Drug Policy in Poland

Systematic Literature Review of Access Pathways to Drugs for Patients with Rare Diseases

OBJECTIVE

This article reviews the assessment pathways that have been implemented worldwide to facilitate access to drugs for patients with rare diseases.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to conduct a systematic literature review. The Ovid (Embase/MEDLINE), Cochrane, Web of Science, Econlit, National Institute of Health Research, Centre for Reviews and Dissemination, and International Network of Agencies for Health Technology Assessment databases were searched. Two independent reviewers screened all titles and abstracts; one reviewer did the full-text review and data extraction. Data were extracted on study general characteristics, general aspects of rare diseases, source of funding, allocation of public resources (e.g., use of health technology assessment), and pricing strategies. Assessment pathways were classified as: (1) separate processes; (2) exception to standard process; (3) standard process with no change; and (4) alternative process. Each assessment pathway was characterized based on its unique characteristics specific to rare diseases focusing on whether they targeted specific aspects of the process, utilized particular methodologies during the evaluation of the evidence, or considered specific attributes in the recommendation.

RESULTS

A total of 5604 unique citations were screened and 158 were included for data extraction. Sixty-one assessment pathways were identified in 43 countries, categorized as separate processes (37%), exceptions to standard processes (32%), standard processes with no changes (26%), and alternative processes (5%). Some countries (10/43; 23%) have more than one assessment pathway available. Assessment pathways varied in their inclusion of a health technology assessment, source of funding, consideration of uncertainty, and pricing strategies.

CONCLUSIONS

The diversity of assessment pathways reflects the complexity of addressing access to treatments for rare diseases. Furthermore, most assessment pathways are from high-income countries; therefore, there is less clarity on what is happening in low- and middle-income countries.

AOTMiT reimbursement recommendations compared to other HTA agencies

Our objective was to compare AOTMiT (Polish: Agencja Oceny Technologii Medycznych i Taryfikacji) recommendations to other HTA (Health Technology Assessment) agencies for newly registered drugs and new registration indications issued by the European Medicines Agency between 2014 and 2019. The study aims to assess the consistency and justifications of AOTMiT recommendations compared to that of other HTA agencies in 11 countries. A total of 2496 reimbursement recommendations published by 12 HTA agencies for 464 medicinal products and 525 indications were analyzed. Our analysis confirmed that the Polish AOTMiT agency seems to bear the closest resemblance to the corresponding HTA agencies from Canada (CADTH) and New Zealand (PHARMAC), when it comes to the outcome of HTA recommendations (positive or negative). Poland had a general scheme for justifying recommendations, similar to that of Ireland-four aspects (i.e., clinical efficacy, safety profile, cost-effectiveness, and impact on the payer's budget) are important for Poland when formulating the final decision. Compared to other countries, Poland shows a noticeably different pattern of justifying reimbursement recommendations, as revealed primarily in terms of budget impact and somewhat less so for cost-effectiveness rationales.

Reimbursement decision-making system in Poland systematically compared to other countries

Introduction: Our objective was to analyze and compare systematically and structurally reimbursement systems in Poland and other countries. Methods: The systems were selected based on recommendations issued by the Polish Agency for Health Technology Assessment and Tariffication (AHTAPol), which explicitly referred to other countries and agencies). Consequently, apart from Poland, the countries included in the analysis were England, Scotland, Wales, Ireland, France, Netherlands, Germany, Norway, Sweden, Canada, Australia and New Zealand. Relevant information and data were collected through a systematic search of PubMed (Medline), Embase and The Cochrane Library as well as competent authority websites and grey literature sources. Results and discussion: In most of the countries, the submission of a reimbursement application is initiated by a pharmaceutical company, and only a few countries allow it before a product is approved for marketing. All of the agencies analyzed are independent and some have regulatory function of reimbursement decision making body. A key criterion differentiating the various agencies in terms of HTA is the cost-effectiveness threshold. Most of the countries have specific mechanisms to improve access to expensive specialty drugs, including cancer drugs and those used for rare diseases. Reimbursement systems often lack consistency in appreciating the same stages, leading to heterogeneous decision-making processes. The analysis of recommendations issued in different countries for the same medicinal product will allow a better understanding of the relations between the reimbursement system, HTA assessment, stakeholders involvement and decision on reimbursement of innovative drugs.

