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Purpose: To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2021 in the United States, with a focus on the nonfederal hospital and clinic sectors., Methods: Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2021 were reviewed-including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, generics, coronavirus disease 2019 (COVID-19) pandemic influence, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2021 were based on a combination of quantitative analyses and expert opinion., Results: In 2020, overall pharmaceutical expenditures in the United States grew 4.9% compared to 2019, for a total of $535.3 billion. Utilization (a 2.9% increase) and new drugs (a 1.8% increase) drove this increase, with price changes having minimal influence (a 0.3% increase). Adalimumab was the top drug in 2020, followed by apixaban and insulin glargine. Drug expenditures were $35.3 billion (a 4.6% decrease) and $98.4 billion (an 8.1% increase) in nonfederal hospitals and clinics, respectively. In clinics, growth was driven by new products and increased utilization, whereas in hospitals the decrease in expenditures was driven by reduced utilization. Several new drugs that will influence spending are expected to be approved in 2021. Specialty and cancer drugs will continue to drive expenditures along with the evolution of the COVID-19 pandemic., Conclusion: For 2021, we expect overall prescription drug spending to rise by 4% to 6%, whereas in clinics and hospitals we anticipate increases of 7% to 9% and 3% to 5%, respectively, compared to 2020. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending., (© American Society of Health-System Pharmacists 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Disclosures: No funding supported the writing of this article. The author is an employee of AmerisourceBergen and leads its Good Neighbor Pharmacy program, which supports independent community pharmacy customers.

Disclosures: No funding was received for the writing of this commentary. The author has nothing to disclose.

At the 2019 World Health Assembly, a significant new resolution was agreed by most countries to start publicly sharing information on the real net prices they pay for medicines in their health systems. The resolution also includes provisions for countries to support other transparency activities. However, an additional proposal to require pharmaceutical companies to submit information on their internal sales figures, internal research and development costs, clinical trial costs and marketing costs for each individual medicine as a condition of registration, and for governments to publish this, was not agreed. Pressure for coordinated international action to increase the transparency of medicine prices and costs has been building for some time, as confidential discounts and rebates on prices of medicines are common. We argue that while it is possible that stakeholders may benefit to some extent from greater transparency on prices, several important policy and economic issues need to be carefully considered. Such transparency, combined with widespread use of international reference pricing, might undermine companies' differential pricing strategies, which are important in fostering wider access to medicines in low- and middle-income countries in particular, noting that access to medicines issues can occur in high-income countries as well. Moreover, there is a further risk that these types of proposals will lead to price fixing, less competition and higher prices than might otherwise be the case. The lack of any commitments in the resolution to greater transparency in payer decision-making processes also risks undermining the credibility of the resolution. The resolution and further transparency measures could have the potential to undermine patient access to medicines in the developing world, lead to higher prices in some markets and compromise long-term development of new medicines for future generations.

With the development of economic globalization and information technology, enterprises pay more attention to the sustainable development of their e-commerce. Under this trend, we study the subsidy strategy commonly used by pharmaceutical e-commerce platforms in two-sided market. Based on the two-sided market theory, we set up the two-sided user's utility function and formulate the subsidy strategy as the decision of platform profit optimization. We show that the platform chooses to subsidize consumers only if the net income from consumer is lower than the total revenue of drug retailers and platforms in each transaction; the maximum profit for platform increases with the intensity of the network externality. This study provides theoretical support and decision-making suggestions for the pharmaceutical e-commerce platforms to capture the market share, obtain higher profits and ultimately achieve the sustainable development goal., Competing Interests: The authors have declared that no competing interests exist.

Introduction: The objectives of this study were to explore factors associated with pharmacy students' intentions to utilize health outcomes by: (1) understanding opinions on health outcomes, (2) understanding the likelihood of using health outcomes in different settings, and (3) predicting pharmacy students' intentions to utilize health outcomes in future jobs., Methods: This study surveyed second-year pharmacy students over two years. The survey contained four components: the theory of planned behavior, opinions on health outcomes, the likelihood of using health outcomes in different settings, and demographics. To predict pharmacy students' intentions to utilize health outcomes in future jobs, a multiple linear regression model was used with behavioral intention as the dependent variable., Results: Of the 376 second-year pharmacy students surveyed, 229 responded (60.90%). Pharmacy students had a positive attitude (mean: 0.77, SD: 0.16), high level of subjective norm (mean: 0.75, SD: 0.18), high level of perceived behavioral control (mean: 0.74, SD: 0.15), and high level of behavioral intention (mean: 0.74, SD: 0.21). They thought health outcomes were important for their future jobs (mean: 0.76, SD: 0.22), and equally important as other courses in the doctor of pharmacy curriculum (mean: 0.49, SD: 0.23). Significant predictors of utilizing health outcomes in future jobs were attitude (0.21; 95% CI: 0.03, 0.40), subjective norm (0.38; 95% CI: 0.23, 0.54), and perceived behavioral control (0.45, 95% CI: 0.27, 0.63)., Conclusions: The second-year pharmacy students in the program studied had positive opinions and expressed high likelihood of applying their health outcomes knowledge and skill after graduation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Medications are one of the fastest growing sources of costs in the health system and the cornerstone of disease management. Despite extensive attention around drug pricing, medications have largely been excluded from CMS-derived, value-based payment models. In this perspective, we synthesize evidence about the impact of three prominent models-primary care-based redesign, ACOs, and bundled payment programs-on medication use, adherence, and costs. We also examine the literature describing similar models implemented by private payors and their relationship with medication use and costs. The exclusion of drug costs from payment reform model design has led to missed opportunities for payors and providers to prioritize effective medication management strategies and has limited our learning about the effects on cost and quality. New CMS-based models are starting to allow greater flexibility in pharmacy benefit design and reward improved medication therapy management. Additionally, health plans, pharmacies, and pharmacy benefit managers are beginning to partner on collaborative value-based pharmacy initiatives. Taken together, these efforts encourage a paradigm shift around drug cost management that more deeply integrates pharmacy into payment and delivery reform with the goal of improving quality and reducing the total cost of care.

