From market access to patient access: overview of evidence-based approaches for the reimbursement and pricing of pharmaceuticals in 36 European countries

Journey from an Enabler to a Strategic Leader: Integration of the Medical Affairs Function in ESG Initiatives and Values

Like most private enterprises, the pharmaceutical industry has deeply rooted environmental, social, and governance (ESG) matters that challenge its long-term sustainability. Overcoming these external challenges requires collaborative and proactive steps as well as procedures guiding the adoption of ESG principles by all internal stakeholders. Environmental challenges such as climate change, and in addition the changes in society, have resulted in the need for governance addressing and coordinating efforts. The core function of medical affairs (MA) is connecting with stakeholders within a company and also between the company and external stakeholders. In this article, we describe the involvement of MA in several aspects of ESG, as a contributor, partner, and implementer. MA has a significant opportunity to emerge as a leading function involved in ESG strategies and their tactical implementation. Although the involvement of MA in the environment pillar of ESG is less, the function can implement changes relating to the conduct of meetings, clinical studies, and the digitalization of medical education via virtual platforms. Due to its patient centricity, MA is tasked to address social determinants of health to improve patients' outcomes. As a linking function within a company and with its external stakeholders, MA can provide proactive input in policy generation and enable effective governance by adherence to standards of accountability, ethics, and compliance, as well as transparency. Championing ESG is a collective responsibility that transcends any single department. It mandates a company-wide commitment. MA represents an essential pivot point in catalyzing the integration of ESG principles within industry, contributing to a healthcare ecosystem that is not merely more sustainable and ethical but also more conducive to patient health and public well-being.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interface policies bridging outpatient and hospital sectors in Europe: can cross-sectorial collaboration in reimbursement and procurement improve access to affordable medicines?

INTRODUCTION

Pharmaceutical systems are frequently characterized by fragmentation, and competences for outpatient and inpatient sectors sit with different authorities, payers, and purchasers. This fragmentation of responsibilities can incentivize shifting expensive therapies and thus patients from one sector to the other.

AREAS COVERED

Reimbursement and procurement policies in Europe addressing unwanted consequences of this fragmentation were identified through literature reviews and surveys with policy-makers. Good practice examples include cross-sectorial reimbursement lists managed by committees with representatives from the outpatient and hospital sectors, specific funding mechanisms, joint procurement involving purchasers from both sectors, actions against procurement contracts prohibiting generic competition, and an extension of Health Technology Assessment to the hospital sector.

EXPERT OPINION

Recognizing fragmentation as a major challenge for pharmaceutical systems, policy-makers in some countries reacted by implementing policies to support cross-sectorial collaboration. However, only a handful of good practice examples exist for reimbursement and procurement policies in Europe. Though robust evaluations are lacking, there are indications that pharmaceutical policies which ensure collaboration at the interface of the outpatient and inpatient sectors would likely result in efficiency gains and better use of public budgets and may serve as lever to improve access to medicines.

The reimbursement process in three national healthcare systems: variation in time to reimbursement of pembrolizumab for metastatic non-small cell lung cancer

In this article, we focus on the reimbursement process, and as an example, characterize the time to reimbursement of pembrolizumab, a PD-1 immune checkpoint inhibitor for treatment of metastatic NSCLC from publicly available websites, in three different healthcare systems: The National Institute for Health and Care Excellence (NICE) in the UK, the Pharmaceutical Benefits Advisory Committee (PBAC) in Australia, and the National Advisory Committee for the Basket of Health Services in Israel, all who have publicly funded health systems which include drug coverage. Our study found that there are substantial differences in time to reimbursement of pembrolizumab for the same conditions in different countries, with NICE and The National Advisory Committee for the Basket of Health Services in Israel approving one condition at the same time, Israel approving two conditions earlier than NICE, and PBAC lagging behind for every condition. These differences could be due to the differences in health policy systems and the many factors that affect reimbursement. Comparing the reimbursement process between different countries can highlight the challenges facing their health systems in early adoption of new treatments.