The "Affordable Medicines" Reimbursement Program in Ukraine: Framework Assessment and Impact Evaluation

OBJECTIVES

In 2017, the government of Ukraine introduced the new Affordable Medicines Program (AMP) for outpatient prescription medicines reimbursement. Despite the evident program implementation benefits, it is highly important to examine the AMP framework to reveal its current tendencies, strengths, and shortcomings that might be useful to support further development and improvement of reimbursement models. This study aimed to evaluate how the pricing strategies applied by the AMP framework might affect the potential to provide patients with affordable medicines.

METHODS

The AMP framework has been evaluated by several parameters characterizing the pricing mechanisms, pharmaceutical manufacturers, the scope of medicines covered by the program, and consumption volumes. The data were collected from official government databases and open sources. The statistics assessment was applied.

RESULTS

In 2017 to 2021, the AMP demonstrated extensive growth of the number of medicines covered, consumption volumes, and the scope of international nonproprietary names reimbursed. The pricing limits used by the AMP framework proportionally were correlated with the number of manufacturers involved. At the same time, the number of medicines containing reimbursed international nonproprietary names but not being covered by the program has been decreasing.

CONCLUSIONS

The AMP framework significantly influences the pharmaceutical market and the potential to provide patients with a wider scope of essential medicines while effectively managing government and patients' healthcare spending. There is a need for the AMP re-evaluation tool enabling timely diagnosing of its shortcomings, assessing the effectiveness and helping to implement its targeted development according to pharmaceutical market tendencies and achievement of desirable patient's health outcomes.

The Potential to Reduce Patient Co-Payment and the Public Payer Spending in Poland through an Optimised Implementation of the Generic Substitution: The Win-Win Scenario Suggested by the Real-World Big Data Analysis

High medication costs are one of the major barriers to patient adherence. Medication affordability might be improved by generic substitution. The aim of this study was to assess the effectiveness of the implementation of generic substitution mechanisms in Poland. This was a retrospective analysis of nationwide real-world big data corresponding to dispensation of metformin preparations in 2019 in Poland. Relevant prescription and dispensation data were compared to assess the prevalence of generic substitution and its economic consequences. Among the 1,135,863 e-prescriptions analysed, a generic substitution was found in only 4.81% of the packs dispensed, based on e-prescriptions issued for metformin under its originator version and 2.73% under generic drugs. It is estimated that if these values were applied to the total Polish drug market, patients could lose the opportunity to lower their co-payment by 15.91% and the national payer to reduce its reimbursement expenditures by 8.31%. Our results point at the suboptimal implementation of generic substitution in Poland. Therefore, relevant actions need to be taken in order to maximise the benefits provided by this mechanism. It could not only lead to the win-win scenario in which both patients and the national payer are secured substantial savings, but it could also have a positive impact on patient adherence.

Uptake of new antidiabetic medicines in 11 European countries

BACKGROUND

Several new antidiabetic medicines (GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT-2 inhibitors) have been approved by the European Medicines Agency since 2006. The aim of this study was to evaluate the uptake of new antidiabetic medicines in European countries over a 10-year period.

METHODS

The study used IQVIA quarterly value and volume sales data January 2006-December 2016. The market uptake of new antidiabetic medicines together with intensity of prescribing policy for all antidiabetic medicines were estimated for Austria, Croatia, France, Germany, Hungary, Italy, Poland, Slovenia, Spain, Sweden, and the United Kingdom. The following measures were determined: number of available new active substances, median time to first continuous use, volume market share, and annual therapy cost.

RESULTS

All countries had at least one new antidiabetic medicine in continuous use and an increase in intensity of prescribing policy for all antidiabetic medicines was observed. A tenfold difference in median time to first continuous use (3-30 months) was found. The annual therapy cost in 2016 of new antidiabetic medicines ranged from EUR 363 to EUR 769. Among new antidiabetic medicines, the market share of DPP-4 inhibitors was the highest. Countries with a higher volume market share of incretin-based medicines (Spain, France, Austria, and Germany) in 2011 had a lower increase in intensity of prescribing policy. This kind of correlation was not found in the case of SGLT-2 inhibitors.

