Value-based Strategies for Encouraging New Development of Antimicrobial Drugs i
Value-basedStrategiesforEncouraging NewDevelopmentofAntimicrobialDrugs
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AbouttheDuke-MargolisCenterforHealthPolicy
TheRobertJ.Margolis,MD,CenterforHealthPolicyatDukeUniversitybringstogetherexpertisefromtheWashington,DCpolicycommunity,DukeUniversityandDukeHealthtoaddressthemostpressingissuesinhealthpolicy.
TheCenter’smissionistoimprovehealthandthevalueofhealthcarebydevelopingandimplementingevidence-basedpolicysolutionslocally,nationally,andglobally.Formoreinformation,visithealthpolicy.duke.edu.
AuthorsGregoryW.DanielDeputyDirector,Duke-RobertJ.Margolis,MD,CenterforHealthPolicyandClinicalProfessor,FuquaSchoolofBusiness,DukeUniversity
MarkB.McClellanDirector,Duke-RobertJ.Margolis,MD,CenterforHealthPolicyandRobertJ.Margolis,MDProfessorofBusiness,MedicineandHealthPolicy,DukeUniversity
MonikaSchneider
ResearchAssociate,Duke-RobertJ.Margolis,MD,CenterforHealthPolicy,DukeUniversity
JingyuanQian
SeniorResearchAssistant,Duke-RobertJ.Margolis,MD,CenterforHealthPolicy,DukeUniversity
GabrielaLavezzariSVPBusinessDevelopment,Biocerna(formerlyResearchDirector,Duke-RobertJ.Margolis,MD,CenterforHealthPolicy,DukeUniversity)
EllendeGraffenreidDirectorofCommunications,Duke-RobertJ.Margolis,MD,CenterforHealthPolicy,DukeUniversity
AdvisoryGroupHalaAudiHead,UKAntimicrobialResistanceReviewTeam
PatrickCourneyaExecutiveVicePresident,Hospitals,QualityandCareDeliveryExcellenceChiefMedicalOfficer,MedicareAdvantage,CostandPrescriptionDrugPlans,Kaiser
EdCoxDirector,OfficeofAntimicrobialProducts,CenterforDrugEvaluationandResearch,FoodandDrugAdministration(FDA)
VanceFowlerProfessorofMedicineandinMolecularGeneticsandMicrobiologyandMemberofDukeClinicalResearchInstitute,DukeUniversitySchoolofMedicine
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RobertGuidosAssociateDirectorforLegislativeAffairs,CenterforDrugEvaluationandResearch,FoodandDrugAdministration(FDA)
StephanHarbarthHead,DRIVE-ABProject,InnovativeMedicinesInitiative
AmandaJezekVicePresident,PublicPolicyandGovernmentRelations,InfectiousDiseasesSocietyofAmerica
JoeLarsenDeputyDirector(Acting),BiomedicalAdvancedResearchDevelopmentAuthority(BARDA)
RamananLaxminarayanDirector,CenterforDiseaseDynamics,Economics&Policy
ShariLingDeputyChiefMedicalOfficer,CentersforMedicareandMedicaidServices(CMS)
LynnMarksSVP,SeniorClinicalAdvisor,InfectiousDisease,GlaxoSmithKline
CliveMeanwellCEO,TheMedicinesCompany
SteveMillerSeniorVicePresidentandChiefMedicalOfficer,ExpressScripts
SumathiNambiarDirector,DivisionofAnti-InfectiveProducts,CenterforDrugEvaluationandResearch,FoodandDrugAdministration(FDA)
KevinOuttersonProfessorofLaw,BostonUniversityExecutiveDirector,CARB-X
EdmundPezallaScholarinResidence,Duke-MargolisCenterforHealthPolicy,DukeUniversityFormerVicePresident,NationalMedicalDirectorforPharmacyPolicyandStrategy,Aetna
CharleneReedCEO,FoundationtoCombatAntimicrobialResistance
JohnRexChiefStrategyOfficer,CARB-XChiefMedicalOfficer,F2G,Ltd.(formerly)SeniorVice-PresidentandChiefStrategyOfficerforInfectiousDiseases,AstraZeneca
John-ArneRottingenAssociateFellowCentreonGlobalHealthSecurity
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ArjunSrinivasanAssociateDirector,HealthcareAssociatedInfectionPreventionPrograms,DivisionofHealthcareQualityPromotion,CentersforDiseaseControlandPrevention(CDC)
MelissaStundickHeadofStrategicAlliances,SperoTherapeutics
EugeneSunChiefExecutiveOfficer,MelintaTherapeutics
UrsulaTheuretzbacherFounder,CentreforAnti-InfectiveAgents
BrentWallaceChiefMedicalOfficer,IntermountainHealthcare
BlakeWisePresidentandChiefOperatingOfficer,Achaogen,Inc.
Acknowledgments:TheauthorswouldliketoacknowledgethefeedbackandguidancethatwereceivedfromourAntimicrobialPaymentReformAdvisoryGroup,andtothankthemforthetimeandeffortthattheycontributedtothedevelopmentofthisproposal.ThisworkwassupportedbyfundsfromtheU.S.FoodandDrugAdministrationandfromMerck&Co.
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TableofContentsExecutiveSummary..............................................................................................................................1
Overview..............................................................................................................................................3
TheProblem.........................................................................................................................................3Weakantimicrobialpipelinewithlowreturnoninvestmentrelativetopublichealthvalue...................3Reimbursementforhigh-priorityantimicrobialsdoesnotreflectpublichealthbenefit...........................4Evidenceofsuperiorityfromclinicaltrialsisnotroutinelyfeasible..........................................................4Diagnosticuncertaintylimitsappropriateuse.........................................................................................5Appropriatestewardshipmeanslowervolume........................................................................................5Fee-for-servicepaymentsfailtoencourageappropriateuse...................................................................6Consequencesofinadequatemarketreimbursementfordevelopment..................................................6
Effortstoimproveantimicrobialdevelopment.....................................................................................6Global“push”and“pull”incentives.........................................................................................................6GlobalsupportforaMarketEntryReward..............................................................................................7U.S.incentives..........................................................................................................................................8
PathforaccomplishingdelinkageintheU.S.......................................................................................10Coreprinciples........................................................................................................................................10
PriorityAntimicrobialValueandEntryAward....................................................................................12QuickAccesstoFundsthroughaMarketEntryReward.........................................................................12Transitioningtopaymentsthatsupportvalue.......................................................................................13
Implementationissues.......................................................................................................................14Determiningeligibledrugcandidates....................................................................................................14Developingevidenceforvalue-basedcontracts.....................................................................................14Financingmechanisms...........................................................................................................................15CareSettings..........................................................................................................................................16DrugsforRareInfections........................................................................................................................17TransitiontoRoutineUseofValue-BasedPaymentsforAntimicrobials................................................17
Conclusion..........................................................................................................................................17
Appendix1.U.S.NetSalesofNew-Molecule,Brand-NameAntibioticDrugsApprovedafter2000,inU.S.dollars(millions)..........................................................18
References.........................................................................................................................................19
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ExecutiveSummaryResistancetocurrentantimicrobialdrugsisagrowingsourceofmorbidity,mortality,andhealthcarecosts.Challengingmarketdynamicshaveledtoaweakpipelineofdrugcandidatestorespondtothesethreats.Combined,thesetwotrendsrepresentasignificantandgrowingthreattoUSandglobalhealthpreparedness.