Current status of health technology assessment research in Japan

Health technology assessment (HTA) is implemented in the decision-making process for the reimbursement and pricing of drugs and medical devices around the world. This study presented the trend and characteristics of HTA research in Japan and worldwide. HTA research increased since the 2010s. Cancer was a prominent subject and the Markov model was a major analytical model in HTA research both globally and in Japan. In Japan, osteoporosis was a more popular topic, but there were fewer surgical research and review articles compared to the global trend. Since Japanese articles on HTA were much fewer than those from the United States, the United Kingdom, and China, various types of HTA research should be encouraged in Japan to promote product innovation and optimize medical expenditures.

A Review of Current Approaches to Defining and Valuing Innovation in Health Technology Assessment

OBJECTIVES

The growing focus on the value of new drugs for patients and society has led to a more differentiated notion of innovation in the context of pharmaceutical products. The goal of this article is to provide an overview of the current debate about the definition and assessment of innovation and how innovation is considered in reimbursement and pricing decisions.

METHODS

To compile the relevant literature, we followed a 2-step approach. First, we searched for peer-reviewed literature that deals with the definition of pharmaceutical innovation. Second, we reviewed health technology assessment (HTA) guidelines of 11 selected countries (Australia, Belgium, Canada, England, France, Germany, Italy, Japan, Norway, Sweden, and The Netherlands) regarding aspects of innovation that are currently considered as relevant by the respective HTA bodies.

RESULTS

All countries in our sample use 1 of 2 types of reward mechanism for novel drugs that they consider provide some sort of benefit. Generally, the focus is on the therapeutic benefit of a drug, whereas, depending on the exact arrangement, other aspects can also be taken into account. A reduction in side effects and aspects of treatment convenience can be invoked in some of the countries. Mostly, however, they are not considered unless they are already captured in the clinical outcomes used to measure the therapeutic benefit.

CONCLUSION

Our review shows that although the health economic literature discusses a range of aspects on how innovation may generate value even without providing an immediate added therapeutic benefit (or on top of it), these are only selectively considered in the reviewed HTA guidelines. For most part, only the added therapeutic value is crucial when it comes to pricing and reimbursement decisions.

A Review of the Evidence on Attitudes, Perceived Impacts and Motivational Factors for European Member State Collaboration for Pricing and Reimbursement of Medicines: Time for the EEA Member States to Apply Their Experience and Expertise in Evidence-Based Decision Making to Their Current Pharmaceutical Policy Challenges

In 2018/2019 there were a number of initiatives for collaboration between Member States in the European Economic Area (EEA) and the European Commission published a Proposal for a Regulation on Health Technology Assessment. In view of the perceived benefits from collaboration, the experiences and challenges of these collaborative initiatives and the possible implications of the proposed legislation, a study of the evidence on attitudes, perceived impacts and the motivational factors towards European Member State collaboration regarding the pricing and reimbursement of medicines was conducted. This study adopted an evidence-based management approach by Barends and Rousseau. The main findings showed that Member States differed in their motivation for collaboration for different pharmaceutical activities. Member States favoured voluntary co-operation for all activities of pricing and reimbursement except for relative effectiveness assessments where Member State authorities had divergent attitudes and prioritised activities related to the sustainability of their healthcare systems and access to medicines. Contrastingly pharmaceutical companies strongly favoured mandatory cooperation for evaluation. Member States motivation for collaboration was highly dependent on the purpose, political will, implementation climate and cultural factors. Currently, with the experiences of ongoing collaborations, following the progress of the discussion at Council, and with a number of inititatives for new pharmaceutical strategy and policy, it is proposed that Member States use their trust, expertise and knowledge of application of evidence-based decision making for pricing and reimbursement of medicines and apply it to decide the future model for Member State collaboration. The applicability of principles of evidence-based management to pharmaceutical policy can be used as a starting point.

A Health Opportunity Cost Threshold for Cost-Effectiveness Analysis in the United States

BACKGROUND

Cost-effectiveness analysis is an important tool for informing treatment coverage and pricing decisions, yet no consensus exists about what threshold for the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained indicates whether treatments are likely to be cost-effective in the United States.

OBJECTIVE

To estimate a U.S. cost-effectiveness threshold based on health opportunity costs.

DESIGN

Simulation of short-term mortality and morbidity attributable to persons dropping health insurance due to increased health care expenditures passed though as premium increases. Model inputs came from demographic data and the literature; 95% uncertainty intervals (UIs) were constructed.

SETTING

Population-based.

