National trends in prescription drug expenditures and projections for 2021.

PURPOSE: To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2021 in the United States, with a focus on the nonfederal hospital and clinic sectors. METHODS: Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2021 were reviewed-including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, generics, coronavirus disease 2019 (COVID-19) pandemic influence, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2021 were based on a combination of quantitative analyses and expert opinion. RESULTS: In 2020, overall pharmaceutical expenditures in the United States grew 4.9% compared to 2019, for a total of $535.3 billion. Utilization (a 2.9% increase) and new drugs (a 1.8% increase) drove this increase, with price changes having minimal influence (a 0.3% increase). Adalimumab was the top drug in 2020, followed by apixaban and insulin glargine. Drug expenditures were $35.3 billion (a 4.6% decrease) and $98.4 billion (an 8.1% increase) in nonfederal hospitals and clinics, respectively. In clinics, growth was driven by new products and increased utilization, whereas in hospitals the decrease in expenditures was driven by reduced utilization. Several new drugs that will influence spending are expected to be approved in 2021. Specialty and cancer drugs will continue to drive expenditures along with the evolution of the COVID-19 pandemic. CONCLUSION: For 2021, we expect overall prescription drug spending to rise by 4% to 6%, whereas in clinics and hospitals we anticipate increases of 7% to 9% and 3% to 5%, respectively, compared to 2020. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

Deprescription in elderly: A spotlight on pharmacoeconomic aspect.

Aging is a complex process and many factors in the elderly, especially multiple diseases and related unnecessary drug use, support a deprescription approach to this age group to save money and health cost. In this review, we have searched for studies related to the pharmacoeconomic aspect of this deprescription approach in the elderly. Few studies are available, but they are promising and effective in paving the way for prospective longitudinal studies to assess the role of deprescription in optimizing the drugs prescribed to aged patients in a way that reduces the costs of both drug adverse effects and/or hospitalization. Awareness of deprescription is important not only to society, but also to hospital stuff and individual patients.

Pharmacoeconomics Evaluations of Oral Anticancer Agents: Systematic Review of Characteristics, Methodological Trends, and Reporting Quality.

OBJECTIVES: To review literature characteristics, describe methodological trends, and assess the reporting quality of the economic evaluations of oral anticancer drugs (OACDs). METHODS: The review included comparative economic evaluations of OACDs. The search was conducted via PubMed, Embase, EconLit, and Economic Evaluation Database, and studies till December 2017 were included. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, literature inclusion and data extraction were performed in duplicate by separate investigators. Outcome measures were literature characteristics, gaps and methodological trends, and reporting quality using the Consolidated Health Economic Evaluation Reporting Standards checklist. Data were summarized on the basis of methodological themes of interest. Descriptive statistics and tabulations were used for result presentation. RESULTS: Out of 241 found articles, 21 were included. There is a recent increasing interest in the economics of OACDs, whereby the cost per quality-adjusted life-year, via cost-utility analysis, is the most used for decision making. Most of the studies were from the payer perspective, and the primary sources of data were clinical trials, expert panels, and medical charts. The dominance status (higher effect, lower cost) was a commonly reported outcome. Decision-analytic modeling was used in most of the studies, mostly including Markov modeling. Studies were highly heterogeneous in methodological aspects, and the included studies did not meet most of the reporting quality criteria. CONCLUSIONS: High heterogeneity in methods in studies may limit the robustness and transferability of results, potentially misleading decision makers toward wrong decisions on OACDs. The transferability and generalizability of results are further limited by a "less than ideal" adherence to current reporting standards.

The evolution of Taiwan's National Health Insurance drug reimbursement scheme.

