Financing and Reimbursement Models for Personalised Medicine: A Systematic Review to Identify Current Models and Future Options

Rositsa Koleva-Kolarova (), James Buchanan, Heleen Vellekoop, Simone Huygens, Matthijs Versteegh, Maureen Rutten- van Mölken, László Szilberhorn, Tamás Zelei, Balázs Nagy, Sarah Wordsworth and Apostolos Tsiachristas
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Rositsa Koleva-Kolarova: University of Oxford
James Buchanan: University of Oxford
Heleen Vellekoop: Erasmus University Rotterdam
Simone Huygens: Erasmus University Rotterdam
Matthijs Versteegh: Erasmus University Rotterdam
Maureen Rutten- van Mölken: Erasmus University Rotterdam
László Szilberhorn: Syreon Research Institute
Tamás Zelei: Syreon Research Institute
Balázs Nagy: Syreon Research Institute
Sarah Wordsworth: University of Oxford
Apostolos Tsiachristas: University of Oxford

Applied Health Economics and Health Policy, 2022, vol. 20, issue 4, No 6, 524 pages

Abstract: Abstract Background The number of healthcare interventions described as ‘personalised medicine’ (PM) is increasing rapidly. As healthcare systems struggle to decide whether to fund PM innovations, it is unclear what models for financing and reimbursement are appropriate to apply in this context. Objective To review financing and reimbursement models for PM, summarise their key characteristics, and describe whether they can influence the development and uptake of PM. Methods A literature review was conducted in Medline, Embase, Web of Science, and Econlit to identify studies published in English between 2009 and 2021, and reviews published before 2009. Grey literature was identified through Google Scholar, Google and subject-specific webpages. Articles that described financing and reimbursement of PM, and financing of non-PM were included. Data were extracted and synthesised narratively to report on the models, as well as facilitators, incentives, barriers and disincentives that could influence PM development and uptake. Results One hundred and fifty-three papers were included. Research and development of PM was financed through both public and private sources and reimbursed largely through traditional models such as single fees, Diagnosis-Related Groups, and bundled payments. Financial-based reimbursement, including rebates and price-volume agreements, was mainly applied to targeted therapies. Performance-based reimbursement was identified mainly for gene and targeted therapies, and some companion diagnostics. Gene therapy manufacturers offered outcome-based rebates for treatment failure for interventions including Luxturna®, Kymriah®, Yescarta®, Zynteglo®, Zolgensma® and Strimvelis®, and coverage with evidence development for Kymriah® and Yescarta®. Targeted testing with OncotypeDX® was granted value-based reimbursement through initial coverage with evidence development. The main barriers and disincentives to PM financing and reimbursement were the lack of strong links between stakeholders and the lack of demonstrable benefit and value of PM. Conclusions Public-private financing agreements and performance-based reimbursement models could help facilitate the development and uptake of PM interventions with proven clinical benefit.

Date: 2022
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DOI: 10.1007/s40258-021-00714-9

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