From a cancer drug fund to value based pricing of drugs
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4388 (Published 12 August 2010) Cite this as: BMJ 2010;341:c4388All rapid responses
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Italy is the country where the largest list of innovative drugs is currently being managed through risk-sharing methods. The advantage is that, as manufacturers claim, the nominal price of these drugs is not too different from the average price in Europe, but our national health system ultimately spends less than the amount predicted from nominal prices because risk-sharing methods and paybacks act as a sort of atypical price reduction.
In the past years, the wide implementation of risk-sharing and payback methods in Italy has promoted a technical debate on this topic aimed at defining in mathematical terms how risk-sharing algorithms can be applied (1-3).
In particular, Messori et al. (3) have observed that two methods of payment-by-results can be differentiated. The first ('pragmatic payback') is aimed at obtaining a rebate in the average cost incurred for treating the concerned patients; in the second ('value-based payback') the payback of treatment failures is a tool that has the purpose to ensure a proportionality between the cost and the clinical benefit in the framework of the so-called value-based approach. In this Rapid Response, we re-present the equations published by Messori et al. in order to make this piece of information available to the international audience.
Pragmatic payback
The starting point in this type of negotiation between national health system and manufacturer is when both parties agree on the discount in the nominal price that the payback should handle to generate the value of the real price. The relationship between real price and nominal price is shown by the following equation:
Equation 1: RP = NP x (1 - FAILURES/100)
where RP is the real price (inclusive of paybacks), NP is the nominal price and FAILURES is the observed rate of failures expressed as percentage. In the pragmatic payback, the main assumption is that the target (or desired) percent discount in the drug price is equal to the percentage of failures subjected to the payback.
One parameter that does not directly appear in this equation is the time-point in the follow-up at which the clinical outcome is determined. To determine this parameter, the Kaplan-Meier curve (indicating the cumulative rate of failures against time) is examined to find the time-point on the x-axis where FAILURES is expected to be equal to the desired value of percent discount (see Figure 1). This procedure allows to identify the (fixed) time-point at which the patients' outcome should be assessed.
This time-point is actually the only parameter determined by the negotiation. In fact, the percent discount generated by paybacks is a consequential parameter based on the assumption that the curve of failures in real patients (observed prospectively) will have the same trend as that of the pivotal trial. Anyhow, if the real patients show more failures than expected, the national health system will receive a greater discount/payback than that expected from the pivotal trial; likewise, if the real patients show fewer failures than expected, the national health system will receive a smaller discount than that initially expected.
Value-based payback
The first step is to assess the incremental clinical benefit of the innovative treatment relative to the standard treatment. The second step is to recognize an economic countervalue to this incremental clinical benefit (4). A countervalue of 5,000 euros can be assigned, for example to each month of overall survival gained, and 2,500 euros to each month of progression-free or disease-free survival gained. In the third step, the economic countervalue of clinical benefit is divided by the cumulative dose needed to treat a typical patient (so that the value-based price of the drug can be determined as cost per dosage unit).
The best situation is when the negotiation is closed based on the value-based approach with no payback. However, there are many cases in which, due to international constraints, the manufacturer is forced to keep a substantial identity between the Italian nominal price and the European nominal prices. In these cases, the payback is introduced so that the nominal price can be kept high, but the payback then produces a sort of delayed discount that leads to a real price lower than the nominal one.
The relationship between the nominal price 'desired' by the manufacturer (NPDES), the value-based price (VBP), and the percentage of failures expected at time of the binary outcome assessment is as follows (3):
Equation 2: NPDES = VBP / (1 - FAILURES/100)
In this equation, the value of NPDES expresses the price that, after adjustment for the payback of all failures, gives the same economic impact as the one resulting from paying all treatments at VBP with no paybacks; hence, the combined effect of a (higher) NP and paybacks is designed to generate an economic impact identical to that resulting from the systematic use of VBP with no implementation of any paybacks. For example, assuming that VBP is 40 euros, the same economic impact (as with VBP=40 euros without paybacks)is obtained if NP is 50 euros with 20% of treatment failures; or NP is 80 euros with 50% of treatment failures; or NP is 100 euros with 60% of treatment failures.