There has been considerable debate on the extent to which future costs should be included in cost-effectiveness analyses of health technologies. In this article, we summarize the theoretical debates and empirical research in this area and highlight the conclusions that can be drawn for current practice. For future related and future unrelated medical costs, the literature suggests that inclusion is required to obtain optimal outcomes from available resources. This conclusion does not depend on the perspective adopted by the decision maker. Future non-medical costs are only relevant when adopting a societal perspective; these should be included if the benefits of non-medical consumption and production are also included in the evaluation. Whether this is the case currently remains unclear, given that benefits are typically quantified in quality-adjusted life-years and only limited research has been performed on the extent to which these (implicitly) capture benefits beyond health. Empirical research has shown that the impact of including future costs can be large, and that estimation of such costs is feasible. In practice, however, future unrelated medical costs and future unrelated non-medical consumption costs are typically excluded from economic evaluations. This is explicitly prescribed in some pharmacoeconomic guidelines. Further research is warranted on the development and improvement of methods for the estimation of future costs. Standardization of methods is needed to enhance the practical applicability of inclusion for the analyst and the comparability of the outcomes of different studies. For future non-medical costs, further research is also needed on the extent to which benefits related to this spending are captured in the measurement and valuation of health benefits, and how to broaden the scope of the evaluation if they are not sufficiently captured.

Objective: We investigated the South African tendering system for medicines to (a) evaluate its impact on prices and market concentration over a 14-year period and (b) analyze the accuracy of government forecasts of drug demand., Methods: We calculated Herfindahl-Hirschman indexes to measure market concentration levels based on all pharmaceutical tender contracts issued by the South African government between 2003 and 2016 (n = 8701). We estimated price indexes to track changes in medicine costs over this period. We compared prices set through tenders in the public health care system to the corresponding prices in the private system. We also analyzed government data on procurement in selected drug classes to assess the accuracy of demand forecasts., Findings: Between 2003 and 2016, the prices of medicines in most tender categories in the public health care system dropped by an average of around 40% or more. The prices of medicines procured for the public system through tenders were almost always lower than those sold in the private system. Tenders generally remained moderately to highly competitive over time (i.e., Herfindahl-Hirschman indexes < 2500), although the number of different firms winning contracts decreased in many categories. There were large discrepancies between the drug need estimates by the government and the quantities it went on to procure, with estimates off by more than 50% in most drug classes (9/16 observations)., Conclusion: Tendering may be an effective measure to lower drug costs. Because most tenders remained competitive over time, price decreases may be durable. South African government officials should monitor the availability and prices of medicines to ensure continued access to affordable medicines for patients, as it may be undermined by the decreasing number of firms winning contracts over time. Given the large discrepancy between forecasts and procurements, the government would benefit from improving the accuracy of its demand forecasts., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Antidepressant prescribing patterns have changed globally over the past few years, with conventional drugs including tricyclic antidepressants and monoamine oxidase inhibitors being replaced by selective serotonin reuptake inhibitors (SSRIs) and novel antidepressants. The objective of this study was to assess antidepressant utilization in Iran from 2006 to 2013 and to show Iran's situation in antidepressant consumption compared with other countries. A cross-sectional study was undertaken using prescription claims data from Iranian insurance agencies. In addition, total antidepressant sales data were obtained from the databank of the national regulatory authority. Medicines were classified according to the Anatomic Therapeutic Chemical (ATC-2012 edition) System. The Organisation for Economic Co-operation and Development data were used to compare national results from Iran with other countries. Antidepressant sales were four-fold higher than those of prescribed antidepressants [24 defined daily doses (DDD)/1000 inhabitants/day were sold whereas 6 DDD/1000 inhabitants/day were prescribed in 2013]. The trend in antidepressant prescriptions and consumption showed increasing use of SSRIs (N06AB). Nortriptyline, fluoxetine, and citalopram accounted for more than 60% of all prescriptions each year. The type of adverse reactions with new expensive antidepressants may seem convincing for the growing tendency toward using these medicines, but considering their high costs, health policymakers have to be aware of the risk of overprescription of newer antidepressant. Drivers of over-the-counter purchase of antidepressants need to be explored., Competing Interests: The authors declare no conflicts of interest., (© Atlantis Press International B.V.)

