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Pricing and reimbursement of pharmaceuticals in Germany What lessons can be learned from abroad?

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  • Around 1982, the Health Insurance Council was underincreasing pressure from patients who demanded that thecosts of heart and liver transplants performed abroad shouldbe reimbursed by sick funds. Because of the ensuing debate,the Health Insurance Council developed a report in 1985,Limits to the Expansion of the Benefit Package (19), statingthat, in the future, all new major health technologies wereto be assessed for their efficacy and cost-effectiveness andwould be admitted to the benefit package according to theirpriority

    1. 1. Pricing and reimbursement of pharmaceuticals in GermanyWhat lessons can be learned from abroad?<br />15 March 2011<br />Pharmerit International<br />Dr. Harald Heemstra<br />
    2. 2. Objective<br /> To discuss the German pricing and reimbursement reform in the context of reimbursement systems in other EU countries<br />In particular the Netherlands<br />
    3. 3. Introduction<br />HTA in the Netherlands<br />1999: Plan to introduce HE as requirement for <br /> reimbursement applications<br />2000: Postponement of HE requirements to 2005<br />2002: Trial period with voluntary submission of HE dossier<br />2005: Mandatory HE reimbursement applications<br />Pharmerit<br />Founded in 2000 in the Netherlands<br />Offices in Rotterdam (NL), York (UK) and Bethesda (US)<br />
    4. 4. Outline of the presentation<br />Introduction and background<br />Timelines<br />Data requirements<br />Assessment of incremental clinical benefit<br />Health economics<br />Exceptions and advice<br />Summary and implications<br />
    5. 5. Introduction and background<br />
    6. 6. BackgroundPrimary actors - Germany<br />Federal Ministry of Health<br />Statutory Health Insurance (GKV)<br />Federal Joint Committee<br /> (G-BA)<br />National Association of Statutory Health Insurance Funds <br />(GKV-SpiBu)<br />Institute for Quality and Efficiency in Health Care<br />(IQWiG)<br />German Agency for Health Technology Assessment<br />(DAHTA) <br />
    7. 7. BackgroundPrimary actors – the Netherlands<br />Ministry of Health (VWS)<br />Private health-care insurers <br />Netherlands Healthcare Insurance Board (CVZ)<br />Commission for Pharmaceutical Aid (CFH)<br />
    8. 8. Timelines<br />
    9. 9. Introduction: Timelines - Germany<br />End of free pricing period if no additional benefit<br />End of free pricing period if additional benefit<br />6 months<br />
    10. 10. TimelinesWhen to submit the value dossier?<br />Very short time to prepare complete dossier:<br />Value dossier needs to be prepared before the request comes!<br />
    11. 11. IntroductionTimelines – The Netherlands<br />Application to MoH<br />HE analysis needed when not clustered<br />Reference pricing<br />Validation MoH, application to CVZ<br />Evaluation of GVS criteria <br />Clustering<br />No clustering<br />90 days<br />In practice: 129-164 days<br />Evaluation of additional clinical benefit + HE<br />CVZ advice to MoH<br />Decision MoH<br />Annex B<br />Annex A<br />
    12. 12. Data requirements<br />
    13. 13. Data requirementsValue dossier - Germany<br />The approved therapeutic indication(s)<br />The medical benefit <br />The additional clinical benefit compared to appropriate comparative therapy<br />The number of patients and patient groups for whom there is a therapeutically meaningful additional benefit<br />The cost of the therapy for GKV<br />The requirements for a quality assured application<br />Crucial for successful reimbursment<br />
    14. 14. Data requirementsReimbursement dossier - Netherlands<br />Pharmacotherapeutic dossier<br />Therapeutical (added) value<br />Pharmacoeconomical dossier<br />Only for unclustered products (Annex 1B)<br />Guidelines for pharmacoeconomical research apply<br />Societal perspective<br />Incremental costs per QALY<br />Cost-consequence estimation<br />
    15. 15. Data requirementsBudget impact: rough estimations<br />Often too high or too low estimation of cost consequenses<br />The forecasted gross budget impact (○) with<br />corresponding uncertainty and the actual budget (•). <br />Thuresson PO, Heeg B, Botteman M, ISPOR 2010<br />
    16. 16. Assessment of incremental clinical benefit<br />
    17. 17. Assessment of incremental clinical benefit Germany- improvement for the patient<br />Incremental clinical benefit seen as crucial factor for succesful reimbursement outcomes<br />System seems inspired by the French ASMR rating system<br />Main clinical trial study design is important!<br />Design RCTs to provide hard evidence on the value of the product <br />
