Challenges in valuing and paying for combination regimens in oncology: reporting the perspectives of a multi-stakeholder, international workshop

BACKGROUND

It is increasingly common for two or more treatments for cancer to be combined as a single regimen. Determining value and appropriate payment for such regimens can be challenging. This study discusses these challenges, and possible solutions.

METHODS

Stakeholders from around the world attended a 2-day workshop, supported by a background paper. This study captures key outcomes from the discussion, but is not a consensus statement.

RESULTS

Workshop attendees agreed that combining on-patent treatments can result in affordability and value for money challenges that delay or deny patient access to clinically effective treatments in many health systems. Options for addressing these challenges include: (i) Increasing the value of combination therapies through improved clinical development; (ii) Willingness to pay more for combinations than for single drugs offering similar benefit, or; (iii) Aligning the cost of constituent therapies with their value within a regimen. Workshop attendees felt that (i) and (iii) merited further discussion, whereas (ii) was unlikely to be justifiable. Views differed on the feasibility of (i). Key to (iii) would be systems allowing different prices to apply to different uses of a drug.

CONCLUSIONS

Common ground was identified on immediate actions to improve access to combination regimens. These include an exploration of the legal challenges associated with price negotiations, and ensuring that pricing systems can support implementation of negotiated prices for specific uses. Improvements to clinical development and trial design should be pursued in the medium and longer term.

Cornerstones of 'fair' drug coverage: appropriate cost sharing and utilization management policies for pharmaceuticals

At the heart of all health insurance programs lies ethical tension between maximizing the freedom of patients and clinicians to tailor care for the individual and the need to make healthcare affordable. Nowhere is this tension more fiercely debated than in benefit design and coverage policy for pharmaceuticals. This paper focuses on three areas over which there is the most controversy about how to judge whether drug coverage is appropriate: cost-sharing provisions, clinical eligibility criteria, and economic-step therapy and required switching. In each of these domains we present 'ethical goals for access' followed by a series of 'fair design criteria' that can be used by stakeholders to drive more transparent and accountable drug coverage.

Barriers to home bowel screening test in South Asians in the UK

Background

Bowel cancer is common and accounts for 10% of all cancer mortality. Early detection significantly reduces mortality. In the UK, the NHS Bowel Cancer Screening Programme invites adults aged 60-74 years to carry out a home screening test biennially. The national target for test completion is 60%; completion is substantially lower (∼30%) amongst South Asian populations. Our aim was to develop a community-based intervention to increase completion of the home bowel screening test in South Asians.

Methods

Multi-methods comprising two stages: 1) group and individual interviews with South Asians aged 50-74 years purposively sampled from community groups for maximum variation. Semi-structured interviews based on the Theoretical Domains Framework (TDF) investigated determinants of bowel screening completion. Interviews were recorded, transcribed, and analysed using framework analysis and findings mapped onto the COM-B Behaviour Change Wheel; 2) Co-production of intervention during two workshops with key stakeholders and target population.

Results

To-date 25 adults recruited of Indian, Pakistani and Bangladeshi ethnicity with variation in age, gender, first language, faith, and compliance with bowel screening. Key barriers and TDF domains that they mapped to were: - lack of knowledge about bowel cancer and screening; lack of language, literacy and physical ability (skills) to carry out the home test; confidence to carry it out correctly (belief about capabilities); appropriate space and time to carry out the test (environmental context and resources); putting off undertaking the test (memory attention and decision processes); risk perception and fear of cancer (emotions). Enablers were: social influences from peers; goals and motivations.

Conclusions

Early results suggest an intervention comprising education, persuasion, modelling and enablement functions could increase completion of the home test.

Key messages

Community engagement and working with community leaders enhanced the success of recruitment. The TDF was a useful framework for identifying barriers to home bowel screening test by South Asians in the South East of England.

Policy perspectives on alternative models for pharmaceutical rebates: a report from the Institute for Clinical and Economic Review Policy Summit

Alternative approaches to the current rebate system are being considered by policymakers and stakeholders in the private insurance market. This paper presents an analysis of three alternative options to the current rebate model: retaining retroactive rebates but requiring 100% pass-through of rebates and fees to plan sponsors; retaining retroactive rebates but requiring that patients share in rebates at the point of sale; and eliminating retroactive rebates and replacing the current structure with upfront discounts. Each alternative approach presents a balance of potential advantages and disadvantages. Policymakers should not assume that switching to an alternative rebate model will deliver unalloyed benefits for patients and the health system.