Mostcompanieshaveexitedtheantimicrobialmarket,andthosethatremainareworkingonasmallnumberofdrugs.Lowreturnoninvestment(ROI)relativetobroadpublichealthbenefitsisamajorcontributortothesparsepipelineofdrugstargetingmultidrug-resistantorganismsthatposeseriouspublichealththreats.LowROIisdrivenlargelybyappropriateantimicrobialstewardshipprograms(ASPs)thatlimittheuseofinnovativetherapiestoappropriatepatients,availabilityofeffectiveandlow-costgenericsfortypicalinfectionsthatlimitnovelantimicrobialuse,andareimbursementsystemthatdoesnotreflectthetruepublichealthvalueofeffectivedrugsformultidrug-resistantorganisms.Inparticular,antimicrobialsforhigh-priority,resistantorganismshaveapublichealthvaluethatfarexceedsthefee-for-service(FFS)paymentforthepatientswhoactuallyhaveresistantinfections.Rather,theirvalueincludesbeingavailableforusewhennecessarytostemthespreadofresistantmicrobesbeforetheytakehold.Becauseofthesechallengingmarketconditions,awiderangeofglobalexperts(includingChathamHouse,theAMRReviewinLondon,andtheDRIVE-ABconsortiumintheE.U.)haverecommendedmuchstrongermarketentryor“pull”economicincentivestoencourageinvestmentstobringsuchantimicrobialstomarket.
However,theseapproacheshavenotyettakenhold.Thepublicinvestmentrequiredisdauntingatatimeofincreasingfiscalpressures.Moreover,bringingaproducttomarketdoesnotassureitscontinuingavailabilityandappropriateuse.Further,theU.S.healthcaresystemreliesonmultipleprivatepayersaswellaspublicfinancing,andapublicfundingapproachmightcrowdoutprivatespendinganddeliverysystems.
TheDuke-MargolisCenterforHealthPolicyisdevelopingU.S.policyapproachesthatcouldprovidebettereconomicincentivestoantimicrobialdevelopersthatsuccessfullybringeffectivedrugstothemarket,providingasocietalbenefitthatexceedsthecostoftheincentive.Workingwithabroad-basedadvisorygroup,Duke-Margolishasdevelopedaproposalforapublicly-leveraged,value-basedpaymentmodeltoaddressthesechallengesinaU.S.context.TheCenterbaseditsworkonseveralprinciples:bepartofacomprehensivestrategy;promoteinnovation,access,andstewardship;besustainableandpredictable,leveragepublicmoneywithprivatefunds;providerapidaccesstofundsuponmarketentry;andalignwithbroadershiftsintheU.S.healthcaresystemtovalueandquality.
OurPriorityAntimicrobialValueandEntry(PAVE)Awardproposalcombinesamarketentryrewardwithpopulation-basedpaymentsfrompublicandprivatepayersthatphaseinovertime.ThemarketentryrewardprovidesfundsoverearlyyearsofmarketingafterFDAapproval.Subsequentpaymentsrelyonthedevelopertoincreaserevenuefrompopulation-basedcontractswithpayersthatarelinkedtovaluetosocietythroughinfectionprevention,availability,supportforsustainableuse,andcontinueddatacollection.Byleveragingbothpublicandprivatesupport,thePAVEAwardprovidesdeveloperswithquickaccesstoasignificantrewarduponmarketentryaswellasstrongincentivesformanufacturerstoengagewithpayersinshiftingreimbursementfromFFStopopulation-basedcontractsthatsupporthigh-value,sustainableuse.ThePAVEAward’srisk-sharingmodeldelinksROIfromvolumeusetorewardandsupportavailabilityandappropriateuseofeffectiveantimicrobials.Thismodeladdressesthefundamentalneedforpublicinvestmentindrugsthatcombatresistantbacterialinfectionsbyresolving
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thecurrentconflictbetweenthedriversofROIandstrongstewardshipprograms,whilereinforcingthe“volumetovalue”shiftinhealthcarepayments,andleveraging,ratherthanreplacing,privatefinancing.Finally,themodelcancomplementandbuilduponapproachessupportedbyprivatefoundations,othercountries,andmultinationalorganizationstofurthergenerateglobalsupportforthedevelopmentofpriorityantimicrobials.
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OverviewIncreasingantimicrobialresistance(AMR)isaseriousandgrowingglobalpublichealththreat.IntheU.S.alone,theseinfectionsaffectmorethantwomillionpeopleannually,causeanestimated23,000deaths,andgenerateanestimatedeconomicburdenexceeding$55billion.1Ifcurrenttrendscontinue,300millionpeopleworldwideareexpectedtodieprematurelyinthenext35yearsduetoantimicrobialresistantinfections.2
InappropriateuseofexistingantimicrobialscontributestothedevelopmentofAMR.Onethirdofthe266.1millioncoursesofantibioticsdispensedtooutpatientsintheU.S.in2014wereeitherunnecessaryorinappropriate,atadirectcostofover$1billionperyear.3–5Further,theIMSInstituteforHealthcareInformaticsestimatesthatantibioticmisuseleadstomorethan$35billioninavoidablecosts.Highprescriptionratesforbroad-spectrumdrugsfurthercontributetoAMRbyincreasingtheselectivepressureonallbacteriatodevelopbroaderresistance.Unfortunately,limiteddevelopmentandadoptionofeffectiveandrapiddiagnostictoolsinclinicalpracticehinderstheuseofnarrow-spectrumantibiotics,whichtargetgroupsofbacteriamoreselectively.
In2013,theCentersforDiseaseControlandPrevention(CDC)releasedareportdetailingthemosturgentresistantbacterialthreatstopublichealth.6Additionaltypesofinfectionsarefacingadwindlingnumberoftreatmentoptions,andtheWorldHealthOrganization(WHO)independentlyidentifiedtwelveprioritybacterialpathogensthatshouldbecometheprimaryfocusofresearchanddevelopment(R&D)efforts.7AlthoughthepublichealththreatsandR&Dprioritieshavebeenidentified,thepipelineofpotentialtreatmentsislimited,highlightingtheneedforpoliciesthatprovidefinancialincentivestosupportdevelopmentandavailability.