BACKGROUND: The rapid growth of health care expenditures, especially pharmaceutical spending, is a challenge for many countries. To control increasing pharmaceutical expenditures and to enhance rational use of drugs, Taiwan's National Health Insurance drug reimbursement system has evolved over time since its introduction in 1995. This study reviewed Taiwan's drug reimbursement scheme: its development and evolution in the last two decades, and implications and impacts of recent policies for drug pricing. We also provide recommendations for possible improvement. METHODS: We conducted a review of Taiwan's National Health Insurance drug reimbursement scheme. We focused on three major components of the scheme: (i) the scope of drug coverage; (ii) pricing system for pharmaceuticals under the scheme; and (iii) adjustment of drug reimbursement prices. We reviewed the literature and public policy documents. RESULTS: The National Health Insurance delisted 176 and another 240 behind-the-counter products (e.g., antacids, vitamins) between 2005 and 2006 to reduce pharmaceutical expenditures. For the pricing of pharmaceuticals, policy evolution can be divided into four phases since 1995; the present system emphasizes stakeholder engagement, health technology assessment, domestic R&D, and improving quality of products. To close the gap between drug reimbursement prices and procurement prices, eight rounds of drug price surveys and adjustments have been implemented since 2000. CONCLUSIONS: Taiwan's National Health Insurance drug reimbursement scheme has evolved substantially over time to provide more equitable and affordable access to prescription medicines. However, more work is still needed as irrational difference in reimbursement and procurement prices persists and the total expenditure of the drug reimbursement scheme continues to increase at unsustainable rates.

How state and federal policies as well as advances in genome science contribute to the high cost of cancer drugs.

During a time when cancer drug prices are increasing at an unprecedented rate, a debate has emerged as to whether these drugs continue to provide good value. In this article I argue that this debate is irrelevant because under today's highly distorted market, prices will not be set with value considerations in mind. As an alternative, I suggest considering the "value" of three policy changes­Medicare's "average sales price plus 6 percent" payment program, laws that require insurance coverage of all new cancer drugs, and the Affordable Care Act­that are fueling manufacturers' willingness to set higher prices. More important than these issues, however, is the revolution that is occurring in molecular biology and its impact on scientists' ability to detect changes in the cancer genome. The lowered cost of discovery is driving more competitors into the market, which under distorted pricing paradoxically encourages drug makers to charge ever higher prices for their products.

Treatment costs of bladder pain syndrome/interstitial cystitis in Austria: a pharmacoeconomic approach following current guidelines.

BACKGROUND: Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic disease with a significant impact on quality of life. A broad range of therapies are used to treat this condition, and patients are often excluded from receiving more expensive and more effective therapies because of cost issues. OBJECTIVE: The objective of this study was to assess the mid- and long-term costs (over 1, 5 and 10 years) of various therapies for BPS/IC. METHODS: Costs in an open-access health system (Austria) for three BPS/IC-specific therapies (intravesical hyaluronan, pentosanpolysulfate and amitriptyline), taken from the American Urological Association guidelines, were evaluated and compared with those of non-specific symptomatic therapies. Response rates for the different therapies were taken from peer-reviewed publications and used to define the need for therapy maintenance with regard to symptom improvement. RESULTS: Despite the highest initial costs, the reduced need for further therapy in patients with long-term symptom remission after hyaluronan therapy resulted in the lowest total treatment costs at all three timepoints. Hyaluronan was cost saving against all alternatives in standard assumptions and in all sensitivity analyses. As a limitation, treatment costs in this study are specific for Austria. However, the template used for calculation of treatment costs can be transferred to all countries by inserting local prices. CONCLUSION: Disease-specific therapies with high remission rates result in significantly lower long-term costs in BPS/IC. Non-specific symptomatic therapies are most expensive. Long-term cost effectiveness is crucial in the treatment of chronic diseases to limit expenses in individual healthcare systems.

How much is the life of a cancer patient worth? A pharmaco-economic perspective.

WHAT IS KNOWN AND OBJECTIVE: Countries struggle to accommodate the introduction of new effective cancer medicines, while containing costs. Our objective is to comment on several pharmaco-economic challenges involved in determining the value of cancer medicines by reviewing cost-effectiveness thresholds for cancer medicines in several countries and by discussing the cost-effectiveness of anti-cancer biotechnology and orphan medicines. COMMENT: A literature search was carried out of PubMed, Centre for Reviews and Dissemination databases, Cochrane Database of Systematic Reviews and EconLit up to August 2009. Health technology assessment agencies in England and Scotland are willing to incur a higher cost per quality-adjusted life year for cancer medicines than for other medicines. Risk-sharing arrangements have been implemented to optimize the value of cancer medicines. The cost-effectiveness of biotechnology medicines in cancer care is challenged by their high price, and depends on the ability to identify the most responsive target population, through use of suitable biomarkers. The evaluation of orphan medicines in cancer care needs to balance the absence of an alternative therapy for a life-threatening disease against the high cost-effectiveness ratio, and usually weak clinical data. WHAT IS NEW AND CONCLUSION: Current strategies used to inform decisions on the funding of expensive anti-cancer medicines are commented on to highlight important issues and problems. Pharmaco-economic evaluation is an important tool for assessing the value of cancer medicines and to inform evidence-based decision making in cancer care. Value-judgments such as preferential consideration of anti-cancer medicines can then be made explicitly.