To determine which failures percentage generates the value of NPDES the equation that handles this relationship is the following:
Equation 3: FAILURESEQ = 100 x (1 - VBP/NPDES)
where FAILURESEQ is the percentage of failures corresponding to the payback that makes the economic impact equal between: (1) VBP without payback; and (2) NPDES with payback of failures.
The Kaplan-Meier curve described in Figure 2 shows how the time-point in the follow-up can be identified to ensure that all of the above conditions are met. In more detail, the first step is to start from the top of the y-axis (100%), then one goes down until the value of y is equal to 100-FAILURESEQ; then one moves horizontally until the survival curve is intercepted, and finally the time-point on the x-axis is determined by moving vertically.
Like in the pragmatic payback, if the real patients receiving the innovative treatment show more failures than those expected from the trial, the manufacturer will refund to the national health system a payback greater than that initially tailored to the value-based price; and vice versa.
Finally, Figure 3 shows the impact on the ratio between VBP and NPDES that results if the outcome assessment is set at early or late values of time in the follow-up. For example, if this time-point is exactly set at the median, NPDES is exactly twice the value of VBP.
References
1. Lucioni C, Mazzi S, Polcaro F. Il Risk Sharing come applicazione del Value Based Pricing. PharmacoEconomics - Italian Research Articles 2010; 12 (2): 71-80.
2. Messori A. Outcome based schemes are more common than you think. BMJ 2010; 341:c3588.
3. Messori A, Fadda V, Maratea D, Trippoli S. Un'esigenza di chiarezza: differenziare il payback 'value-based' da quello non 'value-based'. Pharmacoeconomics - Italian Research Articles 2010;12:201-202.
4. Messori A, Santarlasci B, Trippoli S, Vaiani M. Controvalore economico del farmaco e beneficio clinico: stato dell'arte della metodologia e applicazione di un algoritmo farmacoeconomico. Pharmacoeconomics - Italian Research Articles 2003; 5: 53-67.
5. Simbula S, Burchini G, Caccese E, Orsi C, Santarlasci B, Trippoli S, Messori. Definizione del prezzo dei farmaci e dei dispositivi medici innovativi sulla base del rapporto costo-efficacia. Bollettino SIFO 2007;53:211-15.
6. Claxton K, Briggs A, Buxton MJ, Culyer AJ, McCabe C, Walker S, Sculpher MJ.Value based pricing for NHS drugs: an opportunity not to be missed? BMJ. 2008;336(7638):251-4.
Competing interests: No competing interests
Italy is the country
where the largest list of innovative drugs is currently being managed through
risk-sharing methods. The advantage is that, as manufacturers claim, the
nominal price of these drugs is not too different from the average price in
Europe), but our national health system then spends less than the amount
predicted from nominal prices because risk-sharing methods and paybacks act as
a sort of atypical price reduction.
In the past years, the wide
implementation of risk-sharing and payback methods in Italy has promoted a
technical debate on this topic aimed at defining in mathematical terms how
risk-sharing algorithms can be applied (1-3).
In particular,
Messori et al. (3) have observed that two methods
of payment-by-results can be differentiated. The first ('pragmatic payback') is
aimed at obtaining a rebate in the average cost incurred for treating the
concerned patients. In the second ('value-based payback') the payback of
treatment failures is a tool that has the purpose to ensure a
proportionality between the cost and the clinical benefit.
In this Rapid Response,
we re-present the equations published by Messori et
al.(3) in order to make this piece of information available to the
international audience.
Pragmatic payback
Equation 1: RP = NP x (1 - FAILURES/100)
where RP is the real price (inclusive of
paybacks), NP is the nominal price and FAILURES is the observed rate of
failures expressed as percentage.
