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Risk sharing arrangements for pharmaceuticals: potential considerations and recommendations for European payers
BMC Health Services Researchvolume 10, Article number: 153 (2010)
There has been an increase in 'risk sharing' schemes for pharmaceuticals between healthcare institutions and pharmaceutical companies in Europe in recent years as an additional approach to provide continued comprehensive and equitable healthcare. There is though confusion surrounding the terminology as well as concerns with existing schemes.
Aliterature review was undertaken to identify existing schemes supplemented with additional internal documents or web-based references known to the authors. This was combined with the extensive knowledge of health authority personnel from 14 different countries and locations involved with these schemes.
Results and discussion
A large number of 'risk sharing' schemes with pharmaceuticals are in existence incorporating both financial-based models and performance-based/outcomes-based models. In view of this, a new logical definition is proposed. This is "risk sharing' schemes should be considered as agreements concluded by payers and pharmaceutical companies to diminish the impact on payers' budgets for new and existing schemes brought about by uncertainty and/or the need to work within finite budgets". There are a number of concerns with existing schemes. These include potentially high administration costs, lack of transparency, conflicts of interest, and whether health authorities will end up funding an appreciable proportion of a new drug's development costs. In addition, there is a paucity of published evaluations of existing schemes with pharmaceuticals.
We believe there are only a limited number of situations where 'risk sharing' schemes should be considered as well as factors that should be considered by payers in advance of implementation. This includes their objective, appropriateness, the availability of competent staff to fully evaluate proposed schemes as well as access to IT support. This also includes whether systematic evaluations have been built into proposed schemes.
Expenditure on pharmaceuticals is rising more rapidly than other components of health care with costs of cancer products growing at 21% per annum in recent years [1–5]. This will continue with ongoing demographic changes, instigation of stricter clinical targets and the continued launch of new expensive drugs [5–8]. Increasingly, though there are concerns with the level of health gain of new drugs with a median of just 0.097 Quality Adjusted Life Years (QALYs) versus current standards in an analysis of 281 recent submissions by pharmaceutical companies to the Scottish Medicines Consortium . This compares with the public perception that many new drugs are seen as breakthroughs .
European governments and health authorities have introduced successive reforms and initiatives to address these challenging resource issues including funding new premium priced innovative drugs. These include measures to engineer low prices for generics and originators as well as interchangeable brands within a class [2, 11–16]. They also include steps to improve transparency in classifying new drugs as innovative, linking the perceived degree of innovation of new products to reimbursed prices, and limiting payer exposure to new expensive drugs given their potential significant budget impact [11, 13, 17–23]. Not surprisingly, optimising the use of new expensive technologies is seen as the major challenge faced by health services in Europe as they strive to continue providing comprehensive and equitable healthcare .
Current schemes to limit the growth in pharmaceutical expenditure, ensure health gain is maximised within finite budgets, or both including limiting 'off label' prescribing and prescribing outside identified sub-populations where the value of the technology is greatest. They also include price-volume agreements (PVAs), patient access schemes where typically drugs are provided free for a period of time, 'coverage with evidence development' schemes as well as payment by result schemes based on outcomes achieved in practice. These latter schemes are also known as performance-based contracts, efficiency stipulation schemes or effectiveness guarantee schemes [13, 19–22, 24–35]. All of these schemes have been included within the general term 'risk sharing schemes' either by payers or pharmaceutical companies.
The number and range of risk sharing schemes have grown in recent years no doubt enhanced by patient and physician pressure on governments to accelerate access to new and more costly medicines despite often significant uncertainty surrounding their likely health benefit [10, 36]. This may well be exacerbated by pharmaceutical companies keen to address lost revenues from patent expires, which have recently been estimated at over US$100 bn per year over the next four years . Payers though need to consider the opportunity costs of risk sharing schemes if available resources are not used wisely [36, 38].
Further supply side and demand side initiatives are essential if Europe is to maintain the ideals of socially funded and equitable healthcare. This could mean further expansion of risk sharing schemes. There have been a number of papers published recently that have comprehensively reviewed existing and historic risk sharing schemes offering suggestions for the future [5, 10, 20, 34, 36, 39]. However, there is still considerable confusion surrounding the terminology, which urgently needs to be addressed. There are also concerns among health authority personnel with the level of administrative intensity associated with some of the current schemes and that they could end up contributing substantially to the development costs of new molecules [5, 40, 41]. Certainly in the past, a great deal of the risk associated with outcomes of coverage decisions have been borne by health authorities and insurance companies . This is starting to change given the number of new expensive technologies being launched coupled with their budget impact [6, 23, 34]. These challenges are magnified by the lack of scientific studies evaluating the implementation and outcome of many existing schemes for pharmaceuticals in terms of their overall costs and benefits [10, 34]. This has not been the case with non-pharmacological technologies where 17 policy outcomes have been derived to date from 32 principally non-drug technologies, with in approximately 60% of cases the coverage decision consistent with the outcomes of the study conducted as part of the schemes .
Benefits of risk sharing schemes include enhancing health gain within available resources as well as addressing issues such as the safety of new products in practice . These benefits though have to be balanced against concerns for patient care if new drugs are launched too early with considerable uncertainty regarding their safety as well as potentially paying for cost-ineffective technologies (type I error) .
We believe these concerns need to be discussed and debated before there is a continuing surge in 'risk sharing' schemes. This paper aims to stimulate this debate by:
Proposing logical definitions which can act as a reference for the future
Documenting exemplars from the published literature to illustrate proposed definitions supplemented with additional examples from the co-authors
Documenting the published impact, concerns and outcomes from current schemes from a payer perspective
Summarising considerations that should be borne in mind by payers when contemplating future schemes
Proposing guidance on key criteria for considering future risk sharing schemes again from a payer perspective
A literature review was undertaken by one of the authors (BG) in PubMed, MEDLINE and EMBASE between 2000 and February 2010 using key words. These were 'conditional coverage', 'conditional reimbursement', 'risk sharing', 'coverage with evidence', 'price volume agreements', 'value-based pricing, pharmaceuticals', 'no cure no pay', 'pay back schemes', 'health impact guarantee' and 'outcome guarantee'. This was supplemented by unpublished or "grey literature" references known to the 16 co-authors from European countries and locations involved with considering, evaluating and/or implementing such schemes. The focus is principally on Europe although other schemes relating to pharmaceuticals are also documented for Australia, Canada and the US to provide additional examples.