    18. 18. Assessment of incremental clinical benefit Netherlands: two annexes<br />Annex 1A<br />Products with Interchangeable substitutes Defined as:<br /><ul><li>Same indication
    19. 19. Same route of administration
    20. 20. Same age group of patients
    21. 21. No clinically relevant differences</li></ul>Reimbursement limits based on price of product at reference date (lowest priced product)<br />Annex 1B <br />Products without interchangeable substitutes <br />No reimbursement limits<br />
    22. 22. Reference pricingShare of not substitutable products<br />Netherlands: substitutable with other products<br />
    23. 23. ReferencepricingPrice level of clusteredvsunclustered<br />Source: GIP peilingen 2009<br />
    24. 24. Assessment of incremental clinical benefitFrance: the ASMR system<br />
    25. 25. Assessment of incremental clinical benefitNew products: substantial clinical benefit<br />Source: HAS annual report 2007<br />
    26. 26. Assessment of incremental clinical benefitNew products: limited additional benefit<br />However, only very few new products have major or important improvement in additional benefit<br />Source: HAS annual report 2007<br />
    27. 27. Health economics<br />
    28. 28. Health economicsGermany and the Netherlands<br /> HTA consideration gained importance for market access since mid 1990s <br /> 2000: SHI Health Care Reform Act<br /> - Diagnosis-related Groups<br /> - The German Agency for Health<br /> Technology Assessment <br /> 2003: Health Care Modernization Act<br /> - 2004: Foundation of IQWiG; solely <br /> benefit assessments<br /> - 2010: First economic evaluations to <br /> determine maximum <br />reimbursement rate<br /> 2011: Pharmaceutical Market<br /> Restructuring Act (AMNOG)<br /> HTA evaluations have been performed since the early 1980s<br /> 1982: Health Insurance Council <br /> published the ‘Limits to the <br /> Expansion of the Benefit Package’ <br /> report <br />- Evaluation of efficacy and cost-<br /> effectiveness<br /> 2002: Voluntary submission of HE <br /> applications<br /> 2005: Mandatory submission of HE<br /> applications<br /> 2006: Health Insurance Act<br />- HTA evaluation by the Health Care<br /> Insurance Board (CVZ) <br />
    29. 29. Health economicsGermany<br />Cost analysis important aspect of the value dossier<br />Parties can ask for a cost-benefit analysis after the arbitration committee has reached a decision<br />Perspective of the Statutory Health Insurance (GKV)<br />General methods for the assessment of the relation of benefits to costs<br />
    30. 30. Health economicsThe Netherlands<br />Pharmacoeconomic analysis is obligatory:<br />For annex B products<br />For extensions of the conditions of Annex A or B products<br />Outcomes in incremental costs/QALY<br />No formal ICER threshold<br />Additional factors that play a role:<br />Disease severity<br />Risk for misuse<br />Budget impact<br />
    31. 31. Health economicsDifferences<br /> Health economic guidelines in Germany deviate on certain aspects from Netherlands: <br />
    32. 32. Exceptions and Advice<br />
    33. 33. Execptions apply in both Germany and the Netherlands:<br />ExceptionsGeneral<br />
    34. 34. ExceptionsOutpatient drugs<br /><br /><br />
    35. 35. AdviceScientific advice<br />Scientific advice can be very helpful in designing trials, choosing comparators etc. Especially in complicated cases<br />Eligibility for advice expires with the expiration date for submission of the value dossier<br />
    36. 36. Summary and implications<br />
    37. 37. Summary<br />Timelines<br />Start on time!<br />Also if your product is already reimbursed<br />Data requirements<br />Focus on quality of the data, from main clinical trial design<br />Assessment of incremental clinical benefit<br />Incremental clinical benefit crucial for succesful reimbursement outcome<br />Health economics<br />Gaining importance with the introduction of AMNOG?<br />Exceptions and advice<br />Exceptions apply for orphan drugs<br />Be encouraged to make use of facilities for advice<br />
    38. 38. Implications<br />Effects for international reference pricing:<br />Possible choice to maintain a high price if product placed on reference group<br />Possible choice to withdraw from the German market if price provided is too low<br />Lower sales in Germany <br />International prices will remain high<br />Effects for German patients<br />Germany as portal for market access of pharmaceuticals in Europe?<br />
    39. 39. Thank you<br />Harald Heemstra, PharmD, PhD<br />Pharmerit International<br /> <br />+31 10 4519924<br />