Thispaperdescribeshowtostimulateinvestmentindevelopmentandappropriateuseofhighpriorityantimicrobialdrugs,includinganewproposalthatreflectsU.S.andglobaltrendstowardvalue-based,notvolume-basedpaymentsystems.Ourrecommendationsreflectworkguidedbyamulti-stakeholderAdvisoryGroupthatincludesrepresentativesfromprivateandpublicpayers,pharmaceuticalcompaniesofallsizes,professionalsocieties,academicresearchers,thinktanks,governmentagencies*andpatientadvocacyorganizations,aswellasthroughinteractionswithstakeholdersduringanexpertworkshopandpublicmeeting.
TheProblemWEAKANTIMICROBIALPIPELINEWITHLOWRETURNONINVESTMENTRELATIVETOPUBLICHEALTHVALUE
Avibrantandinnovativeantimicrobialdrugpipelineisneededtoaddressthegrowingpublichealththreatofresistantorganisms,yetasmallnumberofcandidatesareindevelopment.Oftheapproximately40potentialdrugsinclinicaldevelopment,onlysixteenaretargetedtoward“urgent”pathogensand,basedontypicalattritionratesacrossdrugdevelopment,onlysixofthesesixteenareexpectedtobeapprovedbetween2017and2024.8,9Incomparison,morethan170drugsfordiabetesandmorethan700forcancerareinvariousstagesofclinicaldevelopment.10,11
*e.g.,theBiomedicalAdvancedResearchandDevelopmentAuthority(BARDA),theCentersforDiseaseControlandPrevention(CDC),theNationalInstitutesofHealth(NIH),andtheU.S.FoodandDrugAdministration(FDA)
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Onereasonforthelimitedpipelineistherelativelyhighcostanddifficultyofdevelopingantimicrobialsanddemonstratingtheireffectiveness.Drugdevelopmentinmanyclinicalareasisexpensiveandrisky;estimatedcostsacrossallareasrangeupto$1.2-$2.6billionfornoveldrugs,andittakesroughly8yearsformarketapprovalfrominitialINDfiling,withanoverallsuccessrateof10percent.9,12,13Butthereareotherparticularmarket-relatedchallengesthatleadtoinadequateinvestmentinantimicrobialresearchanddevelopment.
REIMBURSEMENTFORHIGH-PRIORITYANTIMICROBIALSDOESNOTREFLECTPUBLICHEALTHBENEFIT
Alongsidesubstantialdevelopmentcostsanduncertainty,thefinancialrewardsforbringingpriorityantimicrobialstomarketarelow.ProductdevelopersevaluatemarketopportunitiesbasedonNetPresentValue(NPV)analysis,whichcomparestheinvestmenttogetadrugtomarketwiththeprojectedfuturereturnsintoday’sdollars.A2014studyfromtheEasternResearchGroupcalculatedaNPVforantimicrobialdrugsintherangeof-$4.5millionto$37.4million,mainlyduetolimitedmarketrevenues.14,15Between2011and2015,themedianyearlysalesofbrand-nameantibioticswithunexpiredpatentsrangedfrom$24millionto$75million(Appendix1)*,comparedtomorethan$500millionformostbrand-nameoncologydrugsapprovedduringthesameperiod.16Amongthesixteennew,brand-nameantimicrobialsapprovedsince2000,onlyfivehavegeneratedannualsalesofmorethan$100million*.Blockbusterdrugstatusrequiresannualsalesover$1billion;antibioticsstruggletoreach10percentofthatgoal.ANPVof$200milliongenerallyhasbeenviewedasabenchmarkabovewhichcompaniesmightdeeminvestmentworthwhile,althoughthisbenchmarkmayvarybysizeandtypeofcompany.17
Incontrasttoreturnsforinnovativetherapiesfornon-communicablediseases,themarketreturnstoantimicrobialdevelopersarelowrelativetothepotentialbenefitstosocietybecausethosewhousethedrugarenottheonlybeneficiariesoftreatment.Rather,benefitsofthesedrugsaccruetothosewhoneverneedtreatment,becausetheavailabilityoftheantimicrobialpreventsthespreadoftheresistantorganism.Thepeoplewhobenefitfromavoidinginfectionsthroughavailabilityandappropriateuseofaneffectivedrugprovidenorevenueforantibioticmanufacturers.Accompaniedbystrongattentiontolimitantimicrobialusetoappropriatecases—sinceusedrivesresistance,overusedrivesresistancemorerapidly—fewindividualswilleverdevelopaseriousresistantinfection.Ideally,theavailabilityofthesehigh-prioritytreatmentswouldbeaccompaniedbystronginfectioncontrolandstewardshipprograms,tominimizetheneedfortheiruse.Fornon-communicablediseaseslikecancer,themainvalueoftreatmentislimitedtotheactualindividualswhoareatriskfororwhodevelopthedisease.
Healthcarepaymentsfocusontheindividualswhoreceivetreatment.Payersandpatientsconsiderthevalueoftreatmenttotheirindividualcases,notthebroaderbenefitsandcostsavingstotheinfectionsthatareprevented.Asaresult,especiallywhenusedappropriately,antimicrobialsforhigh-priorityinfectionsaregenerallylow-revenueproducts.
EVIDENCEOFSUPERIORITYFROMCLINICALTRIALSISNOTROUTINELYFEASIBLE
Newantimicrobialsusuallywillnotcomewithevidencedemonstratingsuperioroutcomescomparedtostandardofcare.18Althoughnewantimicrobialswillhavepreclinicalinvitroandinvivodatashowingtheiractivityagainstbacteriathatareresistanttootherdrugs,demonstratingthismicrobiological
*Derivedfrompubliclyavailablesalesdata2010-2015
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superiorityinstudiesofhumansisnotpossibleroutinely.Thelackofclinicalsuperiorityevidenceisduetobothpracticalconstraintsinantimicrobialclinicaltrialsandthedesirabilityofminimizingtherateofinfectionduetohighlyresistantbacterialstrains.Instead,mostantimicrobialshavebeen,andwillcontinuetobe,studiedusingnon-inferioritytrialdesignsinwhichthenewagentiscomparedtoanotherdrugexpectedtoalsobeactive.Ethically,thecomparisonarminatrialmustbearegimenthatrepresentswhatthetreatingphysicianthinksisthebestcourseoftreatmenttocuretheinfection.Assumingthereisaneffectiveantimicrobialdrugorregimeneffectiveagainstthebacteriaunderstudyandbecausetheoutcomeofinterestisbinary(curevsnocure),theexpectedtreatmenteffectformostnovelantimicrobialsis,atbest,acureratethatisnoworsethanusualcare.