Only papers documenting the nature and content of actual schemes were considered for possible inclusion in this paper. There was no attempt to assess the quality of published papers using established criteria such as the Cochrane Collaboration criteria . This was because this is a 'correspondence' article undertaken by health authority and health insurance personnel evaluating and implementing such schemes rather than a comprehensive review of all risk sharing schemes undertaken as such reviews have recently been published [10, 20, 34].
The schemes were subsequently collated under the proposed definitions to provide guidance to health authority and health insurance personnel as these are the principal intended audience for this paper. Gaps in the knowledge base have been identified with suggestions for the future.
Where possible, Euros are quoted; however, some figures are quoted in GB£s and US $ (€1 = US$1.36, GB£0.90, SEK9.70 - 3 March 2010).
We propose 'risk sharing' schemes for pharmaceuticals should be considered as agreements concluded by payers and pharmaceutical companies to diminish the impact on the payer's budget of new and existing medicines brought about by either the uncertainty of the value of the medicine and/or the need to work within finite budgets. In practice, the agreement lies in setting the scope and realizing the mutual obligations amongst both payers and pharmaceutical companies depending on the occurrence of an agreed condition - the "risk". The "risk" varies by situation, and can include pharmaceutical expenditure higher than agreed thresholds or health gain from a new product lower in practice reducing its value.
We recognise our definition is different to the definition recently proposed by Towse and Garrison - namely these are 'agreements between a payer and a pharmaceutical company where the price level and/or revenue received is related to the future performance of the product in either a research or real-world environment' .However our efforts have been directed towards finding a definition coherently overarching the many agreements introduced in previous years as well as one acceptable to health authority and health insurance personnel. Consequently, we believe it is essential to create a definition according to rules of a logical division. These are firstly that there is only one basis of the division. Secondly, every subject belongs to only one group, where there may be sub-categories of equal rank. Thirdly, every example form the superior group, i.e. risk-sharing schemes, has to fall into either category, i.e. either financial based or performance based.
All the schemes discussed and proposed should have a common denominator that is the "risk shared by the payer and the pharmaceutical company". What differentiates the various schemes is the nature of the risk, i.e. "a probable situation in future". Based on our proposed definition, the many existing 'risk-sharing' schemes can be subdivided into either financial/financial-based models or outcome/performance-based models. This is broader than the definition proposed by Towse and Garrison, which just covers performance-based schemes. However, it is a workable definition from a payer perspective.
Even this division, despite being based on common naming, may be misleading though because it suggests that outcome or performance-based models have little to do with expenditure. In fact, the opposite can be true with price-volume agreements and other financial schemes often having little to do with patient outcomes, concentrating more on keeping expenditure within agreed limits and/or enhancing the value proposition of the new product. Price capping schemes do though bring in an outcome element.
The various examples of risk sharing scheme included within the proposed definition are:
Financial based schemes:
Price-volume agreements (PVAs)/budget impact schemes. These focus on controlling financial expenditure with pharmaceutical companies refunding over budget situations
Patient access schemes. These typically involve either free drug or discounts for an agreed period to enhance the value of new medicines and improve the possibility of their funding/reimbursement. Patient access schemes also include price-capping schemes, which focus on controlling the financial impact but from an individual patient perspective. Typically drugs are provided free once patients have exceeded an agreed utilisation limit to again enhance reimbursement/funding within finite resources
∘ Performance based/outcome-based models. These can include schemes whereby companies refund agreed monies or provide free drug if the desired outcomes are not reached. Alternatively, a price reduction if the new drug fails to deliver the desired health gain in practice. In reality, the latter is likely to lead to price shifting from payers to manufacturers as new drugs may well not be able to fully reproduce the desired benefits once prescribed in a wider population than those in the clinical trials, i.e. the net monetary benefit is lower in reality
As discussed, we believe all existing schemes can be collated into two groups; namely financial/financial-based models or performance-based/outcomes-based models.
Examples of financial-based models include price-volume agreements (PVA) - sometimes referred to as budget impact schemes - and patient access schemes including price capping schemes are included in Table 1[12, 13, 28, 36, 43–53], Table 2[20, 29, 33, 34, 54–57] and Table 3[5, 19–21, 24, 31, 32, 34, 58–68]. This is not a complete list but aims to give a number of examples.
Any further discussion on specific patient access programmes in the US is outside the scope of this paper.
Table 4 gives details of performance-based or outcome-based models in Canada, Europe and USA [10, 19, 20, 25–27, 34, 40, 51, 69–77]. Again, this is not an exhaustive list but aims at giving a number of examples.
In addition to these schemes, the Italian Medicines Agency (AIFA) has recently instigated two different approaches to accelerate reimbursement for new drugs especially where there is limited data available at launch. These include variations on patient access schemes as well as performance-based/outcome contracts [5, 34, 51]. The AIFA Oncologic Working Group suggested two risk sharing arrangements for new anti-cancer medicines to enhance their reimbursement potential based on:
Epidemiological data for the disease
The possibility to clearly define a subset of the population responsive to the treatment
Results from the submitted clinical trials
Bevacizumab - Metastatic carcinoma of the colon or rectum, breast cancer, NSCLC and advanced and/or metastatic renal cell cancer
Dasatinib - Chronic myeloid leukaemia and acute lymphoblastic leukaemia
Erlotinib - NSCLC after failure of at least one prior chemotherapy regimen
Nilotinib - Chronic myeloid leukaemia
Lapatinib - HER2+ breast cancer patients
Sorafenib - Second line treatment for renal cell carcinoma and hepatocellular carcinoma
Sunitinib - Metastatic renal cell carcinoma (first and second line treatment)
Inclusion in either risk sharing scheme depended on the characteristics of the drug and the tumour type and included:
Erlotinib, sunitinib and sorafenib - provided at 50% discount from current prices for an agreed number of cycles. In the case of erlotinib this is 2 months; 12 weeks for sunitinib and sorafenib. As a result, with erlotinib part funding the 50% of patients who would be expected to have disease progression at or before 8 weeks of treatment
Dasatinib and lapatinib - the Italian Health Service fully covers the cost of drugs for the responders following assessment; manufacturers refunding the costs in the case of disease progression
Four new drugs are also currently contained within the Italian conditional reimbursement scheme [34, 51]. This is similar to the US Centre for Medicare and Medicaid conditional coverage scheme under which conditions are set for the continued reimbursement of new technologies [5, 34, 39]. The current scheme in Italy covers ivabradine for chronic angina pectoris, as well as exenatide, sitagliptin and vildagliptin for patients with Type 2 diabetes resistant to current oral treatments [34, 51]. Under this scheme, AIFA fully reimburses the new drugs until further re-evaluation of their actual level of innovation. The main objectives being to evaluate utilisation in routine clinical practice, collect epidemiologic data as well as obtain data on the effectiveness and safety of the new drugs in practice. The measures used to assess effectiveness of the new drugs for diabetes are HbA1c levels. It is the number of angina episodes for new drugs for chronic angina pectoris. By the end of 2008, over 17,000 patients had been enrolled with 7% withdrawals due to therapeutic failure . More recent schemes for new anti-diabetic drugs in Italy have concentrated on co-utilisation with either metformin or sulphonyl ureas. This is because these new drugs should only be prescribed if HbA1c levels are not controlled with existing regimens, or there are unacceptable side-effects with existing drugs at prescribed doses.