CONCLUSIONS

This study found important differences and variability in the uptake of new antidiabetic medicines in the included countries.

Prevalence and Age Structure of Polypharmacy in Poland: Results of the Analysis of the National Real-World Database of 38 Million Citizens

Introduction: Polypharmacy is a risk factor for adverse health outcomes, higher use of medical services and additional costs. The problem has gained attention as a consequence of aging and related multimorbidity. Therefore, there is an urgent need to adopt effective interventions aimed at reducing its burden. In order to achieve this, in-depth understanding of the prevalence of polypharmacy is required. Of particular interest is, however, assessing prevalence of polypharmacy in various age groups, to reach the right target for these interventions. So far, only limited data on polypharmacy among non-elderly individuals have been available.

Aim of study: To assess overall prevalence of polypharmacy in Poland as well as its distribution in various age groups using real-world data.

Methodology: A retrospective analysis of complete dispensation data of national payer organization for the years 2018–2019. The analyzed dataset included data on dispensation of reimbursed drugs, and exclusively for 2019, also non-reimbursed drugs. Polypharmacy was defined as dispensation of ≥5 prescription medications within six months.

Results: In the analyzed national cohort of 38 million Polish citizens, the prevalence of polypharmacy was found to be 11.7% in 2018 and 11.6% in 2019. With age, the prevalence of polypharmacy increased, reaching the value of 56.0% in those aged 80+ in 2018, and 55.0% in 2019. Altogether, among those aged 65+, the polypharmacy was present in 43.1% in 2018, and 42.1% in 2019. In the youngest group of citizens, i.e., among those aged below 20 years, polypharmacy was found in 0.9%, and 0.8% in 2018 and 2019, respectively. Prevalence of polypharmacy, calculated for 2019 according to dispensation of five or more reimbursed and non-reimbursed drugs for the whole Polish population, was 21.8% for January-June, and 22.4% for July-December 2019. Among those aged 65+, the relevant numbers were 62.3%, and 62.9%, respectively.

Conclusion: This study, being the first nationwide assessment of polypharmacy in Poland, confirmed its high prevalence. We found polypharmacy present in over one fifth of Polish society. Peaking in the elderly, polypharmacy occurred in each age group. These results lay the foundations for future interventions focused on reducing the scope of this problem in Poland.

Uncertainty tolerance among experts involved in drug reimbursement recommendations: Qualitative evidence from HTA committees in Canada and Poland

OBJECTIVES

Drug reimbursement decisions often rely on health technology assessment (HTA). Increasingly, new drugs have limited clinical evidence and uncertain clinical benefit. Our goal was to describe how members of drug advisory committees and other stakeholders conceptualize and tolerate uncertainty and how they rationalize uncertainty tolerance.

METHODS

Our triangulated parallel design applied two qualitative methods. We interviewed 31 members of drug advisory committees in Canada and Poland about their information needs and included hypothetical scenarios with uncertain clinical benefits. Respondents speculated about their likely reimbursement recommendation. We analyzed written recommendations of the pan Canadian Oncology Drug Review for drugs with uncertain benefit and compared initial recommendations to the responses from patient and clinician groups.

RESULTS

Uncertainty tolerance varied among committee members and across jurisdictions. In the scenario analysis, 7 Canadian and 11 Polish respondents leaned against recommending a hypothetical drug with uncertain clinical benefit, whereas 5 Canadian and 5 Polish respondents leaned in favour. Those against rationalized that uncertainty increases potential harm; those in favour rationalized that patients often have no alternatives. The document analysis revealed that patients had higher uncertainty tolerance in general.

CONCLUSIONS

Uncertainty tolerance varies among committee members and other stakeholders depending on their backgrounds and on the decision contexts. We argue that policy guidance around uncertainty management could improve the transparency and consistency of recommendations.