Further,ifalargeclinicaltrialcouldbedesignedtofocusonaspecificbacteriumforwhichtherearenoeffectivetherapies,thenthatwouldindicateafailureofpoliciestopreventtheemergenceofawidespreadresistantmicrobe.Ifaccrualofsubstantialnumbersofpatientsintosuchatrialwerepossible,itwouldimplyasituationwithgrimpublichealthimplications.
Fromtheperspectiveofpayersfocusedonvalueforanindividualpatient,adesirefordemonstrationofsuperiorityisunderstandabletojustifycoverageandreimbursementofnewantimicrobialsathigherprices.Butthisperspectivedoesnotaccountforthepublichealthgoalofprovidingrobustavailabilityofantimicrobialswhentheroutinelyviablepathforregulatoryapprovalcannotbeexpectedtoproducesuchevidence.
DIAGNOSTICUNCERTAINTYLIMITSAPPROPRIATEUSE
Alackofsensitive,specific,andrapiddiagnosticsleadstochallengesbothinclinicaluseandinantibioticdevelopment.Inday-to-daypractice,acuteinfectionsrequireimmediatetreatment,butdeterminationofthespecificcauseoftheinfectionissurprisinglydifficult.Thisparadoxicalproblemarisesbecausetheorganismswhicharecommonlypartofthehealthyhumanmicrobiomeareveryoftenthesameorganismswhichcancauseinfectionandmeredetectionofapotentialpathogendoesnotmeanthatitiscausative.Asaresult,physiciansoftenoptforrelativelybroadempiricaltherapyratherthannarrow(er)therapy,andmostoftennewerandnoveltherapies,basedondiagnosticstests.Negativeresults(lackofdetectionofapathogenorlackofdetectionofresistance)areresultsthatareparticularlylikelytobeignoredifthepatienthassignificantriskfactorsforsuchinfections.
Lackofavailablerapiddiagnosticscanalsoposeachallengeinantimicrobialclinicaltrials,particularlywhenatrialseekstostudyinfectionsduetoaspecificbacterium.Ifapatientispotentiallysuitableforsuchaclinicaltrialbutthephysicianisunabletoconfirmthispromptlywithatest,thepatientmaybetreatedwithoneormoreantibioticspriortoenrollment,whichconfoundsexaminationofthetreatmenteffectsofthenewdrugunderstudy.Further,ifapatientisultimatelyfoundtonothavebeeninfectedwiththetargetorganism(withoutarapiddiagnosticthiswouldbeunknownatenrollment),butisenrolledinthetrialbecauseempiricevidencesuggeststhathemaybe,thesponsorwillhavespentadditionaltimeandmoneyfordatathatwillultimatelynotcontributetodrugapproval.Bothscenariossignificantlyincreaseinefficiency.
APPROPRIATESTEWARDSHIPMEANSLOWERVOLUME
Novelantimicrobialdrugsmustbeusedappropriatelytoslowthedevelopmentofresistance.Inhealthcaresettings,thisgoalisaccomplishedthroughASPswiththecoreelements(definedbytheCDC)ofleadershipcommitment,accountability,drugexpertise,action,tracking,reporting,andeducation.19
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Stewardshipplaysacriticalpublichealthrolebyconservingnewdrugsforresistantinfections;however,thispracticealsolimitssalesvolumeandROIfornewantibiotics.Appropriatestewardshipalsomeansthatmostnovelantimicrobialshaveanarrowsetofpatientsforwhomtheymaybeclinicallyappropriate,limitinguse.IntheU.S.,theCentersforMedicareandMedicaidServices(CMS)hasmandatedstewardshipprogramsasaconditionofparticipationinMedicarefornursinghomes,andissuedaproposedruletorequirethesameconditionswithinhospitals.TheCDChassettargetstoreduceinappropriateantibioticuseintheoutpatientsettingby50percentandwithinhospitalsby20percent.Bothactionsareexcellentpublichealthmeasures,butbothaccentuatethedifficultiesofavolume-basedsalesmodelforantibiotics.Thesemeasurescanbereinforcedbyfinancialincentives:reasonablyeffectivegenericdrugsareavailableformostinfections,sothatpayersandpatientsshouldpreferthesealternativestohigh-pricednewantimicrobials.
FEE-FOR-SERVICEPAYMENTSFAILTOENCOURAGEAPPROPRIATEUSE
TheU.S.healthcaresystemreliesonFFSpayments.Thispaymentsystemisapoorfitforantimicrobialsbecausevolume-basedpaymentsarefundamentallyinconflictwithstewardshiptoavoidtheuseofvaluableantimicrobialswhennotneededtodetertheemergenceofresistance.Asanalternativetopressuresfrommanufacturers(andpotentiallypatients)toincreaseutilization,apaymentapproachthatdelinksrevenuefromvolumeofsalescouldprovidebetterincentivesforappropriateuse.InmanyareasofU.S.healthcare,theshiftfromvolume-tovalue-basedreimbursementisencouragingmoreappropriatetreatment.Butsuchpaymentmechanismshavegenerallynotbeenusedforantimicrobials.
CONSEQUENCESOFINADEQUATEMARKETREIMBURSEMENTFORDEVELOPMENT
Failureofcurrentpaymentsystemstorecognizepublichealthbenefits,pressuresforappropriatestewardship,andtheinsufficientimplementationofnewdiagnosticstoaididentificationoftherightdrugfortherightpatientattherighttimeallresultinlowrevenuesforantimicrobialdevelopers,resultinginmanycompaniesleavingtheantimicrobialspace.Remainingsmallandmediumcompaniesstrugglewithsecuringfundsfrominvestors,andlargemanufacturerswithadiversifiedpipelinestruggletojustifyinvestingR&Ddollarsinanareawithanunpredictableandlowreturncomparedtootheropportunities.Theselowrevenueshaveledmanylargerdrugdeveloperstoshifttheirdiscoveryanddevelopmenteffortstomorelucrativeareas.Forexample,AstraZenecarecentlysolditslate-stageantimicrobialportfoliotoPfizerandspunoffitsearlystageworktofocusondevelopingmedicinesinthreefocusedareas,includingoncology.20In2014,oneoftheworld’slargestprivateantibioticR&DeffortswasatCubistPharmaceuticals.AfterbeingacquiredbyMerck,thevastmajorityoftheCubistR&Deffortwasshutdown.21Ofthetop50pharmaceuticalcompanies(rankedbyglobalsales),onlyfivehaveantibioticsinclinicaldevelopment.8
EffortstoimproveantimicrobialdevelopmentGLOBAL“PUSH”AND“PULL”INCENTIVES
Toaddresstheseissues,manyglobaleffortshaveproposedeconomicincentivestostimulateandrewardinnovation,whichinclude“push”and“pull”incentives.“Push”incentivesfocusonreducingtheR&Dcostsfornewantimicrobialsbyprovidingfinancialandinfrastructuresupport.“Pull”incentivesrewardmanufacturersafteranantimicrobialentersthemarket,increasingpotentialrevenue.
