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. 2024 Feb 21;160(4):409–416. doi: 10.1001/jamadermatol.2023.6236

Use of Efficiency Frontiers to Align Prices and Clinical Benefits of Biologic Therapies for Plaque Psoriasis

Alexander C Egilman 1, Aaron S Kesselheim 1,2, Jerry Avorn 1,2, Adam J N Raymakers 1, Benjamin N Rome 1,2,✉
PMCID: PMC10882509  PMID: 38381418

This economic evaluation assesses how the efficiency frontier approach could align prices and clinical benefits of biologic medications for plaque psoriasis and estimates price reductions in the US vs 4 peer countries.

Key Points

Question

How could an efficiency frontier approach be used to better align prices with the clinical efficacy of biologic medications for plaque psoriasis?

Findings

In this economic evaluation, US net prices of 13 biologic therapies for psoriasis ranged from $1664 to $79 277 per year, and clinical efficacy measured by Psoriasis Area Severity Index 90 scores ranged from 17.9% to 71.6%. Prices would need to be reduced by a median of 71% based on an efficiency frontier of the most cost-effective treatments.

Meaning

Use of the efficiency frontier approach could achieve substantially lower prices and better align the costs and benefits of biological psoriasis treatments.

Abstract

Importance

The US lacks a systematic approach for aligning drug prices with clinical benefit, and traditional cost-effectiveness analysis (CEA) faces political obstacles. The efficiency frontier (EF) method offers policymakers an alternative approach.

Objective

To assess how the EF approach could align prices and clinical benefits of biologic medications for plaque psoriasis and estimate price reductions in the US vs 4 peer countries: Australia, Canada, France, and Germany.

Design and Setting

This health economic evaluation used the EF approach to compare the prices and clinical benefits of 11 biologics and 2 biosimilars for plaque psoriasis in the US, Australia, Canada, France, and Germany. Data were collected from February to March 2023 and analyzed from March to June 2023.

Main Outcome Measures

EFs were constructed based on each biologic’s efficacy, measured using the Psoriasis Area and Severity Index (PASI) 90 response rate, and annual treatment cost as of January 2023; US costs were net of estimated manufacturer rebates. Prices based on the EF were compared with traditional CEA-based prices calculated by the Institute for Clinical and Economic Review at a threshold of $150 000 per quality-adjusted life-year gained.

Results

Among 13 biologics, PASI 90 response rates ranged from 17.9% (etanercept) to 71.6% (risankizumab); US net annual treatment costs ranged from $1664 (infliximab-dyyb) to $79 277 (risankizumab). The median (IQR) net annual treatment cost was higher in the US ($34 965 [$20 493-$48 942]) than prerebate costs in Australia ($9179 [$6691-$12 688]), Canada ($15 556 [$13 017-$16 112]), France ($9478 [$6637-$11 678]), and Germany ($13 829 [$13 231-$15 837]). The US EF included infliximab-dyyb (PASI 90: 57.4%; annual cost: $1664), ixekizumab (PASI 90: 70.8%; annual cost: $33 004), and risankizumab (PASI 90: 71.6%; annual cost: $79 277). US prices for psoriasis biologics would need to be reduced by a median (IQR) of 71% (31%-95%) to align with those estimated using the EF; the same approach would yield smaller price reductions in Canada (41% [6%-57%]), Australia (36% [0%-65%]), France (19% [0%-67%]), and Germany (11% [8%-26%]). Except for risankizumab, the EF-based prices were lower than the prices based on traditional CEA.

Conclusions and Relevance

This economic evaluation showed that for plaque psoriasis biologics, using an EF approach to negotiate prices could lead to substantial price reductions and better align prices with clinical benefits. US policymakers might consider using EFs to achieve prices commensurate with comparative clinical benefits, particularly for drug classes with multiple therapeutic alternatives for which differences can be adequately summarized by a single outcome measurement.