PARTICIPANTS

Simulated cohort of 100 000 individuals from the U.S. population with direct-purchase private health insurance.

MEASUREMENTS

Number of persons dropping insurance coverage, number of additional deaths, and QALYs lost from increased mortality and morbidity, all per increase of $10 000 000 (2019 U.S. dollars) in population treatment cost.

RESULTS

Per $10 000 000 increase in health care expenditures, 1860 persons (95% UI, 1080 to 2840 persons) were simulated to become uninsured, causing 5 deaths (UI, 3 to 11 deaths), 81 QALYs (UI, 40 to 170 QALYs) lost due to death, and 15 QALYs (UI, 6 to 32 QALYs) lost due to illness; this implies a cost-effectiveness threshold of $104 000 per QALY (UI, $51 000 to $209 000 per QALY) in 2019 U.S. dollars. Given available evidence, there is about 14% probability that the threshold exceeds $150 000 per QALY and about 48% probability that it lies below $100 000 per QALY.

LIMITATIONS

Estimates were sensitive to inputs, most notably the effects of losing insurance on mortality and of premium increases on becoming uninsured. Health opportunity costs may vary by population. Nonhealth opportunity costs were excluded.

CONCLUSION

Given current evidence, treatments with ICERs above the range $100 000 to $150 000 per QALY are unlikely to be cost-effective in the United States.

PRIMARY FUNDING SOURCE

None.

Drug Reimbursement Regulation in 6 Peer Countries

The US has nearly 4.5% of the world's population but accounts for more than 40% of global drug spending. With the upcoming 2020 election, a top priority of many voters is to better control drug prices and reform the pharmaceutical market. In this Special Communication, the drug price mechanisms and government regulations used in 6 representative peer countries are evaluated: Australia, France, Germany, Norway, Switzerland, and the United Kingdom. Drug price regulation is compared with that currently used in the US. Eight key lessons from the regulations used in these countries and which elements are incorporated into the bills currently making their way through the US Congress are evaluated (2 from the US House of Representatives and 1 from the US Senate). None of these bills is as systemic or comprehensive in its drug pricing mechanisms and regulations as the schemes in the other countries.

Making pharmaceutical research and regulation work for women

The legacy of male bias within pharmaceutical research, regulation, and commercialisation needs to be rectified, argue Sundari Ravindran and colleagues

Pharmaceutical companies' views on a health technology assessment (HTA) entity in Saudi Arabia

Saudi Arabia is undergoing a massive healthcare transformation to fulfill its new, national "Vision 2030." To align with this objective, Saudi Arabia is establishing a new, independent and evidence-based health technology assessment (HTA) entity to help it maximize health gains through efficient use of resources. This study was designed to ascertain how pharmaceutical companies perceive the creation of such a national HTA entity in Saudi Arabia; what they think about it and expect from it. To achieve the study's aim, we held a workshop in Riyadh, Saudi Arabia, lasting four and a half hours and hosted by the Saudi Ministry of Health (MOH). We invited 16 market access directors and managers from different multinational pharmaceutical companies to discuss the establishment of a national HTA entity. The findings from the workshop were structured around three axes: vision and remit; HTA method; and implementation and practical considerations. Overall, the pharmaceutical company participants were positive about HTA's value for the Saudi healthcare system and expressed willingness to adapt to meet its future requirements.

The Emerging Social Science Literature on Health Technology Assessment: A Narrative Review

BACKGROUND

Social scientists have paid increasing attention to health technology assessment (HTA). This paper provides an overview of existing social scientific literature on HTA, with a focus on sociology and political science and their subfields.

METHODS

Narrative review of key pieces in English.

RESULTS

Three broad themes recur in the emerging social science literature on HTA: the drivers of the establishment and concrete institutional designs of HTA bodies; the effects of institutionalized HTA on pricing and reimbursement systems and the broader society; and the social and political influences on HTA decisions.

CONCLUSION

Social scientists bring a focus on institutions and social actors involved in HTA, using primarily small-N research designs and qualitative methods. They provide valuable critical perspectives on HTA, at times challenging its otherwise unquestioned assumptions. However, they often leave aside questions important to the HTA practitioner community, including the role of culture and values. Closer collaboration could be beneficial to tackle new relevant questions pertaining to HTA.