A framework to guide the optimal development and use of real-world evidence for drug coverage and formulary decisions

AIM

To provide a framework for optimizing the development and use of real-world evidence (RWE) in drug coverage decisions. Materials & methods: The Institute for Clinical and Economic Review convened a Policy Summit with representatives from 23 payer and life science companies that compose the Institute for Clinical and Economic Review membership.

RESULTS

Summit participants helped refine a new conceptual framework that emphasizes the central role of contextual considerations and the evidentiary argument that the RWE is intended to support in designing the process for the development and interpretation of RWE.

CONCLUSION

This framework may provide a structured way for pharmaceutical manufacturers and payers to develop a shared understanding of the best way to develop RWE that will ultimately be useful in informing coverage and formulary decisions.

Real-world evidence for coverage decisions: opportunities and challenges

AIM

To explore current uses of real-world evidence (RWE) in the US healthcare system, summarize key concerns and highlight various opportunities that could be realized through best use of RWE. Materials & methods: Information was gathered via a literature review and interviews to generate a background paper for the 2017 Institute for Clinical and Economic Review Policy Summit meeting.

RESULTS

RWE is currently being utilized in drug development decisions, regulatory approval decisions, post-approval monitoring, payer coverage decisions (initial decisions and reassessments) and for outcomes-based contracting. Solutions to key challenges and opportunities for future development are presented.

CONCLUSION

Exciting opportunities for the use of RWE exist, yet important reservations remain. Solutions are within reach if effective partnerships between stakeholders can be nurtured.

Gene therapy: evidence, value and affordability in the US health care system

AIMS

To explore the challenges presented by gene therapies, discuss potential solutions, and present policy recommendations.

METHODS

A review of the literature and series of expert interviews were conducted and discussed at a Policy Forum convened by The Institute for Clinical and Economic Review (ICER). The Policy Forum was attended by independent experts and senior representatives from 20 payer organizations and life sciences companies.

RESULTS

Three categories of challenges are identified: evidence generation, assessing value and affordability. Possible solutions and policy recommendations are presented for each of the three main categories of challenges.

CONCLUSIONS

Gene therapies present exciting opportunities, but also pose major challenges. Dialogue between manufacturers and payers around the issues and possible solutions is crucial.

Indication-specific pricing of pharmaceuticals in the US healthcare system

Aim: To explore the potential of indication-specific pricing (ISP) of pharmaceuticals and to discuss prospects for implementation in the US healthcare system. Materials & methods: The Institute for Clinical and Economic Review convened a policy forum with 44 healthcare leaders from 22 payer and life sciences companies. Models of ISP were discussed. Results: Payers and drug manufacturers saw the potential benefits of an ISP system that balances affordability for payers, sustainability for manufacturers and access for patients. The US healthcare system presents many challenges to implementation, including potential conflicts with existing pricing policies (Medicaid Best Price, average sales price and 340B) and insufficient data systems and analytic capabilities. Conclusion: Possible solutions and policy recommendations for payers and manufacturers are provided.

Public participation in decision-making on the coverage of new antivirals for hepatitis C

Purpose - New hepatitis C medicines such as sofosbuvir underline the need to balance considerations of innovation, clinical evidence, budget impact and equity in health priority-setting. The purpose of this paper is to examine the role of public participation in addressing these considerations. Design/methodology/approach - The paper employs a comparative case study approach. It explores the experience of four countries - Brazil, England, South Korea and the USA - in making coverage decisions about the antiviral sofosbuvir and involving the public and patients in these decision-making processes. Findings - Issues emerging from public participation ac tivities include the role of the universal right to health in Brazil, the balance between innovation and budget impact in England, the effect of unethical medical practices on public perception in South Korea and the legitimacy of priority-setting processes in the USA. Providing policymakers are receptive to these issues, public participation activities may be re-conceptualized as processes that illuminate policy problems relevant to a particular context, thereby promoting an agenda-setting role for the public. Originality/value - The paper offers an empirical analysis of public involvement in the case of sofosbuvir, where the relevant considerations that bear on priority-setting decisions have been particularly stark. The perspectives that emerge suggest that public participation contributes to raising attention to issues that need to be addressed by policymakers. Public participation activities can thus contribute to setting policy agendas, even if that is not their explicit purpose. However, the actualization of this contribution is contingent on the receptiveness of policymakers.

