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Zaric GS. How Risky Is That Risk Sharing Agreement? Mean-Variance Tradeoffs and Unintended Consequences of Six Common Risk Sharing Agreements. MDM Policy Pract 2021; 6:2381468321990404. [PMID: 33623819 PMCID: PMC7876771 DOI: 10.1177/2381468321990404] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/10/2020] [Indexed: 11/23/2022] Open
Abstract
Background. Pharmaceutical risk sharing agreements (RSAs) are
commonly used to manage uncertainties in costs and/or clinical benefits when new
drugs are added to a formulary. However, existing mathematical models of RSAs
ignore the impact of RSAs on clinical and financial risk. Methods.
We develop a model in which the number of patients, total drug consumption per
patient, and incremental health benefits per patient are uncertain at the time
of the introduction of a new drug. We use the model to evaluate the impact of
six common RSAs on total drug costs and total net monetary benefit (NMB).
Results. We show that, relative to not having an RSA in place,
each RSA reduces expected total drug costs and increases expected total NMB.
Each RSA also improves two measures of risk by reducing the probability that
total drug costs exceed any threshold and reducing the probability of obtaining
negative NMB. However, the effects on variance in both NMB and total drug costs
are mixed. In some cases, relative to not having an RSA in place, implementing
an RSA can increase variability in total drug costs or total NMB. We also show
that, for some RSAs, when their parameters are adjusted so that they have the
same impact on expected total drug cost, they can be rank-ordered in terms of
their impact on variance in drug costs. Conclusions. Although all
RSAs reduce expected total drug costs and increase expected total NMB, some RSAs
may actually have the undesirable effect of increasing risk. Payers and
formulary managers should be aware of these mean-variance tradeoffs and the
potentially unintended results of RSAs when designing and negotiating RSAs.
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Affiliation(s)
- Gregory S Zaric
- Ivey Business School, Western University, and Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada
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García-Collado CG, Martínez-de-la-Plata JE, Montoro MDMM, Morales AJ, Hernández MÁC, Martínez FM. Impact of a risk-sharing agreement in rheumatoid arthritis in Spain. Health Policy 2020; 125:335-340. [PMID: 33257093 DOI: 10.1016/j.healthpol.2020.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 10/08/2020] [Accepted: 11/09/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT AND OBJECTIVE Risk-sharing agreements(RSA) allow decision-makers to manage the uncertainty associated with effectiveness and costs of treatments. Our objective was to estimate the economic impact of RSA implementation on treatment of patients diagnosed with rheumatoid arthritis(RA) with certolizumab pegol(CZP) and assess the potential impact of alternative RSA. METHODS Under original RSA, treatment with CZP was reimbursed when the response was optimal (DAS28 score <3.2) or satisfactory (DAS28 score ≥3.2 and reduction from baseline ≥1.2) at 12 weeks. Alternative RSA would additionally include a 50 % reimbursement for moderate responders(DAS28 score >3.2 and ≤5.1, and reduction from baseline between 0.6 and 1.2). We estimated average savings per patient for hospital's pharmacy service(HPS) at 12 weeks, taking into account the pharmacological cost of CZP. Uncertainty associated with effectiveness of CZP was assessed through 1000 Monte Carlo simulations. RESULTS After 12 weeks of treatment, 57.8 % (n = 52) and 22.2 %(n = 20) of patients had optimal and satisfactory responses, respectively, and average disease activity improved by 1.77 points. Average savings for HPS amounted to 876.9€ and 706.4€ per patient under original and alternative RSA, respectively. Savings in simulated cohort reached 846.2€ and 681.8€ per patient, respectively, leading to estimated net savings for HPS of 846,209€ and 681,790€, respectively. CONCLUSIONS RSA implementation on patients with RA treated with CZP has generated savings and improved efficiency within HPS.