In the pragmatic payback, the starting assumption is that the target (or
desired) percent discount in the drug price is equal to the percentage of
failures subjected to the payback. As shown in Figure 1 (available at http://www.monitoraggiterapeutici.org/figures/ebmjfig1nov2010.pdf), the Kaplan-Meier
curve (indicating the cumulative rate of failures against time) is examined to
find the time-point on the x-axis where FAILURES is expected to equal the
desired value. This procedure allows to identify the (fixed) time-point at
which the patients' outcome should be assessed.
This time-point is actually the only parameter blocked from the
negotiation inasmuch as the percent discount generated by paybacks is a
consequential parameter based on the assumption that the curve of failures in
real patients (observed prospectively) will have the same trend as that of the
pivotal trial. Anyhow, if the real patients show more failures than expected,
the national health system receives a greater discount/payback than that
expected from the pivotal trial. Likewise, if the real patients show fewer
failures than expected, the national health system receives a smaller discount
than that initially expected.
Value-based payback
The first step is to assess the incfremental
clinical benefit of the innovative treatment relative to the standard
treatment. The second step is to recognize an economic countervalue
to the incremental clinical benefit (4). A countervalue
of 5,000 euro is
assigned to each month of overall survival gained, and 2,500 euros to each month of progression-free or disease-free
survival gained. In the third step, the economic countervalue
of clinical benefit is divided by the cumulative dose needed to treat a typical
patient so that the value-based price of the drug can be determined as cost per
dosage unit).
The best
situation is when the negotiation is closed based on the value-based approach
with no payback.
However, there
are many cases where, due to international constraints, the manufacturer is
forced to keep a substantial identity between the Italian nominal price and the
European nominal prices. The payback is introduced so that the nominal price
can be kept high, but the payback then produces a sort of delayed discount that
leads to a real price lower than the nominal one.
The relationship
between the nominal price 'desired' by the manufacturer (NPDES), the
value-based price (VBP), and the percentage of failures expected at time of the
binary outcome assessment is as follows (3):
Equation 2: NPDES
= VBP / (1 - FAILURES/100)
To determine which failures percentage generates the value of NPDES, it has
been shown that, in theory, the nominal price can reach whatever value the
manufacture wants because then the consequent payback can lower, to any extent,
the economic impact of the high nominal price.
The equation
that handles this relationship is the following:
Equation 3:
FAILURESEQ = 100 x (1 - VBP/NPDES)
where FAILURESEQ is the percentage of failures subjected to the
payback that makes the economic impact equal between : 1) PVB without payback;
2) PNDES with payback of failures.
The Kaplan-Meier
curve of the pivotal trial (Figure 2 available at http://www.monitoraggiterapeutici.org/figures/ebmjfig2nov2010.pdf) shows how the time-point
in the follow-up can be identified ensuring that all of the above conditions
are met. In more detail, the first step is to start from the top of the y-axis
(100%), then one goes down until the value of y is equal to 100-FAILURESEQ;
then one moves horizontally until the survival curve is intercepted, and
finally the time-point on the x-axis is determined by moving vertically.
Like in the
pragmatic payback, if the real patients receiving the innovative treatment show
more failures than those expected from the trial, the manufacturer will refund
to the national health system a payback greater than that initially tailored to
the value-based price; and vice versa.
Finally, Figure
3 (available at http://www.monitoraggiterapeutici.org/figures/ebmjfig3nov2010.pdf) shows the impact on the
ratio between VBP and NPDES resulting if the outcome assessment is
set at early or late values of time in the follow-up. For example, if this
time-point is exactly set at the median, NPDES is exactly twice the
VBP.
