The impact of the reference pricing policy in China on drug procurement and cost

System dynamics modeling to predict hospitalization costs in adults with inguinal hernia: a single-centre study

BACKGROUND

This research aims to develop a novel methodology and provide innovative insights for accurately forecasting hospitalization expenses by developing an appropriate system dynamics model to predict hospital costs and simulate future trends. The findings are meant to serve as a guide for creating effective policies and measures to curb the growth in hospitalization costs.

METHODS

We selected adults who had inguinal hernia surgery at Beijing Chaoyang Hospital from January 2015 to December 2023 according to the inclusion and exclusion criteria. We identified the primary factors that influence hospitalization costs and conceptualized them as interconnected subsystems within the broader hospitalization cost system. We develop a system dynamics model of hospitalization costs using the stock-flow tree modeling framework based on flow-rate variables.

RESULTS

This study included a total of 23,696 adult patients who had inguinal hernia surgery. The simulation results for the period 2016 to 2033 were generated by running the model in Vensim simulation software. The forecast for 2033 predicts that hospitalization costs for adult inguinal hernia patients at Beijing Chaoyang Hospital will reach 81.28 million RMB. The number of surgeries will rise to 7,913, with 65% (5,104 surgeries) being outpatient procedures. The average cost per hospitalization will be 10,271.35 RMB. The elderly population among surgical patients is expected to increase to 5,323. For every 1,000 laparoscopic surgeries, 454 will be performed. For every 1,000 surgeries, 437 will involve the use of degradable mesh implants. The number of patients with severe comorbidities is expected to reach 6,403, and medication costs are forecasted to be 1.44 million RMB.

CONCLUSIONS

The system dynamics model for hospitalization costs effectively captures the relationships between multiple influencing factors and hospital expenses. The model's reliability and predictive results' credibility are indicated by the high alignment between simulated historical data and actual historical values. Hospitalization costs are projected to increase annually, while per capita hospitalization costs are expected to decrease. Factors such as an aging population, improved cost control policies, and the promotion of outpatient surgeries exert significant influence in this trend.

Testing the unintended cost effects of health policies for generic substitutions: the case of China's National Volume-Based Procurement (NVBP) policy

Generic substitutions are globally considered to contain health expenditures. Yet it is uncertain whether the costs spill over to other medicines or health services. Contextualizing China's National Volume-Based Procurement (NVBP) policy, which promoted generic substitution, this study tests the changes in patients' utilization of generic medicines and whether the costs shift to other pharmaceutics or health services post-policy. This population-based, matched, cohort study uses claims data from Tianjin, China in 2018-2020. We focus on amlodipine, the most commonly used calcium channel blocker with the largest procurement volume. We build comparable post-policy cohorts: Non-switchers who kept using originator amlodipine, Pure-switchers who loyally switched to generic amlodipine, and Back-switchers who switched back-and-forth; and compare between each matched pair, respectively, their annual healthcare costs and that broken down by components, and patients' use of and adherence to amlodipine post-policy. In all, 1185 Pure-switchers, 1398 Back-switchers, and 2330 Non-switchers were identified (mean age: 63.0 years; 58.5% men). For the matched pairs, Pure-switchers (n = 772) incurred annual total medical costs of CNY 9213.5, 12.2% lower than Non-switchers [n = 1544, absolute difference CNY -1309.3, 95% confidence interval (-2645.8, -19.6)]. The cost reduction only results from amlodipine prescriptions in outpatient encounters and are equally borne by health plans and the enrolees. The costs for Pure-switchers and Non-switchers are not different from other medicines, nor from other items including tests, surgeries, beds, and medical consumables for hypertension-related encounters/admissions. Pure-switchers also had higher daily dosage and better adherence to amlodipine than Non-switchers. The differences between Back-switchers and Non-switchers show similar trends but are less profound. China's NVBP policy is effective in controlling pharmaceutical costs. No unintended cost effects have yet been identified in the short run. Other countries may learn from China on a comprehensive set of auxiliary policies, including listing, bidding, purchasing, and reimbursing, to better promote generic substitutions.

Short-term and long-term effects of Sanming healthcare system reform on drug-related expenditures for rural patients with cancer in public hospitals: an interrupted time series analysis using segmented regression model in China

OBJECTIVES

To assess the effects of 'Sanming model' on drug-related expenditures.