Introduction

Concerns about high prescription drug costs have led federal and state policymakers to introduce several reforms to contain spending and better align prices with clinical value. These include new authority for the Centers for Medicare & Medicaid Services to negotiate Medicare drug prices under the Inflation Reduction Act of 2022 and the establishment of several state prescription drug affordability boards.1,2,3 Although value-based assessment of drugs is new to the US, many other countries, including Australia, Canada, France, and Germany, use health technology assessment (HTA) to systematically evaluate the efficacy and safety of new medications and to negotiate prices based on a drug’s added clinical benefits compared with existing therapeutic alternatives.4 After negotiating prices based on these assessments, other countries generally pay less than half of the prices for brand-name drugs compared with the US.5

To quantitatively assess a drug’s clinical benefit and guide reimbursement decisions, many countries use quality-adjusted life-years (QALYs), a measure of how well a treatment lengthens and improves patients’ quality of life.6,7 However, QALY-based analyses have become controversial in the US, criticized as discriminatory by the pharmaceutical industry and some patient groups.8,9 In response to political pressure, Medicare cannot use QALYs as part of drug price negotiation, and some states have included similar prohibitions.9,10 Congress is considering legislation that would broadly ban government health care programs, including Medicare and Medicaid, from using QALYs.11 Several value-assessment methodologies have been proposed as alternatives to conventional QALY-based cost-effectiveness analysis (CEA), although none have been widely adopted in the US.12,13 Germany began formally using efficiency frontiers (EFs) in 2011, and the approach has been suggested as an alternative to conventional CEA.14 The EF method maps the cost of each therapeutic option to outcome measures that can be disease specific.15 By identifying the expected market price for drugs based on the actual level of benefit offered to patients, EFs can help policymakers decide whether a drug’s price is appropriate compared with therapeutic alternatives.

We sought to investigate how EFs can be used by state and federal policymakers to achieve drug prices based on comparative clinical benefits, using the example of plaque psoriasis. For comparison, we also used the EF approach to examine the association between clinical benefits and prices for psoriasis drugs in the US compared with several countries that already use HTA, including Australia, Canada, France, and Germany.

We selected a case study of plaque psoriasis, a chronic inflammatory disease that affects more than 7.5 million adults in the US and has substantial disease and economic burden, because of the availability of multiple costly treatments.16,17 Since 2003, the US Food and Drug Administration (FDA) has approved several systemic immunomodulating biologic medications to treat moderate to severe plaque psoriasis.18 These biologics are more effective treatments than older systemic medications (eg, methotrexate, cyclosporine), topical therapies (eg, corticosteroids), and phototherapy.19 However, biologic medications for plaque psoriasis are also expensive; median net annual drug costs were $35 000 in 2019, and annual patient out-of-pocket costs ranged from $4423 to $6950.20,21 Spending on biologics to treat psoriasis remains a substantial and increasing share of drug spending in the US.17,22,23

Methods

Study Sample

We included 11 biologic drugs approved by the FDA to treat moderate to severe plaque psoriasis, based on the 2019 American Academy of Dermatology/National Psoriasis Foundation treatment guidelines24: adalimumab (Humira), brodalumab (Siliq), certolizumab (Cimzia), etanercept (Enbrel), guselkumab (Tremfya), infliximab (Remicade), ixekizumab (Taltz), risankizumab (Skyrizi), secukinumab (Cosentyx), tildrakizumab (Ilumya), and ustekinumab (Stelara). We also included biosimilars that were marketed as of January 1, 2023; this included 2 biosimilars marketed for infliximab: infliximab-abda (Renflexis) and infliximab-dyyb (Inflectra). We excluded a third infliximab biosimilar, infliximab-axxq (Avsola), because we could not identify price information in the US, Australia, France, and Germany. We did not include adalimumab biosimilars because they launched in 2023.

We obtained drug characteristics from labeling and regulatory information publicly available via Drugs@FDA,25 including mechanism of action, route of administration (subcutaneous or intravenous), date of FDA approval to treat psoriasis, and whether the drug was exclusively approved to treat psoriasis or was also approved to treat other conditions. This study was not submitted for institutional review board approval because it used public, nonpatient-identifiable data and did not constitute human participant research under the Common Rule (45 CFR §46.102). This study was reported in accordance with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guidelines.

