Over the past thirty years, pharmaceutical expenditure has steadily increased in most countries of the Organization for Economic Co-operation and Development (OECD). The need to finance new, often high-cost therapies leads governments to actively "disinvest" products with low therapeutic value, the cost of which was judged to be too high compared to the expected benefit.
Disinvestment has been the subject of many conceptualizations, but it can be defined above all as “partial or complete withdrawal of health resources from any existing health care practices, procedures, technologies or drugs that are deemed to deliver little or no health gain for their cost, and thus are not efﬁcient health resource allocations”.
Disinvestment can take two forms, passive and active. The first is not linked to the direct intervention of the public authorities: a drug will thus be withdrawn from the market by the manufacturer for commercial reasons or because of identified safety problems or simply progressively phased out by the prescribers. Active divestment is driven by a strong political will to improve efficiency of health care through measures that relieve pressure on pharmaceutical budgets and improve the quality of care provided. It is characterized by the withdrawal of certain drugs from public funding (e.g. cancellation of reimbursement lists), by limiting treatment to certain subgroups of patients, by modifying prices or reimbursement rates, or by promoting generic prescribing.
This Issue in Health Economics, which is based on an international study published in the journal PharmacoEconomics in 2015, aims to evaluate the partial or full disinvestment policies of some publicly funded or subsidized drugs in five OECD countries (Australia, Canada, France, New Zealand and the United Kingdom). Experiences in these countries can provide useful insights to other countries which are considering this type of disinvestment, and thus improve the financing capacity of innovative and costly medicines.
While countries rely more heavily on passive disinvestment, they tend to increasingly resort to active disinvestment. We have distinguished between mandatory disinvestment initiatives (e.g., de-listing), incentives (e.g. pharmacist incentives for generic substitution) and initiatives that are simply an encouragement (e.g. recommendations of good practice). We also distinguished two approaches: a generalized approach (for example, by encouraging prescribing generics) and a targeted approach (for example, by restricting treatment to certain subgroups of patients).
Among the different methods used for divesting pharmaceuticals, the most radical, the radiation of medicines from the lists of treatment, is also the one that is the most difficult to implement. Apart from France, which revised in the 2000s its entire pharmacopoeia and drew the consequences of its re-evaluation by massively deregistering products of insufficient therapeutic value, no country has relied heavily on this method. Pressures from healthcare professionals, patient lobbies and pharmaceutical laboratories generally succeeded in counteracting this type of initiative. The other methods – price reduction, generics, treatment restrictions to subpopulations – are more frequently used to a greater or lesser degree by the countries studied.
As these different methods have shown their limits, public authorities should ensure that other means of disinvestment (for example, price reductions or care restrictions) are identified prior to admission to care, or to negotiate a priori discounts in order to ensure that the medicines they reimburse remain efficient while new elements of scientific evidence or the arrival of generics in the class in question modify the cost / benefit ratio of the product. This issue of disinvestment is all the more crucial as the requirements for admission to reimbursement are less severe.
Interview by Anna Marek