DESIGN

Interrupted time series analysis with two time points was conducted to analyse the effects of 'Sanming model' using segmented regression model.

SETTING

Two hundred and eighty public hospitals in Fujian province in China.

PARTICIPANTS

A total of 777 171 inpatients and 792 743 outpatients with cancer who participated in New Rural Cooperative Medical Scheme (NRCMS) were included.

INTERVENTIONS

'Sanming model' was issued by Sanming government in February 2013 and spread to other cities in Fujian province in January 2015.

PRIMARY OUTCOME MEASURES

Four drug-related expenditure variables.

RESULTS

Among inpatients, total drug expenditures and drug expenditures covered by NRCMS dropped instantly after the reform in all hospitals. Although there was insignificant change during the short-term reform period, the total drug expenditures and drug expenditures covered by NRCMS decreased at the rate of ¥20.3 (p=0.0099) and ¥18.8 (p=0.0341) per capita month-to-month during the long-term reform period in Sanming hospitals, respectively. Among outpatients, total drug expenditures and drug expenditures covered by NRCMS decreased at the rate of ¥20.8 (p=0.0335) and ¥18.4 (p=0.0242) per capita month-to-month during the short-term reform period in Sanming hospitals, respectively. However, the downward trend did not continue into the long term. The significant decreases in trend of drug expenditures uncovered by NRCMS were only observed after the reform in provincial hospitals. The ratio of drug expenditures to inpatient (outpatient) expenditures decreased after the reform in all hospitals.

CONCLUSIONS

'Sanming model' had long-term effect in reducing total drug expenditures, drug ratio and drug expenditures covered by NRCMS for rural inpatients with cancer and only short-term positive effect for outpatients. However, there was limited effect of 'Sanming model' on drug expenditures uncovered by NRCMS. 'Sanming model' still needs to accumulate experiences and improves the reform measures dynamically.

Efficacy of generic teriparatide and alendronate in Chinese postmenopausal women with osteoporosis: a prospective study

The efficacy of generic teriparatide in improving BMD at lumbar spine in patients with osteoporosis was similar to that of alendronate. It provided a new choice for osteoporosis treatment in Chinese population.

INTRODUCTION

To determine whether the efficacy of generic teriparatide is noninferior to alendronate for Chinese postmenopausal women with osteoporosis.

METHODS

Eligible patients were randomly assigned (2:1) in a 48-week, open-label design to receive 20 µg sc daily teriparatide or 70 mg oral weekly alendronate. Primary outcome was percentage change in BMD at the lumbar spine from baseline to 48 weeks and was assessed for non-inferiority. The same outcome was further assessed for superiority as a secondary endpoint.

RESULTS

Three hundred ninety-one and 196 participants were randomly assigned to the teriparatide or alendronate group, of whom 379 and 194 receiving at least one dose of teriparatide and alendronate treatment were eligible for the efficacy analysis. Teriparatide was non-inferior to alendronate for BMD change at lumbar spine (treatment difference: 0.7%, 95% CI: - 0.3 to 1.7%), which excluded the predefined non-inferiority margin of - 1.5%. However, teriparatide was not statistically superior to alendronate in improving BMD at lumbar spine (P = 0.169). At 48 weeks, changes in BMD at total hip were - 1.0% and 2.2% in teriparatide and alendronate group, respectively (P < 0.001). The incidence of new fracture showed no statistical difference between groups (P = 0.128). Serum P1NP and β-CTX levels significantly increased in the teriparatide group and markedly decreased in alendronate group (all P < 0.001 vs baseline). The adverse events (AEs) and serious AEs were more common in the teriparatide group than in the alendronate group, which were mainly teriparatide-related hypercalcemia, elevated alkaline phosphatase or parathyroid hormone, dizziness, and arthralgia.

CONCLUSIONS

Teriparatide was not inferior to alendronate in increasing BMD at lumbar spine in Chinese postmenopausal women, and they achieved these effects through different mechanisms.

Changing Characteristics of Pharmaceutical Prices in China Under Centralized Procurement Policy: A Multi-Intervention Interrupted Time Series

Objective: National centralized drug procurement organized by the Chinese government currently represents the largest group purchasing organization worldwide, to establish a reasonable price formation mechanism. This study aimed to evaluate the effects of centralized procurement policy on drug price and price ratio in China.

