A review of international coverage and pricing strategies for personalized medicine and orphan drugs

摘要

Highlights ? Personalized medicine and orphan drugs face similar reimbursement challenges. ? Both lack strong evidence at the time of submission. ? Payers give more lenient coverage decisions to orphan drugs. ? Clearer payer guidelines on what constitutes “quality evidence” are needed. ? Incentivizing socially relevant development requires a more transparent approach. Abstract Background Personalized medicine and orphan drugs share many characteristics—both target small patient populations, have uncertainties regarding efficacy and safety at payer submission, and frequently have high prices. Given personalized medicine's rising importance, this review summarizes international coverage and pricing strategies for personalized medicine and orphan drugs as well as their impact on therapy development incentives, payer budgets, and therapy access and utilization. Methods PubMed, Health Policy Reference Center, EconLit, Google Scholar, and references were searched through February 2017 for articles presenting primary data. Results Sixty-nine articles summarizing 42 countries’ strategies were included. Therapy evaluation criteria varied between countries, as did patient cost-share. Payers primarily valued clinical effectiveness; cost was only considered by some. These differences result in inequities in orphan drug access, particularly in smaller and lower-income countries. The uncertain reimbursement process hinders diagnostic testing. Payer surveys identified lack of comparative effectiveness evidence as a chief complaint, while manufacturers sought more clarity on payer evidence requirements. Despite lack of strong evidence, orphan drugs largely receive positive coverage decisions, while personalized medicine diagnostics do not. Conclusions As more personalized medicine and orphan drugs enter the market, registries can provide better quality evidence on their efficacy and safety. Payers need systematic assessment strategies that are communicated with more transparency. Further studies are necessary to compare the implications of different payer approaches.