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ChathamHouse,aLondon-basedpublicpolicyinstitute,publishedareportin2015proposingantibioticincentivesspanningtheentiredevelopmentpipeline.22Recommendedpre-clinicalandclinicaltrialpushincentivesincludepublicfundingtosupportinitialdiscoveryresearch,andtaxcredits,cashrewards,andpublic-privatepartnershipstoreduceclinicaltrialsanddevelopmentcosts,aswellasamarketentryreward(MER)thatwouldreducethemanufacturers'dependenceonsalesvolumeforROI(alsoknownas“delinkage”).
InMay2016,theReviewonAntimicrobialResistance(AMRReview),commissionedbytheU.K.PrimeMinisterandsupportedbytheWellcomeTrust,publishedadetailedproposaltocombatantimicrobialresistanceincludinganInnovationFundtosupportforearly-stagedevelopmentofantimicrobialsandalump-sumpaymentMERtodevelopersofantimicrobialsmeetingadefinedclinicalneed.23
InJune2016,DRIVE-AB,anEUinitiativecomprisedof23publicandprivatepartners,releasedapreliminaryreportdetailingfivepromisingincentivesforantimicrobialinnovation:1)grantsforearlystageresearch;2)establishinganon-profitdeveloperwhowouldmanageandfinancediscoverythroughcommercialization;3)aMERtodevelopersfollowingapprovalofanantimicrobialthatmeetscertaincriteria;4)an“annuallicensefee”todrugdevelopersforaccesstoaspecifiedvolumeofantimicrobialsaddressingunmetmedicalneeds;5)adual-pricingmodelthatchargesahigherpriceforinappropriateuse.24FinalrecommendationsfromDRIVE-ABwillbereleasedlaterintheyear.
InSeptember2016,stakeholdersfromthepharmaceuticalindustryputtogetheraRoadmapforProgressonCombattingAntimicrobialResistance,whichfolloweduponthepreviousDavosDeclarationthatwassignedbyover100companiesandassociations.25Recommendationsincludedreducingtheenvironmentalimpactofantibioticproduction,encouragingappropriateuseofantibiotics,improvingaccesstoantimicrobialproducts,andgeneratingnewopportunitiesforcollaborationacrossindustryandpublicsectors,whichincludessupportforlumpsumpaymentsuponmarketentry.
TheBostonConsultingGroup(BCG)completedastudyfortheGermanGlobalUnionforAntibioticsResearchandDevelopment(GUARD)InitiativeinFebruary2017.26TworecommendationstargetedresearchanddevelopmentthroughthegenerationofTargetProductProfilestoguidedecisionsforpreclinicalresearch,andaGlobalResearchFundtobeusedtofundprojects,increasethecommunityofantibioticresearchers,andsupportinfrastructure.TwoadditionalrecommendationsincludedaGlobalDevelopmentFundtosupportclinicalresearch,andaGlobalLaunchReward,aMER,withbuiltinsustainabilitymechanismsforthecompanytopaybacktherewardovertimeandundercertainconditions.
GLOBALSUPPORTFORAMARKETENTRYREWARD
AlloftheseglobaleffortsrecommendedsomeformofaMER,whichisdesignedtopayforvitalantimicrobialdrugswithpublicfunds.TheMERprovidessubstantialadditionalrevenuestoreflectpublichealthvaluequicklyafterapproval,andremovestheneedforvolumesales,whichhelpsthedeveloperrecoupinvestments.Aformof‘delinkage’,whichremovesthe‘link’betweendevelopmentcostsandrevenues,theMERenablesuncouplingoftheROIfromthevolumeofdrugsales.DelinkagecouldbenefittheantimicrobialmarketbyremovingdependenceonsalestodriveROI,providingreimbursementandrevenueindependentofsalesvolume,removingtheneedtosethighprices,andprovidingsupportforappropriateuse.
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Asgenerallydescribedabove,implementationoftheMERwouldrequiretheformationofanewentitysuchasatrusttooverseetherewardandthemanagementoftheantimicrobial.Therewardwouldreplaceexistingpaymentsforantimicrobials,befundedbypublicsources,andbemanagedthroughnationalorinternationalcontractsthatwouldpreventmarketing,promotesustainableuse,andensureaccessinlow-resourcecountries.Whilefundsmaybedistributedinalumpsumoryearlypayments,currentproposalsenvisionpaymentsoverfiveyearsformeetingcertainbenchmarks.TheantimicrobialMERwouldneedtobelargeenoughforthedevelopertorecoupR&Dinvestmentsandprovideenoughrevenuetojustifyamoresubstantialcommitmenttothistherapeuticarea.Giventhesignificantpublichealthbenefitsfromthedevelopmentofpriorityantimicrobials,therecommendationshaveestimatedtheeffectivelevelofpublicpaymenttobebetween$500millionto$4billiontoachieveanNPVof$200millionforR&Dinvestmentinapriorityantimicrobial.14,23,27,28
WhiletheMERwouldprovideaclearrewardfordevelopers,thereareseveralchallengeswiththismodel.First,publicfundsaredifficulttoobtainandpotentiallysubjecttoongoingbudgetaryapproval;themoresuchfundscanleverage,notreplace,existingpaymentsources,themorelikelyaneffectiveMERcanbeimplementedandsustained.Second,manufacturershavelittletonoincentivetoremainengagedintheproductlifecycleafterreceivingtherewardunlesssomesalesvolumeincentiveremains.Finally,ifthepaymentforthisdrugwasfullydelinkedfromsalesvolume,thenproviderscouldpotentiallyaccessthedrugforfree,adisincentivetostewardship.Proposalstoaddresstheseissuesincludesettingstrictguidelinesforrewardeligibilityanddevelopingaproviderpricingsystemtoencouragestewardship.However,suchoversightwouldaddfurtheradministrativecosts,andmaynotbeeffective.
U.S.INCENTIVES
TheU.S.hasbeenleveragingpushandpullincentivestopromoteantimicrobialdevelopment.Table1summarizesthepushincentivesthathavebeenproposedorimplementedinrecentyears.TheLimitedPopulationAntibacterialDrug(LPAD)pathway,whichwasincludedinthe21stCenturyCuresAct(2016),providestheopportunityformorestreamlinedclinicaltrialsandanexpeditedapprovalprocessforantibioticsthataddressunmetmedicalneedsforlimitedpatientpopulations,butdoesnotaddresstheproblemoflimitedsalesvolumesleadingtolowexpectedROI.29
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Table1.U.S.PushIncentivesforAntimicrobials
Initiative Sponsororganization Description
Grantfunding NationalInstitutesofHealth(NIH)
Fundsawardedforbasicresearchonbacteriaandantimicrobials.InFY2015,Congressappropriated$100milliontoNIHspecificallyforAMRresearch.
