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Background: The appropriate use of medicines has long been recognized as a fundamental component of medicine policies. We aimed to extract lessons from published research on how policy contexts and mechanisms can affect the outcomes of national- or health-system level interventions to promote appropriate medicine use (defined as an increase in underutilized medications or decrease in inappropriate medication use)., Methods: We conducted a rapid realist review of published evidence concerning system-level policies to promote the appropriate use of medicines in high-income countries with universal prescription drug coverage. We searched MEDLINE and Embase to identify relevant publications. We used a realist evaluation framework to identify contexts, mechanisms, and outcomes for each intervention and to hypothesize which policy contexts and mechanisms supported successful outcomes in terms of relative changes in the prevalence of use of the specific medication classes targeted., Results: From 1,318 identified studies, 18 met our inclusion criteria. 13 distinct policies were identified. Three main policy-related factors underpinned successful interventions: involving providers and patients through program interventions; central coordination through national agencies dedicated to medicine policies; and the establishment of an explicit and integrated national medicine policy strategy., Conclusion: Policymakers can improve coordination of national pharmaceutical policies to reduce harms from inappropriate medicines use, thus improving health outcomes through cost-effective programs., Competing Interests: Declaration of competing interest MC has no real or perceived conflicts of interest; SM has no real or perceived conflicts of interest; CG has no real or perceived conflicts of interest; CAS discloses funding from Pfizer Canada (project: A Quality Improvement Project to Address lower urinary tract symptoms by pharmacists in the community, $109,000.00); JLS has no real or perceived conflicts of interest; CT has no real or perceived conflicts of interest; JPT has no real or perceived conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Because not all medicines are equally safe, effective, and affordable, health systems often use formularies to define explicitly which medicines will be included and excluded from coverage., Objective: We sought to synthesize methods and findings from published studies of formulary variation across health systems in high-income countries., Methods: We conducted a systematic review of peer-reviewed research papers published from 2000 to 2017, inclusively. Because of the heterogeneous nature of the literature, we used an inductive approach to summarize methods and findings., Results: Nine studies met our study inclusion criteria. Included studies used a variety of methods for selecting medicines for analysis, for measuring coverage levels, and for measuring concordance between formularies. Studies assessing variations in coverage of all licensed medicines and found lower rates of cross-national coverage variation than studies of coverage for selected specialty drugs and indications. The one study that focused on coverage of high-volume medicines found the most complete and consistent levels of formulary listings across countries., Conclusion: Although published studies contain interesting findings that likely have prompted discussions about their policy implications, the literature can be improved with greater transparency concerning the overarching objective of work in this area and more rigor concerning the selection, analysis, and reporting of data., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: We sought to estimate size and sources of differences in per capita expenditures on primary care medications in the US versus ten comparable countries combined: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom., Methods: Using market research data on year 2015 volumes and sales of medicines, we measure total per capita expenditures on six categories of primary care prescription drugs: hypertension treatments, pain medications, lipid lowing medicines, non-insulin diabetes treatments, gastrointestinal preparations, and antidepressants. We quantified the contributions of five drivers of the observed differences in per capita expenditures., Results: We estimated that the US spent 203% more per capita on primary care pharmaceuticals than did the ten comparable countries. Despite the difference in spending levels, on average, Americans actually purchased 12% fewer days of related therapies than residents of the comparator countries. Most of the observed difference in expenditures was due to higher transaction prices of medicines and the use of a more expensive mix of medicines in the US., Conclusions: If utilization patterns and pharmaceutical prices in the US were similar to those in the 10 comparator countries combined, total spending on primary care pharmaceuticals would fall by 30% or more. Such evidence on the level and drivers of US pharmaceutical expenditures should inform policies in this sector., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: With the launch of very highly priced therapies and sudden price increases of generics, pressures on health systems have drastically increased., Objectives: We aimed to elicit opinions of key decision makers responsible for national assessment and funding decisions on their experiences to adapt to these new realities., Methods/setting: Through interviews with decision makers of pharmaceutical assessment and/or funding agencies, we describe the challenges systems are currently facing, systems' responses and systems' characteristics facilitating or hindering responses to changes and overarching topics for the future., Results: Among the most common challenges are increased funding pressures, increased uncertainty and lack of transparency in decision-making. Systems' responses include utilization management, changing of assessment processes, stakeholder engagement and a focus on outcomes and on coordinated negotiations. Integrated delivery systems, fixed health care budgets and geographic and historical characteristics facilitate or sometimes hinder responses to change. Future policy emphasis lays on expanding data structures, managing the exit of drugs funded early, and implementing processes for communications with patients and the public., Conclusions: Going forward emphasis has to be given to structured communications with all stakeholders with a specific emphasis on the broader public and patients about financial limits and priority setting in health care., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Institutional payers for pharmaceuticals worldwide appear to be increasingly negotiating confidential discounts off of the official list price of pharmaceuticals purchased in the community setting. We conducted an anonymous survey about experiences with and attitudes toward confidential discounts on patented pharmaceuticals in a sample of high-income countries. Confidential price discounts are now common among the ten health systems that participated in our study, though some had only recently begun to use these pricing arrangements on a routine basis. Several health systems had used a wide variety of discounting schemes in the past two years. The most frequent discount received by participating health systems was between 20% and 29% of official list prices; however, six participants reported their health system received one or more discount over the past two years that was valued at 60% or more of the list prices. On average, participants reported that confidential discounts were more common, complex, and significant for specialty pharmaceuticals than for primary care pharmaceuticals. Participants had a more favorable view of the impact of