unclear whether the presence of orphan designation and HTA specialised processes alone could result in favourable funding recommendations without accounting for other healthcare system-related factors and differences in the decision-making processes across settings. Holistic approaches and better alignment of evidentiary requirements across regulators are needed to optimise access to orphan medicines.
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Affiliation(s)
- Anna-Maria Fontrier
- Department of Health Policy and LSE Health-Medical Technology Research Group (MTRG), London School of Economics and Political Science, UK.
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Paracha N, Hudson P, Mitchell S, Sutherland CS. Systematic Literature Review to Assess Economic Evaluations in Spinal Muscular Atrophy (SMA). PHARMACOECONOMICS 2022; 40:69-89. [PMID: 34658008 PMCID: PMC8994739 DOI: 10.1007/s40273-021-01095-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 05/04/2023]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is a rare, progressive neuromuscular disease that affects individuals with a broad age range. SMA is typically characterised by symmetrical muscle weakness but is also associated with cardiac defects, life-limiting impairments in respiratory function and bulbar function defects that affect swallowing and speech. Despite the advent of three innovative disease-modifying therapies (DMTs) for SMA, the cost of DMTs in addition to the costs of standard of care can be a barrier to treatment access for patients. Health Technology Assessment (HTA) decision makers evaluate the cost effectiveness of a new treatment before making a reimbursement decision. OBJECTIVE The primary objective was to conduct a systematic literature review (SLR) to identify the modelling approaches used in economic evaluations that assess current approved treatments in SMA, with a secondary objective to widen the scope and identify economic evaluations assessing other (non-SMA) neuromuscular disorders. METHODS An SLR was performed to identify available economic evaluations associated with any type of SMA (Type 1, 2, 3 and/or 4). Economic evaluations associated with other (non-SMA) neuromuscular disorders were identified but not further analysed. Electronic searches were conducted in Embase, MEDLINE, Evidence-Based Medicine Reviews and EconLit via the Ovid platform in August 2019, and were supplemented by searches of the grey literature (reference lists, conference proceedings, global HTA body websites and other relevant sources). Eligibility criteria were based on the population, interventions, comparators and outcomes (PICO) framework. Quality assessment of full publications was conducted with reference to a published checklist. RESULTS Nine publications covering eight unique studies met all eligibility criteria for inclusion in the SLR, including four conference abstracts, two peer-reviewed original research articles and three HTA submissions (conducted in Canada, the US and the UK). Evaluations considered patients with early infantile-onset (most likely to develop Type 1 or Type 2 SMA), later-onset SMA and both infantile- and later-onset SMA. Data for the identified economic models were collected from literature reviews and relatively short-term clinical trials. Several intent-to-treat clinical trial populations were used in the studies, which resulted in variation in cycle length and different outcome measures to determine clinical efficacy. The results of the quality assessment on the five full-text, peer-reviewed publications found that they generally provided clear descriptions of objectives, modelling methods and results. However, key decisions, such as choice of economic evaluation, model type and choice of variables for sensitivity analysis, were often not adequately justified. CONCLUSIONS This SLR highlights the need for economic evaluations in SMA to better align in modelling approaches with respect to (i) consistency in model structure and use of motor function milestones as health states; (ii) consensus on measuring quality of life to estimate utilities; (iii) consistency in data collection by registries; and (iv) consensus on SMA-type classification and endpoints that determine intervention efficacy. Future economic evaluations should also incorporate the review group critiques of previous HTA submissions relating to data inputs and approaches to modelling and should include patient data reflective of the SMA population being modelled. Economic evaluations would also be improved with inclusion of long-term efficacy and safety data from clinical trials and valid patient and caregiver utility data.
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KEY LEARNINGS FROM ICER'S REAL WORLD EVIDENCE REASSESSMENT PILOT. Int J Technol Assess Health Care 2022; 38:e32. [PMID: 35357284 DOI: 10.1017/s0266462322000162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Health technology assessment (HTA) agencies are considering adopting a lifecycle approach to assessments to address uncertainties in the evidence base at launch and to revisit the clinical and economic value of therapies in a dynamic clinical landscape. For reassessments of therapies post launch, HTA agencies are looking to real-world evidence (RWE) to enhance the clinical and economic evidence base, though challenges and concerns in using RWE in decision-making exists. Stakeholders are embarking on demonstration projects to address the challenges and concerns and to further define when and how RWE can be used in HTA decision making. The Institute for Clinical and Economic Review piloted a 24-month observational RWE reassessment. Key learnings from this pilot include identifying the benefits and challenges with using RWE in reassessments and considerations on prioritizing and selecting topics relevant for RWE updates.