BroadSpectrumAntimicrobialsProgram
U.S.BiomedicalAdvancedResearchandDevelopmentAuthority(BARDA)
BARDAinvestsnon-dilutivefundinginacompany’santibioticportfoliotohelpcompaniesthroughclinicaltesting.
CARB-X BARDA,NIH&WellcomeTrust
Public-privatepartnership,whichincludeslifescienceacceleratorsandresearchuniversities.FocusingonpreclinicalR&D,aimstobroadlycultivatepromisingnovelantimicrobialproductsthatcanbemovedintoclinicalpipeline.$450millionincommittedfunding2016-2021,witheveryfederaldollarleveragedbyanequalamountinprivatefunds.TheinitialgroupoffundedcompanieswereannouncedinMarch2017.
Taxcreditsforresearchanddevelopment
PendingHousebill,“ReinvigoratingAntibioticandDiagnosticInnovationAct”
Wouldallowcompaniestoreceivetaxcreditsequaling50percentofclinicaltestingexpensesforaqualifyinginfectiousdiseasetherapeuticordiagnostic.
Limitedpopulationantibacterialdrug(LPAD)pathway
Section3042in“21stCenturyCuresAct”
Allowsantimicrobialdrugstobestudiedinsmaller,lessexpensiveclinicaltrials,whichwouldexpeditetheapprovalofthedrug,butwouldlimittheeligiblepatientpopulation.
Inaddition,theU.S.hasimplementedseveralpullincentivestoprovidearewardaftertheproducthasenteredthemarket.TheGeneratingAntibioticIncentivesNow(GAIN)Act(2012)extendstheexclusivityperiodofcertainantimicrobialsbyfiveyears.In2000,CMSlaunchedtheNewTechnologyAdd-OnPayment(NTAP)program,whichprovideshigherMedicarepaymentsfornewmedicalproductsthataredeemedbyCMS,throughanapplicationprocess,toleadtosubstantialclinicalimprovement.NTAPpaymentswerenotdesignedspecificallyforantimicrobials,andonlyoneantimicrobialdrughasbeenapprovedforthisprogramduetoafocusonnon-inferiorityclinicaltrials.
InMarch2017the“ImprovingAccesstoAffordablePrescriptionDrugsAct”wasintroducedintheHouseandtheSenate,andasectionofthisbilldescribesamonetaryprizethatwouldbeprovidedtoantimicrobialdeveloperswhobringtomarketaqualifiedhighprioritydruginexchangeforforfeitureofmarketexclusivityandreasonablepricing.30,31Theseprizeswouldbepaidoutofatwobilliondollar“AntibioticsPrizeFund”.ThisproposalissimilartothosethathavebeenputforwardforaMER,butitisunlikelytomoveforwardduetothebillincludingadditionalrecommendationswithwiderangingimplicationsacrosstheentirehealthcaresector.
Twofurtherpullincentiveproposalshaveattractedconsiderableattention.ThefirstistheDevelopinganInnovativeStrategyforAntimicrobialResistantMicroorganisms(DISARM)Act,whichwasfirst
TheDISARMActandTransferableExclusivityVouchers:Animmediateimpact
Newlegislativeeffortsfocusonprovidinghigherandmorepredictablereimbursementtonewantimicrobialproducts,providingsignificantincentivesforantimicrobialdevelopment.BoththeTEVandtheDISARMActcouldbeintegratedwiththePriorityAntimicrobialValueandEntryAwardproposaltoleveragehealthplanpaymentsandpaymentreformtopromoteavailabilityandappropriateuseofantimicrobials.Eligibilityrequirementswithintheselegislativeproposalswouldcreatecriteriaforeligibilityandmeasuresofappropriateuse,aswellasencouragesurveillancereporting—importantfoundationsforamoresustainablesystemforfinancingandusinghigh-priorityantimicrobialsintheUnitedStates.
Value-basedStrategiesforEncouraging NewDevelopmentofAntimicrobialDrugs
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introducedintheHousein2015andisintendedtoallowbroaderadd-onMedicarepaymentsforinnovativeantimicrobialdrugs.WhiledrugsneedtoreceivespecificapprovalfromCMSunderNTAP,DISARMdrugsautomaticallyqualifyforadditionalpaymentsiftheytreatinfectionscausedbyqualifyingpathogens.TheseadditionalpaymentswouldeliminatethedisincentiveforhospitalstousehighpricedantimicrobialsbyoffsettingthecostoftheantimicrobialtotheMS-DRG,andthepaymentscouldpotentiallysupportbettertrackingofantimicrobialresistanceanduseofpriorityantimicrobialdrugs.However,thisincentivestilllinksrevenuetosalesvolume,potentiallycreatingincentivesforoveruse,anddoesnotrewardthepublichealthvaluefortheantimicrobialbeyondthepatientstreated.
AnotherproposedincentivethatwouldaddressthelinkageofsalesvolumeandROIisthetransferableexclusivityvoucher(TEV).32ThereareseveraladvantagestotheTEV,includingthetangiblereturntothemanufacturerandeaseofimplementation.Further,theTEVdoesnotrequiredirectgovernmentappropriations.However,theTEVischallengedbythefactthatnewrevenuescomefromraisingdrugspendinginothertherapeuticareasbydelayinggenericentry.Further,theTEVitselfdoesnotprovideanyincentiveforappropriatestewardshiporcontinuedavailabilityofthedrugoveritslifecycle.Itwouldrequirestrongadministrativeguardrailstoaddresstheseconcerns.
PathforaccomplishingdelinkageintheU.S.COREPRINCIPLES
Theglobalproposalsoutlinedabove(ChathamHouse,AMRReview,etc.)representimportantstepstopromotedevelopmentofnewantimicrobialdrugs.However,theymaybeinfeasibleforimplementationintheU.S.duetomultiplefactors,includingthelackofasinglepayersystem,limitedpublicfunds,andactivemovementfromvolumetomorepopulation-basedfinancingapproachesacrosstheU.S.healthcaresystem.Inordertoaccommodatetheseuniquefactorswhilestillaligningwithglobaleffortstocombatantimicrobialresistance,wehaveidentifiedeightcoreprinciplestoserveasafoundationforourproposal.Theseprinciples,whiledescribedinpreviousproposals,haveadditionalcomponentstoreflectuniquefactorsthataffecttheU.S.(sidebar).