Clinical Benefits

Data on each biologic’s clinical benefits were obtained from a 2020 network meta-analysis of 60 clinical trials comparing efficacy of treatments for moderate to severe psoriasis approved by the FDA and the European Medicines Agency as of September 17, 2018.26 We validated these results against other network meta-analyses, including a 2018 evidence report by the Institute for Clinical and Economic Review (ICER).27,28,29 We used the same efficacy measurements for the analyses in each country, since the pooled analyses included trials from multiple countries; we did not account for potential differences in efficacy between countries.

In clinical trials of treatments for moderate to severe psoriasis, efficacy is commonly assessed using the Psoriasis Area and Severity Index (PASI), a scoring system reflecting the body surface area of skin affected plus the severity of affected lesions. The primary outcome for clinical trials is reported as the percentage improvement. For example, PASI 90 reflects a 90% reduction in the PASI score after initiating treatment. As medications have become more effective, clinical trials have increasingly shifted from using a primary outcome of PASI 50 or PASI 75 to PASI 90 or PASI 100.30 We used information on PASI 90 since it was commonly measured across trials and better differentiates high-efficacy treatments than lower PASI thresholds.31

Differences in safety among the medications were not considered because rates of serious adverse events and adverse events leading to treatment discontinuation were comparably low for all treatments.32 Based on data obtained from a 2021 network meta-analysis of 59 clinical trials comparing safety of treatments for moderate to severe psoriasis, short-term (12-16 weeks) and long-term (48-56 weeks) serious adverse events ranged from a median of 0.8% to 3.4% and 4.4% to 10.4%, respectively, and there was no statistically significant difference in short- and long-term serious adverse events between biologics.32 Rates of adverse events leading to treatment discontinuation were less than 5% for all biologics.32 Other network meta-analyses have reported similar results.27,33

US and International Prices

We extracted the annual cost of treatment for psoriasis as of January 31, 2023, for each biologic in the US, Australia, Canada (Ontario), France, and Germany using the Eversana NAVLIN Price & Access database.34 This database included ex-factory prices sourced from Micromedex Redbook (US), the Pharmaceutical Benefits Scheme (Australia), the Ontario Drug Benefit Formulary (Canada), the Health Insurance Fund (France), and Lauer Taxe (Germany). Ex-factory prices are the prices at which manufacturers sell their products to wholesalers; in the US, this was represented by wholesale acquisition costs (ie, list price).35 In Canada, prices are negotiated nationally, but provinces can seek additional discounts; we selected prices from Ontario because it is Canada’s most populous province.36,37

For drugs available in multiple strengths or dosage forms, we extracted the cost of the most commonly available strength and dosage form in all markets. Prices per unit were converted to prices per annual course of maintenance treatment, based on the recommended dosing in the labeling approved by the FDA. For drugs dosed by weight, we assumed the average weight for a European adult (70 kg).38 Prices were converted to US dollars using monthly average conversion rates from January 2023.39

Ex-factory prices are frequently subject to additional discounts, including confidential rebates paid by manufacturers to insurers or pharmacy benefit managers. We estimated US net prices after manufacturer rebates using sales-weighted, 4-quarter rolling average non-Medicaid discounts from the SSR Health database.40,41 For Australia, Canada, France, and Germany, we used ex-factory prices because we did not have access to estimated discounts or rebates.

Statistical Analysis

We constructed EFs by plotting clinical efficacy (PASI 90 response rate) and annual treatment cost for each psoriasis biologic, eliminating treatments that were dominated by a different drug with the same or higher benefit at a lower annual treatment cost and connecting nondominated treatments in increasing order of efficacy and price.14 For dominated drugs, we calculated the difference between the actual price and the EF price for a drug with the same degree of benefit.

