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Cancer drug costs and payment issues in European countries.
Wim van Harten MD PhD, Riin Ots, Valesca Retel PhD, Anke Wind MSc.
ECPC June 2017
Affiliations: The Netherlands Cancer Institute; University of Twente; University of Utrecht; Rijnstate Hospital Arnhem; OECI-board.
Cooperation: European Organisation of Cancer Institutes; ECPC
NO Disclosures
Actual costs of cancer drugs (mid 2015)
• Survey send to 51 full members of the OECI + Cancer Core Europe
• Data received from 23 institutes in 16 countries
• 22 institutes from 15 countries included in the study after multiple verification rounds, corrections for VAT ,etc.
van Harten WH, Wind A, de Paoli P, Saghatchian M, Oberst S. Actual Costs of Cancer Drugs in 15 European Countries. Lancet Oncol. 2016 Jan;17(1):18-20.
Actual costs of cancer drugs
• Survey of 9 cancer drugsA. Name Generic name Indication Cost per
vial/tabletCost per vial/tablet
Cost per fullCourse/year
Non-refunded Cost
Herceptin (iv)
Trastuzumab Her 2 positive breast cancer, adjuvant and metastatic setting
150 mg
Perjeta (iv) Pertuzumab Her 2 positive breast cancer, metastatic setting in combination with trastuzumab and docetaxel
420 mg
Mabthera (iv) Rituximab Non Hodgkin lymphoma, chronic lymphatic leukemia and several other hematologic indications
100 mg 500 mg
Avastin ( iv) Bevacizumab Metastatic colorectal cancer, breast cancer, lung cancer, cervical cancer, GBM
100 mg 400 mg
Yervoy (iv) Ipilimumab Metastatic melanoma 50 mg 200 mg
Glivec, Gleevec (po)
Imatinib GIST, CML 100 mg 400 mg
Sutent Sunitinib GIST, CML, NET, metastatic renal cell cancer 12,5 mg 25 mg 50 mg
Zelboraf Vemurafenib Metastatic melanoma 240 mgXtandi Enzalutamide Castration refractory prostate cancer 40 mg
Actual costs of cancer drugsCountry Romania Hungary Poland Lithuania Czech
RepublicEstonia Portugal Spain
(N=2)Italy (N=2) France
(N=2)Germany (N=2)
United Kingdom
Belgium (N=2)
The Nether-lands (N=3)
Norway
GDP/capita (€) 7,500 10,500 10,700 12,400 14,700 14,800 16,600 22,800 26,600 32,200 32,500 34,500 36,000 39,300 73,400
Herceptin®
1 vial/150 mg
(€)a
Trastuzumab
Actual price
563.14 516.47 N/A 476.56 481.82 674.80 N/A 506.88 557.70 542.43 670.00 562.71 517.92 605.25 497.74
List
price
585.26 630.38 537.99 476.56 502.73 N/A 509.13 573.58 913.45 542.43 718.33 562.71 536.76 606.49 523.50
Perjeta®
1 vial/420 mg
(€)a
Pertuzumab
Actual price
2,677.24 2,594.37 N/A N/A 2,590.91 2,762.00 N/A 2,590.18 2,850.81 2,891.10 2,440.00 3,308.01 2,754.72 3,000.00 N/A
List price 2,677.24 N/A 2,419.94 N/A 2,649.10 N/A 2,761.64 2,910.58 4,113.44 2,891.10 2,580.83 3.308.01 2.840.66 3,000.00 2,474.58
Mabthera®
1 vials /100
mg(€)a
Rituximab
Actual price
238.19 N/A N/A N/A N/A 295.27 N/A 210.56 262.39 266.44 N/A 241.16 210.38 271.13 210.80
List
price
247.96 220.53 287.72 N/A 420.91 N/A 228.80 238.06 395.67 266.44 691.62 241.20 218.38 279.27 217.47
Yervoy® 1 vial/50 mg (€)a
Ipilimumab
Actual price
4,024.29 N/A N/A 5,500.00 3,150.91 4,237.38 N/A 2,338.83 2,684.92 3,536.50 3,200.00 N/A 4,250.00 4,144.00 3,143.06
List
price
4,024.29 3,251.40 4,340.73 5,500.00 3,682.73 N/A 2,975.00 4,086.54 5,75484 3,536.50 3,273.25 5,179.56 4,380.80 4,250.00 5.191,65
Xtandi® 1 vial/40 mg (€)a
Enzalutamide
Actual price
27.77 N/A 19.30 N/A 25.79 N/A N/A 21.77 21.51 27.75 N/A N/A 27.50 27.50 N/A
List
price
27.77 N/A N/A N/A 25.79 N/A 26.98 21.10 45.61 28.62 29.98 33.73 28.35 27.50 29.00
(
€)a Prices are in Euro's per lowest dosage
Actual costs of cancer drugs
Country Romania Hungary Poland Lithuania Czech Republic
Estonia Portugal Spain (N=2)
Italy (N=2) France (N=2)
Germany (N=2)
United Kingdom
Belgium (N=2)
The Nether-lands (N=3)
Norway
GDP/capita (€) 7,500 10,500 10,700 12,400 14,700 14,800 16,600 22,800 26,600 32,200 32,500 34,500 36,000 39,300 73,400
Avastin®
1 vial/100 mg
