We read the recent paper by Persson and colleagues with interest [1]. However, we think the paper contained some misunderstandings which we believe should be discussed further, as this paper is likely to be widely read both in Sweden and across Europe.We were concerned with the comments made about cost/QALY cut-offlevels in Sweden, since we found in 2008 [2] and 2009 [3] that the Dental and Pharmaceutical Benefits agency (TLV) has not established cost/QALY cutofflevels. Moreover, the TLV maintained that there should be various levels for different diseases. In addition, the TLV were concerned that companies would play the system if they knew the level in advance and any limit would need re-adjusting with inflation [2, 3]. This was endorsed by Hugosson and Engstrom [4], and referenced by Persson et al. In the reference, Hugosson and Engstrom stated ''no explicit value or threshold exists'' [4]. They also analysed TLV decisions between October 2002 and 2007, and demonstrated there was a correlation between disease severity and willingness to pay. Overall, the QALY averaged euro35,000 for reimbursed drugs, rising to approximately euro100,000 for severe diseases [4]. Hugosson and Engstrom subsequently concluded the TLV had ''not established a threshold value for the QALY'', exacerbated by the low number of rejections during this period [4].We were surprised by the comment that the number of products not reimbursed by the TLV averaged 20 % in the past 9 years. This is because published sources revealed that between October 2002 and March 2005, TLV denied reimbursement for 13 out of 107 drug applications [3, 5, 6]. Moýse and Docteur from the OECD concluded that during this period, ''rejecting a pharmaceutical for reimbursement because the price is too high is a rare occurrence'' [6]. In 2006, 10 % of new chemical entities (4 out of 40 products) were not approved for reimbursement [2, 3], and in 2007, five new applications (10 %) were denied reimbursement [2, 3]. These findings appear to confirm the comments of Hugosson and Engstrom [4]. Between 2009 and 2011, this increased to an average of 17 % of new drug applications denied reimbursement (2011: 4/27 products, 2010: 2/44 products and in 2009: 11/30 products [7]). This is particularly important since the higher the percentage of new premium-priced products granted reimbursement by the TLV, the greater the pressure on county council resources.We were also surprised by comments by Persson et al. that value-based pricing (VBP) is rare for products in the healthcare market. It may be that not all countries use cost/ QALYs in their decision making; however, a number of European countries do apply some form of 'value-based' approach to potential prices when considering reimbursement for new innovative products. For instance, in Austria, a maximum reimbursed price of 10 % above current standards is granted for those new products that are evaluated as having 'added benefit' [8]. This rises to an average price among targeted European countries for new products that are evaluated as having 'substantial benefit' over existing standards, provided the price can be justified by a pharmacoeconomic evaluation [8]. In France, the reimbursed price for new products is directly related to their perceived benefit versus current standards (Evaluation of Therapeutic Benefit [Amelioration du Service Medical Rendu: ASMR] rating) [9], and in Germany there are direct price negotiations for new products with additional benefit between the manufacturers and the Sickness Funds (payers of healthcare) [10]. This is based on the perceived level of health gain versus current standard treatments; divided into substantial, considerable or small - mirroring the situation in France [10]. Recommendations for reimbursing new products in Norway are principally based on cost/QALY considerations [11], and reimbursement considerations for new products in Poland now include an economic analysis (cost-effectiveness/cost-utility analysis) combined with a budget impact analysis [12]. …