In February and September of 2017, the International Society for Pharmacoeconomics and Outcomes Research Health Technology Assessment Council held roundtables focused on Latin America to discuss health technology assessment best practices, collaboration opportunities, and regional experiences regarding health policies to improve the affordability of and access to healthcare technologies. The access to high-cost technologies, increased social pressure to achieve universal coverage, population aging, and the limits of traditional mechanisms to control costs create political pressure to begin considering other pricing alternatives, including value-based pricing, in Latin America. This article attempts to conceptualize key stakeholders' perceptions of their experiences, opportunities, and barriers to implementing value-based pricing in Latin America., (Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Objectives: To examine and compare the use of health technology assessment (HTA) for the reimbursement of new medicines in selected European Union member states with decades of experience in the use of HTA and in countries that have used it regularly since 2000., Methods: The selected countries were categorized into "earlier" adopters (group A: England, Germany, France, and Sweden) and more "recent" adopters (group B: Poland, Bulgaria, Hungary, and Romania). A systematic review of published literature was performed. The analysis and comparison of HTA procedures were done by using an analytical framework., Results: In all countries, the assessment criteria used include effectiveness, safety, relative effectiveness, and economic data. In group A countries, the main objectives are improving quality of care, ensuring equal access, and efficient use of resources. Group B countries have established HTA organizations with official guidelines but often seek the decisions of other developed countries. They place considerable emphasis on the budget impact of new therapies, and HTA is also used as a cost estimation tool for state budgets., Conclusions: HTA organizations have been developed dynamically not only in high-income countries but also in countries with limited resources. The experience and evolution of both can be used by countries that are in the dawn of creating an HTA organization., (Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

A discussion of the main pharmacoeconomic issues related to inhibitors in hemophilia A cannot be separated from an analysis of the most relevant clinical questions. In the field of inhibitors, the clinical evidence includes several controversial topics, such as high-titer versus low-titer inhibitors, the influence of factor VIII products on inhibitor risk, effectiveness of different immune tolerance induction (ITI) treatments, the role of bypassing agents, and development of new non-factor-VIII compounds. In terms of pharmacoeconomic data, numerous cost estimates have been reported in these fields, but this information is strongly influenced by the wide between-country differences in unit costs. Quite reliable data are, however, available regarding expenditure for replacement therapy in patients without inhibitors, increased lifetime costs caused by high-titer inhibitors, and cost of pharmacological interventions aimed at eradicating inhibitors. As regards the cost-effectiveness ratio, the data on ITI are not conclusive; nonetheless, irrespective of the specific treatments employed for inducing tolerance, their costs seem to be offset by the subsequent savings in the cost per patient. Other issues, such as the cost of low-titer inhibitors in patients with hemophilia A and effectiveness of pharmacological interventions aimed at eradicating low-titer inhibitors are not supported by sound data and will require further research. Finally, although the efficacy and safety profiles of novel treatments (e.g., emicizumab, Roche) warrant long-term clinical studies, the economic advantages of these new compounds might be very substantial both in patients with inhibitors and in those at risk of developing inhibitors., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objectives: To review literature characteristics, describe methodological trends, and assess the reporting quality of the economic evaluations of oral anticancer drugs (OACDs)., Methods: The review included comparative economic evaluations of OACDs. The search was conducted via PubMed, Embase, EconLit, and Economic Evaluation Database, and studies till December 2017 were included. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, literature inclusion and data extraction were performed in duplicate by separate investigators. Outcome measures were literature characteristics, gaps and methodological trends, and reporting quality using the Consolidated Health Economic Evaluation Reporting Standards checklist. Data were summarized on the basis of methodological themes of interest. Descriptive statistics and tabulations were used for result presentation., Results: Out of 241 found articles, 21 were included. There is a recent increasing interest in the economics of OACDs, whereby the cost per quality-adjusted life-year, via cost-utility analysis, is the most used for decision making. Most of the studies were from the payer perspective, and the primary sources of data were clinical trials, expert panels, and medical charts. The dominance status (higher effect, lower cost) was a commonly reported outcome. Decision-analytic modeling was used in most of the studies, mostly including Markov modeling. Studies were highly heterogeneous in methodological aspects, and the included studies did not meet most of the reporting quality criteria., Conclusions: High heterogeneity in methods in studies may limit the robustness and transferability of results, potentially misleading decision makers toward wrong decisions on OACDs. The transferability and generalizability of results are further limited by a "less than ideal" adherence to current reporting standards., (Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Introduction: Alzheimer's disease (AD) results in progressively worsening cognitive decline, leading to loss of functional ability, behavior/mood disturbances, institutionalization, and death. Current pharmaceutical therapies only treat the symptoms of cognitive decline yet can be expensive for payers. Areas covered: The authors undertook a systematic review of economic evaluations of pharmaceutical therapies for AD. The literature search encompassed English-language studies indexed in PubMed (Medline), Cochrane Library Current, and Web of Science. The search included articles published between 1 January 1995 and 10 February 2018. The literature suggested AD medications generally dominated comparator treatments (e.g. placebo). Expert opinion: The authors noted several limitations of the included economic evaluations. These limitations suggest the results of the economic evaluations should be interpreted with caution. Many economic models were not transparent with respect to sources of probabilities and cost data, and data collected in certain jurisdictions were applied to other jurisdictions without considering the validity of such applications. Measuring health utilities in cognitively impaired populations raises questions about the validity of quality-adjusted life years, but this issue was unaddressed in the included studies. Most included studies were sponsored by industry and the results tended to overwhelmingly support the manufacturer's product.