References
1. Lucioni C, Mazzi S, Polcaro F. Il Risk Sharing
come applicazione del Value Based Pricing. PharmacoEconomics
- Italian Research Articles 2010; 12 (2): 71-80
2. Messori A. Outcome
based schemes are more common than you think. BMJ 2010; 341:c3588
3. Messori
A, Fadda V, Maratea D, Trippoli S. Un'esigenza di chiarezza: differenziare il payback 'value-based'
da quello non 'value-based'. Pharmacoeconomics - ItalianResearchArticles
2010;12:201-202.
4. Messori
A, Santarlasci B, Trippoli
S, Vaiani M. Controvalore economico del farmaco e
beneficio clinico: stato dell'arte della metodologia e applicazione di un
algoritmo farmacoeconomico. Pharmacoeconomics
- ItalianResearchArticles 2003; 5: 53-67
5. Simbula S, Burchini G, Caccese E, Orsi C, Santarlasci B,
Trippoli S, Messori. Definizione del
prezzo dei farmaci e dei dispositivi medici innovativi sulla base del rapporto
costo-efficacia. Bollettino SIFO 2007;53:211-15
6. Claxton K, Briggs A, Buxton MJ, Culyer AJ,
McCabe C, Walker S, Sculpher MJ.Value based
pricing for NHS drugs: an opportunity not to be missed? BMJ. 2008;336(7638):251-4
Competing interests:
None declared
Competing interests: The starting point in this type of negotiation between national healthsystem and manufacturer is when both parties agree on the discount in thenominal price that the payback is asked to generate the value of the realprice. The relationship between real price and nominal price is shown by thefollowing equation:
The Rapid Response by Messori et al. entitled "Price determination
approaches for innovative treatments: price rebates vs payback of
treatment failures" (published 15 October 2010) has the merit to present
explicit equations for managing access schemes for innovative drugs that
implement the payback of treatment failures.
However, the way Equation 2 has been written in the above-mentioned Rapid
Response is misleading, and so this equation should be revised as shown
below.
Equation 2
(equivalent "nominal price") = VBP /(1 - FAILURES/100)
where the equivalent "nominal price" is the price that, after
adjustment for the payback of all failures, gives the same economic
impact as the one resulting from paying all treatments at VBP with no
paybacks.
In this equation the combined effect of a (higher) nominal price and
paybacks is designed to generate an economic impact identical to that
resulting from the systematic use of VBP with no implementation of any
payback mechanism; hence, the equivalent "nominal price" is always
greater than VBP, but is equal to VBP when there are no failures or no
implementation of paybacks. According to Equation 2, assuming that VBP is
40 euros, the same economic impact as with VBP=40 euros without paybacks
is obtained, for example, if "nominal price" = 50 euros with 20% of
treatment failures; or "nominal price" = 80 euros with 50% of treatment
failures; or "nominal price" = 100 euros with 60% of treatment failures.
Competing interests: No competing interests
In the area of innovative treatments, price rebates are the standard
tool to negotiate whether or not new treatments are to be reimbursed by
third payers and to manage their cost-effectiveness ratio according to the
value for money approach [1-4]. However, when the uncertainty in the
expected clinical benefit prevents a sound determination of a value-based
price tailored to benefit's magnitude, alternative approaches have been
explored. Among these, the payment-by-results method is the one that has
so far attracted more interest [5-8].
In governing the expected expenditure for an innovative agent, the
same overall economic result can be achieved either by obtaining a price
rebate or by implementing the payback of treatment failures (according to
the payment-by-results approach).
Ideally, in the absence of paybacks, the price of the innovative treatment
should be tailored to the magnitude of the clinical benefit, and in these
cases the price is denoted as value-based price.
While different thresholds and different methods of implementation exist
in the area of value-based pricing [1-4], the concept of a value-based
price (denoted herein as VBP, not subjected to any payback mechanisms) is
now widely recognised and, in practical terms, is generally translated
into the maximum cost that the payer can accept for that treatment on the
basis of the current cost/effectiveness threshold.
