| Financial Agreements |
a) Rebate Agreements |
Create two different prices for the same medication: a confidential reduced price for the payer and an official public price (higher) for insurees (Ministry of Health and Long-Term Care 2010; widely used in Ontario). |
[+] Simple to implement. [+] Generate savings for the payers. [−] High opacity. [−] Create artificial marketed medication prices. [−] Disparity between public and private insurees. |
| b) Price–Volume Agreements |
The first simple form of a “risk-sharing” agreement.
The price of the medication is reduced according to drug utilization. |
[+] Improve budget certainty. [+]Greater transparency compared to rebate agreements. [+]Simple to implement. [−]Disparity between public and private insurees. |
| Clinical Agreements |
a) Conditional Coverage Agreements |
The coverage of a medication is conditional upon positive post-marketing clinical data.
(i) Coverage with evidence development agreements (CED): Clinical studies required differ from traditional post-marketing studies, their aim being the reduction of the payer's uncertainty about the clinical effectiveness of the medication. (ii) Conditional treatment continuation agreements (CTC): Coverage is conditional upon evidence of clinical effectiveness for specific patients (clinical targets).
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[+] Option for improving healthcare efficiency and effectiveness. [+] Option for obtaining optimal drug therapy and “value for money.” [+] Provide improved access to a new, promising drug in a timely manner. [+] Reduce any uncertainty that may remain following the drug's clinical evaluation. [−] Risk that the drug be removed from the listowing to lack of strong clinical evidence. [−] Difficulty in assessing clinical outcomes. [−] Lack of transparency. |
| b) Performance-Linked Reimbursement Agreements |
Drug coverage is tied to a specific clinical aspect of the drug.
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(i) Outcome guarantee agreements: “schemes where the manufacturer provides rebates, refunds, or price adjustments if their product fails to meet the agreed upon outcome targets” (Carlson et al. 2010: 184).
Two principal components: a data collection process to assess the performance of the medication for each patient treated and a formula that links the reimbursement or the rebate to the data collected.
(ii) Process of care agreements: “schemes where the reimbursement level is tied to the impact on clinical decision-making or practice patterns.”
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[+] Link the price of a medication to its effectiveness for each patient. [−] Clearly defined evidence-based parametersfor measuring success of the therapy are often missing. [+] Limit uncertainty concerning the drug's impact on clinical decisions. |