confidential discount schemes on their health systems than on the global marketplace. Overall, the frequency, complexity, and scale of confidential discounts being routinely negotiated suggest that the list prices for medicines bear limited resemblance to what many institutional payers actually pay., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Pharmaceutical policy makers are increasingly negotiating reimbursement contracts that include confidential price terms that may be affected by drug utilization volumes, patterns, or outcomes. Though such contracts may offer a variety of benefits, including the ability to tie payment to the actual performance of a product, they may also create potential policy challenges. Through telephone interviews about this type of contract, we studied the views of officials in nine of ten Canadian provinces. Use of reimbursement contracts involving confidential discounts is new in Canada and ideas about power and equity emerged as cross-cutting themes in our interviews. Though confidential rebates can lower prices and thereby increase coverage of new medicines, several policy makers felt they had little power in the decision to negotiate rebates. Study participants explained that the recent rise in the use of rebates had been driven by manufacturers' pricing tactics and precedent set by other jurisdictions. Several policy makers expressed concerns that confidential rebates could result in inter-jurisdictional inequities in drug pricing and coverage. Policy makers also noted un-insured and under-insured patients must pay inflated "list prices" even if rebates are negotiated by drug plans. The establishment of policies for disciplined negotiations, inter-jurisdictional cooperation, and provision of drug coverage for all citizens are potential solutions to the challenges created by this new pharmaceutical pricing paradigm., (Copyright © 2013 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Introduction: Despite first-dollar public coverage for hospital and physician services, Canadians spend more privately on health care than citizens of most other developed countries. We quantified recent growth in private payments by Canadian households for health care., Methods: Using data from 163,081 respondents to Statistics Canada's annual Survey of Household Spending from 1998 to 2009, we calculated inflation-adjusted per-household spending on private health insurance premiums and out-of-pocket payments on six types of health care services. Further, we estimated the prevalence and some socio-economic determinants of households spending over 10% of after-tax income on health care using logistic regression., Results: We found that Canadian households spent $19.8 billion on private payments for health care in 2009. This represents an average of $1523 per household-a 37% increase over 1998. The top three spending categories in 2009 were private health insurance premiums ($5.9 billion), dental ($4.9 billion) and prescription drugs ($4.2 billion). Even after adjusting for inflation, expenditure on every category of health care spending increased between 1998 and 2009. The proportion of households spending more than 10% of after-tax income on health care increased by 56% (from 3.3% to 5.2%). Households including a senior, with a low income, and in British Columbia or the Atlantic Provinces were significantly more likely to reach this threshold., Interpretation: Over the period studied, the burden of private health care expenditures increased substantially for Canadian households. As direct charges reduce the use of necessary health care services, investigation into the health consequences of these increases is warranted., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Canada is the only developed country that has established universal coverage for hospital care and physician services that excludes medically necessary prescription drugs. Lack of public interest in expanding universal coverage to prescription medicines may be one critical factor in explaining this policy puzzle. Historical levels and patterns of attention to financing issues in the media may have implications for public awareness and support for such major health reform. We thus examined the quantity, context, and patterns of coverage of public drug financing in national print media in Canada from 1990 to 2010. We conducted a time series analysis of monthly newspaper article counts to quantify trends in coverage and analyzed article content by applying Down's theory of the "issue-attention cycle" of political attention. We found that baseline coverage of this issue was low throughout the past twenty years with few cycles of increased attention, initiated by focusing events related to general health reform. Issue-attention cycles were driven by coverage of proposed policy solutions simultaneously accompanied by lower levels of coverage of policy problems and barriers to change, before fading rapidly from attention. The observed patterns of media coverage and the intrinsic characteristics of this policy issue suggest that any momentum for reform (or lack thereof) is likely to be driven by elite members of the policy community rather than by way of public engagement. This has implications for the probability of reform and which options may be considered or eventually implemented, as policies developed within elite policy communities may tend to reflect niche interests rather than being reflective of principled policy goals., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To describe recent changes and identify emergent trends in public drug benefit policies in Canada from 2000 to 2010., Methods: For each province, we tracked pharmacare design (namely eligibility, premiums, and patient cost-sharing) over time for three beneficiary groups: social assistance recipients, seniors, and the general non-senior population. We assess which plan designs are emerging as a national standard, where the gaps in public coverage remain, and implications for progress towards national pharmacare., Results: Expansion of public drug coverage has been limited. For social assistance recipients, first-dollar coverage is the standard. Seniors coverage remains varied, though means testing of eligibility or cost-sharing is common. Seniors benefits were significantly expanded in only one province. As of 2010, six provinces have embraced age irrelevant catastrophic income-based coverage, in some, resulting in the elimination of seniors drug benefits., Conclusions: Universal income-based catastrophic coverage appears to be emerging as an implicit national standard for provincial pharmacare. However, due to the variation and high level of patient cost-sharing required under these programs, convergence on this model does not equate to substantial progress towards expanding coverage or reducing interprovincial disparities. Leverage of federal spending power to promote standards for public drug coverage is necessary to uniformly protect Canadians against high drug costs., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

We develop an analytic framework to map out the nature and relative importance of different cost-driving trends in the prescription drug market. This is used to measure prescription drug cost-drivers for the population of seniors in British Columbia during a period when they received comprehensive public drug coverage. Between 1991 and 2001, expenditures on prescription drugs for BC seniors increased from dollar 149 to 320 million. Increases in the population of seniors, and the rate at which they utilized therapies contributed under half of the total cost increase over the period. Changes in the mix of therapies and the type of product selected explained over half of the observed drug expenditure inflation. Increased generic substitution significantly reduced the price of products selected over the period.