Background: Innovative pricing agreements for medicines have been used in European markets for more than 20 years, and offer an opportunity for payers and pharmaceutical companies to align on value, optimise speed to patients, and share risk. Developing successful agreements requires alignment between key stakeholders, yet there is a lack of summative data on how current innovative agreements are used in the real-world (e.g. the level of realised access to medicines, and rebates and discounts, which are often non-transparent)., Methods: This research used a web-based survey of payer stakeholders to determine what kinds of innovative agreements are currently used, anticipated future usage, attitudes, and drivers of adoption. Participants included national and regional payers (or former payers) and hospital-level decision makers., Results: Sixty-six payers completed the survey. Respondents expected that the use of innovative pricing agreements will remain the same or increase in the future. Overall, they felt there is a positive attitude towards new schemes, and that innovative agreements are likely to be used when they reduce total costs or reduce uncertainty., Conclusions: Given payer expectations, pharmaceutical companies should continue to take a role in ensuring that they have sufficient capacity to support payers in the design and implementation of innovative pricing agreements., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

We present a brief overview of the health care system in Hungary, focusing particularly on the pricing and reimbursement procedures of medicines. The National Institute of Health Insurance Fund Management is responsible for the administration of the health insurance system and public reimbursement of health technologies. There are two major types of reimbursement techniques in the outpatient care: the normative reimbursement is applied to all physicians and may be used for all indications listed in the Summary of Product Characteristics, and the indication-linked reimbursement is applied only to specialists who are authorized to prescribe the drug. Pharmaceuticals used in the inpatient care are fully reimbursed and are financed through diagnosis-related groups. Several cost-containment measures such as external price referencing and internal price referencing with blind bidding are applied. Proposing managed entry agreements is a mandatory condition for reimbursing innovative pharmaceuticals. Compared with other countries in the region, the implementation of health technology assessment has a relatively long history in Hungary. The health technology assessment body critically evaluates reimbursement submissions of pharmaceuticals, simple medical devices, and complex medical devices such as hospital technologies., (Copyright © 2017. Published by Elsevier Inc.)

The level of assistance patients with Alzheimer disease (AD) require in their care may be an important predictor of resource use, costs of care, and quality of life. The Dependence Scale (DS), a measure of care-assistance required, was used to estimate costs of care and quality of life of patients with AD categorized into 6 dependence stages based upon the summated item scores of the DS. Data were derived from a 3-year, noninterventional study of 132 patients with probable AD (ages, 50 to 85 y) and caregiver dyads. We investigated the association between DS scores and health care costs, health-related quality of life (HRQoL), caregiver burden and estimated annual costs and HRQoL for 6 dependence stages in adjusted models. DS scores were significant predictors of health care costs, HRQoL, and caregiver burden. The estimated annual health care costs and a measure of HRQoL (EuroQoL-5D) ranged from $11,418 and 1.00 for those at very mild dependence stage to $101,715 and 0.26 for those at very severe dependence stage. DS scores classified into 6 dependence stages provides a useful method to estimate unique levels of care-associated costs and health utilities for pharmacoeconomic evaluations of new treatments for AD.

Objective: To evaluate the quality of Chinese pharmacoeconomic-evaluation literature published between 2012-2014 retrieved from the Chinese National Knowledge Infrastructure (CNKI) in order to assess their adherence to recommendations of the Chinese Pharmacoeconomic Guidelines., Methods: Identified literature was screened according to pre-specified criteria to access legibility for inclusion. Each included piece of literature was systematically compared against the recommendations proposed by the relevant Chinese guidelines., Results: After culling, 259 studies were included in the comparative analysis. When compared to a previous study evaluating the quality of similar literature published between 1997-2007, the results showed improvements in certain technical aspects over the years. Particularly, an improvement was observed in more diverse evaluation methods being used, increased use of cost-utility analysis (2.43% in 2012-2014 vs 0.26% in 1997-2007) and use of discounting (45% in 2012-2014 vs 4.35% in 1997- 2007). In addition, a small number of studies were starting to apply modeling., Conclusion: The quality of economic evaluation literature has improved in recent years, with more researchers realizing the importance and necessity of using discounting, sensitivity analysis, and modeling when conducting economic evaluation. This study also highlights certain important areas needing further attention when conducting economic evaluations in China. These include the ICER threshold of economic analysis, more detailed guidance in performing sensitivity analysis and modeling, as well as transferability of cost data across different regions. Overall, the results would support the positive contribution of the Chinese Economic Guideline in promoting economic evaluations in China.