If the payback of treatment failures is assumed to be an alternative
to price rebate and the payback of each treatment failure covers the
whole expenditure incurred for the unsuccessful patient, the equation
governing the relationship between the "real" price associated with
payback of treatment failures vs VBP is the following:
Equation 1
("real price" in the presence of the payback of treatment
failures) =
= VBP x (1 - FAILURES/100)
where FAILURES is expressed as a percentage and indicates the
observed frequency of treatment failures. Equation 1 shows how the "real
price" decreases as the frequency of treatment failures increases.
According to this equation, if one assumes for example that VBP is 40
euros, the "real price" is 32 euros with 20% of treatment failures, 20
euros with 50% of treatment failures, 16 euros with 60% of treatment
failures, and so on; of course, the "real price" is equal to VBP with 0%
of failures leading to the or with no implementation of any payback
mechanism.
In contrast, based on the assumption that the economic impact must be
identical with and without implementation of paybacks, Equation 2 shows
the relationship between the "nominal price" that can be accepted in the
presence of payback of treatment failures vs VBP:
Equation 2
("nominal price" in the presence of the payback of treatment
failures) =
= VBP x (1 + FAILURES/100)
According to Equation 2, assuming that VBP is 40 euros, the same
economic impact of VBP=40 euros without paybacks is obtained if
"nominal price" = 48 euros with 20% of treatment failures; or "nominal
price" = 60 euros with 50% of treatment failures; or "nominal price" = 64
euros with 60% of treatment failures; also in this case, "nominal price"
is equal to VBP with 0% of failures (or with no implementation of any
payback mechanism). Of course, "nominal price" increases as the frequency
of treatment failures increases; as pointed out above, in this equation
the combined effect of a (higher) nominal price and paybacks is designed
to generate an economic impact identical to that resulting from the
systematic use of VBP with no implementation of any payback mechanism.
Although the algebraic basis for the two relationships shown above is
elementary, the explicit publication of these two equations can be
useful to avoid mathematical uncertainties in the negotiation process
involving innovative treatments.
References
1. Henry D, Hill S, Harris A. Drug prices and value for money. The
Australian pharmaceutical benefits scheme. JAMA. 2005;294:2630-2.
2. Pearson SD, Rawlins MD. Quality, innovation, and value for money--
NICE and the British National Health Service. JAMA. 2005;294:2618-22.
3. Appleby J, Devlin N, Parkin D. NICE's cost effectiveness
threshold. BMJ. 2007; 335:358-9.
4. Steinbrook R. Saying no isn't NICE--the travails of Britain's
National Institute for Health and Clinical Excellence. N Engl J Med.
2008;359:1977-81.
5. Garber AM, McClellan MB. Satisfaction guaranteed--payment-by-
results for biologic agents. N Engl J Med. 2007;357:1575-7.
6. Jack A. Drug pricing--no cure, no cost. BMJ. 2007;335:122-3.
7. Messori A, Trippoli S, Bonacchi M, Sani G. Left-ventricular
assist device as destination therapy: application of the payment-by-
results approach for the device reimbursement. J Thorac Cardiovasc Surg
2009;138(2):480-5.
8. Lucioni C, Mazzi SF, Polcaro F. Il risk sharing come applicazione
del value based pricing. PharmacoEconomics--Italian Research Articles
2010;12 (2):71-80.
Competing interests: No competing interests
I misread the last line of the first paragraph. I thought it said:
Hell hath no fury like a new cancer drug banned.
Competing interests: No competing interests
The question is raised again as to whether populist decisions made by
politicians (who will inevitably have an eye to the electorate's fickle
feelings and the headline writers of the Daily Mail) are the best people
to prioritise and allocate funds, funds which will never be sufficient to
satisfy all demands.
The figures speak for themselves--a drug which may prolong a life for
literally a few weeks, or the salary of a specialist nurse for a year. Of
course we could prefer not to have to choose, but we do. NICE appraisal
seems the least worst way of doing it. Replacing NICE won't create the
extra resources needed to give everyone everything they want, people like
Karol Sikora must know this.