[Application of pharmacoeconomics in clinical management]. / Aplicación de la farmacoeconomía en la gestión clínica.

The present article discusses the importance of clinical management in the transformation of organizations and its role in the daily activities of health professionals and, in particular, of hospital pharmacists. Because of social changes, healthcare models must make the shift from more rigid management models toward new organizational models based on clinical management. From this perspective, pharmacoeconomics is viewed as a useful tool to introduce the criteria of efficiency in all decisions subject to clinical management, including those on pharmacotherapeutics. Subsequently, the application of this discipline is discussed in real decision-making scenarios and settings for its use within the context of the work of hospital pharmacy are proposed.

Impact of pharmacogenomics on clinical practice in oncology.

Multiple drug strategies for many cancer types are now readily available and there is a clear need for tools to inform decision making on therapy selection. Although there is still a long way to go before pharmacogenomics achieves the goal of individualized selection of cancer treatment, promising progress is being made. Genetic testing for thiopurine methyltransferase (TPMT) variant alleles in patients prior to mercaptopurine administration, and for UGT1A1*28 in patients prior to administration of irinotecan therapy, along with the instigation of genotype-guided clinical trials (e.g. TYMS) are important advances in cancer pharmacogenomics. Markers for the toxicity and efficacy of many oncology drugs remain unknown; however, the examples highlighted here suggest progress is being made towards the incorporation of pharmacogenomics into clinical practice in oncology.

Impacts of cost containment strategies on pharmaceutical expenditures of the National Health Insurance in Taiwan, 1996-2003.

INTRODUCTION: Pharmaceutical expenditure (PE) of the National Health Insurance (NHI) programme in Taiwan grew from 62.2 billion Taiwan new dollars (NT dollars) in 1996 to NT94.5 dollars billion in 2003.The government has been introducing many strategies to control PE since the inception of NHI including price adjustment based on the prices of international products or existing products (inter-brands comparison), or market price and volume survey; delegation of financial responsibility to regional bureaux; co-payment for outpatient drugs; generic grouping (the reference pricing scheme based on chemical equivalence); a global budget payment system for clinics and hospitals; and reduction in the flat daily payment rate of the drugs for clinics. The aim of this study was to evaluate the impact of these cost containment strategies on the PE of the NHI programme from 1996 to 2003. METHODS: To take the growth and seasonal trends of monthly PE into consideration, Box and Tiao's time-series event intervention analysis based on the Box-Jenkins auto-regressive integrated moving-average model was applied to evaluate the impact of various cost containment strategies on total and subsector (outpatient, inpatient, clinic and hospital sectors) PE. Monthly data of PE of the NHI programme from 1996 to 2003 (the dependent variables) were obtained from the Bureau of the NHI. Drugs prescribed by dentists and Chinese medical doctors at outpatient departments were excluded. RESULTS: After fitting the patterns of time series and controlling for the calendar effect of the Chinese New Year and the severe acute respiratory syndrome outbreak in 2003, three strategies (generic grouping, delegation of financial responsibility and reduction of the flat payment rate of clinics) were significantly associated with a reduction in PE. However, the hospital global budget strategy offset partial savings from these three strategies. Cumulative savings during the study period were estimated to be NT25.442 dollars billion (US0.80 dollars billion). Of all the strategies, generic grouping was the most effective although it had less effect on the clinic subsector. Neither drug co-payment nor price adjustment based on the international or inter-brand price comparison had significant impacts on PE. CONCLUSION: Generic grouping, reduction of the flat payment rate and delegation of financial responsibility were effective in controlling PE. A global budget alone would be unable to control PE without other direct financial incentives. Neither drug co-payment nor brand-specific price adjustment based on prices of international/existing products had a significant impact on PE.

[Positive and negative aspects of pharmaceutical services in Spain: about antidepressants and antipsychotics]. / Luces y sombras de la prestación farmacéutica en España: a propósito de los antidepresivos y antipsicóticos.

