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.

A Sleeping Giant: Community Pharmacy's Potential Is Unrivaled.

DISCLOSURES: No funding was received for the writing of this commentary. The author has nothing to disclose.

What Was, Is No More: Community Pharmacy Economics.

DISCLOSURES: No funding supported the writing of this article. The author is an employee of AmerisourceBergen and leads its Good Neighbor Pharmacy program, which supports independent community pharmacy customers.

Talkin' About a Resolution: Issues in the Push for Greater Transparency of Medicine Prices.

At the 2019 World Health Assembly, a significant new resolution was agreed by most countries to start publicly sharing information on the real net prices they pay for medicines in their health systems. The resolution also includes provisions for countries to support other transparency activities. However, an additional proposal to require pharmaceutical companies to submit information on their internal sales figures, internal research and development costs, clinical trial costs and marketing costs for each individual medicine as a condition of registration, and for governments to publish this, was not agreed. Pressure for coordinated international action to increase the transparency of medicine prices and costs has been building for some time, as confidential discounts and rebates on prices of medicines are common. We argue that while it is possible that stakeholders may benefit to some extent from greater transparency on prices, several important policy and economic issues need to be carefully considered. Such transparency, combined with widespread use of international reference pricing, might undermine companies' differential pricing strategies, which are important in fostering wider access to medicines in low- and middle-income countries in particular, noting that access to medicines issues can occur in high-income countries as well. Moreover, there is a further risk that these types of proposals will lead to price fixing, less competition and higher prices than might otherwise be the case. The lack of any commitments in the resolution to greater transparency in payer decision-making processes also risks undermining the credibility of the resolution. The resolution and further transparency measures could have the potential to undermine patient access to medicines in the developing world, lead to higher prices in some markets and compromise long-term development of new medicines for future generations.

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.

Pharmacy students' intentions to utilize pharmacoeconomics, pharmacoepidemiology, and health outcomes in future jobs.

INTRODUCTION: The objectives of this study were to explore factors associated with pharmacy students' intentions to utilize health outcomes by: (1) understanding opinions on health outcomes, (2) understanding the likelihood of using health outcomes in different settings, and (3) predicting pharmacy students' intentions to utilize health outcomes in future jobs. METHODS: This study surveyed second-year pharmacy students over two years. The survey contained four components: the theory of planned behavior, opinions on health outcomes, the likelihood of using health outcomes in different settings, and demographics. To predict pharmacy students' intentions to utilize health outcomes in future jobs, a multiple linear regression model was used with behavioral intention as the dependent variable. RESULTS: Of the 376 second-year pharmacy students surveyed, 229 responded (60.90%). Pharmacy students had a positive attitude (mean: 0.77, SD: 0.16), high level of subjective norm (mean: 0.75, SD: 0.18), high level of perceived behavioral control (mean: 0.74, SD: 0.15), and high level of behavioral intention (mean: 0.74, SD: 0.21). They thought health outcomes were important for their future jobs (mean: 0.76, SD: 0.22), and equally important as other courses in the doctor of pharmacy curriculum (mean: 0.49, SD: 0.23). Significant predictors of utilizing health outcomes in future jobs were attitude (0.21; 95% CI: 0.03, 0.40), subjective norm (0.38; 95% CI: 0.23, 0.54), and perceived behavioral control (0.45, 95% CI: 0.27, 0.63). CONCLUSIONS: The second-year pharmacy students in the program studied had positive opinions and expressed high likelihood of applying their health outcomes knowledge and skill after graduation.

Subsidy strategy of pharmaceutical e-commerce platform based on two-sided market theory.

With the development of economic globalization and information technology, enterprises pay more attention to the sustainable development of their e-commerce. Under this trend, we study the subsidy strategy commonly used by pharmaceutical e-commerce platforms in two-sided market. Based on the two-sided market theory, we set up the two-sided user's utility function and formulate the subsidy strategy as the decision of platform profit optimization. We show that the platform chooses to subsidize consumers only if the net income from consumer is lower than the total revenue of drug retailers and platforms in each transaction; the maximum profit for platform increases with the intensity of the network externality. This study provides theoretical support and decision-making suggestions for the pharmaceutical e-commerce platforms to capture the market share, obtain higher profits and ultimately achieve the sustainable development goal.

Biosimilars and implications for pharmacy practice: Ready or not, here they come

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Payment Reform, Medication Use, and Costs: Can We Afford to Leave Out Drugs?

Medications are one of the fastest growing sources of costs in the health system and the cornerstone of disease management. Despite extensive attention around drug pricing, medications have largely been excluded from CMS-derived, value-based payment models. In this perspective, we synthesize evidence about the impact of three prominent models-primary care-based redesign, ACOs, and bundled payment programs-on medication use, adherence, and costs. We also examine the literature describing similar models implemented by private payors and their relationship with medication use and costs. The exclusion of drug costs from payment reform model design has led to missed opportunities for payors and providers to prioritize effective medication management strategies and has limited our learning about the effects on cost and quality. New CMS-based models are starting to allow greater flexibility in pharmacy benefit design and reward improved medication therapy management. Additionally, health plans, pharmacies, and pharmacy benefit managers are beginning to partner on collaborative value-based pharmacy initiatives. Taken together, these efforts encourage a paradigm shift around drug cost management that more deeply integrates pharmacy into payment and delivery reform with the goal of improving quality and reducing the total cost of care.