The last Prime Minister but one, Anthony Blair, made breast cancer a
priority saying that his mother had suffered from it. Now David Cameron
has been elected Prime Minister-by the skin of his teeth-after, amongst
other things, promising to make cancer drugs available to all. Very Santa
Claus of him, but I prefer to trust the impartial and systematic
deliberations of NICE rather than the gut feelings of vote seekers
informed by focus groups.
There are some promising but costly new drugs in the pipeline for
metastatic melanoma, as we have heard on the national news again this
week, no doubt the drug companies are doing their best to place the
stories with the media. Of course I hope the drugs will work and be
affordable, but decisions to fund them at the £30,000 for an extra
3 months of life level we are hearing about should be systematically and
unemotionally weighed against the QUALYs that could be gained by earlier
detection by training primary care workers better in diagnosis. And indeed
against non cancer priorities.
We should remember Dennis Burkitt's tap turner-offers and floor wiper-uppers. The floor wipers are doing a great job, but it would do more good and be
cheaper if someone turned off the tap. The floor wipers are feted and
drive Rolls Royces, the tap turners are ignored and ride bicycles.
Competing interests:
teacher of dermoscopy to GPs
Competing interests: No competing interests
Differentiating between “value-based” payment by results and not “value-based” payment by results
NOTE: Some time ago, the website of BMJ has undergone a technical restyling. Since the readability of our Rapid Response published on 10 November 2010 has been negatively affected by this restyling, we have re-uploaded the same response in the technical environment of new BMJ website.
Italy is the country where the largest list of innovative drugs is currently being managed through risk-sharing methods. The advantage is that, as manufacturers claim, the nominal price of these drugs is not too different from the average price in Europe), but our national health system then spends less than the amount predicted from nominal prices because risk-sharing methods and paybacks act as a sort of atypical price reduction.
In the past years, the wide implementation of risk-sharing and payback methods in Italy has promoted a technical debate on this topic aimed at defining in mathematical terms how risk-sharing algorithms can be applied (1-3).
In particular, Messori et al. (3) have observed that two methods of payment-by-results can be differentiated. The first ('pragmatic payback') is aimed at obtaining a rebate in the average cost incurred for treating the concerned patients. In the second ('value-based payback') the payback of treatment failures is a tool that has the purpose to ensure a proportionality between the cost and the clinical benefit.
In this Rapid Response, we re-present the equations published by Messori et al.(3) in order to make this piece of information available to the international audience.
Pragmatic payback
The starting point in this type of negotiation between national health system and manufacturer is when both parties agree on the discount in the nominal price that the payback is asked to generate the value of the real price. The relationship between real price and nominal price is shown by the following equation:
Equation 1:
RP = NP x (1 - FAILURES/100)
where RP is the real price (inclusive of paybacks), NP is the nominal price and FAILURES is the observed rate of failures expressed as percentage.
In the pragmatic payback, the starting assumption is that the target (or desired) percent discount in the drug price is equal to the percentage of failures subjected to the payback. As shown in Figure 1, the Kaplan-Meier curve (indicating the cumulative rate of failures against time) is examined to find the time-point on the x-axis where FAILURES is expected to equal the desired value. This procedure allows to identify the (fixed) time-point at which the patients' outcome should be assessed.
This time-point is actually the only parameter blocked from the negotiation inasmuch as the percent discount generated by paybacks is a consequential parameter based on the assumption that the curve of failures in real patients (observed prospectively) will have the same trend as that of the pivotal trial. Anyhow, if the real patients show more failures than expected, the national health system receives a greater discount/payback than that expected from the pivotal trial. Likewise, if the real patients show fewer failures than expected, the national health system receives a smaller discount than that initially expected.