Method: Monthly drug procurement data of public medical institutions were extracted from the national procurement database, including 11 pilot cities and 36 months from January 2018 to December 2020. Centralized procured INNs (International Nonproprietary Names) (n = 25) and their alternative INNs (n = 96) were selected as study samples. Centralized procured INNs were divided into bid-winning and non-winning products according to the bidding results. Drug price, price distribution, and price ratio were measured. Multi-intervention interrupted time series analysis was performed to estimate the policy impacts in two centralized procurement periods.

Results: The price of centralized procured INNs showed an immediate drop of 44.57% (β = -0.59, p < 0.001) at the policy implementation, among which bid-winning drugs decreased by 61.71% (β = -0.96, p < 0.001). No significant change in the price level or trends was found for non-winning products and alternative drugs in the first-year procurement period (all p-values > 0.05). During the second-year procurement period, alternative drugs in four therapeutic categories detected significant increases in the price level (all p-values < 0.05). The overall coefficient of variation of price distribution exhibited upward trends after policy implementation. Among the most centralized procured INNs, the price ratio between certificated generics (generics that have passed the consistency evaluation) and original drugs declined significantly after policy intervention (p < 0.05), whereas the price ratio between uncertificated and certificated generics increased significantly (p < 0.05).

Conclusion: Chinese government-organized group purchasing resulted in prominent price reduction of bid-winning drugs. The policy observed a short-term “spillover” effect of synergistic price reduction, while the effect wore off after 1-year procurement period. The extremely dispersed price distribution, as well as unreasonable price ratios, requires further effective price regulation means.

Efficacy of Yigu® versus Aclasta® in Chinese postmenopausal women with osteoporosis: a multicenter prospective study

Zoledronic acid (ZOL) is a therapy inhibiting bone resorption. In this study, generic ZOL (Yigu®) showed its clinical efficacy consistency with original ZOL (Aclasta®) in Chinese postmenopausal women with osteoporosis. This study provides a practical basis for the application of Yigu® in Chinese population.

INTRODUCTION

Yigu® has been approved its bioequivalence to Aclasta®. However, the clinical efficacy and safety of Yigu® have not been evaluated yet. Here, we compared the effectiveness and safety between Yigu® and Aclasta® in Chinese postmenopausal women with osteoporosis and assessed the efficacy of intravenous infusion of ZOL.

METHODS

This was a randomized open-label, active-controlled study in postmenopausal women with osteoporosis of 14 clinical centers in China. Postmenopausal women with osteoporosis were recruited and randomized to receive a single infusion of 5 mg Yigu® or Aclasta®. The primary endpoint was the percentage change in bone mineral density (BMD) at lumbar spine after 12 months of treatment and was assessed for equivalence. The secondary endpoint was the percentage change in BMD at proximal femur after 12 months. Additional secondary endpoints were percentage changes in BMD at the above sites after 6 months of treatment and changes in bone turnover biomarkers during ZOL treatment. Safety was also evaluated and compared between two groups.

RESULTS

A total of 458 postmenopausal women with osteoporosis were enrolled (n = 227, Yigu®; n = 231, Aclasta®). The mean percentage change in the BMD had no statistical difference at the lumbar spine (5.32% vs 5.18%), total hip (2.72% vs 2.83%), and femoral neck (2.37% vs 2.81%) between Yigu® and Aclasta® groups after 12 months of treatment. The mean difference of BMD change at the lumbar spine after 12 months between two groups was 0.15% (95% CI: - 0.71 to 1.00, equivalence margin: - 1.5%, 1.5%), demonstrating the treatments were equivalent. Meanwhile, the decreases in the P1NP and β-CTX showed no difference between two groups after 14 days and 6 and 12 months of treatment. As regards the whole sample, BMD significantly increased after 12 months of treatment. Also, serum C-terminal telopeptide of type 1 collagen (β-CTX) and procollagen 1 N-terminal peptide (P1NP) significantly decreased at each visit period. The overall adverse events were comparable and quite well between two groups.

CONCLUSION

Intravenous infusion of zoledronic acid achieved the potent anti-resorptive effects which led to significant increase in BMD of Chinese postmenopausal women with osteoporosis. Yigu® was equivalent to Aclasta® with respect to efficacy and safety.