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Affiliation(s)
| | | | | | - Alberto Jiménez Morales
- Pharmacy Departament, Hospital Virgen de las Nieves, Avenida de las Fuerzas Armadas 2, 18014, Granada, Spain
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Mellors T, Withers JB, Ameli A, Jones A, Wang M, Zhang L, Sanchez HN, Santolini M, Do Valle I, Sebek M, Cheng F, Pappas DA, Kremer JM, Curtis JR, Johnson KJ, Saleh A, Ghiassian SD, Akmaev VR. Clinical Validation of a Blood-Based Predictive Test for Stratification of Response to Tumor Necrosis Factor Inhibitor Therapies in Rheumatoid Arthritis Patients. NETWORK AND SYSTEMS MEDICINE 2020. [DOI: 10.1089/nsm.2020.0007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
| | | | - Asher Ameli
- Scipher Medicine, Waltham, Massachusetts, USA
| | - Alex Jones
- Scipher Medicine, Waltham, Massachusetts, USA
| | | | - Lixia Zhang
- Scipher Medicine, Waltham, Massachusetts, USA
| | | | - Marc Santolini
- Center for Research and Interdisciplinarity (CRI), University Paris Descartes, Paris, France
| | - Italo Do Valle
- Center for Complex Network Research, Department of Physics, Northeastern University, Boston, Massachusetts, USA
| | - Michael Sebek
- Center for Complex Network Research, Department of Physics, Northeastern University, Boston, Massachusetts, USA
| | - Feixiong Cheng
- Center for Complex Network Research, Department of Physics, Northeastern University, Boston, Massachusetts, USA
| | - Dimitrios A. Pappas
- Division of Rheumatology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
- CORRONA, LCC, Waltham, Massachusetts, USA
| | - Joel M. Kremer
- CORRONA, LCC, Waltham, Massachusetts, USA
- Albany Medical College, The Center for Rheumatology, Albany, New York, USA
| | - Jeffery R. Curtis
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Alif Saleh
- Scipher Medicine, Waltham, Massachusetts, USA
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Antonanzas F, Juárez-Castelló C, Lorente R, Rodríguez-Ibeas R. The Use of Risk-Sharing Contracts in Healthcare: Theoretical and Empirical Assessments. PHARMACOECONOMICS 2019; 37:1469-1483. [PMID: 31535280 DOI: 10.1007/s40273-019-00838-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The aim of this review is to provide a summary of the literature on risk-sharing agreements, including conceptual, theoretical and empirical (number of agreements and their achievements) perspectives, and stakeholders' perceptions. METHODS We conducted a systematic literature search in MEDLINE from 2000 to April 2019, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology, and completed it with a manual search of other publications (mainly grey literature). The search was restricted to publications with English abstracts; the initial identification of articles was restricted to the title, abstract and key words fields. The geographical scope was not restricted. RESULTS Over 20 studies proposed different taxonomies of risk-sharing contracts, which can be summarised as financial and paying-for-performance agreements. Theoretical studies modelling the incentives to implement risk-sharing agreements are scarce; they addressed different types of contracts and regulatory contexts, characterizing the drug prices and the optimal strategies of the involved agents. Empirical studies describing specific agreements are abundant and referred to different geographical contexts; however, few articles showed the economic results and assessed the value of such contracts. Stakeholders' perceptions of risk-sharing contracting were favourable, but little is known about the economic and clinical advantages of specific agreements. Whether risk-sharing contracts have yielded the desired results for healthcare systems remains uncertain. CONCLUSION Risk-sharing contracts are increasingly used, although the lack of transparency and aggregated registries makes it difficult to learn from these experiences and assess their impact on healthcare systems.