Overview and Analysis of the Cost of Drug Programs in Poland: Public Payer Expenditures and Coverage of Cancer and Non-Neoplastic Diseases Related Drug Therapies from 2015-2018 Years

Background

In Poland drug programmes developed by the Minister of Health and financed by the National Health Fund are special reimbursement frameworks of innovative, expensive, and mostly hospital based medical products used for a small number of patients.

Research Design

The research presented in this paper is based on data analysis published by the National Health Fund in Poland. The analysis focused on estimating public payer expenditure on drugs available within drug programmes from 2015 to 2018.

Results

In subsequent years, reimbursement of drugs used within drug programmes was associated with the National Health Fund budget expenditure of 635 mln USD, 755 mln USD, 854 mln USD, and 921 mln USD, respectively. Reimbursement of oncology drug programmes constituted 48.1%, 42.5%, 47.1%, and 52.4% and were approximately 305, 312, 402, 483 mln USD, whereas values of non-oncology drug programmes were approximately 330, 434, 452, and 438 mln USD which constituted 51.9%, 57.5%, 52.9%, and 47.6% respectively.

Conclusion

Despite the fact that the expenditure on drug programs in Poland are increasing every year, they undoubtedly improve the patient’s access to the most innovative oncological and nononcological therapies in the Polish healthcare system.

Patients' Preferences and Willingness to Pay for Solid Forms of Oral Medications-Results of the Discrete Choice Experiment in Polish Outpatients

Purpose: Personal preferences play an important role in the patients’ decision process whether to adhere to treatment, or not. The purpose of this study is to assess Polish outpatients’ preferences for solid forms of oral medications across various scenarios. Methods: The convenience sample of 200 outpatients took part in this study. According to the discrete choice experiment (DCE) design, participants were provided with selection of tablets and capsules, in different shapes, sizes, colors, and copayment levels and were asked to state their preferences. DCE results were analyzed using mixed logit (MXL) models. Results: MXL models revealed patients’ willingness to pay for various solid forms of medications. The most preferred combination of drug parameters were: small yellow capsule for chronic treatment, and small yellow long tablet for short-term treatment. Study participants were happy to pay extra 6.52 PLN (≈1.63 EUR) for this drug formulation per month of antihypertensive treatment, and 14.44 PLN (≈3.61 EUR) for this drug formulation per 7-days’ long course of antibiotic treatment, respectively. Conclusion: Results suggest that color, shape, and size of solid form of oral medications are important predictors of patients’ acceptance. It can not only be expressed in monetary value, but also may serve as an important hint for companies designing new drugs, or policymakers who are happy to improve patient adherence with better prescribing, or dispensing. However, our findings are probably country-specific, and further research is necessary to better understand the relationship between solid drug characteristics, and patient’s preferences across countries.

Valuation of EQ-5D-5L Health States in Poland: the First EQ-VT-Based Study in Central and Eastern Europe

OBJECTIVE

Cost-utility analyses are becoming increasingly important in Central and Eastern Europe. We aimed to develop a Polish utility tariff for EQ-5D-5L health states.

METHODS

Face-to-face, computer-assisted interviews were collected in a representative sample. Each respondent followed a standardised protocol to collect ten composite time trade-off and seven discrete choice experiment observations. In the Bayesian approach, several model specifications were compared based on model fit, the usability of the final value set and how they reflect the elicitation procedure (e.g. censoring). A hybrid approach (using composite time trade-off and discrete choice experiment data) was employed in the final set, which was compared with the existing ones: EQ-5D-3L and EQ-5D-5L cross-walk.

RESULTS

Data from 1252 respondents (11,480 composite time trade-off valuations and 8764 discrete choice experiment pairs) were collected over the period June to October 2016. The final model accounted for random parameters, error scaling with fat tails, censoring at - 1, unwillingness to trade in time trade-off by the religious people and Cauchy distribution in discrete choice experiments. Pain/discomfort impacts the utility most: the disutility equals 0.575 when at level 5. In the value set, 4.4% of EQ-5D-5L states are worse than dead. The new value set has a comparable range (minimum of - 0.590 compared to - 0.523) and the same ordering of the first three dimensions (pain/discomfort, mobility, self-care) as the EQ-5D-3L value set and the EQ-5D-5L cross-walk value set. Moreover, it is more sensitive to a moderate decline in health.