In a sensitivity analysis, we constructed an EF for the US excluding biologics with available biosimilar competitors (ie, infliximab and its biosimilars) because some policymakers may not wish to reference prices for branded drugs against available generics or biosimilars. In an additional analysis, we compared each drug’s price based on the EF with the price that would achieve an incremental cost-effectiveness threshold of $150 000 per QALY gained. Threshold prices were obtained from ICER’s 2018 evidence report on psoriasis treatments, which modeled the incremental cost-effectiveness for each drug relative to placebo.27 We chose $150 000 because it is the upper bound of the willingness-to-pay threshold used by ICER and other prominent US organizations, such as the American College of Cardiology.42,43 Statistical analyses were performed using Microsoft Excel, version 16.65.

Results

Sample Characteristics

Among the 11 biologics, 7 (64%) were initially approved by the FDA to treat moderate to severe psoriasis; 4 (36%) had been previously approved to treat other conditions (Table 1). As of January 2023, 2 biologics were exclusively approved to treat psoriasis: brodalumab and tildrakizumab. The 11 biologics targeted multiple biological pathways: 4 for tumor necrosis factor, 3 for interleukin 23, 3 for interleukin 17, and 1 for interleukin 12/23. All of the biologics were administered via subcutaneous injection, except infliximab and its biosimilars, which were administered intravenously.

Table 1. Characteristics of Biologics Approved to Treat Moderate to Severe Psoriasis.

Generic name (brand name) Date of FDA approval for psoriasis Targeted biologic pathway Route of administration Approved exclusively for psoriasisa
Adalimumab (Humira) 1/18/2008b Tumor necrosis factor Subcutaneous No
Brodalumab (Siliq) 2/15/2017 Interleukin 17 Subcutaneous Yes
Certolizumab pegol (Cimzia) 5/24/2018b Tumor necrosis factor Subcutaneous No
Etanercept (Enbrel) 4/30/2004b Tumor necrosis factor Subcutaneous No
Guselkumab (Tremfya) 7/13/2017 Interleukin 23 Subcutaneous No
Infliximab (Remicade) 9/26/2006b Tumor necrosis factor Intravenous No
Ixekizumab (Taltz) 3/22/2016 Interleukin 17 Subcutaneous No
Risankizumab (Skyrizi) 4/23/2019 Interleukin 23 Subcutaneous No
Secukinumab (Cosentyx) 1/21/2015 Interleukin 17 Subcutaneous No
Tildrakizumab (Ilumya) 3/20/2018 Interleukin 23 Subcutaneous Yes
Ustekinumab (Stelara) 9/25/2009 Interleukin 12/23 Subcutaneous No
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Abbreviation: FDA, US Food and Drug Administration.

a

As of January 2023.

b

Drug was originally FDA approved to treat a different condition, and psoriasis was added to the label via a supplemental FDA application.

Efficacy and Prices

The PASI 90 response rate ranged from 17.9% (etanercept) to 71.6% (risankizumab). Four biologics had PASI 90 response rates higher than 67%, 5 had response rates below 50%, and 2 had PASI 90 response rates between 50% and 67%.

The median (IQR) US prerebate annual treatment cost was $70 400 ($57 611-$86 115). After adjusting for rebates, the median (IQR) US net annual treatment cost was $34 965 ($20 493-$48 942) (Table 2). Annual median (IQR) treatment costs were lower in Australia ($9179 [$6691-$12 688]), Canada ($15 556 [$13 017-$16 112]), France ($9478 [$6637-$11 678]), and Germany ($13 829 [$13 231-$15 837]) (eTable in Supplement 1). Prices were not available for tildrakizumab in the US (due to a lack of rebate estimates) and brodalumab in Australia (not accessible through the Pharmaceutical Benefits Scheme).44

Table 2. Estimated Prices for Psoriasis Biologics in the US using Efficiency Frontier (EF) and Cost-Effectiveness Analysis (CEA) Approaches.