Targeting improved patient outcomes using innovative product listing agreements: a survey of Canadian and international key opinion leaders

Objectives

To address the uncertainty associated with procuring pharmaceutical products, product listing agreements (PLAs) are increasingly being used to support responsible funding decisions in Canada and elsewhere. These agreements typically involve financial-based rebating initiatives or, less frequently, outcome-based contracts. A qualitative survey was conducted to improve the understanding of outcome-based and more innovative PLAs (IPLAs) based on input from Canadian and international key opinion leaders in the areas of drug manufacturing and reimbursement.

Methods

Results from a structured literature review were used to inform survey development. Potential participants were invited via email to partake in the survey, which was conducted over phone or in person. Responses were compiled anonymously for review and reporting.

Results

Twenty-one individuals participated in the survey, including health technology assessment (HTA) key opinion leaders (38%), pharmaceutical industry chief executive officers/vice presidents (29%), ex-payers (19%), and current payers/drug plan managers/HTA (14%). The participants suggested that ~80%–95% of Canadian PLAs are financial-based rather than outcomes-based. They indicated that IPLAs offer important benefits to patients, payers, and manufacturers; however, several challenges limit their use (eg, administrative burden, lack of agreed-upon endpoint). They noted that IPLAs are useful in rapidly evolving therapeutic areas and those associated with high unmet need, a quantifiable endpoint, and/or robust data systems. The Canadian Agency for Drugs and Technologies in Health, the pan-Canadian Pharmaceutical Alliance, and other arms-length organizations could play important roles in identifying uncertainty and endpoints and brokering pan-Canadian PLAs. Industry should work collaboratively with payers to identify uncertainty and develop innovative mechanisms to address it.

Conclusion

The survey results indicated that while challenging, use of IPLAs may be associated with various benefits. Collaboration among stakeholders remains key: Canadian agencies could play an important role in the success of these agreements, while industry should be proactive in offering solutions that will help improve outcomes across the entire health care system.

Evidence of horsemanship and dogmanship and their application in veterinary contexts

This review collates peer-reviewed evidence for desirable attributes for those who work with dogs and horses. It is written with a particular focus on the veterinary profession. Although veterinarians and veterinary nurses (VNs) occupy variable roles when interacting with their patients, several behavioural attributes emerge as helpful across the range of such roles. In light of recent research on the value of considering animals' arousal and affective state as predictors of behaviour and welfare, best practice in human-horse and human-dog-interactions is outlined. The attributes of affiliation, safety and positive reinforcement seem to contribute greatly to the development and maintenance of moderate arousal and positive affect in animals. The information in this review article is offered in an attempt to show why veterinary professionals with good horsemanship are likely to remain safe, and to introduce the concept of dogmanship. In the light of the peer-reviewed evidence assembled here, it is arguable that veterinary teams, comprising both veterinarians and VNs, can become scholars in these areas. The benefits of this approach for practitioner safety, animal welfare and client satisfaction are likely to be significant.

How long does biomedical research take? Studying the time taken between biomedical and health research and its translation into products, policy, and practice

BACKGROUND

The time taken, or 'time lags', between biomedical/health research and its translation into health improvements is receiving growing attention. Reducing time lags should increase rates of return to such research. However, ways to measure time lags are under-developed, with little attention on where time lags arise within overall timelines. The process marker model has been proposed as a better way forward than the current focus on an increasingly complex series of translation 'gaps'. Starting from that model, we aimed to develop better methods to measure and understand time lags and develop ways to identify policy options and produce recommendations for future studies.

METHODS

Following reviews of the literature on time lags and of relevant policy documents, we developed a new approach to conduct case studies of time lags. We built on the process marker model, including developing a matrix with a series of overlapping tracks to allow us to present and measure elements within any overall time lag. We identified a reduced number of key markers or calibration points and tested our new approach in seven case studies of research leading to interventions in cardiovascular disease and mental health. Finally, we analysed the data to address our study's key aims.

RESULTS

The literature review illustrated the lack of agreement on starting points for measuring time lags. We mapped points from policy documents onto our matrix and thus highlighted key areas of concern, for example around delays before new therapies become widely available. Our seven completed case studies demonstrate we have made considerable progress in developing methods to measure and understand time lags. The matrix of overlapping tracks of activity in the research and implementation processes facilitated analysis of time lags along each track, and at the cross-over points where the next track started. We identified some factors that speed up translation through the actions of companies, researchers, funders, policymakers, and regulators. Recommendations for further work are built on progress made, limitations identified and revised terminology.

CONCLUSIONS

Our advances identify complexities, provide a firm basis for further methodological work along and between tracks, and begin to indicate potential ways of reducing lags.

