Reimbursement Price Research Articles

Transarterial radioembolization vs transarterial chemoembolization with drug-eluting beads for treating hepatocellular carcinoma: a cost-effectiveness analysis in Japanese healthcare system.

Transarterial radioembolization (TARE) is effective for unresectable hepatocellular carcinoma; however, it awaits approval in Japan. This study aimed to simulate the cost-effectiveness of TARE over chemoembolization when TARE is approved in Japan and identify the requirements for cost-effectiveness. A Markov model was constructed to analyze the costs and effectiveness associated with TARE and transarterial chemoembolization with drug-eluting beads (DEB-TACE) for 2-month cycles over 5years. In the primary analysis, the intention-to-treat survival data were used to calculate transition probabilities, whereas the ancillary analysis assessed the per-protocol survival data. DEB-TACE costs were calculated using the Japanese nationwide claims Diagnosis Procedure Combination database between April 2018 and March 2022, whereas TARE costs were estimated using database and international sources. The incremental cost-effectiveness ratio (ICER) was determined based on the payer's perspective and compared with the Japanese willingness-to-pay threshold of 5 million Japanese yen (JPY) (31,250 USD) per quality-adjusted life years (QALY). From the claims database, 6,986 patients with hepatocellular carcinoma who received DEB-TACE were identified. In the primary analysis, the ICER was 5,173,591 JPY (32,334 USD)/QALY, surpassing the Japanese willingness-to-pay threshold. However, the ancillary analysis showed a lower ICER of 4,156,533 JPY (25,978 USD)/QALY, falling below the threshold. The one-way deterministic sensitivity analysis identified progression-free survival associated with TARE and DEB-TACE, DEB-TACE costs, and radioactive microsphere reimbursement price as key ICER influencers. The primary analysis suggested that setting the reimbursement price of radioactive microspheres below 1.399 million JPY (8,744 USD), approximately 2.8% lower than the price in the United Kingdom, would place the ICER below the Japanese willingness-to-pay threshold. Under specific conditions, TARE can be a more cost-effective treatment than DEB-TACE. If the reimbursement price of radioactive microspheres is set approximately 2.8% lower than that in the United Kingdom, TARE could be cost-effective compared with DEB-TACE.

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) after four years of implementation – is it making an impact on quality of inpatient care and financial protection in India?

BackgroundIndia launched a national health insurance scheme named Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in 2018 as a key policy for universal health coverage. The ambitious scheme covers 100 million poor households. None of the studies have examined its impact on the quality of care. The existing studies on the impact of AB-PMJAY on financial protection have been limited to early experiences of its implementation. Since then, the government has improved the scheme’s design. The current study was aimed at evaluating the impact of AB-PMJAY on improving utilisation, quality, and financial protection for inpatient care after four years of its implementation.MethodsTwo annual waves of household surveys were conducted for years 2021 and 2022 in Chhattisgarh state. The surveys had a sample representative of the state’s population, covering around 15,000 individuals. Quality was measured in terms of patient satisfaction and length of stay. Financial protection was measured through indicators of catastrophic health expenditure at different thresholds. Multivariate adjusted models and propensity score matching were applied to examine the impacts of AB-PMJAY. In addition, the instrumental variable method was used to address the selection problem.ResultsEnrollment under AB-PMJAY was not associated with increased utilisation of inpatient care. Among individuals enrolled under AB-PMJAY who utilised private hospitals, the proportion incurring catastrophic health expenditure at the threshold of 10% of annual consumption expenditure was 78.1% and 70.9% in 2021 and 2022, respectively. The utilisation of private hospitals was associated with greater catastrophic expenditure irrespective of AB-PMJAY coverage. Enrollment under AB-PMJAY was not associated with reduced out-of-pocket expenditure or catastrophic health expenditure.ConclusionsAB-PMJAY has achieved a large coverage of the population but after four years of implementation and an evidence-based increase in reimbursement prices for hospitals, it has not made an impact on improving utilisation, quality, or financial protection. The private hospitals contracted under the scheme continued to overcharge patients, and purchasing was ineffective in regulating provider behaviour. Further research is recommended to assess the impact of publicly funded health insurance schemes on financial protection in other low- and middle-income countries.

