The Evolution of HTA in Emerging Markets Health-Care ... - TREE

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OHE Consulting Report for PhRMA 5 January 2011 The NDRC operates two primary drug pricing regulations: (1) uniform price ceilings applicable to generics satisfying GMP standards, and (2) ‘independent pricing’ for imported Western branded products, mostly patented medicines, off-‐patent originators, and follow-‐on generics of superior quality (presumably in terms of convenience in dosing schedules and administration). In theory this can include Chinese manufacturers, but most Chinese manufacturers are producing generic drugs. This ‘independent pricing’ policy enables ‘superior’ drug products (in terms of safety and efficacy) to get higher prices. The NDRC has also in place mandatory retail price cuts for ‘older’ drugs (the size of price cuts averaging around 20%). These mandatory price cuts failed to control pharmaceutical expenditures since less attention was given to rational use of medicines (with many hospitals and doctors having an incentive to overprescribe) and some domestic drug producers responded to these mandatory price cuts for ‘older’ drugs by launching ‘new’ drugs which were branded generic versions of the old drugs with a new name, formulation and packaging. However, the effect has been to squeeze the local Chinese generics drug industry. Experts suggest this reflects a policy objective of trying to reduce the number of suppliers to get rid of the less efficient ones and so reduce prices. There has been a recent reform of the Essential Drug List (EDL) by the MoH (in terms of which drugs are included). The MoH is using the EDL to try to reduce costs in public hospitals, which would have to use the EDL. It has had the effect of reducing the potential for hospitals to increase the revenues from the 15% mark up by using higher priced drugs and replacing local purchasing with a regional procurement exercise to get suppliers for the EDL list. It is not at all clear how much evidence has been used to generate the EDL. It seems the EDL was comprised mostly by committees of opinion leader doctors listing what they like to prescribe. The EDL is made up of two lists A and B. List A includes all drugs considered ‘clinically necessary, widely used, safe and efficacious; and price advantageous among its class’. EDL A is the national drug list and cannot be modified by local governments. EDL B is similar except that the prices of products listed tend to be higher than similar products listed on EDL A. Local governments are only allowed to modify the national EDL by adding up to 15% to the number of drugs listed in EDL A. Although it is stated that cost-‐effectiveness is not a criteria for the selection of EDL drugs, recent revisions of EDL guidelines explicitly ask for the involvement of health-‐economists in the determination of the EDL. Some foreign drug companies already have been voluntarily submitting pharmacoeconomic data along with their conventional submissions for listing on the EDL. However, as we noted earlier, it is not clear how evidence-‐based EDL listing decisions are. The MoHRSS is now trying to introduce pricing rules for the reimbursement prices it pays for the two insurance schemes (UEBMI and URBMI) for which it is responsible. It is not clear how this works in relation to the NDRC, but if NDRC sets the maximum price (or the drug qualifies for independent pricing) then MoHRSS as the payer can decide on what kind of drugs it will reimburse and at what rate, rather than the maximum price. In this selection process, it may plan to use HTA principles, but the drug cap itself is set by NDRC rather than MoHRSS. The NDRC, like other government bodies, recognise that use of pharmacoeconomics might be beneficial in the price setting process, but no official guidelines have been put forward in practice. As the independent pricing arrangement is reserved including an “innovative category” which covers the majority of imported Western patented drugs. NDRC does not set the prices for these products, although it does set the prices of generic named versions, and innovators are allowed a percentage mark up above that price. 90
OHE Consulting Report for PhRMA 5 January 2011 Whilst MoHRSS does not have price setting power, which is reserved for NDRC, it can work on the drug procurement process. Traditionally, there is a 35% -‐ 50% mark up between the manufacturer's wholesale price and the retail price, and drugs typically go through many "middle men" wholesalers before finally reaching the pharmacy department in hospitals. The EDL arrangements include Provincial procurement to replace individual hospital buying. A2.6 The role of HTA in China Chen, Banta and Tang (2009) note that there has been, in China, a long interest in the adoption of HTA dating back to the 1980’s when The World Bank gave strong encouragement for its adoption. However, there seems to be no clear path for the implementation of HTA in China (nor does it seem to be a priority for decision-‐makers). Doherty, et al (2004) reports that HTA is rarely used in either the public or private sectors as pharmaceutical policy and medical decision-‐making is still based on traditional approaches of establishing efficacy, safety and quality, and then using cost-‐based price controls. The authors note that a survey of HTA literature on China showed that researchers in government agencies or industry did not seem to play much role in the conduct of the studies identified. Studies were conducted by independent academic groups. Tarn, et al (2008) noted that pharmacoeconomics is a newly developed discipline in China and a systematic review of 380 pharmacoeconomics and outcome research articles relating to China showed that approaches and methods for conducting HTA are not standardized. The authors also report that pharmacoeconomic data have not been widely used in management of hospital formularies. However, whilst pharmacoeconomic data have not been used as a decision-‐making criterion in China, as we noted above, an increasing number of (international) pharmaceutical companies in China have started using pharmacoeconomic evaluations as supportive evidence in drug reimbursement applications, and in marketing activity. The use of HTA is conceptually accepted in government’s documents (for example documents from the NRDC, MoHRSS and MoH) but nothing has been outlined as to the specifics of HTA. Academics have been active in proposing a formal guideline, and in 2005 some general principles for HTA were put forward by the Chinese Medical Doctor Association. In 2008, a Pharmacoeconomics Specialist Committee was formed, which is charged with the task of updating the principles and pushing it into the policy making arena. More recently, in late 2010, we understand that revised guidelines developed at Peking University have been circulated, and a number of stakeholders including some government agencies and officials have been involved in discussions about them. HTA, in China, is therefore not formally conducted in a systematic fashion and therefore there is no formal arrangement for the financing of HTA. Currently HTA projects are sponsored by manufacturers on a small scale and the use of HTA is limited and based on short study horizons. Many HTA projects are organised by drug manufacturers through contracts with academia, with outputs for ‘internal’ company use. The MoH considers cost-‐effectiveness and HTA analysis as part of its modus operatus. The MoH has signed a Memorandum of Understanding (MoU) with the UK National Institute for Health and Clinical Excellence (NICE). According to the NICE web site “with UK Department for International Development (DFID), WHO and World Bank support, NICE is looking to help the MoH build capacity (institutional and technical) and to pilot the development/adaptation of evidence informed clinical 91
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The Evolution of HTA in Emerging Markets Health-Care ... - TREE

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