Procurement change in Canada: an opportunity for improving system performance

The Canadian healthcare system is undergoing restructuring of how goods and services are purchased. A conference "Navigating Hospital and Health System Procurement" was organized by MEDEC and the Canadian College of Health Leaders to examine the issues. This paper describes the implications and opportunities these changes present for healthcare policy, regulation, practice, and the supplier marketplace.

Summary report of the ECHTA/ECAHI project. European Collaboration for Health Technology Assessment/Assessment of Health Interventions

Health technology assessment (HTA) seeks to inform health policy makers by using the best scientific evidence on the medical, social, economic, and ethical implications of investments in health care. Technology is broadly defined to include the drugs, devices, medical, and surgical procedures used in health care, as well as measures for prevention and rehabilitation of disease, and the organizational and support systems in which health care is provided.

Executive summary of the ECHTA/ECAHI project. European Collaboration for Health Technology Assessment/Assessment of Health Interventions

Health technology is an indispensable part of any nation's healthcare system. During the past 50 years, all member states that comprise the European Union have increased their technological base for health care, both in terms of knowledge and by investments in equipment, devices, and pharmaceuticals. Generally, this process has gone well. However, several problems have emerged related to the acquisition, diffusion, and use of modern health technology. Concerns have been also raised about the effectiveness and efficiency of already established procedures in health care.

Health technology assessment in the United Kingdom

The National Health Service (NHS) provides universal health coverage for all British citizens. Most services are free of charge, although modest copayments are sometimes applied. About 11% of the population also has private insurance. General practitioners, generally the first point of contact for accessing the system, are independent contractors who serve as gatekeepers for specialist and hospital services and enjoy substantial clinical autonomy. Hospitals are public and are regionalized, but the 1990 reforms made them self-governing trusts that contract with local purchasers (health authorities and general practitioner fundholders). Reforms beginning in 1990 moved the NHS away from a centralized administrative structure to more pluralistic arrangements in which competition, as well as management, influences how services develop. Health technology and health technology assessment (HTA) have gained increasing attention in the NHS during this period, as part of a wider NHS Research and Development (R&D) Strategy. The strategy promotes a knowledge-based health service with a strong research infrastructure and the capacity to critically review its own needs. HTA is the largest and most developed of the programs within the strategy. It has a formal system for setting assessment priorities involving widespread consultation within the NHS, and a National Co-ordinating Centre for Health Technology Assessment. The strategy supports related centers such as the U.K. Cochrane Centre and the NHS Centre for Reviews and Dissemination. A hallmark of the HTA program is strong public participation. The United Kingdom has made a major commitment to HTA and to seeking effective means of reviewing and disseminating evidence.

Priority setting for health technology assessment. Theoretical considerations and practical approaches. Priority setting Subgroup of the EUR-ASSESS Project

This report is about setting priorities for health technology assessment (HTA). HTA examines systematically the consequences of the application of health technologies (broadly defined to include any health care intervention) to support decision making in policy and practice. Only a fraction of existing health technologies have been formally evaluated, and many more appear each year. Resources for HTA are, however, limited so that priorities have to be set, whether explicitly or implicitly. The aim of setting priorities for HTA should be to identify those assessments that offer the greatest benefits in relation to their cost, and thus to maximize the benefit derived from investments in HTA.

The NHS R&D Information Systems Strategy (ISS)

Following a strategy study which reported in August 1992 the NHS R&D Information Systems Strategy (ISS), a strategic framework for information systems, has been developed to support research and development in the NHS. This paper summarizes its main features, illustrates the benefits which specific information systems will bring, and outlines how the products of the programme are disseminated and accessed.

Economic appraisal in the British National Health Service: implications of recent developments

This paper discusses the role of economic appraisal in the U.K. National Health Service, with particular emphasis on the impact of the recent reforms. A number of agencies, including the Department of Health, research councils, health authorities and industry, fund appraisals, the majority of which are carried out by academic researchers. To date there is little formal documentation of the impact of appraisals. The recent reforms should, in principle, increase the opportunities and demand for economic appraisal. The reforms establish an internal market for health care with separate roles for purchasers and providers. There are opportunities for using appraisals in deciding whether or not to place a contract, in deciding on the contract specification and in monitoring the prescribing budgets of general medical practitioners. The new NHS research and development strategy also places particular emphasis on research into the effectiveness and cost-effectiveness of health technologies, and on getting the results of research used in decision making.