CONCLUSIONS

The new value set supports consistency with past decisions in cost-utility studies, while offering a better assessment of even moderate improvements in health. It could represent an option for Central and Eastern Europe countries lacking their own value sets.

Navigating joint HTA, procurement, and fair pricing: evidence-based insights and practical recommendations - A meeting report from ISPOR regional conference in Warsaw, 2019

Introduction: The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) organized its first Central Eastern European regional meeting in 2019 in Warsaw, Poland. Area covered: The scientific program of the two-day conference covered a broad range of topics presented from the perspective of the region. Specifically, the focus was on cross-country collaboration within different steps of health technology assessment (HTA) and the need for local HTA adaptations in decision-making. Expert commentary: Attended by approximately 200 delegates from many countries and by several high level ISPOR leaders, the conference provided a valuable opportunity to exchange knowledge and strengthen the scientific network among experts from different stakeholder groups on issues specific to the region.

Drug Policy in Greece

OBJECTIVES

To provide a detailed overview of the recent reforms in pharmaceutical pricing and reimbursement processes as well as in other important areas of the pharmaceutical policy in Greece.

METHODS

Information was collected via a structured questionnaire. The study used publicly available resources, such as publications, relevant legislation, and statistical data, while health experts were also consulted.

RESULTS

Recent pharmaceutical reforms included significant price cuts, increased co-payments and some provisions for vulnerable groups, rebates/clawbacks, mandatory electronic prescribing and prescription by international nonproprietary name, generics substitution, prescription limits and detailed auditing, centralized procurement, as well as changes in the pricing and reimbursement processes, with the introduction of positive and negative lists and an internal price referencing system. Price lists are compiled by the National Organization for Medicines and are issued by the Ministry of Health (MoH). An advisory pricing committee comprising representatives of stakeholder groups was abolished in early 2018. Nevertheless, under the new provisions, a health technology assessment body for the economic evaluation of reimbursed drugs is to be established for the first time in Greece. The committee is to be staffed by experts appointed by a ministerial decision of the MoH. The specific features of the process are yet to be determined.

CONCLUSIONS

The pricing and reimbursement decision-making processes are centralized under the competence of the MoH. Despite the good intentions of the reformers, there are still some aspects of transparency, equity, and long-term sustainability that remain under question in Greece.

Pharmaceutical Regulation in Central and Eastern European Countries: A Current Review

Objectives: The aim of this study was to review reimbursement environment as well as pricing and reimbursement requirements for drugs in selected Central and Eastern Europe (CEE) countries. Methods: A questionnaire-based survey was performed in the period from November 2016 to March 2017 among experts involved in reimbursement matters from CEE countries: Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, and Romania. A review of requirements for reimbursement and implications of Health Technology Assessment (HTA) was performed to compare the issues in above-mentioned countries. For each specified country, data for reimbursement costs, total pharmaceutical budget, and total public health care budget in the years 2014 and 2015 were also collected. Questionnaires were distributed via emails and feedback data were obtained in the same way. Additional questions, if any, were also submitted to respondents by email. Pricing and reimbursement data were valid for March 2017. Results: The survey revealed that the relation of drug reimbursement costs to total public healthcare spending ranged from 0.12 to 0.21 in the year 2014 and 2015 (median value). It also revealed that pricing criteria for drugs, employed in the CEE countries, were quite similar. External reference pricing as well as internal reference pricing were common in mentioned countries. Positive reimbursement lists were valid in all countries of the CEE region, negative ones were rarely used; reimbursement decisions were regularly revised and updated in the majority of countries. Copayment was common and available levels of reimbursement differed within and between the countries and ranged from 20 to 100%. Risk-sharing schemes were often in use, especially in the case of innovative, expensive drugs. Generic substitution was also possible in all analyzed CEE countries, while some made it mandatory. HTA was carried out in almost all of the considered CEE countries and HTA dossier was obligatory for submitting a pricing and reimbursement application. Conclusions: Pricing and reimbursement requirements are quite similar in the CEE region although some differences were identified. HTA evaluations are commonly used in considered countries.