Asdescribedabove,severalglobalorganizationshaveproposedtheuseofpublicfundstospurinnovation,butsoleuseofpublicfundsisnotapreferredoptionintheU.S.Instead,weproposeapartialpubliccontribution(reflectingpublicgood,populationhealthneeds,andappropriateuse)buildingoncontinuedpaymentsfrommultiplepublicandprivatepayers.Whilethesepayersserve
Coreprinciplesforantimicrobialeconomicincentives
1. Beapartofacomprehensivestrategy,whichpromotesdevelopmentacrossthelifecycleofadrug,andenablesthesuccessofbothsmallandlargedevelopers
2. Promoteandrewardinnovation3. Promoteaccess
4. Promotestewardshipsothatantibioticsaresustainableovergenerations
5. Besustainableanddependableoverthelongdrugdevelopmentcycle(atleastadecade)
6. Leveragepublicfundswithprivatepayments
7. Providedeveloperswithrapidaccesstofundsuponmarketentry
8. Supportandalignwithbroadershiftsinpaymentmodelstovalueandqualityandawayfromvolumeandintensity
Value-basedStrategiesforEncouraging NewDevelopmentofAntimicrobialDrugs
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distinctpopulationswithdifferentbenefitdesignsandotherfeatures,theyaregenerallymovingfromvolumetovalue-basedpaymentmodels,whichourproposalreinforcesforantimicrobials.
Theshiftfromvolume-tovalue-basedpaymentwithintheU.S.issupportedbyavarietyofmechanisms,includingAlternativePaymentModels(APMs),whichareaimedatreducingunnecessaryhealthcostswhilesustainingorimprovingthequalityofcare.Thisshiftisoftenimplementedthroughpartialorfullepisode-basedbundledpayments(e.g.,onepaymenttoallproviderstreatinganepisodeofcare),orper-patientpayments(e.g.,per-memberper-monthpaymenttoapatient’sprimaryproviders).TheAlternativePaymentModelFrameworkfromtheHealthCarePaymentLearning&ActionNetwork(HCPLAN)outlinesapathtomovefromFFStopopulation-basedpayments.33Withinthisframework,thegoalistoachievepaymentsthatarepartiallyorfullyattheepisode-orperson-levelforapopulationofpatients.
APMsareexpandingintheU.S.,andpreviousexperimentshaveprovidedevidenceofreductioninhealthcosts,especiallyincontrollingexcessspendingoninpatientcare,reducingtheaverageMedicarepaymentperepisodebytwotosixpercenteachyear.34TheMedicareAccessandCHIPReauthorizationAct(MACRA)of2015enablesphysiciansandprovidersworkingwiththemtotransitiontopaymentsbasedonqualityratherthanvolumeofcare.
Sofar,therehavebeenlimitedexamplesoftheuseofvalue-ratherthanvolume-basedpaymentsfordrugs,butsomecompanieshaveenteredintorisk-sharingagreementsbasedontheperformanceofthedrug;forexample,AmgenhasnegotiateddealswithseveralpayersfortheirPCSK9inhibitorwherepayersarereimbursedaportionofthedrugcostifagreed-uponperformancemetricsarenotmet.Therearearangeofoperationalandregulatorychallengestotheimplementationofsuchmodelsthatcomplicatetheirroutineuse,particularlyinareaslikeantimicrobialsthatcurrentlyrepresentonlyasmallpartofhealthcarepayments.Butantimicrobialsmayhavethegreatestbenefitfromashiftawayfromvolume-basedpaymentbecauseofstewardshipconcerns.Ashiftfromvolume-basedtowardper-personpaymentsforacoveredpopulation,aswellaspaymentsthatarelinkedtomeasuresofappropriateuseandcontinuedvalue,couldprovidemuchstrongerincentivesforappropriateuse—andcouldbeimplementedinamannerthatdoesnotincreaseoutlaysforpayers.Additionalpublicmarketentryrewardpayments—toreflectthepublichealthvalueoftheantimicrobial—couldreinforcethisvalue-basedpaymentstructure.Aswedescribebelow,publicsupportformarketentrylinkedtothisshiftinpaymentcouldprovideincentivesformanufacturerstoworkwithotherstakeholderstohelpovercomethebarrierstovalue-basedpaymentsforantimicrobials.
Value-basedStrategiesforEncouraging NewDevelopmentofAntimicrobialDrugs
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PriorityAntimicrobialValueandEntryAwardToaddressthefundamentalpublichealthneedforadditionalfinancialsupportforthedevelopment,availability,andappropriateuseofhigh-priorityantimicrobialdrugswithintheU.S.healthcaresystem,weproposeapublicly-leveraged,value-basedpaymentmodel.Thismodel,calledthePriorityAntimicrobialValueandEntry(PAVE)Award,supportsandrewardsaccesstoandsustainableuseofinnovativeantimicrobialdrugs,whileprotectingthepublic’shealthfromresistantinfections.ThePAVEAwardprovidesdevelopersquickaccesstoasignificantrewarduponmarketentryofaneffectiveantimicrobial,andprovidesstrongincentivestoshiftreimbursementfrominsuranceplanstopopulation-andvalue-basedcontracts,notpaymentsbasedonvolumeofsales(Figure1).Thefollowingsectionsdescribethedetailsofthemodel,whichcombinesaversionoftheMERuponmarketentrywithsubsequentpaymentscontingentupondemonstratingincreasingrevenuefromvalue-basedcontractswithpayerslinkedtoavailability,sustainableuse,andcontinueddatacollection.
QUICKACCESSTOFUNDSTHROUGHAMARKETENTRYREWARD
ThefirstcomponentofthePAVEAward,whichisbuiltupontheexistingMERmodel,includesapubliclyfinancedpullincentive,ashasbeenrecommendedbymultiplegroups.Thispublicfundingwouldreflectasocietalcontributiontoaglobalthreat.InthePAVEAward,theMERcomponentwouldbeavailableoverthefirstfewyearsuponmarketentryforaverylimitedsetofhighpriorityantimicrobialswithspecificeligibilitycriteriatogivemanufacturerscleardevelopmentgoals,andthemagnitudeoftheMERcouldincreaseifthedrugmeetsadditional,desiredcharacteristicsthatarebeneficialtolargerpublichealthneeds,suchasanovelmechanismofaction,oralavailability,ornewclassofdrug.35ThisphaseofthePAVEAwardwouldprovidedeveloperspredictablerevenue,contingentonthedrug’smarketavailability,lackofprolongedshortages,orfailuretomeettheconditionsforsupportingashifttosustainablepaymentdescribedbelow.