Hospital Prices for Physician-Administered Drugs for Patients with Private Insurance

BackgroundHospitals can leverage their position between the ultimate buyers and sellers of drugs to retain a substantial share of insurer pharmaceutical expenditures.MethodsIn this study, we used 2020–2021 national Blue Cross Blue Shield claims data regarding patients in the United States who had drug-infusion visits for oncologic conditions, inflammatory conditions, or blood-cell deficiency disorders. Markups of the reimbursement prices were measured in terms of amounts paid by Blue Cross Blue Shield plans to hospitals and physician practices relative to the amounts paid by these providers to drug manufacturers. Acquisition-price reductions in hospital payments to drug manufacturers were measured in terms of discounts under the federal 340B Drug Pricing Program. We estimated the percentage of Blue Cross Blue Shield drug spending that was received by drug manufacturers and the percentage retained by provider organizations.ResultsThe study included 404,443 patients in the United States who had 4,727,189 drug-infusion visits. The median price markup (defined as the ratio of the reimbursement price to the acquisition price) for hospitals eligible for 340B discounts was 3.08 (interquartile range, 1.87 to 6.38). After adjustment for drug, patient, and geographic factors, price markups at hospitals eligible for 340B discounts were 6.59 times (95% confidence interval [CI], 6.02 to 7.16) as high as those in independent physician practices, and price markups at noneligible hospitals were 4.34 times (95% CI, 3.77 to 4.90) as high as those in physician practices. Hospitals eligible for 340B discounts retained 64.3% of insurer drug expenditures, whereas hospitals not eligible for 340B discounts retained 44.8% and independent physician practices retained 19.1%.ConclusionsThis study showed that hospitals imposed large price markups and retained a substantial share of total insurer spending on physician-administered drugs for patients with private insurance. The effects were especially large for hospitals eligible for discounts under the federal 340B Drug Pricing Program on acquisition costs paid to manufacturers. (Funded by Arnold Ventures and the National Institute for Health Care Management.)

Price increase negotiations to address drug shortages in South Korea's national health insurance.

South Korea has adopted a unique approach to address drug shortages by increasing reimbursement prices within its National Health Insurance Service. This study aims to analyze the characteristics, increase rates, affecting factors, and budget impacts of products that have increased price through the negotiation system. Between 2007 and 2022, there were price increase negotiations over 244 items. Of these, price increase negotiations were successful for 217 items, resulting in an agreement rate of 89%. The average rate of price increase for the agreed-upon products was 37.8%, and the overall budget increase for drugs with price increases (n = 217) was approximately 24.5%. Budget impact of each variable of the negotiated agreements showed that the number of negotiated agreement items was smaller after 2015 than before 2015, but each total budget impact (initial budget, increased budget, and final budget) and the average budget impact were higher. Although domestic companies accounted for a larger overall budget, the average budget per item was larger for multinational companies. The correlation analysis of the ratio of price increase and budget impact variables showed that the ratio of price increase was positively and significantly correlated with the increased budget, while it was negatively but not significantly correlated with the initial and final budgets. The South Korean model of increasing reimbursement prices in public insurance for drugs at risk of shortages serves as an exemplary case for not only securing patient access but also considering budget management.

OP148 Influence Of The Hospital-Based Health Technology Assessment Unit On New Technologies Transfer At The National Level In Kazakhstan

IntroductionThe hospital-based Health Technology Assessment (HB-HTA) Unit in the Hospital of the President’s Affairs Administration has been operating since 2015 and is the first example of the implementation of the HB-HTA system in Kazakhstani hospitals. In addition to assessing the feasibility of implementing new health technologies (HTs) into the hospital’s practice, the Unit also interacts with the National Regulatory Authority (NRA) to transfer new technologies into the National Reimbursement System (NRS). We report on the transformation of the HB-HTA Unit from a stand-alone entity to an integrated, specialized agency.MethodsData were drawn from reports of the HB-HTA Unit and internal NRA documents. Inclusion of new HTs into the NRS consists of the following sequential stages: (i) implementing the technology in at least one hospital; (ii) filing an application with the Ministry of Health Care (MoH) in the field of HTA to resolve the issue of reimbursement at the national level; (iii) in case of a positive decision, approval at the national level of the clinical protocol for using the medical intervention; (iv) agreement on the reimbursement price of the technology.ResultsBased on positive recommendations from the HB-HTA report in 2015, the hospital implemented 19 new nuclear medicine technologies. In 2016, the hospital initiated an application to the MoH to include these technologies in the NRS (previously, these technologies were carried out only for a fee or with private insurance). From 2016 to 2020, a positive decision from the MoH was received, protocols for medical interventions were published at the national level, and cost estimates were formulated. In 2021, 19 new medical services in nuclear imaging and scintigraphy were included in the NRS.ConclusionsDespite the long and bureaucratic process of including new HTs in the NRS, the HB-HTA Unit managed to speed up this process. One of the main priorities of the integrated HB-HTA Unit is to promote the transfer of HTs into the health system at the national level.