Mental disorders mortality rates are low but they are extremely disabling so that the diagnosis and treatment of mental illness is an important task for public health and it is central in current therapy strategies and sanitary policy. The aim of this study is to analyse conditions influencing antidepressants and antipsychotics use in Spain from 1997 to 2004. Tryciclic antidepressants have been of first-choice in depression treatment for many years but their side effects profile are related to a lack of treatment adherence. Trying to increase tolerance, new antidepressants have been developed and research into new therapeutic uses is being done. These are some of the reasons causing an increase in medical utilization and costs. Medical boxes sold have increased from 14,14 million in 1997 to 26,76 million in 2004, meaning 168,61 and 447,11 million euros respectively. Antipsychotic use has been maintained, 11,74 million boxes in 1997 and 12,65 in 2004; however, there has been a rise in price from 61,84 to 317,46 million euros due to second generation antipsychotics prescription (mainly risperidone and olanzapine) Some conditions have contributed to current situation: increased number of diagnosed patients with depression and other mental disorders, new approved therapeutic uses and a rise in elderly people receiving new antipsychotic agents. Moreover, promotional marketing is causing an increase in new recently commercialised drugs use.

Penny and pound wise: pharmacoeconomics from a governmental perspective.

Because of growing pressure on the healthcare budget in The Netherlands, appropriate justification of current expenditures and future investments in public healthcare are becoming increasingly important. Therefore, the Dutch Ministry of Health, Welfare and Sport is expanding its use of pharmacoeconomic evaluation in informed reimbursement decision-making of new pharmaceuticals. Since June 2002, pharmaceutical companies have been invited to submit a pharmacoeconomic dossier with their reimbursement applications of innovative drugs. As of January 2005 submission of a pharmacoeconomic dossier is mandatory for all drugs claiming to have therapeutic value. Currently, several European governmental and non-governmental organisations are making efforts to harmonise pharmacoeconomic research guidelines at the EU level. Ultimately, this may facilitate a more efficient way of conducting pharmacoeconomic research and encourage the use of pharmacoeconomic data by national assessment agencies and governments. It is anticipated that international pharmaceutical companies will increasingly invest in pharmacoeconomics while government staff will become more experienced in appraising the dossiers, thus resulting in an upward momentum in the quality and usability of pharmacoeconomic data. From the Dutch government's perspective, the use of pharmacoeconomic evaluation in reimbursement decision-making should offer a true opportunity for pharmaceutical companies to present the added value for money of new drugs. Using pharmacoeconomic data, costs, benefits and effects of pharmaceuticals are increasingly being considered from a societal perspective, thus going beyond the sole consideration of the impact on the pharmaceutical budget.

La economía del la salud: ¿debe ser de interés para el campo sanitario? / Health economics: should it concern the health sector?

This paper addresses the most important features of health economics, especially its scope and applications within the sphere of health. Health economics is a field of study which allows countries to gear their health policies toward making more rational use of their resources and expanding and improving their health care services. Such policies should, on the other hand, aim to generate strategies for adequately managing human, technical, economic, and financial resources so as to reap the finest health benefits possible. A knowledge of how economics can be applied to health will enable health professionals to introduce an economics culture into their daily work. In other words, it will allow them to keep in mind the scope of their various working tools¾health planning, national health accounts and accounting, and economic assessment methods, which include health and pharmaceutical technology assessment and pharmacoeconomics¾as well as the place that economics has in health research. Hopefully, a knowledge of these aspects of economic analysis will provide decision-makers with one more tool they can apply in selecting more efficient options and attaining the highest health benefits at the lowest possible cost for the national health system

[Health economics: should it concern the health sector?]. / La economía del la salud: debe ser de interés para el campo sanitario?

This paper addresses the most important features of health economics, especially its scope and applications within the sphere of health. Health economics is a field of study which allows countries to gear their health policies toward making more rational use of their resources and expanding and improving their health care services. Such policies should, on the other hand, aim to generate strategies for adequately managing human, technical, economic, and financial resources so as to reap the finest health benefits possible. A knowledge of how economics can be applied to health will enable health professionals to introduce an economics culture into their daily work. In other words, it will allow them to keep in mind the scope of their various working tools--health planning, national health accounts and accounting, and economic assessment methods, which include health and pharmaceutical technology assessment and pharmacoeconomics--as well as the place that economics has in health research. Hopefully, a knowledge of these aspects of economic analysis will provide decision-makers with one more tool they can apply in selecting more efficient options and attaining the highest health benefits at the lowest possible cost for the national health system.