Introduction: The influence of patient gender on the economic impact of health care has increasingly been examined in the recent literature. Gender appears to have an impact on healthcare resource consumption, due to possible differences in the patient's response to a chosen therapeutic management strategy or to a healthcare intervention., Objective: The present work is aimed at collecting and reviewing evidences about the relationship between gender and economic consumption in health based on worldwide scientific literature published in the last 5 years., Method: We conducted a narrative review of evidence from an initial pool of 904 articles, selecting information about gender-specific economic impact in any therapeutic area., Results: After title, abstract and full text review, 111 articles were relevant to the paper scope. The reviewed studies seem to be confirming that a difference exists between males and females in the economic implications of healthcare management and that those differences are particularly relevant for cardiovascular and metabolic pathologies. Preliminary evidence suggests overall healthcare costs are slightly higher in females than males, while some specific and non-quantitative items of resource consumption, such as quality of prescriptions, might favour male patients. Results do not allow to clearly claiming an overall cost shift towards males or females, since their polarization varies depending on the considered cost item or event category., Conclusion: Studies suggested the presence of a gender difference in overall healthcare resource consumption and costs. Nevertheless, these aspects still lack thorough examination in literature and further analyses would be required on longer time periods., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

While the politics of tapping into anger about high drug prices would seem to have made Proposition 61 an easy sell, the initiative actually had a lot going against it. The pharmaceutical industry didn't take it lightly, raising over $100 million to defeat it.

Background: In recent years, there has been rapid growth in pharmaceutical spending in China. In addition, the country faces many challenges with regards to the quality, pricing and affordability of drugs. Pricing and reimbursement are important aspects of pharmaceutical policy that must be prioritised in order to address the many challenges., Methods: This review draws on multiple sources of information. A review of the academic and grey literature along with official government statistics were combined with information from seminars held by China's State Council Development Research Center to provide an overview of pharmaceutical pricing and reimbursement in China., Results: Pricing and reimbursement policy were analysed through a framework that incorporates supply-side policies, proxy-demand policies and demand-side policies. China's current pharmaceutical policies interact in such a way to create dysfunction in the form of high prices, low drug quality, irrational prescribing and problems with access. Finally, the country's fragmented regulatory environment hampers pharmaceutical policy reform., Conclusions: The pricing and reimbursement policy landscape can be improved through higher drug quality standards, greater market concentration, an increase in government subsidies, quality-oriented tendering, wider implementation of the zero mark-up policy, through linking reimbursement with rational prescribing, and the promotion of health technology assessment and comparative effectiveness research. Addressing broader issues of regulatory fragmentation, the lack of transparency and corruption will help ensure that policies are created in a coherent, evidence-based fashion., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Over the last 30 years, medical expenditure has increased throughout the world. The main reasons estimated to lay behind it include aging, ever more chronic diseases and new emerging diseases, new drugs, expanded indications of current drugs, and development of pharmaceutical industry. A challenge for healthcare professionals is to sustain current quality of care and enable medical innovations while attempting to contain costs. The overall goal is to demonstrate the pharmacoeconomic value, i.e. a balance of economic, humanistic and clinical outcomes.

Comparative effectiveness research (CER) is an important branch of pharmacoeconomics that systematically studies and evaluates the cost-effectiveness of medical interventions. CER plays instrumental roles in guiding government public health policy programs and insurance. Countries throughout the world use different methods of CER to help make medical decisions based on providing optimal therapy at a reduced cost. Expenses to the healthcare system continue to rise, and CER is one-way in which expenses could be curbed in the future by applying cost-effectiveness evidence to clinical decisions. China, India, South Korea, and the United Kingdom are of essential focus because these country's economies and health care expenses continue to expand. The structures and use of CER are diverse throughout these countries, and each is of prime importance. By conducting this thorough comparison of CER in different nations, strategies and organizational setups from different countries can be applied to help guide public health and medical decision-making in order to continue to expand the establishment and role of CER programs. The patient-centered medical home has been created to help reduce costs in the primary care sector and to help improve the effectiveness of therapy. Barriers to CER are also important as many stakeholders need to be able to work together to provide the best CER evidence. The advancement of CER in multiple countries throughout the world provides a possible way of reducing costs to the healthcare system in an age of expanding expenses.