HTA206 How Do the Stricter Pricing Regulations of the Statutory Health Insurance Financial Stabilization Act (GKV-FINSTG) Affect Reimbursement Prices of New Drugs in Germany?

HTA206 How Do the Stricter Pricing Regulations of the Statutory Health Insurance Financial Stabilization Act (GKV-FINSTG) Affect Reimbursement Prices of New Drugs in Germany?

Cost impact of the ESC/EAS 2019 dyslipidemia guidelines recommended use of PSCK9i in very-high-risk patients with an LDL <1.8mmol/L for secondary prevention

Abstract ESC/EAS 2019 dyslipidemia guidelines give a class 1 recommendation to achieve a goal LDL-C of 1.4mmol/L in patients deemed very high risk. It is recommended to use a high dose statin and ezetimibe as first/second line therapies(1). In secondary prevention a class 1 recommendation is given for the addition of a PCSK9 inhibitors, if an LDL-C of 1.4mmol/L is not achieved. ODYSSEY and FOURIER used an LDL-C of >1.8mmol/l for trial inclusion, mean baseline LDL-C 2.25mmol/L and 2.38mol/l respectively(2, 3). Current Irish reimbursement criteria limit availability of PCSK9i due to high cost. Our aim was to determine the cost of PCSK9i therapy in patients post-PCI with an LDL-C of 1.5 – 1.8mmol/L and the potential cardiovascular benefit of a 1mmol/L reduction in LDL-C in this cohort. Methods We retrospectively analyzed patients at 6 - 8 weeks post-PCI in University Hospital Limerick (UHL) between January 2016 to December 2019. The cost analysis was based on a hierarchal analysis of patients on high dose statin, with an LDL-C >1.4mmol/L. Due to a low rate of prescribed ezetimibe we calculated the expected LDL-C, in patients on high dose statin with a presumed 25% reduction in LDL-C with the addition of ezetimibe. PCSK9i cost was based on the cohort of patients who would have an expected LDL-C >1.4 & <1.8mmol/L despite treatment with high dose statin and ezetimibe. Cost was based on current pack reimbursement price of evoculmab, €8117.17 yearly. To calculate the benefit of a 1mmol/L LDL-C reduction in secondary prevention with PCSK9i therapy, we used a number needed to treat (NNT) of 21 over 5 years to prevent 1 CV death or myocardial infarctions based on meta-analysis data(4). Results A total of 784 patients were included in our analysis, who would be potentially eligible for a PCSK9i based on current ESC/EAS 2019 dyslipidemia guidelines with an expected LDL-C >1.4mmol/L. Baseline characteristics, mean age 63.6years, male 76.8%, 64.28% hypertension, 51.4% diabetes mellitus, smoking history 23.5%. Of the 784 patients potentially eligible for a PCSK9i, 375/784 (47.8%) had LDL-C of between 1.4mmol/L – 1.8mmol/L. Current cost for PSCK9i therapy for this patient cohort at our institution would result in potential total cost of €3,043,938.75 per year. In comparison expected cost of statin therapy in this group is €81,883.2 per year. 5 years of treatment with PCSK9i, assuming at least 1mmol/L reduction in LDL-C would be expected to prevent 17.8 CV deaths or MI’s in our cohort or €171,007.79 per event. In comparison the cost of statin therapy in this total cohort is €81,883.2 per year. Discussion Current cost of PCSK9i therapy in relation to first/second line lipid therapies makes prescribing prohibitive for patients with an LDL-C <1.8mmol/L. Additionally, the estimated cost of PCSK9i therapy to prevent one CVD/MI, limits the ability for this to become standard practice in Ireland, within the cohort of post-PCI patients with an LDL 1.4 – 1.8mmol/L.