(€)a
Bevacizumab
Actual
price
283.67 N/A 176.53 237.12 N/A 345.26 N/A 278.01 300.33 250.65 N/A 335.16 312.26 321.54 260. 93
List
price
297.47 274.65 317.73 237.12 261.82 N/A 266.41 328.67 412.86 250.65 286.88 335.16 322.89 321.08 286. 58
Glivec®
1 tab/100 mg
(€)a
Imatinib
Actual
price
15.05 N/A N/A 17.93 15.80 7.06 N/A 18.26 16.35 18.23 24.00 19.85 19.37 20.96 17.51
List
price
15.12 16.46 17.60 17.93 15.86 N/A 18.05 18.98 25.10 19.02 24.56 19.85 20.31 20.96 17.74
Sutent®
1 cap/12,5 mg
(€)a
Sunitinib
Actual
price
37.52 N/A N/A 38.48 34.03 38.16 N/A 39.33 42.50 41.44 N/A N/A 43.38 36.56 37.85
List
price
37.52 37.02 44.89 38.48 36.18 N/A 42.38 40.80 66.01 45.39 52.72 38.70 46.45 43.91 38.19
Zelboraf®
1 tab/240 mg (€)a
Vemurafenib
Actual
price
38.96 N/A 34.88 27.15 29.22 N/A N/A 33.61 34.94 29.01 26.00 N/A 30.21 29.32 23.16
List
price
38.96 37.35 37.67 27.15 29.22 N/A 27.92 39.66 55.61 30.48 27.42 43.16 34.82 37.81 34.12
(
€)a Prices are in Euro's per lowest dosage
Actual costs of cancer drugsCountry Lithuania Spain (N=2) France (N=2) The Netherlands
(N=3)
GDP/capita (€) 12,400 22,800 32,200 39,300
Perjeta® 1 vial/420 mg Pertuzumab
Actual price N/A 2,590.18 2,891.10 3,000.00
Official price N/A 2,910.58 2,891.10 3,000.00
Mabthera® 1 vial/100 mg Rituximab
Actual price N/A 210.56 266.44 271.13
Official price N/A 238.06 266.44 279.27
Yervoy® 1 vial/ 50 mgIpilimumab
Actual price 5,500.00 2,338.83 3,536.50 4,144.00
Official price 5,500.00 4,086.54 3,536.50 4,250.00
Actual costs of cancer drugs (2015)Country Romania Estonia United Kingdom Norway
GDP/capita (€) 7,500 14,800 34,500 73,400
Herceptin®
1 vial/150 mg (€)a
Trastuzumab
Actual price 563.14 674.80 562.71 497.74
Official price 585.26 N/A 562.71 523.50
Avastin® 1 vial/100 mg (€)aBevacizuma
Actual price 283.67 345.26 335.16 260. 93
Official price 297.47 N/A 335.16 286. 58
Glivec® 1 tab/100 mg (€)aImatinib
Actual price 15.05 7.06 19.85 17.51
Official price 15.12 N/A 19.85 17.74
„Actual costs of cancer drugs in 15 European countries“
Wim van Harten, Anke Wind, Paolo de Paoli, Mahasti Saghatchian, Simon Oberst
•Official or list prices differ substantially between countries
•Actual prices differ even more between countries (up to 58% lower)
•Reductions on list prices were very different between countries.
Qualitative Follow up study
• Concise Questionnaire with 14 questions, covering following topics:
- negotiations
- payments
- budget
- patient perspective
• Send to 76 members of OECI
• Analysis: descriptive
Country
Belgium 2
Czech Republic 1
Denmark 2
Estonia 2
Finland 1
France 2
Hungary 1
Italy 8
Norway 1
Poland 1
Portugal 1
Romania 1
Russia 1
Slovenia 1
Spain 1
The Netherlands 2
UK 1
29
Qualitative survey results from:
• 17 countries
• 29 centres
Discount mechanisms incidence frequencies in participating centres
Agreed discount- deduction made in advance of its payment
Price/volume agreement- when sales volume exceeds the forecast, discount is applied
23
14
17
0
5
10
15
20
25
Additionally mentioned:• Tenders (local and national) • Public market • Pre-determined max price • Government purchase • Purchase groups • Drug programs • Risk or cost sharing• Managed entry agreements• Performance based• Success fee• Cashback
Correspondingly: 79,31%; 48,28% and 58,62% from participating centers
Payment modes in participating centers
18
8
17
2
9
0
5
10
15
20
25
Pay for performance No cure, no pay Paybacks Parallel trade Other
Correspondingly: 62,07%; 27,59%; 58,62%; 6,90% and 31,03%
Q2 Why price information may not be available
6
12
5
13
8
17
0
2
4
6
8
10
12
14
16
18
Not covered Drug not available/not used
No fixed price For trial use only Drug is for free Confidential/cannot disclousure
Correspondingly: 20,69%; 41,38%; 17,24%; 44,83%; 27,59%; 58,62%
Joint negotiations
26
3
0 5 10 15 20 25 30
Yes
No
Are joint negotiations allowed?