Value-based payback
The first step is to assess the ncremental clinical benefit of the innovative treatment relative to the standard treatment. The second step is to recognize an economic “countervalue” to the incremental clinical benefit (4). A countervalue of 5,000 euro is assigned to each month of overall survival gained, and 2,500 euros to each month of progression-free or disease-free survival gained. In the third step, the economic countervalue of clinical benefit is divided by the cumulative dose needed to treat a typical patient so that the value-based price of the drug can be determined as cost per dosage unit).
The best situation is when the negotiation is closed based on the value-based approach with no payback.
However, there are many cases where, due to international constraints, the manufacturer is forced to keep a substantial identity between the Italian nominal price and the European nominal prices. The payback is introduced so that the nominal price can be kept high, but the payback then produces a sort of delayed discount that leads to a real price lower than the nominal one.
The relationship between the nominal price 'desired' by the manufacturer (NPDES), the value-based price (VBP), and the percentage of failures expected at time of the binary outcome assessment is as follows (3):
Equation 2:
NPDES = VBP / (1 - FAILURES/100)
To determine which failures percentage generates the value of NPDES, it has been shown that, in theory, the nominal price can reach whatever value the manufacture wants because then the consequent payback can lower, to any extent, the economic impact of the high nominal price.
The equation that handles this relationship is the following:
Equation 3:
FAILURESEQ = 100 x (1 - VBP/NPDES)
where FAILURESEQ is the percentage of failures subjected to the payback that makes the economic impact equal between : 1) PVB without payback; 2) PNDES with payback of failures.
The Kaplan-Meier curve of the pivotal trial (Figure 2) shows how the time-point in the follow-up can be identified ensuring that all of the above conditions are met. In more detail, the first step is to start from the top of the y-axis (100%), then one goes down until the value of y is equal to 100-FAILURESEQ; then one moves horizontally until the survival curve is intercepted, and finally the time-point on the x-axis is determined by moving vertically.
Like in the pragmatic payback, if the real patients receiving the innovative treatment show more failures than those expected from the trial, the manufacturer will refund to the national health system a payback greater than that initially tailored to the value-based price; and vice versa.
Finally, Figure 3 shows the impact on the ratio between VBP and NPDES resulting if the outcome assessment is set at early or late values of time in the follow-up. For example, if this time-point is exactly set at the median, NPDES is exactly twice the VBP.
Andrea Messori, Valeria Fadda, Dario Maratea, Sabrina Trippoli
Laboratorio SIFO di Farmacoeconomia, 50100 Firenze e 59100 Prato, Italy
References
1. Lucioni C, Mazzi S, Polcaro F. Il Risk Sharing come applicazione del Value Based Pricing. PharmacoEconomics - Italian Research Articles 2010; 12 (2): 71-80
2. Messori A. Outcome based schemes are more common than you think. BMJ 2010; 341:c3588
3. Messori A, Fadda V, Maratea D, Trippoli S. Un'esigenza di chiarezza: differenziare il payback 'value-based' da quello non 'value-based'. Pharmacoeconomics – ItalianResearchArticles 2010;12:201-202.
4. Messori A, Santarlasci B, Trippoli S, Vaiani M. Controvalore economico del farmaco e beneficio clinico: stato dell'arte della metodologia e applicazione di un algoritmo farmacoeconomico. Pharmacoeconomics - Italian Research Articles 2003; 5: 53-67
5. Simbula S, Burchini G, Caccese E, Orsi C, Santarlasci B, Trippoli S, Messori. Definizione del prezzo dei farmaci e dei dispositivi medici innovativi sulla base del rapporto costo-efficacia. Bollettino SIFO 2007;53:211-15
6. Claxton K, Briggs A, Buxton MJ, Culyer AJ, McCabe C, Walker S, Sculpher MJ.Value based pricing for NHS drugs: an opportunity not to be missed? BMJ. 2008;336(7638):251-4
Competing interests: No competing interests