Do higher hospital reimbursement prices improve quality of care?

ABSTRACT Does higher medical spending improve quality of care? We estimate the effect of changes in regulated reimbursement prices for hospitals on multiple dimensions of hospital quality, including mortality outcomes, surgical complications, process quality and patient satisfaction. We exploit an exogenous variation in reimbursement prices between the years 2006 and 2010 based on a reform of hospital financing in Germany. We find that changes in reimbursement prices do not affect quality of care. This effect is precisely estimated, and we can rule out effect sizes that are large relative to the overall variation in quality indicators across hospitals.

Reporting reimbursement price decisions for onco-hematology drugs in Spain.

Even using well-established technology assessment processes, the basis of the decisions on drug price and reimbursement are sometimes perceived as poorly informed and sometimes may be seen as disconnected from value. The literature remains inconclusive about how Health Technology Assessment Bodies (HTAb) should report the determinants of their decisions. This study evaluates the relationship between oncology and hematology drug list prices and structured value parameters at the time of reimbursement decision in Spain. The study includes all new onco-hematological products (22), with a first indication authorized between January 2017 and December 2019 in Spain and pricing decisions published up until October 2022. For each product, 56 contextual and non-contextual indicators reflecting the structured multiple criteria decision analysis (MCDA) - Evidence-based Decision-Making (EVIDEM) framework were measured. The relationship between prices and the MCDA-EVIDEM framework was explored using univariate statistical analyses. Higher prices were observed when the standard of care included for combinations, if there were references to long-lasting responses, for fixed-duration treatment compared to treatment until progression and treatment with lower frequencies of administration; lower prices were observed for oral administration compared to other routes of administration. Statistically significant associations were observed between prices and the median duration of treatment, the impact on patient autonomy, the ease of use of the drug, and the recommendations of experts. The study suggests that indicators related to the type of standard of care, references to long-lasting responders, the convenience of the use of the drug, and the impact of treatment on patient autonomy, as well as contextual indicators such as the existence of previous clinical consensus, are factors in setting oncology drug prices in Spain. The implementation of MCDA-EVIDEM methodologies may be useful to capture the influence on pricing decisions of additional factors not included in legislation or consolidated assessment frameworks such as the European Network for Health Technology Assessment (EunetHTA) core model. It may be opportune to consider this in the upcoming revision of the Spanish regulation for health technology assessments and pricing and reimbursement procedures.

Cost-effectiveness of pemigatinib as a second-line treatment for advanced intrahepatic cholangiocarcinoma with fibroblast growth factor receptor 2 fusions in Taiwan: from the evidence of the phase II trial and the perspective of Taiwan's National Health Insurance Administration

BackgroundIn December 2022, the Taiwan National Health Insurance Administration (NHIA) announced the reimbursement of three dosages of pemigatinib 4.5 mg, 9 mg, and 13.5 mg for treating advanced intrahepatic cholangiocarcinoma (ICC) with fibroblast growth factor receptor 2 (FGFR2) fusions/rearrangements and set the reimbursement price for pemigatinib 4.5 mg at NT$6600. This study aims to analyze the cost-effectiveness of pemigatinib 13.5 mg as a second-line treatment compared to mFOLFOX and 5-FU chemotherapy for advanced ICC patients with FGFR2 fusions/rearrangements from the perspective of Taiwan’s NHIA.MethodsThis study used a 3-state partitioned survival model to analyze the 5 year cost-effectiveness of pemigatinib as a second-line treatment for advanced ICC patients in whom first-line gemcitabine-based chemotherapy failed and to compare the results with those for the mFOLFOX and 5-FU chemotherapy regimens. Overall survival and progression-free survival were estimated from the FIGHT-202 trial (pemigatinib), ABC-06 trial (mFOLFOX), and NIFTY trial (5-FU). The price of pemigatinib 13.5 mg was set at the potentially highest listing price (NT$17,820). Other parameters of utility, disutility, and costs related to advanced ICC were obtained from the published literature. The willingness-to-pay threshold was three times the forecasted gross domestic product per capita in 2022 (NT$2,928,570). A 3% discount rate was applied to quality-adjusted life-years (QALYs) and costs. Several scenario analyses were performed, including a gradual price reduction for pemigatinib. Deterministic sensitivity analysis, probabilistic sensitivity analysis (PSA), and value of information were performed to assess uncertainty.ResultsPemigatinib was not cost-effective compared to mFOLFOX or 5-FU in the base-case analysis. When the price of pemigatinib was reduced by 50% or more, pemigatinib gained a positive net monetary benefit (mFOLFOX: NT$55,374; 5-FU: NT$92,437) and a 72% (mFOLFOX) and 77.1% (5-FU) probability of being cost-effective. Most of the uncertainty came from the medication cost of pemigatinib, health state utility, and the overall survival associated with pemigatinib.ConclusionsAccording to the NCCN guidelines, the daily use of pemigatinib 13.5 mg at the hypothesized NHIA price of NT$17,820/13.5 mg was not cost-effective compared to mFOLFOX or 5-FU. The price reduction scenario suggested a 50% price reduction, NT$8910 per 13.5 mg, for advanced ICC patients with FGFR2 fusions/rearrangements.