19
10
0 5 10 15 20 25 30
Yes
No
Are joint negotiations happening?
90% of participating centers said that joint negotiations are allowed in 94% of the countries
66% of participating centers said that joint negotiations are actually used (in 59% of the countries)
Joint negotiations are not allowed within the purchase process of cancer drugs by the local legislation between institutes/hospitals in 3 responded institutes:- 1 from Russia- 2 from Italy (regional differences)
Joint negotiations
Financial limitations
• In 83% of responded institutes and 95% of participating countries physicians are recommended to choose generic (off-patent) treatment if there is no need for the specific brand product
• In 52% of responded institutes and in 59% of the participating countries there has been some cancer drugs either nor accepted (skipped or delayed) from coverage because of their high cost
18
7
30
5
10
15
20
Yes No Other, Specify
Does treatment choiches have financial limitations?
Correspondingly: 62%, 24% and 10% in participating centers
Correlation between budget sufficiency and whether treatment choices have been affected by financial limitations
Patient perspectiveIn 48% of participated hospitals additional financial support (besides coverage) for cancer drugs is provided to patients by:
• Government solidarity funds• Private insurances• Cancer foundations• Early access programs• Hospitals6
23
0 5 10 15 20 25
Yes
No
Out of pocket costs
Out-of-pocket costs are in 5 countries out of 17 (29%)
Correspondingly: 79% do not have to pay out-of-pocket costs
Q13: Is there any additional financial support (besides coverage) for cancer drugs provided to the patients?
Additional financial support is provided by:• Government• Foundations• Private insurances• Hospital• Drug industry• Medical need programs• Early access programs
Results from 19 ECPC member organisations
Country Bel
giu
mB
osn
ia a
nd
H
erze
govi
na
Bu
lgar
ia
Cze
ch R
epu
blic
Den
mar
k
Esto
nia
Fin
lan
d
Fran
ce
Gre
ece
Hu
nga
ry
Ital
y
Irel
and
Isra
el
Latv
ia
No
rway
Port
uga
l
Pola
nd
Ro
man
ia
Ru
ssia
Serb
ia
Slo
ven
ia
Spai
n
Swed
enTh
e N
eth
erla
nd
s
Turk
ey
Un
ited
Kin
gdo
m
OECI X X X X X X X X X X X X X X X X X
ECPC X X X X X X X x X X X X X X X X X X X
General results from ECPC
78
5147
29
49
24
15
42
24
63
41
58
37
29
8 10
19
3
0
10
20
30
40
50
60
70
80
90
Do you think patients in yourcountry are missing out on the
best possible treatment dueto financial problems?
Do you think the patient inyour country are aware theyare missing out on treatment
options?
Do you think patients havedifficulties applying for health
insurance?
Do you think this matter(affordability) is given enough
attention by otherstakeholders (hospitals,
governments, insurances,etc.)?
Is additional financial supportprovided for patients?
Is in your country financial counseling provided for
cancer patients?
ECPC memebers responses
Yes (%) No (%) NA (%) No answer (%)
Questionnaire is still open, and we would appreciate your contribution!
https://goo.gl/forms/TnpTaidwS6zSDIhl2
Email: [email protected]
• To date, the pharmaceutical industry has not presented transparent explanations or calculations underlying their pricing decisions.
• No recent overview/updates of actual prices in EU countries
• Unequal access in various EU countriesN
• Small countries (=small markets?) at disadvantage in view of negotiating power.o
• Innovative cooperation/measures needed to secure government and funding agencies (+patients) interests
n countries have disadvantage for negotiations due to small market share
Unequal access to cancer care and related services
Sustainability of cancer care can be at risk
Cancer drug costs and payment issues in European countries.
Ongoing process
• Intention to follow up on the actual cancer drugs costs inventory, using the input from this first stage survey (?)
• Privately funded health economics and scenario/modelling (PhD-) study to start Sept 2017:
-reviews, stakeholder involvement and scenario studies on alterative models
- modeling funding and/or pricing alternatives for present patent and licensing- and R&D system in developing drugs
- proposing most promising models for pilot projects to governments and charities.
Cancer drug costs and payment issues in European countries.
• Consensus is needed on transparent pricing system features that would be acceptable to all/most parties? What purpose is the External Reference Price system serving?
• 79% of participating centres said that patients do not need to pay out-of-pocket costs, but 48% of centres stated additional financial support is provided to (fund)patients (drugs)
• 52% centres have experienced cancer drugs not accepted (skipped or delayed) due to high price and 62% say treatment choices are affected by financial limitations
• 51% of patient organisation representatives feel that pts are missing adequate treatment options
• Firm and continuous action needed by all stakeholders to change the patent and pricing system.