Purpose of Review: To analyse the most recently published studies on the prevalence of allergic conjunctivitis alone or in association with allergic rhinitis, and the clinical and demographic aspects of the disease., Recent Findings: Allergic conjunctivitis or conjunctival symptoms are present in 30-71% of patients with allergic rhinitis. Allergic conjunctivitis alone has been estimated in 6-30% of the general population and in up to 30% in children alone or in association with allergic rhinitis. Seasonal allergic conjunctivitis is the most frequent form; however, studies from tertiary, ophthalmology referral centers report that the chronic forms, such as vernal and atopic keratoconjunctivitis, are the most frequently seen by ophthalmologists. A recent large survey performed at a national level involving 304 ophthalmologists showed that the majority of patients with allergic conjunctivitis suffer annually of few episodes of mild ,intermittent conjunctivitis. However, 30% of patients are affected by frequent episodes with intense and persistent symptoms. Treatment is frequently not appropriate., Summary: Even though allergic conjunctivitis is often associated to allergic rhinitis, epidemiology studies frequently do not include specific ophthalmological evaluations. An understanding of allergic conjunctivitis disease, its prevalence, demographics and treatment paradigms will provide important information towards understanding its pharmacoeconomics and burden on the national health systems.

Future costs are not usually included in economic evaluations. The aim of this study was to assess the extent of published economic analyses that incorporate future costs. A systematic review was conducted of economic analyses published from 2008 to 2013 in three general health economics journals: PharmacoEconomics, Value in Health and the European Journal of Health Economics. A total of 192 articles met the inclusion criteria, 94 of them (49.0%) incorporated future related medical costs, 9 (4.2%) also included future unrelated medical costs and none of them included future nonmedical costs. The percentage of articles including future costs increased from 2008 (30.8%) to 2013 (70.8%), and no differences were detected between the three journals. All relevant costs for the perspective considered should be included in economic evaluations, including related or unrelated, direct or indirect future costs. It is also advisable that pharmacoEconomic guidelines are adapted in this sense.

During a time when cancer drug prices are increasing at an unprecedented rate, a debate has emerged as to whether these drugs continue to provide good value. In this article I argue that this debate is irrelevant because under today's highly distorted market, prices will not be set with value considerations in mind. As an alternative, I suggest considering the "value" of three policy changes—Medicare's "average sales price plus 6 percent" payment program, laws that require insurance coverage of all new cancer drugs, and the Affordable Care Act—that are fueling manufacturers' willingness to set higher prices. More important than these issues, however, is the revolution that is occurring in molecular biology and its impact on scientists' ability to detect changes in the cancer genome. The lowered cost of discovery is driving more competitors into the market, which under distorted pricing paradoxically encourages drug makers to charge ever higher prices for their products., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: The rapid growth of health care expenditures, especially pharmaceutical spending, is a challenge for many countries. To control increasing pharmaceutical expenditures and to enhance rational use of drugs, Taiwan's National Health Insurance drug reimbursement system has evolved over time since its introduction in 1995. This study reviewed Taiwan's drug reimbursement scheme: its development and evolution in the last two decades, and implications and impacts of recent policies for drug pricing. We also provide recommendations for possible improvement., Methods: We conducted a review of Taiwan's National Health Insurance drug reimbursement scheme. We focused on three major components of the scheme: (i) the scope of drug coverage; (ii) pricing system for pharmaceuticals under the scheme; and (iii) adjustment of drug reimbursement prices. We reviewed the literature and public policy documents., Results: The National Health Insurance delisted 176 and another 240 behind-the-counter products (e.g., antacids, vitamins) between 2005 and 2006 to reduce pharmaceutical expenditures. For the pricing of pharmaceuticals, policy evolution can be divided into four phases since 1995; the present system emphasizes stakeholder engagement, health technology assessment, domestic R&D, and improving quality of products. To close the gap between drug reimbursement prices and procurement prices, eight rounds of drug price surveys and adjustments have been implemented since 2000., Conclusions: Taiwan's National Health Insurance drug reimbursement scheme has evolved substantially over time to provide more equitable and affordable access to prescription medicines. However, more work is still needed as irrational difference in reimbursement and procurement prices persists and the total expenditure of the drug reimbursement scheme continues to increase at unsustainable rates.

Background: Drug costs increasingly pose a burden upon the otherwise inadequate health care resources and rational drug utilization is an important segment of every national health policy. Optimal patient care should be the goal of rational pharmacotherapy, whereby the economic burden of treatment is just one of the elements to be considered on choosing appropriate therapy.The aim of this study was to determine distribution and trends in the outpatient utilization of generic versus brand name psychopharmaceuticals and to evaluate the rationality of prescribing psychopharmaceuticals during a ten-year period., Methods: Using the World Health Organization Anatomical-Therapeutic-Chemical classification/Defined Daily Doses (ATC/DDD) methodology, the number of DDD was calculated from data collected from pharmacies on the number and size of drug packages. The ratio of generic and brand name drug costs served as an indicator on assessing the rationality of drug utilization., Results: Total cost for psychopharmaceuticals increased by 20.1%, more for brand name than for generic agents (32.7% vs. 7.4%). The highest share of generic psychopharmaceuticals as compared with brand name drugs according to DDD per 1000 inhabitants per day (DDD/1000/day) was in the group of psycholeptics (83.6% in 2001 vs. 82.2% in 2010), most in hypnotics and sedatives, and least in antipsychotics. The share of generic psychopharmaceuticals in total drug utilization according to financial indicators decreased by 9.6% and according to DDD/1000/day by 12%. The greatest decrease was in antidepressants, i.e. by 33.8% according to financial indicators and by 46% according to DDD/1000/day; and in antipsychotics by 30.9% according to DDD/1000/day, while showing an increase by 8.5% according to financial indicators. In the therapeutic subgroup of mood stabilizers, the share of generic drugs in total drug utilization declined by 32% according to DDD/1000/day, but increased by 25.1% according to financial indicators., Conclusions: The lack of uniform national guidelines and the still strong impact of pharmaceutical industry marketing continue favoring the rise in prescribing brand name antidepressants and antipsychotics. Depression, schizophrenia and bipolar diseases are complex diseases. As a result, specific measures are needed to encourage the prescribing of generic psychopharmaceuticals.

