September, 2009 - SUPPORT Summary of a systematic review | print this article |
Pharmaceutical pricing and purchasing policies are used to determine or affect the prices that are paid for drugs. Examples are price controls, maximum prices, price negotiations, reference pricing, index pricing and volume-based pricing policies. This review found evidence for reference pricing and index pricing. In reference drug pricing, which is a reimbursment tool, a reference drug is chosen amongst drugs that are considered as therapeutically similar, and the price of the reference drug is reimbursed. For drugs that are more expensive than the reference drug, the patient has to pay the expenses above the reference price. An index price is the maximum refundable price to pharmacies for drugs within an index group. An index group consists of therapeutically interchangeable drugs. The price is refunded independent of which drug is dispensed.
− Can reduce third party drug expenditures by inducing a shift in drug use towards less expensive drugs
− Produces no adverse effects on health
Review Objectives: To determine the effects of pharmaceutical pricing and purchasing policies on drug use, healthcare utilisation, health outcomes and costs (expenditures). | ||
Review Objectives: To assess the effects of policies regarding direct patient payments for drugs on drug use, health care utilisation, health outcomes and costs (expenditures). | ||
/ | What the review authors searched for | What the review authors found |
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Interventions |
Randomised controlled trials (RCT), non-randomised controlled trials (CCT), con-trolled repeated measures studies (CRM), interrupted time series analyses (ITS) and controlled before-after studies (CBA) of policies on price and purchasing that de-termine or are intended to affect the price that is paid for drugs. |
11 studies were found. Some of them had more than one design i.e. different designs for different out-comes
7 ITS 1 ITS/CBA/CRM 1 CRM/RM 2 CBA/RM This review found evidence for reference pricing (10 studies) and index pricing (1 study).
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Participants | Health care consumers and providers |
In all the Canadian studies the patients were Phar-macare beneficiaries: senior citizens aged 65 years and older. The other studies included all beneficiar-ies of national drug insurance plans, including vul-nerable groups of people from all ages.
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Settings | Large jurisdiction or system of care. Juris-dictions could be regional, national or in-ternational. Studies within organisations, such as health maintenance organisations were included if the organisation was multi-sited and served a large population. |
The reference pricing studies: Canada (6), USA (1), Australia (1), Germany (1) and Sweden (1). The index pricing study was from Norway
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Outcomes | Drug use (prescribed, dispensed or actu-ally used), Healthcare utilisation, Health outcomes, Costs (expenditures), including drug costs and prices, other health care costs and policy administration costs. |
Seven studies reported a single effect measure (one outcome) and four did not specify a primary out-come. None of the studies presented data on all out-comes and none reported administration costs |
Date of most recent search: October 2005 | ||
Limitations: This review has minor limitations. |
Beta-lactam antibiotics compared to Bata-lactam + Aminoglycoside for the treatment of suspected late onset sepsis in new born infants |
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Patient or population: patients in treatment for suspected late onset neonatal sepsis Settings: High income countries Intervention: Beta-lactam monotherapy (Timentin) Comparison: Bata-lactam + Aminoglycoside combination therapy (Flucloxacilin + Gentamicin) |
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Outcomes | Impact | Relative effect (95% CI) |
No of Participants (studies) |
Quality of the evidence (GRADE) |
Drug use:
Reference Drug
Drug use: Reference Drug
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Use of reference drug increased by 60 to 196% immediately after a transition period following the introduction of the policy. At follow up (6 months to a year) the relative increase of the drug was larger in one study and smaller in two.
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(4 studies)
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(4 studies) |
Moderate
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Drug use: Cost share drug
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Use of cost share drug decreased immediately by 19 to 42%. In 1 out of 3 studies that provided data at 6 months, a larger reduction was observed. |
31 per 1000 (2 to 588) | (4 studies) |
Moderate
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CI: Confidence interval; RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see explanations) | ||||
1 No information on method of randomization is provided. Allocation concealment is unclear. Blinding is not documented for the intervention or outcome. 2 Estimate from only one study with few events. Very wide confidence interval consistent with either important harms or important benefits from the therapy |
This review includes 11 studies evaluating the effects of pharmaceutical pricing and purchasing policies. All of them were done in developed countries (Canada, USA, Australia, Germany, Sweden and Norway). None of the studies presented data on all outcomes. The studies provided data on drug use (7 studies), drug expenditures from a drug insurer’s perspective (5), drug prices (3), health outcomes (2), and health care utilisation (4). None of the studies reported effects on patient drug expenditures or other costs (either intervention costs or those in other parts of the health service).
Ten out of the 11 studies in the review evaluated this intervention.