Health Technology Assessment Implementation in Ukraine: Current Status and Future Perspectives

OBJECTIVES

The need for improving healthcare decision making by implementing health technology assessment (HTA) has been a top priority in Ukraine since 2016. This study sought to provide a tailor-made HTA implementation roadmap, drawing on insights from national stakeholders.

METHODS

We conducted a survey using a questionnaire already applied in previous HTA research. We assessed the status of HTA when reforms were initiated in 2016 and examined perspectives on possible future developments among policy makers and representatives of pharmaceutical companies and patient organizations.

RESULTS

Thirty-two respondents answered the survey. Forty-eight percent of respondents were not aware of HTA training in Ukraine, but 91 percent preferred having either a graduate or postgraduate training. Experts stated that funding for HTA research and for critical appraisal of HTA submissions was limited, but in the future, they would increase funding mainly from public sources. A public HTA agency with academic support was the most preferred organizational structure. Eighty-eight percent of respondents opted for full transparency, making the HTA agency's recommendations and the related appraisal reports publicly available. A great majority of participants preferred mandating the use of local data in certain categories and indicated the importance of evaluating the transferability of international evidence. Healthcare priority and cost-effectiveness were the most important criteria for decisions, applied with a soft explicit threshold.

CONCLUSIONS

Ukraine is in the early phase of implementing HTA and our study provides a clear vision of national stakeholders about the future directions. In addition, learning from the experiences of other countries may help the implementation process.

Shedding light on the HTA consultancy market: Insights from Poland

Research on health technology assessment (HTA) from a policy perspective typically examines public HTA bodies, with little attention devoted to how manufacturers develop their evidence submissions. Taking Poland as a crucial case, we explored the market of HTA consultancy firms which assist drug manufacturers in developing these submissions, called HTA reports. We reviewed 318 HTA reports from 2012 to 2015, data from the Polish National Company Registry, the content of HTA consulting firms' websites, and appraisal reports developed by the Polish HTA body. We identified HTA consultancy firms which developed 96-98% HTA reports. We found that the transparency of information about the authors of HTA reports provided by the HTA body had improved between 2012 and 2015. Six companies with market shares from 10 to 30% dominated the market. The market size was estimated to be 5-6 million EUR annually. HTA consultancies had a broad service portfolio related to preparation of HTA reports. Over 90% of HTA reports did not meet the official minimum quality requirements, and only half of the resubmissions took into account remarks made by the HTA body. Our study provides insights into the structure, evolution and role of the for-profit HTA consultancy market as a crucial part of the public HTA system. This raises important policy points about transparency and regulation at the intersection of public and private sectors in HTA.

Timely, consistent, transparent assessment of market access evidence: implementing tools based on the HTA Core Model® in a pharmaceutical company

Objectives

Evidence requirements and assessment methods access differ between health technology assessment (HTA) agencies. The HTA Core Model^® provides a standardized approach to HTA, targeting evidence sharing and collaboration between participating HTA bodies. It is fit for purpose from an industry perspective and was used by pharmaceutical company Roche to develop a framework for internal assessment of evidence required for market access and coverage/reimbursement (“access evidence”).

Methods

Tools were developed to systematically scope, assess, plan, and summarize access evidence generation. The tools were based mainly on the first four HTA Core Model^® domains and rolled-out in selected development teams in 2017. Five months after full implementation, the impact of tools was assessed in an internal survey.

Results

Systematic access evidence generation started with the Access Evidence Questionnaire, to scope evidence requirements and identify evidence gaps. Findings were summarized in the Access Evidence Metric, which assessed the alignment of available/planned evidence against HTA bodies’ requirements and developed scope mitigation strategies. The Access Evidence Plan was then used to plan and document (additional) evidence generation. Once generated, evidence was summarized in the Access Evidence Dossier. A survey of twenty-seven Roche employees involved in evidence generation showed that the tools made discussions around access strategies and evidence more efficient and transparent.

Conclusions

The HTA Core Model^® provided a useful framework around which to optimize internal evidence generation and assessment. The benefits of using a standardized HTA approach in industry mirror those expected from implementing the HTA Core Model® in HTA agencies.