EE564 Study on the Value Pricing of COVID-19 Vaccine in China Based on the Evidence of Cost-Effectiveness Analysis

To provide evidence for medical pricing of COVID-19 vaccination by analyzing the cost-effectiveness of different types of COVID-19 vaccines (namely, inactivated, adenovirus, recombinant protein, and mRNA vaccines) using RCT and real-world effectiveness data. Firstly, cost-effectiveness analysis of a whole inoculation of four kinds of COVID-19 vaccines was conducted, using the efficacy and effectiveness data driven from multi-center random clinical trials (RCT) or meta-analyses, while the cost data was collected from real-world. Secondly, the incremental cost-effectiveness ratio (ICER) of a whole inoculation in avoiding COVID-19 related infection, hospitalization, ICU admission, and death were calculated and compared, and then the most cost-effective vaccine was set as the comparator. Finally, prices of vaccines were adjusted to reach an equal ICER with the comparator vaccine. When medical insurance purchasing price of inactivated vaccine per dose was at 20.00 CNY, the cost of a whole inoculation should be capped at 62.34 CNY, including vaccine cost, transportation cost, storage cost and injection fee; therefore, the net price per dose of inactivated, adenovirus, recombinant protein, and mRNA vaccines were 18.80, 48.10, 9.03, and 17.51 CNY, respectively. Vaccination was cost-saving, and among them, mRNA vaccine was the most cost-saving strategy. Under the comprehensive consideration of the effects in avoiding COVID-19 related infection, hospitalization, ICU admission, and death, the prices of a whole inoculation of four kinds of vaccines should be reduced to 52.80, 48.92, 53.35, and 62.34 CNY, and the price per dose should be at 14.32, 35.49, 6.22, and 17.51 CNY, respectively. COVID-19 vaccines are cost-saving in preventing COVID-19 related infection, hospitalization, ICU admission, and avoiding death from a societal perspective, regardless of the type. Medical insurance reimbursement price of COVID-19 vaccines can be set and adjusted based on economic evaluation using RCT and real-world effectiveness evidence.

Cost of image-guided percutaneous nephrostomy among cervical cancer patients at Muhimbili National Hospital in Tanzania

BackgroundMost cervical cancer patients in developing countries seek care in health facilities with an advanced disease, often characterized by obstructive uropathy. This study aims to estimate the cost of an image-guided percutaneous nephrostomy (PCN), which was recently introduced at Muhimbili National Hospital to manage obstructive uropathy.MethodsThis was a cross-sectional study that was conducted between February and June 2021, from the provider’s perspective. The study involved forty-eight (n = 48) cervical cancer patients with obstructive uropathy. A micro-costing approach was used to identify, quantify and value both capital and recurrent cost items consumed by the patients. Cost data were collected in Tanzanian shillings and converted to USD with the relevant exchange rate. Analysis was performed in Microsoft Excel (Microsoft Excel®, Microsoft Corporation).ResultsThe unit cost of image-guided PCN at Muhimbili National Hospital was estimated at 380.4 USD. The main cost drivers were the single-use Nephrostomy catheters, Amplatz guide wire, and Micro-puncture set. The estimated unit cost is higher than the reimbursement price of 237.4 USD charged by the National Health Insurance Fund, and the 259.4 USD and 172.9 USD charged by the hospital for private and public patients, respectively.ConclusionImage-guided PCN for cervical cancer patients costs three times the minimum monthly government wage. The study underscores the importance of conducting costing studies to inform pricing and reimbursement decisions in Tanzania.