This study aimed to review European national health-economic (HE) guidelines and to identify recent developments in guideline recommendations by comparing the findings with those of a review published in 2001. Guidelines were identified by searching websites of the Internal Society for Pharmacoeconomics and Outcomes Research (ISPOR) and government health insurance agencies, and by a literature review. National guidelines showed broad consistency in ranking clinical data sources and choice of comparators for HE analysis, but varied in recommended costs to be included, methods related to cost calculation and discounting. Many European countries have developed or revised national HE guidelines. The recommendations in these guidelines differ in some key aspects, limiting transferability of outcomes of HE evaluations.

Background: Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic disease with a significant impact on quality of life. A broad range of therapies are used to treat this condition, and patients are often excluded from receiving more expensive and more effective therapies because of cost issues., Objective: The objective of this study was to assess the mid- and long-term costs (over 1, 5 and 10 years) of various therapies for BPS/IC., Methods: Costs in an open-access health system (Austria) for three BPS/IC-specific therapies (intravesical hyaluronan, pentosanpolysulfate and amitriptyline), taken from the American Urological Association guidelines, were evaluated and compared with those of non-specific symptomatic therapies. Response rates for the different therapies were taken from peer-reviewed publications and used to define the need for therapy maintenance with regard to symptom improvement., Results: Despite the highest initial costs, the reduced need for further therapy in patients with long-term symptom remission after hyaluronan therapy resulted in the lowest total treatment costs at all three timepoints. Hyaluronan was cost saving against all alternatives in standard assumptions and in all sensitivity analyses. As a limitation, treatment costs in this study are specific for Austria. However, the template used for calculation of treatment costs can be transferred to all countries by inserting local prices., Conclusion: Disease-specific therapies with high remission rates result in significantly lower long-term costs in BPS/IC. Non-specific symptomatic therapies are most expensive. Long-term cost effectiveness is crucial in the treatment of chronic diseases to limit expenses in individual healthcare systems.

OBJECTIVE. To investigate the status of pharmacoeconomics education in Egyptian schools of pharmacy and compile and construct recommendations on how Egypt and similar countries could improve their educational infrastructure in pharmacoeconomics. METHODS. A modified version of a published survey instrument was sent to all schools of pharmacy in Egypt (n= 24). The data were assessed to identify associations between offering pharmacoeconomics education and school characteristics. RESULTS. Usable responses were obtained from 20 schools (response rate: 83%). Only 7 schools offered pharmacoeconomics education, with a median of 20 teaching hours per semester. Among respondents, 4 schools had instructors with some training in pharmacoeconomics and only 1 school had a faculty member with PhD-level training. Only 4 schools offered graduate-level courses in pharmacoeconomics. Eight additional schools expressed interest in teaching pharmacoeconomics in the near future. Having 1 or more faculty members with training in pharmacoeconomics was significantly associated with offering pharmacoeconomics education (p = 0.03). CONCLUSIONS. Pharmacoeconomics education in Egypt is still in its infancy and there exists a unique opportunity for well-trained instructors and researchers to fill this gap. Providing structured pharmacoeconomics education to student pharmacists, researchers, and stakeholders can help countries establish an integrated scientific community that can start applying pharmacoeconomic evidence to healthcare decision-making.

In recent years, spending on prescription drugs contributes substantially to the continuous growth in health expenditure in most Western countries. This increase in spending is influenced by both a rise in the use of existing drugs and by the adoption of new and expensive drugs. Risk-sharing agreements between pharmaceutical companies and health insurers have emerged as insurers began to deny reimbursement of expensive innovative treatments with unfavorable cost-effectiveness ratios. This occurred in cases where the expected budgetary impact was too high or when the long-term effectiveness was questionable. Risk sharing agreements serve the interests of both the insurers and the drug manufacturers. Pharmaceutical companies' interests are to dispel the uncertainties encountered by the health insurers white deciding on drug reimbursement. The insurers are interested in these agreements in order to reduce the budgetary risk while allowing their patients access to innovative drugs. Currently, only a few risk sharing agreements have been implemented, and the scientific literature on such schemes is still sparse. Since the health insurers' interest is to develop mechanisms that will contain health costs, without affecting the insured, it appears that this trend will continue to emerge. It is also likely that the adoption of similar mechanisms in the Israeli National List of Health Services updating process, would improve the accuracy of early estimates of the budgetary impact, and the actual use of the new technologies would be close to early estimates. This article reviews the principles of risk-sharing schemes and issues involved in the actual implementation of such agreements.

