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

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 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

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

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: r.ots@nki.nl

• 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.

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