Future Costs in Cost-Effectiveness Analyses: Past, Present, Future.

There has been considerable debate on the extent to which future costs should be included in cost-effectiveness analyses of health technologies. In this article, we summarize the theoretical debates and empirical research in this area and highlight the conclusions that can be drawn for current practice. For future related and future unrelated medical costs, the literature suggests that inclusion is required to obtain optimal outcomes from available resources. This conclusion does not depend on the perspective adopted by the decision maker. Future non-medical costs are only relevant when adopting a societal perspective; these should be included if the benefits of non-medical consumption and production are also included in the evaluation. Whether this is the case currently remains unclear, given that benefits are typically quantified in quality-adjusted life-years and only limited research has been performed on the extent to which these (implicitly) capture benefits beyond health. Empirical research has shown that the impact of including future costs can be large, and that estimation of such costs is feasible. In practice, however, future unrelated medical costs and future unrelated non-medical consumption costs are typically excluded from economic evaluations. This is explicitly prescribed in some pharmacoeconomic guidelines. Further research is warranted on the development and improvement of methods for the estimation of future costs. Standardization of methods is needed to enhance the practical applicability of inclusion for the analyst and the comparability of the outcomes of different studies. For future non-medical costs, further research is also needed on the extent to which benefits related to this spending are captured in the measurement and valuation of health benefits, and how to broaden the scope of the evaluation if they are not sufficiently captured.

The impact of pharmaceutical tendering on prices and market concentration in South Africa over a 14-year period.

OBJECTIVE: We investigated the South African tendering system for medicines to (a) evaluate its impact on prices and market concentration over a 14-year period and (b) analyze the accuracy of government forecasts of drug demand. METHODS: We calculated Herfindahl-Hirschman indexes to measure market concentration levels based on all pharmaceutical tender contracts issued by the South African government between 2003 and 2016 (n = 8701). We estimated price indexes to track changes in medicine costs over this period. We compared prices set through tenders in the public health care system to the corresponding prices in the private system. We also analyzed government data on procurement in selected drug classes to assess the accuracy of demand forecasts. FINDINGS: Between 2003 and 2016, the prices of medicines in most tender categories in the public health care system dropped by an average of around 40% or more. The prices of medicines procured for the public system through tenders were almost always lower than those sold in the private system. Tenders generally remained moderately to highly competitive over time (i.e., Herfindahl-Hirschman indexes < 2500), although the number of different firms winning contracts decreased in many categories. There were large discrepancies between the drug need estimates by the government and the quantities it went on to procure, with estimates off by more than 50% in most drug classes (9/16 observations). CONCLUSION: Tendering may be an effective measure to lower drug costs. Because most tenders remained competitive over time, price decreases may be durable. South African government officials should monitor the availability and prices of medicines to ensure continued access to affordable medicines for patients, as it may be undermined by the decreasing number of firms winning contracts over time. Given the large discrepancy between forecasts and procurements, the government would benefit from improving the accuracy of its demand forecasts.

Value-Based Pricing in Latin America: How Far Away Are We?

In February and September of 2017, the International Society for Pharmacoeconomics and Outcomes Research Health Technology Assessment Council held roundtables focused on Latin America to discuss health technology assessment best practices, collaboration opportunities, and regional experiences regarding health policies to improve the affordability of and access to healthcare technologies. The access to high-cost technologies, increased social pressure to achieve universal coverage, population aging, and the limits of traditional mechanisms to control costs create political pressure to begin considering other pricing alternatives, including value-based pricing, in Latin America. This article attempts to conceptualize key stakeholders' perceptions of their experiences, opportunities, and barriers to implementing value-based pricing in Latin America.

Comparing Use of Health Technology Assessment in Pharmaceutical Policy among Earlier and More Recent Adopters in the European Union.

OBJECTIVES: To examine and compare the use of health technology assessment (HTA) for the reimbursement of new medicines in selected European Union member states with decades of experience in the use of HTA and in countries that have used it regularly since 2000. METHODS: The selected countries were categorized into "earlier" adopters (group A: England, Germany, France, and Sweden) and more "recent" adopters (group B: Poland, Bulgaria, Hungary, and Romania). A systematic review of published literature was performed. The analysis and comparison of HTA procedures were done by using an analytical framework. RESULTS: In all countries, the assessment criteria used include effectiveness, safety, relative effectiveness, and economic data. In group A countries, the main objectives are improving quality of care, ensuring equal access, and efficient use of resources. Group B countries have established HTA organizations with official guidelines but often seek the decisions of other developed countries. They place considerable emphasis on the budget impact of new therapies, and HTA is also used as a cost estimation tool for state budgets. CONCLUSIONS: HTA organizations have been developed dynamically not only in high-income countries but also in countries with limited resources. The experience and evolution of both can be used by countries that are in the dawn of creating an HTA organization.