Drug (brand name) PASI 90 response rate, % Estimated net price/y, $ Price based on EF (% reduction), $a Price based on EF excluding biosimilar competitors (% reduction), $b Price based on traditional CEA (% reduction), $c
Etanercept (Enbrel) 17.9 46 967 519 (99) 8344 (82) 35 400 (25)
Tildrakizumab (Ilumya) 36.8 NAd NAd NAd NAd
Adalimumab (Humira) 43.7 54 867 1267 (98) 20 371 (63) 39 800 (27)
Ustekinumab (Stelara) 43.9 25 182 1273 (95) 20 464 (19) 37 800 (NA)e
Certolizumab pegol (Cimzia) 45.6 31 910 1322 (96) 21 257 (33) 39 700 (NA)e
Infliximab (Remicade) 57.4 6426 1664 (74) NA 35 000 (NA)e
Infliximab-dyyb (Inflectra) 57.4 1664 1664 (0)f NA 35 000 (NA)e
Infliximab-abda (Renflexis) 57.4 5797 1664 (71) NA 35 000 (NA)e
Secukinumab (Cosentyx) 61.4 36 926 11 019 (70) 28 622 (22) 39 400 (NA)e
Guselkumab (Tremfya) 67.3 41 852 24 818 (41) 31 372 (25) 41 500 (1)
Brodalumab (Siliq) 70.6 58 041 32 536 (44) 32 911 (43) 41 500 (28)
Ixekizumab (Taltz) 70.8 33 004 33 004 (0)f 33 004 (0)f 39 700 (NA)e
Risankizumab (Skyrizi) 71.6 79 277 79 277 (0)f 79 277 (0)f 39 800 (50)
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Abbreviations: NA, not applicable; PASI 90, 90% reduction in the Psoriasis Area and Severity Index.

a

Price that would be required for the drug to be on the EF.

b

Price that would be required for the drug to be on the EF that excluded infliximab and its biosimilars.

c

Price that would be required for the drug to be cost-effective at an incremental cost-effectiveness threshold of less than $150 000 per quality-adjusted life-year gained compared with placebo. These prices were obtained from a 2018 report from the Institute for Clinical and Economic Review.27

d

Net price was unable to be estimated because rebate estimates were unavailable from SSR Health. The US price for the drug was excluded from the analysis.

e

The cost-effective price was higher than the current net price.

f

No change in price because the drug was included in the EF.

In each country except Germany, infliximab or its biosimilars had the lowest treatment cost: $1664 (postrebate) in the US, $4095 in Australia, $8450 in Canada, and $3289 in France. In Germany, the lowest treatment cost was $11 005 for both etanercept and certolizumab. Risankizumab, which had the highest PASI 90 response (71.6%), had the highest or second-highest costs of any biologic in each country except Canada, costing $79 277 (postrebate) in the US, $16 121 in Australia, $16 112 in Canada, $12 110 in France, and $18 940 in Germany. The most expensive biologic was guselkumab ($16 775) in Australia, infliximab ($16 928) in Canada, and ustekinumab ($20 835) in Germany.

Price vs Benefit

In the US, the EF included infliximab-dyyb; ixekizumab, which cost $31 340 more than infliximab-dyyb and had a PASI 90 response rate 13.4% higher ($2339 per percentage increase in PASI 90 response rate); and risankizumab, which cost $46 273 more than ixekizumab and was 0.8% more effective ($57 842 per percentage increase in PASI 90 response rate) (Figure 1). Based on the EF, prices for psoriasis drugs in the US would need to be reduced by a median (IQR) of 71% (31%-95%) to align with prices for the most cost-effective therapeutic alternatives (Table 2). For all drugs except for risankizumab, the EF approach yielded lower price estimates than a conventional cost-effectiveness approach using a willingness-to-pay threshold of $150 000 per QALY. The EF approach always resulted in estimated prices equal to or lower than existing US net prices; by contrast, 4 drugs (excluding infliximab and its biosimilars) had current estimated net prices lower than the threshold-based price based on CEA.

Figure 1. Efficiency Frontier for Psoriasis Biologics in the US.

Figure 1.