Concerns with current schemes
There are already a considerable number of 'risk sharing' schemes in operation globally. However, there are concerns with existing schemes that need be addressed before they should become a routine part of future reimbursement or contracting negotiations especially given the suspicion among payers that a number of proposed schemes are extensions of pharmaceutical company marketing activities.
Whilst price-volume agreements (PVA) shift cost considerations from the payer to the pharmaceutical company, which is important especially if there are concerns that new medicines will be prescribed in a wider population than envisaged, there are concerns that the patients initially prescribed the drug will not always be those most likely to gain the greatest benefit [10, 36]. The growing use of health informatics can help here. In addition, PVA schemes may not always consider issues such as compliance, which is a growing issue with the recent study by Cramer and colleagues showing that only 59% of patients take their cardiovascular and antidiabetic medication for more than 80% of days on therapy each year . There are also concerns that pharmaceutical companies may additionally benefit from early access of new technologies with as yet unproven efficacy and safety even within such schemes unless the value of the new drugs has been critically evaluated by trained professionals. However, it is recognised PVA schemes may be the optimal method to finance new medicines especially where there are currently limited demand side measures to control off-label prescribing or prescribing in patient populations where the new medicine is less cost-effective [36, 79].
Physician Association concerns in Germany with discount and rebate initiatives between Pharmaceutical Companies and the Sickness Funds in Germany include a lack of transparency. This can create problems for the Physician Associations in calculating and monitoring drug budgets as well as providing prescribing guidance to meet their responsibility to monitor and manage drug budgets and advise physicians when their allocated budgets are likely to be breached. This is especially important in Germany as physicians can be fined for being over budget . Physician Association advice can be different to the advice given by Sickness Fund personnel to ambulatory care physicians to help improve the quality and efficiency of their prescribing especially if the value of discussed drugs is altered by discounts given by pharmaceutical companies. Matters can be further complicated when rebates and discounts are given for one drug on condition that there will be a predefined increase in utilisation and expenditure of a second drug.
This is different to the US where combined or bundling of rebates is now generally discouraged by Managed Care Organisations (MCOs) as it impedes transparency. This is particularly important where rebates are passed onto patients. As a result, contracts are increasingly focusing on individual drugs. Proposals for formulary inclusion are also increasingly being considered for drugs where there is support to improve adherence and compliance given concerns that poor compliance could severely compromise effectiveness potentially leading to increased medical and/or drug expenditure in practice to produce the desired clinical outcomes [78, 81–83]. MCOs such as Horizon Blue Cross Blue Shield of New Jersey are conducting research to improve the understanding of barriers to enhance compliance, with the findings likely to be incorporated into future initiatives including formulary listing considerations. Having said this, the first consideration for formulary inclusion of new medicines should always be their comparative efficacy and safety versus current formulary drugs. Only when two medicines are seen as essentially similar will the inclusion of schemes aimed at enhancing adherence and compliance be considered for potential formulary listing. Alongside this, 'price protection' clauses are also now being written into some contracts where manufacturers have sought price increases in the past.
Concerns with patient access schemes involving free drug or discounts include opportunity costs, even if this reduces the overall cost/QALY for the new product, as this could still result in significant additional cost for the payers. Alongside this, the administrative burden associated with additional patient monitoring as well as collating and submitting information are also concerns. Concerns with price capping schemes again include the administrative burden such as proof that only appropriate patients have been incorporated into the scheme and that they have reached the agreed limit. This is especially important when the number of patients where these will be applicable in reality is low. For example, there is only one eligible patient in Serbia that would currently qualify under the price capping scheme for bevacizumab in operation in either Italy or Sweden (Table 3). Alongside this, obtaining replacement stock or credit can be a lengthy process especially if manufacturers operate via wholesalers. Such processes may also impact on the accuracy of local medicine utilisation systems making future comparisons difficult. Lastly, pharmaceutical companies may wish to help with data collection and verification, which has to be denied if there are issues with patient integrity.
Whether the objective of the scheme is fully explicit
Whether the level of evidence is sufficient to make robust decisions initially. This includes whether there is a sufficiently strong correlation between any surrogate measures included in the phase III trials and the postulated health gain. This also includes concerns if meta analyses have been undertaken with only indirect comparisons. Limited outcome data also makes it difficult to undertake any sub-group analysis to ascertain potential patient populations where the value of new drugs will be greatest
Who will fund additional evidence generation given the high acquisition costs of most new technologies and concerns that considerable expenditure will be spent on marketing activities to promote new drugs rather than spent on further clinical trials
Who will fund drug provision if rebated drugs go out of date before suitable patients can be found
The reliability of registry and other data generation schemes unless comparable control groups. Concerns can be diminished if subsequent studies are undertaken by independent organisations
Accelerating the uptake of new drugs in practice, i.e. including patients in registry studies or provisional reimbursement schemes may accelerate their uptake in practice. The utilisation of new drugs may also be greater if companies provide additional support such as nurses to help with case finding and monitoring. This may be balanced though through reducing 'off label' use if physicians know prescribed indications are being monitored.
