Risk sharing in managed entry agreements—A review of the Swedish experience

BackgroundIn 2014 managed entry agreements (MEA) between Swedish health care payers (county councils), the reimbursement authority (the Dental and Pharmaceutical Benefits Agency (TLV)) and pharmaceutical companies were introduced to facilitate early and equal access to treatments. MEAs complement the value-based pricing system for out-patient drugs and enables stake-holders to negotiate risk-sharing agreements.AimThe aim of the study was to review existing agreements, describe the type of uncertainty dealt with, and to analyze incentives created using the literature on performance-based reimbursement schemes in Sweden.MethodA document review of all agreements made in the period January 2015 to August 2019 was conducted, classifying agreements by the type of uncertainty dealt with.ResultsAgreements were made for 56 products during the studied time period (45 ongoing), mainly in the fields of hepatitis C (n = 10) and oncology (n = 14). Uncertainties addressed in ongoing agreements included size of treated population (10), treatment duration (13), and effectiveness (9). The mechanism for risk-sharing was limited to refunds based on patient numbers, duration or just flat-rate refunds. The estimated refund in 2018 was 50 % of total sales.DiscussionThis review show that the main driver behind risk sharing in Sweden so far have seem to be affordability rather than managing uncertainty.     

谈判药品报销政策的满意度研究:以西安市为例

目的 调查参保者和药店工作人员对西安市谈判药品挂账过渡期报销政策的知晓率与满意度,为医保谈判药品政策落地提供依据。方法 对3家西安市特定药店工作人员及到店购买谈判药品的参保者进行问卷调查,对青岛市、成都市及西安市人社局相关人员、西安市药店相关人员及参保者进行访谈。结果 参保者对西安市谈判药品挂账过渡期报销政策总体知晓率较低,药店工作人员总体知晓率较高;参保者和药店工作人员总体满意度都较高。被调查者对该政策不满意的方面主要是政策普及程度不够、需先垫付药品报销部分费用、报销程序繁琐等。结论 相关部门应加强谈判药品相关政策宣传,加快出台特药定点药店管理办法,完善医保信息化系统等。     

Pricing and Reimbursement of Pharmaceuticals. A New Culture for the Community Pharmacist.

Pricing and reimbursement of pharmaceuticals are of concern for pharmacists. Different countries have different ways of organising their health care systems. The place for pharmaceuticals within these systems also differ. This article looks into the price and reimbursement systems for medicinal products in Germany, Sweden, the UK and Norway. Various ways of organising the pharmaceutical market emerge. Some existing measures have been in place for a long time while others have been introduced more recently. A common goal for the four countries seems to be the drive to cut costs, and attempts to do this can be directed through various reimbursement systems, by focusing on prices or by influencing the physicians' prescribing behaviour, either through the use of advice or through the use of budgets. It is important for the pharmacists to have indepth knowledge of the price and reimbursement system they have to work within in order to be of full service to their customers.     

基于价值定价的多适应证药品医保支付国际经验及启示

目的:为完善我国多适应证药品基于价值定价的医保支付提供参考。方法:梳理多适应证药品价值定价的理论基础和实现流程,分析法国、德国、英国、意大利和瑞典的价值评估指标和基于价值定价的医保支付策略,为我国多适应证药品医保支付提出建议。结果与结论:价值定价的实现首先需要制定一个价值框架以定义、测量、整合价值,再通过建立模型将总价值转化为价格。各国多适应证药品根据价值定价的整体思路一致,但价值评估指标存在差异。英国和瑞典主要以药物经济学方法测得的质量调整生命年(QALYs)和增量成本-效果比(ICERs)为价值标准,法国、德国和意大利则更侧重于以药品的临床治疗价值和临床指标改善程度为标准。在多适应证药品的医保支付策略方面,法国采取的是基于预期使用量的单一加权法,德国采取的是基于价值和使用量的组合加权法,英国采取的是名义医保支付标准结合患者准入协议法,意大利采取的是名义医保支付标准结合管理准入协议法,瑞典则采用不同适应证不同商品名的独立支付法。我国可在借鉴上述多国经验的基础上,探索适应我国国情的多适应证药品的价值定价策略,综合借鉴和使用多种医保支付策略,完善患者及药品使用信息收集机制,为实施多适应证药品价值定价和医保支付策略提供信息支持。     

我国大病医疗保险报销规则研究

大病医疗保险中的道德风险对医疗保险基金的可持续运行带来挑战。本文对能够减少道德风险的大病医保报销模式展开了研究。理论分析表明,在最大化社会总福利的目标下,应对选择低费用治疗方案的消费者提供补贴,对选择高费用治疗方案的消费者设定自付比例。模拟表明这种差异化报销规则相对于单一报销规则,降低了医疗费用和医疗保险费。本文还对模拟所用的参数选择进行了敏感性检验,结果表明,不同的参数选择不会改变本文所揭示的机理。     

Radiotherapy access in Belgium: How far are we from evidence-based utilisation?

IntroductionUnderutilisation of radiotherapy has been observed worldwide. To evaluate the current situation in Belgium, optimal utilisation proportions (OUPs) adopted from the European SocieTy for Radiotherapy and Oncology – Health Economics in Radiation Oncology (ESTRO-HERO) project were compared to actual utilisation proportions (AUPs) and with radiotherapy advised during the multidisciplinary cancer team (MDT) meetings. In addition, the impact of independent variables was analysed.Materials and methodsAUPs and advised radiotherapy were calculated overall and by cancer type for 110,810 unique cancer diagnoses in 2009–2010. Radiotherapy utilisation was derived from reimbursement data and distinguished between palliative and curative intent external beam radiotherapy (EBRT) and/or brachytherapy (BT). Sensitivity analyses regarding the influence of the follow-up period, the survival length and patient's age were performed. Advised radiotherapy was calculated based on broad treatment categories as reported at MDT meetings.ResultsThe overall AUP of 37% (39% including BT) was lower than the OUP of 53%, but in line with advised radiotherapy (35%). Large variations by tumour type were observed: in some tumours (e.g. lung and prostate cancer) AUP was considerably lower than OUP, whereas in others there was reasonable concordance (e.g. breast and rectal cancer). Overall, 84% of treatments started within 9 months following diagnosis. Survival time influenced AUP in a cancer type-dependent way. Elderly patients received less radiotherapy.ConclusionAlthough the actually delivered radiotherapy in Belgium aligns well to MDT advices, it is lower than the evidence-based optimum. Further analysis of potential barriers is needed for radiotherapy forecasting and planning, and in order to promote adequate access to radiotherapy.