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.

A pharmacoeconomic evaluation of cholinesterase inhibitors and memantine for the treatment of Alzheimer's disease.

INTRODUCTION: Alzheimer's disease (AD) results in progressively worsening cognitive decline, leading to loss of functional ability, behavior/mood disturbances, institutionalization, and death. Current pharmaceutical therapies only treat the symptoms of cognitive decline yet can be expensive for payers. Areas covered: The authors undertook a systematic review of economic evaluations of pharmaceutical therapies for AD. The literature search encompassed English-language studies indexed in PubMed (Medline), Cochrane Library Current, and Web of Science. The search included articles published between 1 January 1995 and 10 February 2018. The literature suggested AD medications generally dominated comparator treatments (e.g. placebo). Expert opinion: The authors noted several limitations of the included economic evaluations. These limitations suggest the results of the economic evaluations should be interpreted with caution. Many economic models were not transparent with respect to sources of probabilities and cost data, and data collected in certain jurisdictions were applied to other jurisdictions without considering the validity of such applications. Measuring health utilities in cognitively impaired populations raises questions about the validity of quality-adjusted life years, but this issue was unaddressed in the included studies. Most included studies were sponsored by industry and the results tended to overwhelmingly support the manufacturer's product.

Innovative pharmaceutical pricing agreements in five European markets: A survey of stakeholder attitudes and experience.

BACKGROUND: Innovative pricing agreements for medicines have been used in European markets for more than 20 years, and offer an opportunity for payers and pharmaceutical companies to align on value, optimise speed to patients, and share risk. Developing successful agreements requires alignment between key stakeholders, yet there is a lack of summative data on how current innovative agreements are used in the real-world (e.g. the level of realised access to medicines, and rebates and discounts, which are often non-transparent). METHODS: This research used a web-based survey of payer stakeholders to determine what kinds of innovative agreements are currently used, anticipated future usage, attitudes, and drivers of adoption. Participants included national and regional payers (or former payers) and hospital-level decision makers. RESULTS: Sixty-six payers completed the survey. Respondents expected that the use of innovative pricing agreements will remain the same or increase in the future. Overall, they felt there is a positive attitude towards new schemes, and that innovative agreements are likely to be used when they reduce total costs or reduce uncertainty. CONCLUSIONS: Given payer expectations, pharmaceutical companies should continue to take a role in ensuring that they have sufficient capacity to support payers in the design and implementation of innovative pricing agreements.

From Homer and Hippocrates to modern personalized medicine: is there a role for pharmacoepigenomics in the treatment of alcohol addiction?

From the earliest times to the present, alcohol has evolved as part of life and culture. For most adults, moderate alcohol use is harmless, however, it lies at one end of a range that moves through alcohol abuse to alcohol addiction. Alcohol addiction is a serious and chronic psychiatric disorder that, on top of its heavy consequences on health, also brings significant social and economic losses to individuals and society at large. Pharmacotherapy of alcohol addiction exists, but its effectiveness varies significantly among individuals. Genomic and nongenomic factors are significant contributors to interindividual variation in the clinical presentation of alcohol problems and the response to a given treatment. In addition, emerging evidence suggests pharmacoepigenomics of alcohol addiction as a novel promising area for improvement of alcohol addiction management.

Inhibitors in Hemophilia A: A Pharmacoeconomic Perspective.

A discussion of the main pharmacoeconomic issues related to inhibitors in hemophilia A cannot be separated from an analysis of the most relevant clinical questions. In the field of inhibitors, the clinical evidence includes several controversial topics, such as high-titer versus low-titer inhibitors, the influence of factor VIII products on inhibitor risk, effectiveness of different immune tolerance induction (ITI) treatments, the role of bypassing agents, and development of new non-factor-VIII compounds. In terms of pharmacoeconomic data, numerous cost estimates have been reported in these fields, but this information is strongly influenced by the wide between-country differences in unit costs. Quite reliable data are, however, available regarding expenditure for replacement therapy in patients without inhibitors, increased lifetime costs caused by high-titer inhibitors, and cost of pharmacological interventions aimed at eradicating inhibitors. As regards the cost-effectiveness ratio, the data on ITI are not conclusive; nonetheless, irrespective of the specific treatments employed for inducing tolerance, their costs seem to be offset by the subsequent savings in the cost per patient. Other issues, such as the cost of low-titer inhibitors in patients with hemophilia A and effectiveness of pharmacological interventions aimed at eradicating low-titer inhibitors are not supported by sound data and will require further research. Finally, although the efficacy and safety profiles of novel treatments (e.g., emicizumab, Roche) warrant long-term clinical studies, the economic advantages of these new compounds might be very substantial both in patients with inhibitors and in those at risk of developing inhibitors.