The length of follow up - especially if this is long (β interferon scheme in the UK - below)
The general administrative burden for all key stakeholders. This also includes the costs associated with the instigation of additional evaluation units such as those proposed by NICE in England. The PASAG (Patient Access Scheme Assessment Group) is already established in Scotland to help evaluate proposed risk sharing schemes; similarly the Patient Access Scheme Liaison Unit within NICE. Both units are already adding to the administrative burden of current risk sharing schemes
Compliance - especially for long term chronic conditions. This issue must be fully addressed where pertinent else all key stakeholder groups will lose out
Pricing, i.e. pharmaceutical companies may be tempted to initially over price their new drug in expectation of price cuts/cost shifting downstream as the evidence base grows
On the other hand, pay-for-performance schemes do encourage pharmaceutical companies to develop biomarkers or other methods that help target patient populations where health gain and hence value is greatest. This is especially important for new cancer drugs given the limited aggregate health gain of most new drugs including those for cancer and their appreciable cost per patient .
There have been a number of concerns with the β interferon scheme for multiple sclerosis in the UK, which need to be considered by payers when evaluating future schemes [25, 40, 91–93]. These include:
Flaws in the actual model due to difficulties in fully mapping out the quality of life and natural history of MS to the trial outcomes, which were based on changes in EDSS scores (Expanded Disability Status Score)
Concerns that the model was heavily influenced by assumptions about future discounting and did not account for example for the cost of azathioprine
The model did not appear to fully account for patients discontinuing treatment early because of side-effects
The length of follow-up
Concerns that within ten years the β interferons and glatiramer acetate may have been supplanted by newer drugs reducing the whole rationale behind the scheme
Funding and administration support
Primary Care Trusts generally did not receive any additional funding to cover the cost of these drugs
Hospitals also did not receive additional funding for more extensive follow-up consultations and for completing the necessary forms reducing their involvement in practice
Concerns generally with the necessary infrastructure required including specialist nurses as well as concerns where the costs of the additional administrative burden would come from
The administrative burden, lack of communication, and concerns with passing on savings have all been highlighted as key issues with current schemes for cancer drugs in the UK . Recent research among hospitals yielded :
73% of hospitals reported they did not have the capacity to manage current schemes as these typically required additional staff to manage, co-ordinate and track them. This is especially the case if hospital personnel have to spend valuable time manually tracking patients, retrospectively adjusting stock control systems and ensuring necessary financial systems are in place to fully realise any savings
A need for greater flexibility around the time limits for processing claims
A need for good communication between key stakeholder groups, e.g. in the case of bortezomib every missed claim results in a loss of GB£12,000
The need to ensure savings are passed back to the payers - this is not happening in 47% of hospitals
These findings again highlight concerns with existing schemes that need to be adequately addressed in the future before risk sharing schemes become a routine part of future reimbursement considerations.
Conclusions and future proposals
We believe there are only a limited number of situations where 'risk sharing' schemes should be considered in the future, as well as key issues that need to be considered by payers before entering into future 'risk sharing' arrangements. These are summarised below and have arisen due to the increasing launch of new expensive technologies putting considerable strain on European healthcare systems. They do not apply to the classical PVA/budget impact schemes, which have been discussed earlier.
Situations where risk sharing schemes could be considered by payers in the future include where:
the objectives and scope of the scheme are explicit and transparent
the new drug is a novel treatment in a high priority disease area with expected net health gain, and there are currently few if any effective treatments. In addition, translational science suggests good effectiveness in reality and delaying treatment before all the outcome data is available may not be in key stakeholder's interest. This can subsequently be verified by independent studies
new drugs are seen as effective in priority disease areas but there are potential concerns with long term safety
new drugs could have a substantial beneficial impact on service delivery and patient safety in practice but it has been difficult to prove this within the confines of a phase III trial
the likely health gain can be determined within a limited time frame. This is especially important in patients with advanced cancers in order not to waste time and resources
proposed patient access schemes in priority disease areas substantially lower health service costs to enhance reimbursement having factored in all administrative costs. This must though take into account the possibility of rebated drugs going out-of-date before they can be used or whether current systems have the ability to fully track patients and potential rebates, e.g. the cost of missed claims with bortezomid (above). Overall, rebate schemes do appear to provide a more accurate record of drug usage than the provision of free drug, as well as help ensure only appropriate patients are prescribed the new drug, enhancing their appeal
We believe proposed risk sharing schemes should be rejected where:
effective and low cost standards already exist for the population in question with proven long term outcomes. This includes provisional reimbursement schemes which may encourage companies to launch new expensive products with only limited surrogate data
Health Authorities will end up funding a substantial proportion of a new drug's development costs
patient compliance is a key consideration to improve health, and this has not been adequately addressed in the proposed scheme
there is a high administrative burden for the health service versus the likely health gain and/or perceived financial benefits
In addition, proposed schemes must be based on robust evidence ('coverage with evidence') for potential consideration. This includes robust translational science which has suggested beneficial outcomes in reality. Schemes must also include unambiguous and easily measured 'evidence based' effectiveness criteria evolved from good biological research and comprehensive clinical trials. Where there is insufficient evidence to make robust decisions, we believe reimbursement or funding should initially be considered only at similar prices to current standards. Prices can subsequently be increased in all or sub-populations as more data becomes available demonstrating increased value in practice. In this way limiting the financial exposure of payers as well as limiting Type 1 errors.