Cost Change of Elective Percutaneous Coronary Artery Intervention for Chronic Coronary Syndrome in Japan From 2010 to 2019.

Because of revisions to insurance reimbursement costs, medical fees have changed for investigations and percutaneous coronary intervention (PCI) treatment of chronic coronary syndrome (CCS). In this retrospective study, we investigated these changes and their effects on mortality and cardiovascular events. We included 1,483 patients who underwent elective PCI for CCS between April 2010 and September 2019. The primary outcomes were changes in PCI procedure fees and all included hospitalization fees due to the biennial revisions of reimbursement costs across 5 time periods (~2 years each). Secondary outcomes were rates of survival and freedom from major adverse cerebral and cardiovascular events (MACCE) in each time period. Patient characteristics were generally unchanged over the study period; however, treatment procedures changed significantly, with changes in the approach site (from transfemoral to transradial access; P<0.0001) and final device (from bare-metal stents to drug-eluting stents; P<0.0001), and an increase in the use of imaging modalities (P<0.0001). Medical fee parameters (primary outcomes) decreased significantly from 2010 to 2019 (P<0.001): PCI procedure fees decreased by 25%, whereas all included hospitalization fees decreased by 20%. There were no significant differences in survival or freedom-from-MACCE rates between periods. Because of revisions to reimbursement prices, there were rapid and significant decreases in PCI procedure and hospitalization fees for CCS. These changes had no effect on mortality or cardiovascular events.

Cost-effectiveness analysis of cardiac implantable electronic devices with reactive atrial-based antitachycardia pacing.

Reactive atrial-based anti-tachycardia pacing (rATP) in pacemakers (PMs) and cardiac resynchronization therapy defibrillators (CRT-Ds) has been reported to prevent progression of atrial fibrillation, and this reduced progression is expected to decrease the risk of complications such as stroke and heart failure (HF). This study aimed to assess the cost-effectiveness of rATP in PMs and CRT-Ds in the Japanese public health insurance system. We developed a Markov model comprising five states: bradycardia, post-stroke, mild HF, severe HF, and death. For devices with rATP and control devices without rATP, we compared the incremental cost-effectiveness ratio (ICER) from the payer's perspective. Costs were estimated from healthcare resource utilisation data in a Japanese claims database. We evaluated model uncertainty by analysing two scenarios for each device. The ICER was 763 729 JPY/QALY (5616 EUR/QALY) for PMs and 1,393 280 JPY/QALY (10 245 EUR/QALY) for CRT-Ds. In all scenarios, ICERs were below 5 million JPY/QALY (36 765 EUR/QALY), supporting robustness of the results. According to a willingness to pay threshold of 5 million JPY/QALY, the devices with rATP were cost-effective compared with control devices without rATP, showing that the higher reimbursement price of the functional categories with rATP is justified from a healthcare economic perspective.

HTA85 Possible Impact of Orphan Threshold Reduction to 20 Million Euro in the Framework of Early Benefit Assessment and Reimbursement Price in Germany

HTA85 Possible Impact of Orphan Threshold Reduction to 20 Million Euro in the Framework of Early Benefit Assessment and Reimbursement Price in Germany

HPR133 Impact of International Reference Pricing (IRP) on Medicines Reimbursement Prices in Bosnia and Herzegovina

HPR133 Impact of International Reference Pricing (IRP) on Medicines Reimbursement Prices in Bosnia and Herzegovina

PD49 Burden And Cost Of Anterior Cruciate Ligament Reconstruction And Reimbursement Of Its Treatment In Indonesia: An Observational Study