Uptake of and Expenditure on Direct-Acting Antiviral Agents for Hepatitis C Treatment in Australia

BACKGROUND

Direct-acting antiviral agents (DAAs) have revolutionised treatment for the hepatitis C virus (HCV). Currently, treatment costs between 20,000 and 80,000 Australian dollars ($A) per patient. The Australian Federal Government provided $A1 billion over 5 years to subsidise these drugs.

OBJECTIVE

The aim of this paper was to evaluate the uptake and financial impact of DAA prescribing in Australia.

METHODS

We undertook a retrospective analysis of Medicare prescription and expenditure data for March 2016 to August 2017. Prescription numbers and expenditure data were extracted from the Medicare Statistical Reports website. Numbers of prescriptions were converted to per capita rates. HCV prevalence measures were used to provide context to prescription rates. All costs were reported in $A, year 2017 values.

RESULTS

Nationally, 211,184 DAA prescriptions were reimbursed. Whilst $A3.6 billion was expended through the Pharmaceutical Benefits Scheme, confidential pricing agreements precluded calculation of the precise cost. In 18 months, estimated expenditure greatly exceeded the $A1 billion in funding for 5 years. Nationally, the rate of prescriptions was 872/100,000 individuals. Prescription rates were highest in the Australian Capital Territory (1087/100,000) and lowest in Western Australia (625/100,000) despite HCV prevalence being comparable to the national rate in both regions.

CONCLUSIONS

Uptake of DAAs has been enthusiastic in the first 18 months of this funding agreement. However, the lack of transparency due to the confidential special pricing agreements means actual government expenditure is unknown. Post-marketing review by the Pharmaceutical Benefits Advisory Committee may enable renegotiation of DAA prices with the sponsors.

Decision-making criteria for medicine reimbursement in Slovenia: an expert panel discussion

Background

Rational and transparent Health Technology Assessment and reimbursement decision-making are crucial for healthcare system sustainability. A part of the reimbursement process are decision-making criteria which should be clearly defined.

Methods

The study aimed to obtain an insight into understanding and relevance of potential criteria for the medicine reimbursement decision-making process in Slovenia.

A semi-structured guided focus panel was performed in June 2017 with five Slovenian experts covering principal healthcare system sectors. First, criteria understanding and relevance for medicine reimbursement decision-making were discussed. Second, healthcare priorities and societal values affecting decision-making were debated. The analysis was carried out with NVivo 11 by two independent researchers who coded the verbatim transcript in three coding steps based on the experts’ interpretations and original ideas.

Results

Seven decision-making criteria were derived. Among those, the impact a disease has on the lives of patient family and caregivers and the indirect medicine benefit for them were new aspects comparing to the existing criteria set in Slovenia. The experts expressed that the same decision-making criteria are relevant for evaluating any health technology, allowing for different criteria weights. They also suggested a system that would allow re-evaluation of reimbursement decisions once real-world clinical data are available.

Conclusions

As proposed by the international frameworks and tools, the Slovenian healthcare experts consider including multiple aspects more ethical and comprehensive than considering a single criterion, e.g. cost-effectiveness, existing in some healthcare systems. They recognize that in the existing decision-making process, health perspectives of the public represent a largely missed aspect.

Opinions and potential solutions regarding dissemination bias from funding agencies of biomedical research in Europe

RATIONALE, AIMS, AND OBJECTIVES

Several studies have found that about half of research results from clinical trials are never published. Until now, there has been little information on the views that funding agencies of biomedical research in Europe have regarding this issue and its possible solutions.

METHODS

An electronic survey was conducted among funding agencies from 34 European countries. Participants were asked about their opinions, policies, and potential solutions regarding dissemination bias. On the basis of the results of this survey and the input of the OPEN Consortium and of representatives of stakeholder groups in the knowledge generation process, we formulated recommendations for funding agencies to reduce dissemination bias.

RESULTS

We received responses from 64 funding agencies of biomedical medicine from most European countries, out of 245 that were contacted (26%). Of these, 56 funded research at the national and/or international level and were therefore eligible to participate. Policies encouraging publication increased over time: 33 (58.9%) of agencies enforced them in 2005 compared to 38 (67.6%) in 2012. However, only 13 (23.2%) had knowledge of the publications related to research funded in 2005, 23 (41.1%) were able to provide only an estimate, and 20 (35.7%) did not know at all. Regarding recommendations to control dissemination bias, we propose that funding agencies request the dissemination of research results irrespective of the direction of findings. We also call for measures that allow evaluating funded projects past the contractual period and until dissemination of results. Funding agencies should create publicly accessible databases with information on funded projects and dissemination efforts.