We believe key considerations when payers are reviewing proposed schemes include transparency, ethical considerations, staffing, evaluation and exit strategies. Transparency and ethical considerations include:
Funding arrangements for any registries as well as administration costs must be transparent
Any ethical, legal and clinical governance considerations must be fully addressed when proposing and developing future schemes. This includes issues of ownership of the data, especially if schemes are operated within health services, intellectual property rights and opportunities for appeal
Future risk sharing schemes should be open to all pertinent companies and not just selected companies. This builds on the established procurement processes, and could be in the form of 'requests for risk sharing' schemes among competing companies in given disease areas/patient populations
Staffing/funding considerations include whether:
Appropriate professionals are in place to fully evaluate proposed schemes, otherwise decisions may be compromised. This includes clinical, clinical pharmacology, pharmacy, IT and economic experts
Continued funding of competent personnel (clinical and IT), as well as comprehensive IT infrastructures, is in place to effectively develop and implement follow-up registries where pertinent
There are high ethical standards in the evaluation of proposed schemes. This includes the declaration of any contacts and conflicts of interest between experts and pharmaceutical companies that could potentially jeopardise evaluations
Finally, we believe evaluations must be built into future schemes based on good science given the paucity of published studies to date and concerns with many current schemes. In the past, pharmaceutical companies may have been unwilling to broadcast their schemes especially patient access schemes. However, there are now established payer networks to address this, and publication is seen as a major way forward for health authorities to learn from each another. Any evaluation must include the overall costs involved with implementing and conducting the schemes as well as their outcome. 'Exit' strategies must also be considered in advance should the effectiveness and/or safety of new drugs turn out to be worse in reality leading to their possible withdrawal during the lifetime of the scheme.
Consequently we believe future schemes must have realistic time scales, must not involve appreciable administrative burden if part of routine clinical care unless addressed, and must take cognisance of any likely changes in care during their lifetime, i.e. standard drugs losing their patent and/or clinical standards changing.
We hope that this paper will stimulate further debate and discussion especially in Europe about future risk sharing arrangements for pharmaceuticals amongst all key stakeholder groups.
Lee T, Emanuel E: Tier 4 drugs and the fraying of the social compact. NEJM. 2008, 359: 333-5. 10.1056/NEJMp0804261.
Wettermark B, Godman B, Andersson K, Gustafsson LL, Haycox A, Bertele V: Recent national and regional drug reforms in Sweden - implications for pharmaceutical companies in Europe. Pharmacoeconomics. 2008, 26: 537-50. 10.2165/00019053-200826070-00001.
Garattini L, Motterlini N, Cornago D: Prices and distribution margins of in-patent drugs in pharmacy: A comparison in seven European countries. Health Policy. 2008, 85: 305-13. 10.1016/j.healthpol.2007.08.005.
Clement F, Harris A, Li JJ, Yong K, Lee K, Manns BJ: Using effectiveness and cost-effectiveness to make drug coverage decisions - a comparison of Britain, Australia and Canada. JAMA. 2009, 302: 1437-43. 10.1001/jama.2009.1409.
McCabe C, Bergmann L, Bosanquet N, Ellis M, Enzmann H, von Euler M, Jönsson B, Kallem K-J, Newling D, Nussler V, Paschen B, de Wilde R, Wilking N, Teale C, Zwierzina H: Market and patient access to new oncology products in Europe: a current, multidisciplinary perspective. Annals of Oncology. 2009, 20: 403-12. 10.1093/annonc/mdn603.
Garattini S, Bertele V, Godman B, Haycox A, Wettermark B, Gustafsson L: Enhancing the rational use of new medicines across European healthcare systems - A Position Paper. Eur Jn Clinical Pharmacology. 2008, 64: 1137-8. 10.1007/s00228-008-0537-z.
Cook J, Vernon J, Mannin R: Pharmaceutical risk-sharing agreements. Pharmacoeconomics. 2008, 26: 551-6. 10.2165/00019053-200826070-00002.
Godman B, Wettermark B, Hoffman M, Andersson K, Haycox A, Gustafsson LL: Multifaceted national and regional drug reforms and initiatives in ambulatory care in Sweden; global relevance. Expert Rev Pharmacoeconomics Outcomes Res. 2009, 9: 65-83. 10.1586/1473718.104.22.168.
Walker A, Booth C, Brown A, Paterson K: How much good do new medicines do? Basic & Clin Pharm & Toxicology. 2009, 105 (Suppl 1): 29.
McCabe C, Stafinski T, Edlin R, Menon D: Access with evidence development schemes - a framework for description and evaluation. Pharmacoeconomics. 2010, 28: 143-52. 10.2165/11530850-000000000-00000.
Godman B, Bucsics A, Burkhardt T, Haycox A, Seyfried H, Weininger P: Insight into recent reforms and initiatives in Austria; implications for key stakeholders. Expert Rev. Pharmacoeconomcis Outcomes Res. 2008, 8: 357-71. 10.1586/1473722.214.171.1247.
Godman B, Haycox A, Schwabe U, Joppi R, Garattini S: Having your cake and eating it: Office of Fair Trading proposal for funding new drugs to benefit patients and innovative companies. PharmacoEconomics. 2008, 26: 91-8. 10.2165/00019053-200826020-00001.
Sermet C, Andrieu V, Godman B, Van Ganse E, Haycox A, Reynier JP: Ongoing pharmaceutical reforms in France; considerations for other countries and implications for key stakeholder groups in France. Applied Health Economics and Health Policy. 2010, 8: 7-24.
Seeley E, Kanavos P: Generic medicines from a societal perspective: Savings for healthcare systems?. Eurohealth. 2008, 14: 18-22.
Godman B, Schwabe U, Selke G, Wettermark B: Update of recent reforms in Germany to enhance the quality and efficiency of prescribing of Proton Pump Inhibitors and lipid-lowering drugs. Pharmacoeconomics. 2009, 27: 1-4. 10.2165/00019053-200927050-00010.
Godman B, Burkhardt T, Bucsics A, Wettermark B, Weininger P: Impact of recent reforms in Austria on utilisation and expenditure of PPIs and lipid lowering drugs; implications for the future. Expert Rev Pharmacoeconomcis and Outcomes Research. 2009, 9: 475-84. 10.1586/erp.09.43.
AIFA - Italian Medicines Agency: Working Group on Innovative Drugs. Criteria for Ranking Therapeutic Innovation of New Drugs and Elements for Supplementing the Dossier for Admission to the Reimbursement System (document approved by the AIFACTS on July 10, 2007) (accessed 3 March 2010), [http://www.agenziafarmaco.it/allegati/integral_document.pdf]
Office of Fair Trading (UK): The pharmaceutical price regulation system: an OFT study. Annexe K: International survey of pharmaceutical pricing and reimbursement schemes. 2007, London: The Office of Fair Trading, [online] [Accessed 3 March 2010], [http://www.oft.gov.uk/shared_oft/reports/comp_policy/oft885k.pdf]
Anon: Innovative approaches to pricing. IMS Pharma Pricing & Reimbursement. 2007, 224-227. (Accessed 3 March 2010), [http://www.imshealth.com/deployedfiles/imshealth/Global/Content/StaticFile/Are_Traditional_Pricing_Models_Thing_of_Past.pdf]
Briggs A, Ritchie K, Fenwick E, Chalikidou K, Littlejohns P: Access with evidence development in the UK - past experience, current initiatives and future potential. Pharmacoeconomics. 2010, 28: 163-70. 10.2165/11531410-000000000-00000.