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Chambers JD, Margaretos NM, Enright DE, Wang R, Ye X. Is an Orphan Drug's Cost-Effectiveness Associated with US Health Plan Coverage Restrictiveness? PHARMACOECONOMICS 2022; 40:225-232. [PMID: 34697718 DOI: 10.1007/s40273-021-01096-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Orphan drugs' high prices raise questions about whether their costs are worth their benefits. We examined the association between an orphan drug's cost-effectiveness and health plan coverage restrictiveness. METHODS We analyzed a dataset of US commercial health plan coverage decisions (information current as of 2019) for orphan drugs (n = 3298). We used multi-level random-effect logistic regression to examine the association between orphan drug cost-effectiveness and coverage restrictiveness. We identified cost-effectiveness estimates from the Tufts Medical Center Cost-Effectiveness Analysis Registry, and from the Institute for Clinical and Economic Review's value assessments. We included only cost-effectiveness studies not funded by product manufacturers. We included the following independent variables: cancer indication, availability of alternatives, pediatric population, number of years since US Food and Drug Administration (FDA) approval, disease prevalence, annual cost, additional non-orphan indication, safety, and inclusion in a FDA expedited review program. RESULTS Plans restricted drug coverage in 29.7% (n = 981) of decisions. Plans were more likely to restrict drugs with incremental cost-effectiveness ratios of $50,000-$175,000 per quality-adjusted life-year [QALY] (odds ratio = 1.855, p < 0.05), $175,000-$500,000 per QALY (odds ratio = 1.859, p < 0.05), and >$500,000 per QALY/dominated (odds ratio = 2.032, p < 0.01), compared to drugs with incremental cost-effectiveness ratios <$50,000 per QALY. Plans more often restricted drugs with non-cancer indications, having available alternatives, with more recent approval, in an FDA expedited review program, and for which the FDA additionally issued approval for a non-orphan disease. Plans more often restricted drugs with higher annual costs, and drugs indicated for higher prevalence diseases. All findings p < 0.05. CONCLUSIONS Among other factors, an orphan drug's cost-effectiveness was associated with health plan drug coverage restrictiveness.
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Affiliation(s)
- James D Chambers
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA.
| | - Nikoletta M Margaretos
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
| | - Daniel E Enright
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
| | - Rosa Wang
- Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
| | - Xin Ye
- Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
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Xoxi E, Facey KM, Cicchetti A. The Evolution of AIFA Registries to Support Managed Entry Agreements for Orphan Medicinal Products in Italy. Front Pharmacol 2021; 12:699466. [PMID: 34456724 PMCID: PMC8386173 DOI: 10.3389/fphar.2021.699466] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
Italy has a well-established prominent system of national registries to support managed entry agreements (MEAs), monitoring innovative medicinal products (MPs) with clinical as well as economic uncertainties to ensure appropriate use and best value for money. The technological architecture of the registries is funded by pharmaceutical companies, but fully governed by the national medicines agency (AIFA). A desktop analysis was undertaken of data over a 15-year timeframe of all AIFA indication-based registries and associated EMA information. The characteristics of registries were evaluated, comparing orphan MPs vs. all MPs exploring cancer and non-cancer indications. OMP (orphan medicinal product) registries’ type vs. AIFA innovation status and EMA approval was reviewed. Of the 283 registries, 182 are appropriateness registries (35.2% relate to OMPs, with an almost equal split of cancer vs. non-cancer for OMPs and MPs), 35 include financial-based agreements [20% OMPs (2 non-cancer, 5 cancer)], and 60 registries are payment by result agreements [23.3% OMPs (4 non-cancer, 10 cancer)]. Most OMPs (53/88) came through the normal regulatory route. With the strengthening of the system for evaluation of innovation, fewer outcomes-based registries have been instigated. AIFA has overcome many of the challenges experienced with MEA through developing an integrated national web-based data collection system: the challenge that remains for AIFA is to move from using the system for individual patient decisions about treatment to reviewing the wealth of data it now holds to optimize healthcare.
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Affiliation(s)
- Entela Xoxi
- Graduate School of Health Economics and Management, Catholic University of the Sacred Heart, Rome, Italy
| | - Karen M Facey
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Americo Cicchetti
- Graduate School of Health Economics and Management, Catholic University of the Sacred Heart, Rome, Italy
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