Valeur et prix des médicaments innovants onéreux : entre politique de rationnement et politique de résultat

Value and Price for Innovative but Expensive Medical Technologies: The Politics of Rationing and the Politics of Results

The relationship between price and value for expensive pharmaceuticals has ignited debates internationally. The allocation of resources is becoming even more sharply contested in the ever more constrained financial context. In some nations, access to these medications increasingly is managed and limited using decision-theoretic tools, and in particular on cost utility analyses. But this leaves open important and perplexing questions. What is the role of actual prices in the “cost” portion of these decision tools? What is the role of clinical outcome in the “utility” portion of these tools? This article begins by distinguishing two divergent approaches to balancing price and value. It then outlines a third approach, performance- based contracts for drug reimbursement. These contracts link the price paid to the outcomes promised (as part of authorization for market access) and obtained (as measured in the experience of patients taking the drugs), in real world settings (and not merely in research settings). Performance- based contracts permit a rapid negotiation of list prices (publicly available prices) and the subsequent modification of these prices through nonpublic, confidential rebates based on actual outcomes. The facilitation of price setting and rebates permits rapid patient access, drug marketing, while simultaneously allowing the public payer to retain budgetary discipline and ensure that public funds are only expended on care that achieves the desired results.