Hirschler B: Roche plans to address cost of Avastin in Europe. 2008, (Accessed 3 March 2010), [http://uk.reuters.com/article/idUKL1834800720070418]
de Pourville G: Risk-sharing arrangements for innovative drugs. A new solution to old problems. Eur J Health Econ. 2006, 7: 155-7. 10.1007/s10198-006-0386-6.
Anon: Cancer drugs costing £50 billion will crush the NHS, says expert. 2008, (Accessed 3 March 2010), [http://www.dailymail.co.uk/health/article-1053628/Cancer-drugs-costing-50billion-crush-NHS-says-expert.html]
Jirillo A, Vascon F, Giacobbo M: Bevacizumab in advanced cancer, too much or too little?. Annals of Oncology. 2008, 19: 1817-8. 10.1093/annonc/mdn564.
Breckenridge A, Walley T: Risk sharing and payment by results. Clin Pharmacol and Therapeutics. 2008, 83: 666-7. 10.1038/clpt.2008.15.
Møldrup C: No cure, no pay. BMJ. 2005, 330: 1262-4. 10.1136/bmj.330.7502.1262.
Chapman S, Reeve E, Rajaratnam G, Neary R: Setting up an outcomes guarantee for pharmaceuticals: New approach to risk sharing in primary care. BMJ. 2003, 326: 707-9. 10.1136/bmj.326.7391.707.
Carapinha C: Setting the stage for risk-sharing agreements: International experiences and outcomes-based reimbursement. SA Fam Pract. 2008, 50: 62-5.
NICE draft recommendation on the use of drugs for renal cancer. 2009/009. [Accessed 3 March 2010], [http://www.nice.org.uk/media/420/AD/2009009DraftNICEGuidanceDrugsRenalCancerv2.pdf]
Medical News Today: Final NICE Kidney Cancer Guidance Recommends sunitinib. 2009, [Accessed 3 March 2010], [http://www.medicalnewstoday.com/articles/143681.php]
NICE: Lenalidomide for the treatment of multiple myeloma in people who have received at least one prior therapy. 2009, [Accessed 3 March 2010], [http://www.nice.org.uk/nicemedia/pdf/TA171GuidanceWord.doc]
HemOnc today: UK's NICE approves lenalidomide in relapsed multiple myeloma. 2009, [Accessed 3 March 2010], [http://www.hemonctoday.com/article.aspx?rid=41000]
Robertson J, Walkom E, Henry D: Transparency in pricing arrangements for medicines listed on the Australian Pharmaceutical Benefits Scheme. Aust Health Rev. 2009, 33: 192-9. 10.1071/AH090192.
Stafinski T, McCabe C, Menon D: Funding the unfundable - mechanisms for managing uncertainty in decisions on the introduction o new and innovative technologies into healthcare systems. Pharmacoeconomics. 2010, 28: 113-42. 10.2165/11530820-000000000-00000.
Taylor L: New UK PPRS includes 3.9% price cut, flexible pricing and generic substitution. 2008, Accessed 3 March 2010), [http://www.eatg.org/eatg/Global-HIV-News/Access-to-treatment/New-UK-PPRS-includes-3.9-price-cut-flexible-pricing-and-generic-substitution]
Towse A, Garrison L: Can't get no satisfaction? Will pay for performance help? Toward an economic framework for understanding performance-based risk sharing agreements for innovative medical products. Pharmacoeconomics. 2010, 28: 93-102. 10.2165/11314080-000000000-00000.
Jack A: Balancing Big Pharma's books. BMJ. 2008, 336: 418-9. 10.1136/bmj.39491.469005.94.
Barrett A, Riques T, Small M, Smith R: How much will Herceptin really cost?. BMJ. 2006, 333: 1118-20. 10.1136/bmj.39008.624051.BE.
Mohr P, Tunis S: Access with evidence development - the US experience. Pharmaceoeconomics. 2010, 28: 153-62. 10.2165/11531050-000000000-00000.
Leader. Looking beyond the headlines. The Lancet Oncology. 2007, 8: 561-10.1016/S1470-2045(07)70178-X.
Williamson S: Patient access schemes for high-cost cancer medicines. Lancet. 2010, 11: 111-2. 10.1016/S1470-2045(09)70402-4.
