The Swedish Institute for Health Economics (IHE), Lund, Sweden.
Lund Institute of Economic Research, School of Economics and Management, Lund University, Lund, Sweden.
Appl Health Econ Health Policy. 2018 Apr;16(2):157-165. doi: 10.1007/s40258-018-0377-7.
Many pharmaceuticals are effective in multiple indications and the degree of effectiveness may differ. A product-based pricing and reimbursement system with a single price per product is insufficient to reflect the variable values between different indications. The objective of this article is to present examples of actual pricing and reimbursement decisions using current value-based pricing in Sweden and to discuss their implications and possible solutions. The value of several cancer drugs was estimated for various indications based on a willingness-to-pay threshold of 1 million SEK (EUR 104,000) per QALY gained. For some drugs, the estimated value was higher than the drug acquisition cost in several indications, whilst in others, the estimated value was lower than the drug acquisition cost. Drugs used in combination present a special case. If a drug prolongs survival and consequently also a continued use of the anchor drug, the combination use may not be cost effective even at a zero price. In a product-based pricing and reimbursement system, patients may not get access to drugs or access may be delayed and manufacturers may be discouraged to invest in future indications. To overcome these issues, there are several approaches to link price and value. One approach is a "weighted-average" price based on an average of the value across all indications. Another is "multi-indication pricing," which enables price differentiation between indications. However, there are several barriers for applying multi-indication pricing and reimbursement schemes. One barrier is the lack of existing administrative infrastructure to track patients' indications.
许多药物在多种适应证中都有效，其有效性程度可能有所不同。基于产品的定价和报销系统，每个产品只有一个价格，不足以反映不同适应证之间的可变价值。本文的目的是展示瑞典当前基于价值的定价中实际定价和报销决策的示例，并讨论其影响和可能的解决方案。根据获得每 QALY 支付意愿阈值为 100 万瑞典克朗（10.4 万欧元），对几种癌症药物在不同适应证中的价值进行了估计。对于一些药物，在几种适应证中，估计的价值高于药物购置成本，而对于其他药物，估计的价值低于药物购置成本。联合使用的药物则是一个特殊情况。如果一种药物延长了生存时间，并且因此也延长了锚定药物的使用时间，那么即使药物价格为零，联合使用也可能没有成本效益。在基于产品的定价和报销系统中，患者可能无法获得药物，或者获得药物的时间可能会延迟，而且制造商可能会不愿意投资未来的适应证。为了克服这些问题，有几种方法可以将价格与价值联系起来。一种方法是基于所有适应证的平均值的“加权平均”价格。另一种是“多适应证定价”，可以在适应证之间实现价格差异化。然而，应用多适应证定价和报销方案存在几个障碍。一个障碍是缺乏现有的行政基础设施来跟踪患者的适应证。
