The expansion of the reimbursement decision space: A conceptual framework and taxonomy of new policy options

Abstract

Previously "fourth hurdle" decisions regarding whether to reimburse/cover/recommend new technologies on the basis of their cost-effectiveness have been considered largely binary in nature: based on the price set by the manufacturer and the evidence available a decision maker decides to either reimburse or not to reimburse the product. However, in recent years there has been an emergence of new policy options which expand the decision options available when considering new technologies with immature evidence bases. These include flexible pricing, risk sharing agreements, coverage with evidence development and patient access schemes.

This paper aims to provide a conceptual framework within which these new policy options can be evaluated focusing on the value of the technology, the value of evidence and the consideration of irreversibilities and sunk costs. On the basis of this framework a taxonomy of the new policies is defined. The goal is to help policy makers understand under what circumstances these different policy instruments may be beneficial to the health care system. Examples of these new policies in practice will then be critically examined in relation to the proposed framework.