Pharmaceutical Pricing Evidence From a Healthcare System With Multiple Cost-per-Quality-Adjusted Life-Year Thresholds.

Abstract

Objectives: To study drug pricing in a reimbursement system accepting a higher cost per quality-adjusted life-year for drugs targeting conditions of higher severity. We investigate whether higher incremental cost-effectiveness ratios (ICERs) are observed for conditions of higher severity, how close to the highest acceptable cost-per-quality-adjusted life-year threshold drug prices are set, and whether the thresholds are applied as price ceilings. Furthermore, we explore factors other than severity that might affect pricing.

Methods: Disease severity and ICERs were extracted from publicly available reimbursement decisions made between 2017 and 2024 by the Swedish Dental and Pharmaceutical Benefits Agency. Linear regression assessed whether ICERs increase significantly with severity and other covariates and whether the same covariates explain deviations from the highest acceptable ICERs. We also assessed whether higher severity was associated with a higher likelihood of having confidential rebates in place.

Results: A total of 84 decisions reported ICERs and disease severity. ICERs increased significantly with severity (P < .01). The average ICER was 30.6% lower than the relevant threshold, and there was no evidence of pricing above the thresholds. Very high severity was associated with a 27.4% higher probability than moderate severity of the ICER including confidential rebates (P < .01). ICERs including rebates were associated with 19.1 percentage points smaller deviations from the threshold (P < .01).

Conclusions: Prices tend to be set below the reimbursement system's thresholds and these appear to be ceilings, but decision makers should anticipate that drug companies will adjust prices in response to reimbursement policy, at least to some degree.