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.
Survey of 9 cancer drugs Actual costs of cancer drugs A. Name Generic name Indication Cost per vial/tablet Cost per vial/tablet Cost per full Course/year Nonrefunded Cost Herceptin (iv) Trastuzumab Her 2 positive breast cancer, adjuvant and metastatic setting Perjeta (iv) Pertuzumab Her 2 positive breast cancer, metastatic setting in combination with trastuzumab and docetaxel 150 mg 420 mg Mabthera (iv) Rituximab Non Hodgkin lymphoma, chronic lymphatic leukemia and several other hematologic indications Avastin ( iv) Bevacizumab Metastatic colorectal cancer, breast cancer, lung cancer, cervical cancer, GBM 100 mg 500 mg 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 mg Xtandi Enzalutamide Castration refractory prostate cancer 40 mg
Country Romania Hungary Poland Lithuania Czech Republic Actual costs of cancer drugs Estonia Portugal Spain (N=2) Italy (N=2) France (N=2) Germany (N=2) United Kingdom Belgium (N=2) The Netherlands (N=3) 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 Perjeta 1 vial/420 mg ( ) a Pertuzumab Mabthera 1 vials /100 mg( ) a Rituximab Actual price List price Actual price 563.14 516.47 N/A 476.56 481.82 674.80 N/A 506.88 557.70 542.43 670.00 562.71 517.92 605.25 497.74 585.26 630.38 537.99 476.56 502.73 N/A 509.13 573.58 913.45 542.43 718.33 562.71 536.76 606.49 523.50 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 Actual price List price Yervoy Actual 1 vial/50 mg ( ) a price Ipilimumab List price ( ) a Prices are in Euro's per lowest dosage 238.19 N/A N/A N/A N/A 295.27 N/A 210.56 262.39 266.44 N/A 241.16 210.38 271.13 210.80 247.96 220.53 287.72 N/A 420.91 N/A 228.80 238.06 395.67 266.44 691.62 241.20 218.38 279.27 217.47 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 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 Norway Xtandi 1 vial/40 mg ( ) a Enzalutamide Actual price List 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 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
Actual costs of cancer drugs ) a Prices are in Euro's per lowest dosage 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 Netherlands (N=3) 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 List 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. 93 297.47 274.65 317.73 237.12 261.82 N/A 266.41 328.67 412.86 250.65 286.88 335.16 322.89 321.08 286. 58 Norway Glivec 1 tab/100 mg ( ) a Imatinib Sutent 1 cap/12,5 mg ( ) a Sunitinib Actual price List price Actual price List 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 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 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 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 Actual 1 tab/240 mg ( ) a price Vemurafenib List 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 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
Actual costs of cancer drugs Country 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 Yervoy 1 vial/ 50 mg Ipilimumab Actual price N/A 210.56 266.44 271.13 Official price N/A 238.06 266.44 279.27 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 ( )a Bevacizuma Glivec 1 tab/100 mg ( )a Imatinib Actual price 283.67 345.26 335.16 260. 93 Official price 297.47 N/A 335.16 286. 58 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 25 advance of its payment 20 15 10 5 0 23 14 17 Correspondingly: 79,31%; 48,28% and 58,62% from participating centers Price/volume agreement- when sales volume exceeds the forecast, discount is applied 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
Payment modes in participating centers 25 20 15 18 17 10 5 8 9 0 Pay for performance No cure, no pay Paybacks Parallel trade Other 2 Correspondingly: 62,07%; 27,59%; 58,62%; 6,90% and 31,03%
Q2 Why price information may not be available 18 16 17 14 12 10 12 13 8 6 4 6 5 8 2 0 Not covered Drug not available/ not used Correspondingly: 20,69%; 41,38%; 17,24%; 44,83%; 27,59%; 58,62% No fixed price For trial use only Drug is for free Confidential/ cannot disclousure
Joint negotiations No 3 Are joint negotiations allowed? 90% of participating centers said that joint negotiations are allowed in 94% of the countries Yes 26 0 5 10 15 20 25 30 No Are joint negotiations happening? 10 66% of participating centers said that joint negotiations are actually used (in 59% of the countries) Yes 19 0 5 10 15 20 25 30
Joint negotiations 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)
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 20 15 Does treatment choiches have financial limitations? 18 10 5 0 7 Yes No Other, Specify 3 Correspondingly: 62%, 24% and 10% in participating centers
Q9: In your country, are treatment choices for cancer care affected by financial limitations?
Q4: Do you think the current drug pricing system in your country is transparent?
Q8: Is the budget for cancer drugs sufficient in your institute or/ country?
Correlation between budget sufficiency and whether treatment choices have been affected by financial limitations
Patient perspective Out of pocket costs In 48% of participated hospitals additional financial support (besides coverage) for cancer drugs is provided to patients by: No Yes 6 23 Government solidarity funds Private insurances Cancer foundations Early access programs Hospitals 0 5 10 15 20 25 Out-of-pocket costs are in 5 countries out of 17 (29%) Correspondingly: 79% do not have to pay out-ofpocket costs
Patient perspective
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
Belgium Bosnia and Herzegovina Bulgaria Czech Republic Denmark Estonia Finland France Greece Hungary Italy Ireland Israel Latvia Norway Portugal Poland Romania Russia Serbia Slovenia Spain Sweden The Netherlands Turkey United Kingdom Results from 19 ECPC member organisations Country 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 90 ECPC memebers responses 80 70 60 50 40 30 20 10 0 78 15 Do you think patients in your country are missing out on the best possible treatment due to financial problems? 3 3 51 42 Do you think the patient in your country are aware they are missing out on treatment options? 7 47 24 29 Do you think patients have difficulties applying for health insurance? Yes (%) No (%) NA (%) No answer (%) 29 63 8 Do you think this matter Is additional financial support (affordability) is given enough provided for patients? attention by other stakeholders (hospitals, governments, insurances, etc.)? 49 41 10 24 58 19 Is in your country financial counseling provided for cancer patients?
Questionnaire is still open, and we would appreciate your contribution! https://goo.gl/forms/tnptaidws6zsdihl2 Email: r.ots@nki.nl
Cancer drug costs and payment issues in European countries. 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
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.
Acknowledgements: Participating centers, OECI board, ECPC Prof Alwin Huitema NKI, Koos van der Hoeven RadboudUMC NKI Psychosocial Research and Epidemiology group: Riin Ots, Anke Wind, Valesca Retel Prof. Wim H. van Harten MD PhD