CONCLUSION

Despite having policies to encourage publication of results, most funding agencies fail to implement such measures or to ensure compliance. We propose recommendations that could be incorporated in the blueprint of calls for proposals and contracts agreed upon by funding agencies and grant recipients.

Transparency in practice: Evidence from ‘verification analyses’ issued by the Polish Agency for Health Technology Assessment in 2012–2015

Transparency is recognised to be a key underpinning of the work of health technology assessment (HTA) agencies, yet it has only recently become a subject of systematic inquiry. We contribute to this research field by considering the Polish Agency for Health Technology Assessment (AHTAPol). We situate the AHTAPol in a broader context by comparing it with the National Institute for Health and Care Excellence (NICE) in England. To this end, we analyse all 332 assessment reports, called verification analyses, that the AHTAPol issued from 2012 to 2015, and a stratified sample of 22 Evidence Review Group reports published by NICE in the same period. Overall, by increasingly presenting its key conclusions in assessment reports, the AHTAPol has reached the transparency standards set out by NICE in transparency of HTA outputs. The AHTAPol is more transparent than NICE in certain aspects of the HTA process, such as providing rationales for redacting assessment reports and providing summaries of expert opinions. Nevertheless, it is less transparent in other areas of the HTA process, such as including information on expert conflicts of interest. Our findings have important implications for understanding HTA in Poland and more broadly. We use them to formulate recommendations for policymakers.

Who’s afraid of institutionalizing health technology assessment (HTA)?: Interests and policy positions on HTA in the Czech Republic

This article identifies the interests and policy positions of key health policy stakeholders regarding the creation of a health technology assessment (HTA) agency in the Czech Republic, and what considerations influenced them. Vested interests have been suggested as a factor mitigating the diffusion of HTA bodies internationally. The Czech Republic recently considered and discarded establishing an HTA agency, making it a good case for studying actors’ policy positions throughout the policy debates. Findings are based on in-depth, semi-structured expert and elite interviews with 34 key Czech health policy actors, supported by document analysis and extensive triangulation. Findings show that the HTA epistemic community of ‘aspiring agents’ was the only actor strongly in favor of an HTA body. Payers and the medical device and diagnostics industry were against it; patients and clinicians had no clear preferences. Original decision-makers were in favor but a new minister of health opted for a simpler policy alternative to solve his need for expertise. Existing institutions, policy alternatives and the institutional design of a future HTA body influence domestic actors’ preferences for or against an HTA agency. Domestic and international proponents of HTA should give serious thought to their concerns when advocating for HTA bodies.

Setting priorities in the health care sector - the case of oral anticoagulants in nonvalvular atrial fibrillation in Denmark

Aim

Resources devoted to health care are limited, therefore setting priorities is required. It differs between countries whether decision-making concerning health care technologies focus on broad economic perspectives or whether focus is narrow on single budgets (“silo mentality”). The cost perspective as one part of the full health economic analysis is important for decision-making. With the case of oral anticoagulants in patients with nonvalvular atrial fibrillation (NVAF), the aim is to discuss the implication of the use of different cost perspectives for decision-making and priority setting.

Methods

In a cost analysis, the annual average total costs of five oral anticoagulants (warfarin and non-vitamin K oral anticoagulants [NOACs; dabigatran, rivaroxaban, apixaban, and edoxaban]) used in daily clinical practice in Denmark for the prevention of stroke in NVAF patients are analyzed. This is done in pairwise comparisons between warfarin and each NOAC based on five potential cost perspectives, from a “drug cost only” perspective up to a “societal” perspective.

Results

All comparisons of warfarin and NOACs show that the cost perspective based on all relevant costs, ie, total costs perspective, is essential for the choice of therapy. Focusing on the reimbursement costs of the drugs only, warfarin is the least costly option. However, with the aim of therapy to prevent strokes and limit bleedings, including the economic impact of this, all NOACs, except rivaroxaban, result in slightly lower health care costs compared with warfarin. The same picture was found applying the societal perspective.