Sturm H, Austvoll-Dahlgren A, Aaserud M, et al: Pharmaceutical policies: effects of financial incentives for prescribers (Review). Cochrane database of Systematic Reviews. 2007, Art No.: CD006731 DOI: 10.1002/14651858.CD006731, 3
de Swaef A, Antonissen Y: Pharmaceutical Pricing and Reimbursement Information, Belgium. 2007, (Accessed 3 March 2010), [http://ppri.oebig.at/Downloads/Results/Belgium_PPRI_2007.pdf]
Espín J, Rovira J: Analysis of differences and commonalities in pricing and reimbursement systems in Europe. A study funded by DG Enterprise and Industry of the European Commission. 2007, (Accessed 3 March 2010), [http://kce.docressources.info/opac/index.php?lvl=notice_display&id=912]
Pudersell K, Vetka A, Rootslane L, Mari Mathiesen, et al: Pharmaceutical Pricing and Reimbursement Information, ESTONIA. 2007, (Accessed 3 March 2010), [http://ppri.oebig.at/Downloads/Results/Estonia_PPRI_2007.pdf]
Health Systems in Transition. Estonia Health. 2008, 10 (1): (Accessed 3 March 2010), [http://www.hpm.org/Downloads/reports/HiT_reports/Hit_Estonia_2008.pdf]
Grandfils N: Drug price setting and regulation in France. Working paper (DT number 16). 2008, (accessed 3 March 2010), [http://www.irdes.fr/EspaceAnglais/Publications/WorkingPapers/DT16DrugPriceSettingRegulationFrance.pdf]
Comite Economique Des Produits De Sante: Healthcare Products Pricing Committee Annual Report. 2008, [Accessed 3 March 2010], [http://www.sante.gouv.fr/ceps/doc/rapport_activite_ceps_2008_anglais.pdf]
European Legal Developments Bulletin: 2007, 19 (2): 17-19. spring
Kovács T, Rózsa P, Szigeti S, et al: Pharmaceutical Pricing and Reimbursement Information, HUNGARY. 2007, (Accessed 3 March 2010), [http://ppri.oebig.at/Downloads/Results/Hungary_PPRI_2007.pdf]
Folino Gallo P, Deambrosis P: Pharmaceutical risk-sharing and conditional reimbursement in Italy. 2008, Krakow, (Accessed 3 March 2010), [http://www.ceestahc.org/pliki/symp2008/gallo.pdf]
Barros P, de Almeida Simões J: Health Systems in Transition. 2007, 9 (5): Portugal: Health system review 2007 (Accessed 3 March 2010)
Teixeira I, Vieira I: Pharmaceutical Pricing Reimbursement Information, Portugal. 2008, (Accessed 3 March 2010), [http://ppri.oebig.at/Downloads/Results/Portugal_PPRI_2008.pdf]
Cetuximab for first line treatment of metastatic colorectal cancer (MCRC). 2009, [Accessed 3 March 2010], [http://www.nice.org.uk/nicemedia/pdf/ColorectalCancerCetuxamibACD2ManPAS.pdf]
NICE draft recommendation on the use of drugs for renal cancer. 2009/009. [Accessed 29 July 09], [http://www.nice.org.uk/media/420/AD/2009009DraftNICEGuidanceDrugsRenalCancerv2.pdf]
Medical News Today: Final NICE Kidney Cancer Guidance Recommends sunitinib. 2009, [Accessed 3 March 2010], [http://www.medicalnewstoday.com/articles/143681.php]
Anon: Scottish Medicines Consortium - cetuximab, 100 mg/20 ml and 500 mg/100 ml solution for intravenous infusion. 2010, (Accessed 3 March 2010), [http://www.scottishmedicines.org.uk/files/cetuximab%20Erbitux%20RESUBMISSION%20FINAL%20January%202010%20for%20website.pdf]
Anon: Final NICE Guidance Recommends Lucentis(R) (Ranibizumab) For Wet AMD in UK. Scrip News. 2008, (Accessed 03 Jan 2010), [http://www.scripnews.com/news/nice-confirms-lucentis-choice-for-wet-amd-526]
NICE: Costing statement: Ustekinumab for the treatment of adults with moderate to severe psoriasis. [Accessed 3 March 2010], [http://www.nice.org.uk/nicemedia/pdf/TA180UstekinumabForTheTreatmentOfPsoriasisCostingStatement.pdf]
Anon: Scottish Medicines Consortium - ustekinumab 45 mg solution for injection. 2010, (Accessed 28 February 2010), [http://www.scottishmedicines.org.uk/files/ustekinumab%20Stelara%20FINAL%20January%202010%20Amended%2004.02.10%20for%20website.pdf]
Herper M: Top of The Cancer Market?. 2006, (Accessed 3 March 2010), [http://www.forbes.com/2006/10/12/cancer-drug-pricing-biz-cz_mh_1012drugs.html]
Pollack A: Genentech Caps Cost of Cancer Drug for Some Patients. 2006, (Accessed 29 June 09), [http://www.consumerwatchdog.org/patients/articles/?storyId=14384&bIndex=0]
United Healthcare: Injectable claim edit (maximum dosage drug policy). 2008, (Accessed 3 March 2010), [https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Clinician%20Resources/Cancer%20Oncology/Injectable%20Drug%20March08%20NB%20Article.pdf]
Anon: Generic Biotech Products: Are the Floodgates Open? At Whose Expense?, Biotech Business. 2008, (3 March 2010), [http://www.biotechnologyhealthcare.com/journal/fulltext/3/4/BH0304022.pdf]
Amgen: Amgen Introduces Comprehensive Financial Assistance Programs for Cancer Patients. (Accessed 3 March 2010), [http://findarticles.com/p/articles/mi_m0EIN/is_2006_Sept_27/ai_n16836635/]
Sanofi-Aventis: Sculptra™ Patient Access Program. [Accessed 3 March 2010], [http://www.pparx.org/resources/2008-05-19.SanofiAventis.Sculptra_Patient_Access_Program.3008.pdf]
Gilead: Need Help Paying for TRUVADA?. [Accessed 3 March 2010], [http://www.truvada.com/pat400_paying_for_your_hiv_meds.aspx]
Hart Carly: Free Prescription Drugs to Unemployed Courtesy of Pfizer, Inc. 2009, [http://www.associatedcontent.com/article/1747496/free_prescription_drugs_to_unemployed.html]
Anderson P: Clozapine comes with money-back offer. (accessed 3 March 2010), [http://www.mentalhealth.com/mag1/p51-cloz.html]
Fuschillo C, Ascoli F, Franzese G, Campana F, Cello C, Galdi M, La Pia S, Cetrangolo C: Alzheimer's disease and acetylcholinesterase inhibitor agents: a two-year longitudinal study. Arch Gerontol Geriatr Suppl. 2004, 187-94. 10.1016/j.archger.2004.04.026. 9
Bellelli G, Lucchi E, Minicuci N, Rozzini L, Bianchetti A, Padovani A, Trabucchi M: Results of a multi-level therapeutic approach for Alzheimer's disease subjects in the "real world" (CRONOS project): a 36-week follow-up study. Aging Clin Exp Res. 2005, 17: 54-61.
Anon NICE: Final appraisal determination bortezomib monotherapy for relapsed multiple myeloma. (accessed 3 March 2010), [http://www.nice.org.uk/nicemedia/pdf/FAD.pdf]
Garber A, McCellan M: Satisfaction guaranteed - 'Payment by results' for biologic agents. NEJM. 2007, 357: 1575-7. 10.1056/NEJMp078204.
Chapman S, Reeve E, Rajaratnam G, Neary R: Outcomes guarantee for lipid-lowering drugs: results from a novel approach to risk sharing in primary care. Br J cardiol. 2004, 11: 205-10.