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Affiliation(s)
| | | | - Reyes Lorente
- Department of Economics, University of La Rioja, Logroño, Spain
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Defining response to TNF-inhibitors in rheumatoid arthritis: the negative impact of anti-TNF cycling and the need for a personalized medicine approach to identify primary non-responders. Clin Rheumatol 2019; 38:2967-2976. [PMID: 31520227 DOI: 10.1007/s10067-019-04684-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/02/2019] [Accepted: 07/05/2019] [Indexed: 02/07/2023]
Abstract
Current guidelines recommend treating rheumatoid arthritis (RA) patients to reach low disease activity or remission, however, most biologic-naive RA patients fail to reach treatment targets on their first biologic therapy. Approximately 90% of biologic-naive RA patients receive a tumor necrosis factor alpha inhibitor (anti-TNF) as their first biologic treatment, even though several alternative mechanism of action (MOA) therapies are approved as first-line options. After 3 months of therapy, patients may remain on anti-TNF therapy even if they fail to achieve the treatment target, mainly due to formulary structures. This means patients have to endure a second and even a third ineffective anti-TNF-called anti-TNF cycling-before changing MOA. This significantly delays patients from reaching their treatment targets. All anti-TNF drugs target the same molecular and inflammatory pathways; thus, it is not surprising that most patients who are primary non-responders to their initial anti-TNF therapy fail to achieve their treatment targets when cycled through alternative anti-TNFs. This suggests that primary non-responders should be switched to an alternative MOA therapy rather than enduring anti-TNF cycling. Avoiding anti-TNF cycling would prevent disease progression and improve quality of life for RA patients who are primary non-responders to anti-TNFs. The development of a personalized medicine approach to identify primary non-responders to anti-TNFs prior to treatment would allow significantly more patients to reach their treatment target by treating them with alternative MOA therapies as first-line therapies.
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Fautrel B, Alten R, Kirkham B, de la Torre I, Durand F, Barry J, Holzkaemper T, Fakhouri W, Taylor PC. Call for action: how to improve use of patient-reported outcomes to guide clinical decision making in rheumatoid arthritis. Rheumatol Int 2018; 38:935-947. [PMID: 29564549 PMCID: PMC5953992 DOI: 10.1007/s00296-018-4005-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 03/03/2018] [Indexed: 01/05/2023]
Abstract
Current guidelines for the management of rheumatoid arthritis (RA) recommend early treatment and a treat-to-target goal of remission or low disease activity. Over the past decade, this approach has been extremely successful in reducing disease activity and joint damage in patients with RA. At the same time, however, overall patient perception of well-being appears to have decreased with respect to outcome measures considered important by patients themselves, such as pain, fatigue, physical function and quality of life. The timely and effective use of patient-reported outcomes (PROs) could encourage physicians to focus more on the impact of RA on patients and how patients are feeling. This in turn would facilitate shared decision making between patients and physicians, ultimately leading to a more patient-centered approach and improved patient care. Indeed, PROs provide information about individual patients that complements information provided by physical assessment and composite scores, and can also be used to guide patient care, such as determining whether a clinic visit is needed or whether treatment modifications are necessary. This is particularly important for patients who do not achieve the aspirational target of remission or low disease activity with pharmacological treatment. A number of validated PRO questionnaires are available, but how and which PROs should be incorporated into rheumatology clinical practice as part of the decision-making process is still controversial. Combining PROs with technology, such as computer adaptive tests, electronic PRO systems, web-based platforms and patient dashboards, could further aid PRO integration into daily rheumatology clinical practice.
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Affiliation(s)
- Bruno Fautrel
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Universités, UPMC Universitaire Paris 06, Paris, France
- Department of Rheumatology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Rieke Alten
- Schlosspark-Klinik University Medicine, 14059, Berlin, Germany
| | - Bruce Kirkham
- Department of Rheumatology, Guys and St Thomas' NHS Trust, Great Maze Pond, London, SE1 9RT, UK
| | | | | | - Jane Barry
- Eli Lilly and Company, Basingstoke, Hampshire, UK
| | | | - Walid Fakhouri
- Eli Lilly and Company, Indianapolis, IN, USA
- Eli Lilly and Company, Basingstoke, Hampshire, UK
| | - Peter C Taylor
- Botnar Research Centre, NDORMS, University of Oxford, Oxford, UK.
