1. Pharmaceutical policies: effects of reference pricing, other pricing, and purchasing policies (Updated Review)
Presenter:
Angela Acosta
Funding Sources / Conflict of Interest Disclosure: “I have no actual or potential conflict of interest in relation to this presentation.”
Thank you for having me here…
Well Im gonna present some of the methodological relevant changes and main results of this update.
This update was developed as my thesis project of the Clinical and Health Care Effectiveness master program of the Universidad of Buenos Aires in Argentina, and as part of a colombian research project on generic medicines of the Faculty of Pharmacy in the Universidad Nacional de Colombia.

2. All Authors
Acosta A1, Ciapponi A2, Aaserud M3, Vietto V4, Austvoll-Dahlgren A5, Kösters JP6, Vaca C7, Machado M8, Diaz Ayala DH8, Oxman A5 1 School of Pharmacy, Universidad Nacional de Colombia, Colombia 2 Argentine Cochrane Centre IECS, Institute for Clinical Effectiveness and Health Policy, Hospital Italiano de Buenos Aires, Southern American Branch of the Iberoamerican Cochrane Centre, Buenos Aires, Argentina 3 Statens Legemiddelverk, Norwegian Medicines Agency, Oslo, Norway 4 Division of Family and Community Medicine, Hospital Italiano de Buenos Aires, Argentina 5 Norwegian Knowledge Centre for the Health Services, Oslo, Norway 6 The Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark 7 Grupo RAM, Universidad Nacional de Colombia, Bogota, Colombia 8 Departamento de Farmacia, Universidad Nacional de Colombia, Bogota, Colombia
It involved a hard and large amounts of work, that’s the reason of having to many authors as you can see, besides that it allows me to have the support of the original authors as well as the unrestricted techical support from the coordinator of the IECS Cochrane Center in Argentina.
It is important to remark the first main feature of this update was the coherent setup of a collaboration network between three countries: Norway, Argentina and Colombia.
So many thanks to Andy Oxman and his team form the Norwegian Knowledge Centre for the Health Services and also to Agustin Ciaponni from IECS Argentina.

3. Objective: To determine the effects of pharmaceutical pricing and purchasing policies on health outcomes, healthcare utilisation, drug expenditures and drug use.
PHARMACEUTICAL PRICING AND PURCHASING POLICIES
INTERNAL REFERENCE PRICING
Are important interventions that could improve people’s health.
Are interventions used as cost-containment measures to determine or affect the prices that are paid for drugs.
Are interventions that establishes a benchmark or reference price within a country. (maximum level of reimbursement for a group of drugs)
PHARMACEUTICAL
POLICIES
Other policies include price controls, maximum prices, index pricing, price negotiations and volume-based pricing., but still have sparce evidence of its effects.
What we found with this update is the migration in the scope of policies like reference priciing policies (PPRI glossary and LA examples)
Glossary of Pharmaceutical Terms of the WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies (2011).
External reference pricing (External price referencing): The practice of using the price(s) of a medicine in one or several countries in order to derive a benchmark or reference price for the purposes of setting or negotiating the price of the product in a given country.
Internal reference pricing (Internal price referencing): The practice of using the price(s) of identical medicines (ATC 5 level) or similar products (ATC 4 level) or even with therapeutic equivalent treatment (not necessarily a medicine) in a country in order to derive a benchmark or reference price for the purposes of setting or negotiating the price or reimbursement of the product in a given country.
And as we stated in this update there are recent policy implementations dealinf with the PPIR scope of pricing policies, which is the case of Colombia since 2013.

4. Methods No protocol changes with this update,
TYPES OF STUDY
Ramdomised trials
Non randomised trials
ITS (with or without control group)
RM (Each individual contributed data to each point of time)
Controlled RM
CBA
TYPE OF PARTICIPANTS
Large jurisdiction or system of care
Regional, national, international
Health maintenance organisations (multiple sites and served a large population)
TYPE OF INTERVENTIONS
Policies defined as laws; rules; financial and administrative orders made by governments, non-government organisations or private insurers
TYPE OF OUTCOMES MEASURES
Drug use,
healthcare utilisation,
health outcomes or
costs (expenditures)
Methods
No protocol changes with this update,
We included LILACS as a new database for electronic searches with emphasis in LA countries,
We assessed the risk of bias for each new study that was included using the ‘risk of bias’ tool described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) and additional criteria developed by the Cochrane EPOC Group (EPOC 2013a).

5. Results:
  We included 18 studies (seven identified in the update): 17 of reference pricing, one of which also assessed maximum prices, and one of index pricing. None of the studies were trials. All included studies used ITS or RM analyses. The quality of the evidence was low or very low for all outcomes. Four studies reported effects on mortality and healthcare utilisation, however they were excluded because of study design limitations. 
Two reference pricing studies reported median relative insurer’s cumulative expenditures of – 18%, ranging from -36% to 3%: Cummulative expenditure by one year for the involved group of medicines that pretends to affect the reference price.
Four reference pricing studies reported median relative insurer’s expenditures of – 10%, ranging from -53% to 4%: Expenditure one year after the intervention for the involved group of medicines that pretends to affect the reference price.
Four reference pricing studies reported median relative change of 15% at one year after the transition period in reference drugs prescriptions, ranging from -14% to 166%.
Three reference pricing studies reported median relative change of -39% at one year after the transition period in reference drugs prescriptions, ranging from -87% to -17%.

6. The majority of the studies of pricing and purchasing policies that met our inclusion criteria evaluated reference pricing.
We found that internal reference pricing may reduce expenditures in the short term by shifting drug use from cost share drugs to reference drugs.
Index pricing may reduce the use of brand drugs, increase the use of generic drugs, and may also slightly reduce the price of the generic drug when compared with no intervention.
Conclusions
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