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The efficiency frontier (blue line) connects the most cost-effective, nondominated treatments; in the US, these included infliximab-dyyb, ixekizumab, and risankizumab. Biologics denoted with a blue circle were originally approved to treat psoriasis, whereas those denoted with an orange circle were originally marketed to treat a nonpsoriasis indication and subsequently received approval to treat psoriasis. PASI 90 indicates 90% reduction in the Psoriasis Area Severity Index.

In the sensitivity analysis excluding infliximab and its biosimilars, the EF included ixekizumab and risankizumab; other biologics were all dominated (eFigure in Supplement 1). Excluding infliximab and its biosimilar competitors, prices for psoriasis drugs in the US would need to be reduced by a median (IQR) of 25% (19%-43%) to align with EF prices.

All EFs using prices from Australia, Canada, France, and Germany included risankizumab, and all except Germany included infliximab or its biosimilars (Figure 2). Additionally, ixekizumab was on the EF for Australia and Germany, while the EF for Canada and France included brodalumab. Compared with the US, the necessary median (IQR) price reductions to match the EF were of smaller magnitude in Canada (41% [6%-57%]), Australia (36% [0%-65%]), France (19% [0%-67%]), and Germany (11% [8%-26%]) (eTable in Supplement 1).

Figure 2. Efficiency Frontiers for Psoriasis Biologics in Australia, Canada, France, and Germany.

Figure 2.

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The efficiency frontier (blue line) connects the most cost-effective, nondominated treatments; these included all 3 infliximab biosimilars, ixekizumab, and risankizumab in Australia; infliximab-abda, brodalumab, and risankizumab in Canada; all 3 infliximab biosimilars, brodalumab, and risankizumab in France; and ixekizumab and risankizumab in Germany. Biologics denoted with a blue circle were originally approved to treat psoriasis, whereas those denoted with an orange circle were originally marketed to treat a nonpsoriasis indication and subsequently received approval to treat psoriasis. PASI 90 indicates 90% reduction in the Psoriasis Area Severity Index.

Discussion

The EF approach to comparing the financial cost and clinical benefits of psoriasis biologics demonstrated that prices in the US for these drugs would need to be lowered by a median of 71% to align with prices for the most cost-effective therapeutic options. These findings suggest that EFs could be used by state and federal payers, as well as private health insurers and pharmacy benefit managers, to achieve substantially lower prices for biological psoriasis treatments and better align their prices with the clinical benefits they offer to patients.

Ex-factory prices for psoriasis biologics in the US were 4 to 8 times higher than in 4 peer countries; even after accounting for rebates in the US, prices were 2 to 4 times higher. Additionally, the price reductions necessary to match the EF-based prices in these 4 countries were less than with US prices, suggesting that these countries are paying prices more commensurate with comparative clinical benefit. This is not surprising because each of these 4 countries negotiate drug prices based on their clinical benefits compared with existing treatment options.45

This case study highlights some of the key differences between 2 methods used by foreign HTA organizations to negotiate drug prices to align with clinical benefit: EFs and CEA thresholds. EFs compare price and clinical outcomes data in a simple and straightforward way, without the need for complex modeling required in traditional CEA. In its simplest form, the EF approach uses a disease-specific outcome measured directly in clinical trials. This means that the EF approach is particularly well suited to clinical scenarios in which the difference between treatments can be adequately compared using a single measurement of safety or effectiveness. One such scenario includes the biologic treatments for psoriasis, given variations in efficacy but comparable safety profiles. However, even within a disease area, it is not uncommon for trials of different drugs to use different outcome measurements, which could make it difficult to conduct head-to-head comparisons.46 In the case of psoriasis, the primary trial outcomes have evolved from PASI 50 to PASI 90 as treatments have become more effective, but PASI 90 results were available for all biologics in this study.26,30

Traditional CEA consolidates varying measurements of drug safety and effectiveness (eg, life extension and quality of life) into a standard metric—typically the QALY. Therefore, CEA offers advantages when assessing drugs that differently affect multiple clinically important safety and effectiveness outcomes. Additionally, CEA can more easily incorporate downstream effects, such as lower treatment costs that might result from a treatment that is more effective or has fewer adverse effects, or gains in productivity for patients or their caregivers.