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Abstract
OBJECTIVES Australia relies on managed entry agreements (MEAs) for many medicines added to the national Pharmaceutical Benefits Scheme (PBS). Previous studies of Australian MEAs examined public domain documents and were not able to provide a comprehensive assessment of the types and operation of MEAs. This study used government documents approved for release to examine the implementation and administration of MEAs implemented January 2012 to May 2016. METHODS We accessed documents for medicines with MEAs on the PBS between January 2012 and May 2016. Data were extracted on Anatomical Therapeutic Classification (ATC), type of MEA (financial, financial with outcomes, outcomes, and subcategories within each group), implementation and administration methods, source of MEA recommendation, and type of economic analysis. RESULTS Of all medication indication pairs (MIPs) recommended for listing, one-third had MEAs implemented. Our study of eighty-seven MIPs had 170 MEAs in place. The Government's expert health technology assessment (HTA) committee recommended MEAs for 90 percent of the eighty-seven MIPs. A total of 81 percent of MEAs were simple financial agreements: the majority either discounts (32 percent) or reimbursement caps (43 percent). Outcome-based MEAs were least common (5 percent). Ninety-two percent of MEAs were implemented and operated through legal agreements. Approximately half of the MIPs were listed on the basis of accepted claims of cost-minimization. Forty-nine percent of medicines were in ATC L group. CONCLUSION Advice from HTA evaluations strongly influences the implementation of ways to manage uncertainties while providing access to medicines. The government relied primarily on simple financial agreements for the managed entry of medicines for which there were perceived risks.
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Santos-Moreno P, Alvis-Zakzuk NJ, Villarreal-Peralta L, Carrasquilla-Sotomayor M, Paternina-Caicedo A, Alvis-Guzmán N. A comprehensive care program achieves high remission rates in rheumatoid arthritis in a middle-income setting. Experience of a Center of Excellence in Colombia. Rheumatol Int 2017; 38:499-505. [PMID: 29248952 DOI: 10.1007/s00296-017-3903-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 12/03/2017] [Indexed: 12/18/2022]
Abstract
Management of rheumatoid arthritis (RA) in many Latin-American countries is impaired by fragmentation and scarce healthcare provision, resulting in obstacles to access, diagnosis, and treatment, and consequently in poor health outcomes. The aim of this study is to propose a comprehensive care program as a model to provide healthcare to RA patients receiving synthetic DMARDs in a Colombian setting by describing the model and its results. Health outcomes were prospectively collected in all patients entering the program. By protocol, patients are followed up during 24 months using a treat-to-target strategy with a patient-centered care (PCC) model, meaning that a patient should be seen by rheumatologist, physical and occupational therapist, physiatrist, nutritionist and psychologist, at least three times a year according to disease activity by DAS28. Otherwise, patients receive standard therapy. The incidence of remission and low disease activity (LDA) was calculated by periods of follow-up. A total of 968 patients entered the program from January 2015 to December 2016; 80.2% were women. At baseline, 41% of patients were in remission, 17% in LDA and 42% in MDS/SDA. At 24 months of follow-up, 66% were in remission, 18% in LDA and only 16% in MDS/SDA. Regarding DAS28, the mean at the beginning of the time analysis was 3.1 (SD 1.0) and after 24 months it was 2.4 (SD 0.7), showing a statistically significant improvement (p < 0.001). In all patients, the reduction of disease activity was 65% (95% CI, 58-71). Patients entering the PCC program benefited from a global improvement in disease activity in terms of DAS28.
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Affiliation(s)
| | | | | | | | | | - Nelson Alvis-Guzmán
- Grupo de Investigación en Gestión Hospitalaria y Políticas de Salud. Universidad de la Costa, Barranquilla, Atlántico, Colombia
- Grupo de Investigación en Economía de la Salud. Universidad de Cartagena, Cartagena, Colombia
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