This review identified one study from Norway evaluating this intervention.
Findings | Interpretation* |
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APPLICABILITY | |
The target population were vulnerable groups covered by national insurance plans. The studies included a reduced group of drugs.
All of the 11 studies included were developed in high-income countries. Thus there is uncertainty regarding the transferability of the results to low and middle-income country settings and other drug classes.
All of the 11 studies included were developed in high-income countries. Thus there is uncertainty regarding the transferability of the results to low and middle-income country settings and other drug classes. |
Applicability of these interventions to low and middle-income country settings depends on several factors such as: Availability of adequate incentives for patients, physicians, pharmacists and pharmaceutical companies to comply with the reference price system There should be significant price differences between the drugs in a reference group before the reference price system is introduced, with relatively high prices on the drugs most used. Provision of clinical and managerial information support for users the availability and access to drugs. The quality of generics drugs should be considered. The existence of a regulatory framework which allows generic substitution and/or prescribing by International Non-Proprietary Name (INN) could be important for a better system perform . |
EQUITY | |
Overall, the targeted population was the beneficiaries of national health insurance plans. However the included studies provided little data regarding differential effects of the interventions for disadvantaged populations within the studied beneficiaries. |
Some interventions relied on technologies such as pharmaceutical drugs, may not always be appropriate when attempting to contact low income households. Implementation of pricing reference in such settings may exacerbate health inequities in population without health care access Doctors should be directly asked to recomend the less expensive medicine included in the reference or index pricing policy to the underserved population. |
ECONOMIC CONSIDERATIONS | |
Some of the findings summarised here are based on two- level measures: inmediate and short-term effects after the interventions. The review did not address the long-term effects and how support should best be provided. Price levels could modify the effects of reference drug pricing. Reasonable mechanisms for exemptions for patients that need it for medical reasons. None of the studies provided a full analysis of cost-effectiveness.
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It is not clear if the effects on drug prices would be mantained in the long term. Studies with short-term follow up showed different trends on the effect on prices. To achieve savings there should be significant price differences between the drugs in a reference group before the reference price system is introduced, with relatively high prices on the drugs most used. Too limited exemptions could lead to higher co-payments of the most effective drugs and incentive the prescription of less effective drugs by physicians. Too generous exemptions could reduce the savings, by not shifting the drug use towards cheaper drugs. |
MONITORING & EVALUATION | |
Evaluations in the majority of included studies focus on relatively short term outcomes. |
Longer-term analyses would provide important supplementary evidence although the risk for bias related to other confounding interventions could increase with the length of the observation period. Availability of pharmaceutical bioequivalence studies are needed to implement safe policies. It is important to have a clear legal provision of what are generics in each country. |
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low- and middle-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
Austvoll-Dahlgren A, Aaserud M, Vist G, Ramsay C, Oxman AD, Sturm H, Kösters JP, Vernby , Å. Pharmaceutical policies: effects of cap and co-payment on rational drug use. Cochrane Database of Systematic Reviews: Reviews 2008 Issue 1
Sturm Heidrun, Austvoll-Dahlgren Astrid AA, Aaserud Morten, Oxman Andrew D, Ramsay Craig, Vernby Åsa, Kösters Jan Peter. Pharmaceutical policies: effects of financial incentives for prescribers. Cochrane Database of Systematic Re-views: Reviews 2007 Issue 3
Aaserud M, Dahlgren AT, Sturm H, Kösters JP, Hill S, Furberg CD, Grilli R, Henry DA, Oxman AD, Ramsay C, Ross-Degnan D, Soumerai SB. Pharmaceutical poli-cies: effects on rational drug use, an overview of 13 reviews (protocol). Cochrane Database of Systematic Reviews: 2006 Issue 2
Gabriel Bastías & Gabriel Rada, School of Medicine, Pontificia Universidad Católi-ca de Chile, Chile
one declared. For details, see: www.support-collaboration.org/summaries/coi.htm
This summary has been peer reviewed by: Morten Aaserud, Norway; Sabine Vo-gler, Austria; Anban Pillay, South Africa; Esperança Sevene, Alda do Rosário Elias Mariano and Julie Cliff, Mozambique.
Bastías G, Rada G. Do pharmaceutical pricing and purchasing policies have ef-fects on drug use, health care utilisation, health outcomes and costs? A SUPPORT Summary of a systematic review. September 2009. www.support-collaboration.org/summaries.htm
Keywords
All Summaries: evidence-informed health policy, evidence-based, systematic re-view, health systems research, health care, low- and middle-income countries, de-veloping countries, primary health care