Dominic Jones-Phillips

Apex Healthcare Consulting Limited

Author of: What is pricing and reimbursement?

PicDominic Jones-Phillips BSc MRes PhD is Market Access Director at Apex Healthcare Consulting. After completing a PhD in Experimental Rheumatology at the University of Leeds, he joined the Payer Insight and Reimbursement Strategy team at Abacus International. While at Abacus for almost five years, Dominic worked on a range of market access projects, from stakeholder mapping and competitor intelligence, to value message development and testing. Dominic went on to lead primary and secondary research activities, gaining an in-depth knowledge of market access and reimbursement across the EU5 countries and other major international HTA systems. As Market Access Director at Apex Healthcare Consulting, Dominic takes the leads in developing and delivering payer engagement and market access strategy research for a range of biotech and pharmaceutical clients.

Summary: What is pricing and reimbursement?

  • Pricing and reimbursement can mean a variety of things in many different spheres of industry. For a pharmaceutical manufacturer launching a new product, pricing and reimbursement broadly refers to establishing a price and obtaining a positive reimbursement decision, or formulary listing status, for their product.
  • For most manufacturers, key countries in which to gain a favourable price for their products are the USA and the five largest European countries: France, Germany, Italy, Spain and the UK (EU5), with many other countries referencing the prices achieved in the EU5 and USA when negotiating with manufacturers.
  • The three biggest and most influential countries among the EU5 are the UK, France and Germany, and it is these countries that also have the most well-developed and transparent national drug and device assessment processes.
  • The processes through which the USA and individual countries in the EU facilitate a new product – gaining a favourable price and securing reimbursement – differ greatly, with each country having clear national, regional and local decision-making processes.
  • When you approach setting a price and ensuring your product is reimbursed, a number of processes need to be considered; each one can impact eventual uptake and, therefore, the reimbursement of your product. These include:
    – Understanding the patient pathway
    – Understanding price setting and negotiations linked to health technology assessment (HTA)
    – Engaging with payers and purchasers
    – Considering whether involvement of any unique funding bodies (for example, the Cancer Drugs Fund in the UK) is required.
  • Pharmaceutical companies often develop separate ‘US’ and ‘ex-US’ launch strategies for their products; however, each of the major EU countries has different clinical evidence and comparator requirements, which suggests that a simple ex-US pricing and reimbursement strategy cannot work.
  • Conducting the appropriate background work in order to engage with payers early, understand the spectrum of comparators and be able to clearly justify your choices is, therefore, a key step to take.
  • National-level health technology assessment can set a list price and grant access to national formularies; however, much of the actual reimbursement subsequently requires engagement and evidence-based discussions with clinicians, commissioners, regional and local-level payers and a clear understanding of patient-focused outcomes and holistic cost-saving benefits.