GPs working in clinical commission-ing groups (CCGs), supported bytheir medicines management teams,now have a gatekeeper role and willneed to establish mechanisms for man-aging the entry of new medicines intoclinical practice and also deciding whichestablished drugs they should supportin their formularies.
Innovative proposals from manufac-turers for optimising a medicines clinicaleffectiveness or making it more cost-effective in comparison to a competitorsproduct provide an opportunity for newCCG commissioners to think again aboutwhether to list certain drugs on a formu-lary and support their use locally.
Volume-based rebatesVolume-based rebates are based onagreement to offer cash reimbursementto commissioners when predeterminedusage thresholds for a particular productare met or exceeded. These schemesoffer the potential for significant savingsin common chronic diseases like COPD ordiabetes or product areas such as enteralnutrition.
A simple scheme might involve amanufacturer offering a cash rebatedirect to the CCG based on the volume ofa particular product prescribed. In more
complex schemes the cash sum might bebased on the percentage of the productprescribed.
Such schemes can work well for theCCG if the product involved is either abranded generic and therefore equivalentto competitors or is as effective as otherdrugs in a class.
However, there are potential pitfalls.CCGs will need to ensure that the manu-facturer is not going to raise the cost ofthe product once patients have beenswitched to it. The deal also needs to berobust so that if competitors lower theirprices the cost of the product will also fallaccordingly (see Table 1).
The longevity of any deal is importantas it is becoming an increasing concernthat patients may be being switched toooften and that some GPs are increasinglyunwilling to take part in switch pro-grammes.
Value-added servicesIt is not always about the money. In thepast and maybe increasingly so in thefuture, manufacturers may offer addi-tional help and support for variousaspects of patient care and support forthe CCG. In return CCGs will be asked tochoose their particular brand of a drug.
Prescriber 5 September 2013 z 55prescriber.co.uk
Pharma deals for CCGs: too hard to ignore?Inderjit Singh MSc, MRPharmS, PDip
GPs working in CCGs nowhave a role in managing theentry of drugs into their localformularies. The authordescribes the variousschemes offered by manu -facturers that allow CCGs tomake savings when theirproducts are purchased.
nmanaged entry of medicines is important to ensure finan-cial control
n the pharmaceutical industry will work in partnership tosupport cost-effective prescribing
n outcome-based agreements can be utilised to share thefinancial risk of prescribing new drugs
n along with scoping reduced acquisition costs, there areopportunities to work in partnership to deliver improvedclinical outcomes that will bring down overall spend byreducing co-morbidities and polypharmacy
The help may be as simple as auditsupport to assess adherence with theQuality and Outcomes Framework (QOF)or a grant to support a new service offer-ing such as a specialist nurse-led clinic.
Care needs to be taken when settingup services to ensure that funding iseither sustained or plans are made forwhen the funding ceases.
Outcome-based rebatesOutcome-based rebates use data onspend and short-term proxy outcomemeasures to underwrite the promisedperformance of a new drug when trialsare compared with those observed inpractice. In these schemes the manufac-turer shares the risk with the NHS com-
missioner that a drug will not perform aspredicted. Data are then collected andoutcomes from treatment observed inpractice are compared with those pre-dicted in the agreement.
Such schemes will offer to reimbursethe full cost when medicines have notworked at all when used over a reason-able time period on the basis that theNHS should not be expected to pay fortreatment failures. These schemes mayalso share the risk between the manufac-turer and the commissioner on the basisthat a certain amount of treatment failurewill be due to patient nonadherence.
Adherence supportImproving adherence has the potential togreatly improve clinical outcomes.Manufacturers may offer packages ofsupport alongside their products thatmight include telehealth options wherepatients are contacted regularly toencourage adherence and possibly tomanage certain problems.
Simple telehealth solutions devel-oped and deployed by manufacturerscan greatly improve performance of theirmedicines in terms of achievement ofshort-term clinically-orientated out-comes as proxies for long-term out-
comes. New CCG commissioners maywish to buy into this.
Legal restraintsIt is important to note that tendering in pri-mary care is not permitted under the cur-rent Pharmaceutical Price RegulationScheme (PPRS) pricing system, whichstates: The UK health departments do notsupport additional or alternative initiativesby health authorities in respect of the pric-ing of such supplies (branded prescriptionmedicines) in primary care. Therefore,manufacturers cannot at the momentoffer discounts on the actual drug costs.
CCGs will need to carefully considercash-back schemes to avoid legal pot-holes, and if a proposed scheme is vol-ume based they also need to carefullyconsider its robustness and the full costof implementation. However, it is likelythat added-value schemes will be diffi-cult for CCG commissioners to ignore.
Declaration of interestsNone to declare.
Inderjit Singh is chief pharmacist,University Hospitals Birmingham NHSFoundation Trust, Queen ElizabethHospital
n ANALYSIS l CCG deals
56 z Prescriber 5 September 2013 prescriber.co.uk
Table 1. Glucophage SR retrospective discount scheme an example of a scheme that still works even if a com-petitor lowers their price
company offer a 12.5% rebate on the cost ofGlucophage SR prescribed in the CCG
metformin SR is a category C product so coststhe same whether prescribed by generic or bybrand
if generic metformin SR ever becomes cheaperthan Glucophage SR, the company promises toreimburse the difference plus the discount