The 80,000 inhabitants of the lower part of Le Havre obtain their water supply from two karstic springs, Radicatel and Saint-Laurent. Until 2000, the Radicatel water was settled when turbidity exceeded 3 NTU, then filtered and chlorinated, whereas the Saint-Laurent water was simply chlorinated. Our study aimed to characterize the link between water turbidity and the incidence of acute gastroenteritis (AGE). Records on drug sales used for the treatment of AGE were collected from January 1994 to June 1996 (period 1) and from March 1997 to July 2000 (period 2). Daily counts of drug sales were modeled using a Poisson Regression. We used data set 2 as a discovery set, identifying relevant (i.e. both significant and plausible) exposure covariates and lags. We then tested this model on period 1 as a replication dataset. In period 2, the daily drug sales correlated with finished water turbidity at both resources. Settling substantially modified the risk related to turbidity of both raw and finished waters at Radicatel. Correlations were reproducible in period 1 for water from the Radicatel spring. Timeliness of treatment adaptation to turbidity conditions appears to be crucial for reducing the infectious risk due to karstic waters.

Recently, the separate trajectories of pharmacy benefit management and pharmacogenomics converged. Pharmacogenomic tests have become more widely available for clinical use and at costs within the range of typical health care services. Pharmacy benefit payers continue to seek the precision they can apply to their coverage policies and clinical programs that pharmacogenomics offers. We describe how pharmacogenomics can now make sense as part of a pharmacy benefit and also how pharmacogenomics can be applied in a benefit coverage policy and clinical programs. Detail is provided on clinical program development and implementation processes featuring pharmacogenomics. We also discuss the research needed to support ongoing program development involving pharmacogenomics and describe the current roles of benefit payers and administrators in these research efforts. The legal and ethical dimensions of applying pharmacogenomics in pharmacy benefits are covered and in particular how benefit payers and administrators need to navigate between genetic exceptionalism and applicable laws and regulations. Finally, some thoughts are provided on future opportunities and challenges for pharmacogenomics in pharmacy benefit management and pharmacy in general., (© 2012 Pharmacotherapy Publications, Inc.)

The pricing strategy of innovative medicines is based on the therapeutic value in the largest pharmaceutical markets. The cost-effectiveness of new medicines with value based ex-factory price is justifiable. Due to the international price referencing and parallel trade the ex-factory price corridor of new medicines has been narrowed in recent years. Middle income countries have less negotiation power to change the narrow drug pricing corridor, although their fair intention is to buy pharmaceuticals at lower price from their scarce public resources compared to higher income countries. Therefore the reimbursement of new medicines at prices of Western-European countries may not be justifiable in Central-Eastern European countries. Confidential pricing agreements (i.e. confidential price discounts, claw-back or rebate) in lower income countries of the European Union can alleviate this problem, as prices of new medicines can be adjusted to local purchasing power without influencing the published ex-factory price and so the accessibility of patients to these drugs in other countries. In order to control the drug budget payers tend to apply financial risk sharing agreements for new medicines in more and more countries to shift the consequences of potential overspending to pharmaceutical manufacturers. The major paradox of financial risk-sharing schemes is that increased mortality, poor persistence of patients, reduced access to healthcare providers, and no treatment reduce pharmaceutical spending. Consequently, payers have started to apply outcome based risk sharing agreements for new medicines recently to improve the quality of health care provision. Our paper aims to review and assess the published financial and outcome based risk sharing methods. Introduction of outcome based risk-sharing schemes can be a major advancement in the drug reimbursement strategy of payers in middle income countries. These schemes can help to reduce the medical uncertainty in coverage decisions for valuable innovative healthcare technologies. However risk-sharing schemes can also reduce the transparency of pharmaceutical pricing and reimbursement, as the payback, and consequently the actual price per patient can be calculated only retrospectively. Therefore risk-sharing agreements can be interpreted as special forms of confidential pricing agreements to facilitate the implementation of differential pricing in middle income countries.

Despite the weak economy and more people lacking health insurance, the proportion of Americans reporting problems affording prescription drugs remained level between 2007 and 2010, with more than one in eight going without a prescribed drug in 2010, according to a new national study from the Center for Studying Health System Change (HSC). While remaining stable overall, access to prescription drugs improved for working-age, uninsured people, likely reflecting a decline in visits to health care providers, as well as changes in the composition of the uninsured population. Likewise, elderly people eligible for both Medicare and Medicaid saw a sharp drop in prescription drug access problems. The most vulnerable people--the uninsured, those with low incomes, people in fair or poor health, and those with multiple chronic conditions--continued to face the most unmet prescription needs. For example, 48 percent of uninsured people in fair or poor health went without a prescription drug because of cost concerns in 2010, almost double the rate of insured people with the same reported health status.