title: Disinvestment and Value-Based Purchasing Strategies for Pharmaceuticals: An International Review.
abstract: Pharmaceutical expenditure has increased rapidly across many Organisation for Economic Cooperation and Development (OECD) countries over the past three decades. This growth is an increasing concern for governments and other third-party payers seeking to provide equitable and comprehensive healthcare within sustainable budgets. In order to create headroom for increasing utilisation, and to fund new high-cost therapies, there is an active push to 'disinvest' from low-value drugs. The aim of this article is to review how reimbursement policy decision makers have sought to partially or completely disinvest from drugs in a range of OECD countries (UK, France, Canada, Australia and New Zealand) where they are publicly funded or subsidised. We employed a systematic literature search strategy and the incorporation of grey literature known to the authorship team. We canvass key policy instruments from each country to outline key approaches to the identification of candidate drugs for disinvestment assessment (passive approaches vs. more active approaches); methods of disinvestment and value-based purchasing (de-listing, restricting treatment, price or reimbursement rate reductions, encouraging generic prescribing); lessons learnt from the various approaches; the potential role of coverage with evidence development; and the need for careful stakeholder management. Dedicated sections are provided with detailed coverage of policy approaches (with drug examples) from each country. Historically, countries have relied on 'passive disinvestment'; however, due to (1) the availability of new cost-effectiveness evidence, or (2) 'leakage' in drug utilisation, or (3) market failure in terms of price competition, there is an increasing focus towards 'active disinvestment'. Isolating low-value drugs that would create headroom for innovative new products to enter the market is also motivating disinvestment efforts by multiple parties, including industry. Historically, disinvestment has mainly taken the form of price reductions, especially when market failures are perceived to exist, and restricting treatment to subpopulations, particularly when a drug is no longer considered value for money. There is considerable experimentation internationally in mechanisms for disinvestment and the opportunity for countries to learn from each other. Ongoing evaluation of disinvestment strategies is essential, and ought to be reported in the peer-reviewed literature.
authors.affiliation: Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, NSW, Australia, bonny.parkinson@chere.uts.edu.au.
authors.forename: Bonny
authors.initials: B
authors.lastname: Parkinson
authors.forename: Catherine
authors.initials: C
authors.lastname: Sermet
authors.forename: Fiona
authors.initials: F
authors.lastname: Clement
authors.forename: Steffan
authors.initials: S
authors.lastname: Crausaz
authors.forename: Brian
authors.initials: B
authors.lastname: Godman
authors.forename: Sarah
authors.initials: S
authors.lastname: Garner
authors.forename: Moni
authors.initials: M
authors.lastname: Choudhury
authors.forename: Sallie-Anne
authors.initials: SA
authors.lastname: Pearson
authors.forename: Rosalie
authors.initials: R
authors.lastname: Viney
authors.forename: Ruth
authors.initials: R
authors.lastname: Lopert
authors.forename: Adam G
authors.initials: AG
authors.lastname: Elshaug
mesh_terms: D003657:Decision Making; D016527:Drug Costs; D004363:Drug Utilization / Q000191:economics*; D006291:Health Policy; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000191:economics*; D066150:Organisation for Economic Co-Operation and Development; D062505:Value-Based Purchasing / Q000191:economics*