IntroductionThe number of anterior cruciate ligament reconstruction (ACLR) procedures is increasing. However, the likelihood of not allocating sufficient funds for the ACLR procedure in a developing country, especially in Indonesia, is high. This study aimed to analyze costs for ACLR procedures in Indonesia’s resource-limited context, determine the burden of ACLR, and propose national prices for ACLR reimbursement.MethodsA retrospective observational study was conducted on the cost of ACLR from a payer perspective using inpatient billing records from 1 January 2019 to 31 December 2019 from four hospitals. The national burden of ACLR was calculated and national prices for reimbursement were developed.ResultsOf the 80 ACLRs performed, 53 (66%) were isolated ACLRs and 27 (34%) were combined with meniscus treatment. The mean hospital costs incurred per ACLR procedure were USD 2,853 (IDR 40.4 million), which was mainly attributed to the orthopedic implants (USD 1,387; IDR 19.6 million). The costs of ACLR with combined meniscus treatment were estimated to be 35 percent higher than for isolated ACLR. The national burden of ACLR revealed a total budget of USD 367.4 million (IDR 5.2 trillion) per 100,000 patients for ACLR with additional meniscus treatment and USD 271.3 million (IDR 3.8 trillion) per 100,000 patients for the isolated ACLR procedure.ConclusionsACLR procedures in Indonesia are underbudgeted. Adjustment of reimbursement prices for ACLR procedures is needed to facilitate access for the Indonesian people. This study showed varying cost estimates for ACLR in Indonesia, necessitating a new reimbursement system that takes various clinical and patient factors into account.

HPR81 Evaluation of the Hungarian Generic Program Between 2010 and 2021

In Hungary, there is no regular price revision for originator products, so it is reasonable to assume that the distributor of the originator product would not in principle reduce the price. In 2010, the rules of the active substance or therapy based reference pricing were significantly tightened, allowing for a reduction in drug budget expenditure. In our research, we investigate how much the reference price reimbursement, which has been in place since 2011, has been able to reduce pharmaceutical expenditure and how much it has saved.

Trends in utilization, reimbursement, and price for DOACs and warfarin in the US Medicaid population from 2000 to 2020.

The use of direct oral anticoagulants (DOACs) is widely increasing in the United States (US). Warfarin has been the conventional anticoagulant used in the past few decades, but it has been gradually replaced by DOACs. The objective of the study was to analyze trends in utilization, reimbursement, and price for those anticoagulants in the US Medicaid population. Retrospective data analysis was conducted using the National Summary Files for the Medicaid State Drug Utilization Data. Study drugs included dabigatran, rivaroxaban, apixaban, edoxaban and warfarin. The study assessed secular trends of utilization, reimbursement, and per-prescription price. The data was collected from the first quarter of 2000 through to the second quarter of 2020 restricted for outpatient prescriptions only. During the 21-year study period, a substantial rise in total expenditures on warfarin and DOACs was observed from $144 million in 2000 to $694 million in 2020. Moreover, the utilization of DOACs has increased significantly since the first approval of Xarelto in 2010 from 1079 in 2011 to 1.5 million in 2019. The per-prescription price of DOACs increased from an average of $200 in 2011 to $407 in 2020. Conversely, the total number of prescriptions of Warfarin and branded Coumadin decreased from 2.4 million to 1.4 million and from 3.9 million to less than a million, respectively. The present study demonstrated a change in the trends of US expenditure and utilization for warfarin and DOACs with DOACs representing the majority of market share of both spending per prescription and reimbursement.

Modeling Tiered Pricing Frameworks: A Simulation Approach

Drug plans take different approaches to determining reimbursement prices for generic drugs. One common approach is to set the maximum reimbursement price as a percentage of the price of the interchangeable branded drug. In many countries this percentage depends on the number of generic entrants, a model we call "tiered pricing." This paper seeks to enhance understanding of how to set the tiers. We construct a simple model of tiered pricing and set parameters to match evidence on generic drug costs and the distribution of revenues. Using simulation methods, we then assess different tier structures in terms of total surplus and average drug cost. We find when tiers are bunched tightly together welfare outcomes are poor. Moreover, there are large welfare gains from increasing the number of tiers from one to two, and only small welfare gains from increasing the number of tiers beyond four. The choice of tiers has substantial welfare and cost implications. While it is possible to refine the simulation analysis based on specific market characteristics, an optimal tier structure, such as the one we propose in the paper, should have at least two tiers.