Office of Fair Trading (UK): The Pharmaceutical Price regulation System - An OFT study. 2007, (accessed 3 March 2010), [http://www.oft.gov.uk]
Boggild M, Palace J, Barton P, Ben-Shlomo Y, Bregenezer T, Dobson C, Gray R: Multiple sclerosis risk sharing scheme: two year results of clinical cohort study with historical comparator. BMJ. 2009, 339: b4677-10.1136/bmj.b4677.
Haan G, Rutten F: No cure, no pay: an acceptable way of financing fertility treatments? Health Policy. 1989, 13: 239-49.
Cramer JA, Benedict A, Muszabek N, Keskinaslan A, Khan Z: The significance of compliance and persistence in the treatment of diabetes, hypertension and dyslipidaemia: a review. Int J Clin Pract. 2008, 62: 76-87. 10.1111/j.1742-1241.2007.01630.x.
Wettermark B, Godman B, Jacobsson B, Haaijer-Ruskamp F: Soft Regulations in Pharmaceutical Policymaking: An Overview of Current Approaches and their Consequences. Appl Econ Health Policy. 2009, 7: 1-11.
Hyde R: Doctors to pay for patients' medicine in Germany. Lancet. 2007, 370: 1118-10.1016/S0140-6736(07)61494-9.
Yack D: Adherence to long-term therapies - Evidence for action. WHO 2003 - WHO/MNC/03.01. (Accessed 3 March 2010), [http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf]
Horne R, Weinman J, Barber N, et al: Concordance, adherence and compliance in medicine taking. NCCSDO. 2005, (Accessed 3 March 2010), [http://www.npci.org.uk/adherence_to_medicines/atm/intro/resources/library_horne_final_report.pdf]
Perreault S, Dragomir A, Blais L, Berrard A, Lalonde L, White M, Pilon D: Impact of better adherence to statin agents in the primary prevention of coronary artery disease. Eur J Clin Pharmacol. 2009, DOI 10.1007/s00228-009-0673-0
Garattini S, Bertele' V: How can we regulate medicines better. BMJ. 2007, 335: 803-5. 10.1136/bmj.39281.615706.94.
Apolone G, Joppi R, Bertele V, Garattini S: Ten years of marketing approvals of anticancer drugs in Europe: regulatory policy and guidance documents need to find a balance between different pressures. British Journal of Cancer. 2005, 93: 504-9. 10.1038/sj.bjc.6602750.
Joppi R, Dematte L, Menti AM, Pase D, Poggiani C, Mezzalira L: The Italian Horizon Scanning project. Eur J Clin Pharmacol. 2009, (published online - DOI 10.1007/s00228-009-0666-z)
Claxton K, Briggs A, Buxton M, Culyer A, McCabe C, Walke S, Sculpher M: Value based pricing for NHS drugs: an opportunity not to be missed?. BMJ. 2008, 336: 252-4. 10.1136/bmj.39434.500185.25.
Pegler S, Underhill J: Evaluating promotional material from industry: an evidence-based approach. Pharmaceutical Jn. 2005, 274: 271-4.
Walley T: Fair pricing for medicines in the UK. Expert Rev Pharmacoeconomics and Outcomes Res. 2007, 7: 207-9. 10.1586/14737126.96.36.199.
Webb D, Walker A: Value-based pricing of drugs in the UK. Lancet. 2007, 369: 1415-6. 10.1016/S0140-6736(07)60648-5.
Walley T: Neuropsychotherapeutics in the UK; what has been the impact of NICE? CNS Drugs. 2004, 18: 1-12.
Duerden M, Gogna N, Godman B, Eden K, Mallinson M: Current National Initiatives Policies to control drug costs in Europe: UK perspective. J Ambulatory Care Manage. 2004, 27: 132-8.
Sudlow S, Counsel C: Problems with UK government's risk sharing scheme for assessing drugs for multiple sclerosis. BMJ. 2003, 326: 288-92. 10.1136/bmj.326.7385.388.
The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/10/153/prepub
We acknowledge the help of Roberta Joppi with providing additional details on the situation in Italy. We also acknowledge the help of Jan Jones with providing details of the situation in Scotland as well as critiquing earlier drafts. In addition, we acknowledge the help of Inês Teixeira with critiquing the details of current risk sharing arrangements in Portugal. This work was in part supported by grants from the Karolinska Institutet.
There are no conflicts of interest of any author. However, the majority of authors are employed by health authorities or health insurance agencies.
No author received financial assistance with writing this paper.
JA - involved with appraising risk sharing schemes from across Europe and categorising them to provide direction to the Ministry of Health in Poland whilst developing new laws surrounding such schemes. KW and GOS provided support with this whilst both at the National Health Fund in Poland, and critiqued the final draft. BG - main author involved with constructing the general direction of the paper, collating the various schemes as well as producing the drafts including current concerns and future proposals for comment. BO - helped critique the discussions on Poland as well as the potential future direction. HH - critiqued the comments on Germany and provided guidance on the nature and construction of future schemes from a Physician Association perspective. OL - provided advice and comment on current schemes in Estonia and potential ways forward. SJ - actively involved with critiquing clinical and economic issues for new and existing drugs in HBCBS of NJ. This includes potential 'risk sharing' arrangements as well as programmes to enhance compliance, which is also seen as a growing problem especially for patients with chronic diseases. As a result, provided input and direction on the situation in USA. CS - provided feedback on current schemes in France. CZ - critiqued the recommendations based on her perspective as a payer in a leading region in Spain. MK - provided data on current schemes in Serbia as well as critiqued the future guidance based on her experience working for the Republic Institute for Health Insurance in Serbia. RG - actively involved in the first risk sharing schemes for Stockholm. Provided a different perspective when reviewing such schemes to give guidance for the future. KG - provided feedback on current schemes in Lithuania as well as critiqued proposed recommendations. AH - gave advice on the VELCADE scheme in the UK. He is also a member of a NICE appraisal group, and his knowledge was used to develop and critique proposed developments. SG - helped to critique the drafts based on his considerable experience in Italy and across Europe. LLG - contributed significantly to the discussions and future direction based on his extensive experience in Sweden with chairmanship of the Regional Drugs and Therapeutics Committee in Stockholm County Council, including methodologies to enhance the rational use of drugs, as well as general experience with informatics
All authors have read and approved the final manuscript