Some state and federal policymakers have prohibited use of QALYs in response to criticisms that they discriminate by age and disability. While such critiques are controversial and may be misguided,11 EFs may be particularly helpful in cases where QALYs are prohibited since they can readily accommodate clinical outcomes directly measured in trials.

The EF approach leverages existing price competition within a drug class, identifying savings for medicines that are higher cost and of equal or lower clinical effectiveness than available therapeutic alternatives. EFs may be particularly useful when there is existing within-class competition and when generic or biosimilar competitors are available. For instance, among the 11 biologics and 2 biosimilars approved to treat psoriasis, the EF approach yielded lower prices than conventional CEA for all drugs except risankizumab.

The standard EF approach places no price restraints on the most effective drug in a class. In the case of psoriasis biologics, risankizumab cost $40 067 more than ixekizumab, despite having a PASI 90 response rate less than 1% higher. As a result, modified approaches may be needed, such as bundling and setting reference prices for drugs with similar efficacy, before implementing the EF. By comparison, many versions of CEA conducted in the US and internationally either have explicit or implicit ranges that bound the willingness to pay for incremental improvements in health.

Finally, biologic treatments for psoriasis are well suited for the EF framework because there are many competing therapies, but the EF approach might not be applicable to certain therapeutic areas because it requires a minimum of 2 treatment options. By contrast, a traditional CEA approach can be used to compare the costs and benefits of a single treatment, compared with no active treatment or a standard of care.

Limitations

This study had several limitations. First, most of the biologics in this study were approved for multiple indications, and the clinical benefits they provide in treating conditions other than psoriasis would be expected to contribute to their price. Absent indication-specific pricing, payers using any method of negotiating prices based on clinical outcomes must consider how to combine results from different indications into a single price. Second, we did not have access to confidential rebates and discounts outside of the US, so we compared estimated net US prices with ex-factory prices in Australia, Canada, France, and Germany. As such, the estimates of prices outside of the US are conservatively high, and it is possible that prices in these countries would become more closely aligned with drugs’ clinical benefit after accounting for rebates. Third, we did not account for differences in administration costs. For example, infliximab and its biosimilars are administered intravenously; although the costs of administering the drug are much smaller than the cost of the drug itself, the costs of patient and caregiver time to receive regular infusions could lead us to underestimate the cost of infliximab. Fourth, we assumed that the use and clinical benefits of these drugs were comparable in each of the countries assessed; we believe that this is a good assumption because many drugs are approved for use based on international trials rather than country-specific data, but some countries might prefer to use data that are more tailored to their clinical and cultural needs. Finally, the estimated net prices of the biologics in the US were based on SSR Health data, which are useful but have well-described limitations.40

Conclusions

In this economic evaluation of biologic treatments for plaque psoriasis, we demonstrated how the EF approach could be implemented in the US to achieve substantially lower prices and to better align prices with clinical benefits to patients. This approach may appeal to policymakers as an alternative to traditional CEAs that rely on politically charged QALYs, but its use is limited to situations in which there are multiple therapeutic alternatives for which differences can be adequately summarized by a single outcome measurement.

Supplement 1.

eTable. Estimated Prices for Psoriasis Biologics in Australia, Canada, France, and Germany Using Efficiency Frontiers

eFigure. Efficiency Frontier Excluding Infliximab and its Biosimilar Competitors, United States

jamadermatol-e236236-s001.pdf (657.3KB, pdf)
Supplement 2.

Data Sharing Statement

jamadermatol-e236236-s002.pdf (16.4KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eTable. Estimated Prices for Psoriasis Biologics in Australia, Canada, France, and Germany Using Efficiency Frontiers

eFigure. Efficiency Frontier Excluding Infliximab and its Biosimilar Competitors, United States

jamadermatol-e236236-s001.pdf (657.3KB, pdf)
Supplement 2.

Data Sharing Statement

jamadermatol-e236236-s002.pdf (16.4KB, pdf)

Articles from JAMA Dermatology are provided here courtesy of American Medical Association

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