Conclusion

Many broad cost-effectiveness analyses of NOACs exist. However, in countries with budget focus in decision-making this information does not apply. The present study’s case of oral anticoagulants has shown that decision-making should be based on health care or societal cost perspectives for optimal use of limited resources. Otherwise, the risk is that suboptimal decisions will be likely.

Towards Integrated Health Technology Assessment for Improving Decision Making in Selected Countries

OBJECTIVES

To assess the level of comprehensiveness of health technology assessment (HTA) practices around the globe and to formulate recommendations for enhancing legitimacy and fairness of related decision-making processes.

METHODS

To identify best practices, we developed an evaluation framework consisting of 13 criteria on the basis of the INTEGRATE-HTA model (integrative perspective on assessing health technologies) and the Accountability for Reasonableness framework (deliberative appraisal process). We examined different HTA systems in middle-income countries (Argentina, Brazil, and Thailand) and high-income countries (Australia, Canada, England, France, Germany, Scotland, and South Korea). For this purpose, desk research and structured interviews with relevant key stakeholders (N = 32) in the selected countries were conducted.

RESULTS

HTA systems in Canada, England, and Scotland appear relatively well aligned with our framework, followed by Australia, Germany, and France. Argentina and South Korea are at an early stage, whereas Brazil and Thailand are at an intermediate level. Both desk research and interviews revealed that scoping is often not part of the HTA process. In contrast, providing evidence reports for assessment is well established. Indirect and unintended outcomes are increasingly considered, but there is room for improvement. Monitoring and evaluation of the HTA process is not well established across countries. Finally, adopting transparent and robust processes, including stakeholder consultation, takes time.

CONCLUSIONS

This study presents a framework for assessing the level of comprehensiveness of the HTA process in a country. On the basis of applying the framework, we formulate recommendations on how the HTA community can move toward a more integrated decision-making process using HTA.

Equity, barriers and cancer disparities: study of the Spanish Society of Medical Oncology on the access to oncologic drugs in the Spanish Regions

Purpose

The Spanish Society of Medical Oncology (SEOM) has conducted a study on the access to oncologic drugs across the 17 Spanish Regions with the aim of identifying potential heterogeneities and making proposals for eliminating the barriers identified at the different levels.

Methods

An Expert Panel made up of medical oncologists designed a survey on certain indications approved for 11 drugs in the approach of breast cancer, melanoma, lung cancer, prostate cancer and support treatment. This survey was sent to 144 National Health System (NHS) hospitals.

Results

77 hospitals answered the survey. The information modules analysed were: scope of the Commission that establishes binding decisions related to drug access; conditions, stages and periods of drug application, approval and administration processes; barriers to accessing drugs.

Conclusions

The study shows variability in drug access. The SEOM makes proposals addressed to reducing the differences identified and homogenizing drug access conditions.

Published and unpublished evidence in coverage decision-making for pharmaceuticals in Europe: existing approaches and way forward

BACKGROUND

Dissemination bias occurs when only some results emerging from clinical research reach their intended audience in the knowledge translation process. Given that coverage decisions increasingly rely on evidence, it is important to explore the types of evidence considered. This paper aimed to examine the evidence base used by regulatory institutions involved in pricing and reimbursement of pharmaceuticals in a broad range of European countries, as well as their awareness of and approach towards dissemination bias.

METHODS

A mixed methods approach was adopted. Regulatory documents and published literature were identified in systematic searches and relevant documents were analysed. An online survey was carried out to verify and expand insights.

RESULTS

Forty-two relevant regulatory documents and 10 publications were included. The survey had a 35% response rate, yielding valid responses for 13 countries. A fragmented impression was obtained for most countries indicating a general lack of transparency regarding both processes of decision-making and approaches towards unpublished information. Dissemination bias was rarely consistently considered. Practices for the identification and inclusion of all available evidence varied considerably, as did the influence of missing evidence on decision-making. Differences were often attributable to the regulatory context and/or institutional principles.

CONCLUSIONS

Best practice is difficult to generalize given the identified variations. Individual exemplary practices support the necessity for institutional exchange at international level. Increased institutional commitment to transparency of methods and processes should be advocated.