Figure1.OutlineofPAVEaward
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TheMERwouldneedtobelargeenoughtojustifyacommitmenttoantimicrobialdevelopment,butmustalsobesustainable.WhiletheCentersupportstheconceptofasubstantialentryrewardforaproductthatmeetstheeligibilitycriteria,wefavoranapproachthatdoesn’tcompletelyrelyonthereward,toensurethatthemajorityoftherevenuefrompayersshiftstoalternativepaymentmodelsthatpromoteappropriatestewardship.FFSpaymentsforthesehigh-priorityantimicrobialsareonlyadequateifthereisahighprevalenceofhighlyresistantinfections,whichwouldbedevastatingfromthepublichealthperspective.
TRANSITIONINGTOPAYMENTSTHATSUPPORTVALUE
ThefirstcomponentofthePAVEAwarddiffersfromthetraditionalMERbyprovidingannualpayments,withthelargestportionpaidinyearone,andwithsignificantbutdecliningpaymentsthroughyearsfiveorsixasdirectpaymentsfordrugavailabilityanduserampup.Themagnitudeofthesepaymentswillvarydependingonthedrug,withthosedrugsthatrepresentahighersocietalvaluereceivinglargerpayments.
ThesecondcomponentofthePAVEAwarddirectlyincentivizesthecompanytoweanofftheMERthroughdecliningpaymentsthroughyearsfiveorsix,witheachyear’spaymentcontingentupondevelopersdemonstratinganincreasingshareoftheirrevenuefrompopulation-basedAPMslinkedtovaluetosocietythroughavailability,supportforsustainableuse,andcontinueddatacollection.ThistransitionwouldensurethatdrugsalesshifttoAPMsdelinkedfromvolume.ThespecificAPMpaymenttermsandoverallpaymentswillcontinuetobedeterminedthroughcontractnegotiationsbetweenthemanufacturerandpayers,supportedbymeasuresthatreflectvalueandstewardshipinthecoveredpopulations(Figure1).
Whilethesecontractswouldprovideapredictableandsustainablesourceofrevenueforantimicrobialdevelopers,itisimportanttoemphasizethatitwillnotresultinhigherdrugcoststopayers;rather,itcreatesincentivesandopportunitiesforthemtopaydifferently.ThesenewcontractswouldnotrequirepayerstopaymorethaninFFSmodels,butwouldstructurepaymentswithagreateremphasisonpublichealthinreturnforaccesstothedrug.Astheinfrastructureforvaluemeasurementgrows,developingthesecontractswillbeeasierandgainmorewidespreadacceptance.
Suchvalue-basedarrangementsmightinvolveapaymenttothemanufacturerforaccesstothedrugregardlessofthenumberofunitsutilized;paymentswouldbetiedtovaluetothecoveredpopulationratherthanvolumeofsales.Ifstewardshipprotocolsareinplaceandtransmissionofresistanceiscontained,lowdrugutilizationwouldbeexpected,buthavingadrugforalowprevalenceinfectionwouldbehighlyvaluable.Forexample,amanufacturermightcontractwithahealthplanona“permemberpermonth”(PMPM)basisforprovidingthedrugwhenneeded.Amanufacturermightalsoenterintoepisode-basedpaymentcontractstoprovidethedrugasneededforallhospitalizedpatientsincertainDRGs.Inbothcases,thecontractedpaymentwouldnotdependonthevolumeofthedrugactuallyused.Rather,theper-memberorper-episodepaymentwouldvarybasedonmeasuresof,forexample,appropriateuseorcontinuedeffectivenessoftheantimicrobial.Paymentsmightalsobetiedtothedevelopmentofbetterdataandevidenceonthebenefitsandrisksofthedrug,whichcouldsupportbetterpaymentcontractsinthefuture.Inthecaseofinpatientdrugsorphysician-administereddrugsforMedicarebeneficiaries,thisreformcouldbesupportedbythedevelopmentandadoptionofMedicareAPMpilotsbytheCenterforMedicareandMedicaidServicesthatcouldalignwiththeprivateAPMcontracts.
Value-basedStrategiesforEncouraging NewDevelopmentofAntimicrobialDrugs
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ImplementationissuesDETERMININGELIGIBLEDRUGCANDIDATES
ThePAVEAwardmodelisintendedtopromotedevelopmentandsustainableuseofhigh-prioritydrugsthatcontributetothereductionofdrugresistantbacteria,andtheincentivecriteriashouldbetailoredspecificallytomeettheseneeds.TargetproductprofilescouldsetclearexpectationsofthedesireddrugcharacteristicsthatarerequiredtoqualifyforthePAVEAward,layingoutexpectedantimicrobialactivityandotherperformancestandardsforthedrug.Sucheligibilitycriteriawouldbenefitfromfurtherdevelopment,bothintheU.S.andinternationally.Near-termversionsofPAVEpaymentscouldbeawardedtodrugsthatmeetexistingcriteriarelatedtothepublichealthbenefit,suchasoralformsthatcouldbeusedmoreeasilytocontrolanoutbreakearlyoranovelmechanismofactionthatcouldplausiblysupportnewtypesofantibioticsforwhichresistancehasnotdeveloped.35TheWHOandCDClistsofferagoodstartingpointforprioritizingpathogensthatthedrugsshouldtarget.CARB-X,theleadingpublic-privatepartnershipsupportingpre-clinicalantibioticR&D,usestheseliststoprioritizeinvestments.However,asnewresistantbacteriaemerge,theeligibilitylistwillneedtoadapttothesechanges,sothecriteriawillneedtohavebuilt-inflexibilityandwillneedtobeupdatedonaperiodicbasis.
DEVELOPINGEVIDENCEFORVALUE-BASEDCONTRACTS
SuccessfulimplementationofthePAVEAwardwillrequirecooperationbetweendevelopers,payers,andproviders.Thecontractsshouldencourageshort-andlong-termsavingsfromreducedinappropriateuse,aswellasreducedinfection-relatedcosts,suchasextendedhospitalstays,treatmentcomplications,andadditionalinfections.
Asdescribedabove,demonstrationofsuperiorityduringclinicaldevelopmentcomparedtootherproductsisnearlyimpossibleandundesirableforpublichealthbecauseincreasingthenumberofpeopleforwhomthesedrugsareappropriatewouldmeanthatresistanceand/ortransmissionareincreasing.Continueddevelopmentofeffectivenessevidenceinthepost-marketsettingsisequallychallenging(thedrugwillbeusedsparinglylimitingsamplesize,highriskinfectionswithcomplicatingcomorbiditiescanleadtodeathevenwiththeuseofeffectiveantibiotics).However,continuedcollectionofdata
Public-privatepartnershipsprovideaccountabilitywhilesupportinginnovation
Public-PrivatePartnershipscandeliverresultsthataresuperiortoeithergovernmentorprivateactorsalone.CARB-Xisanewpublic-privatepartnershipprovidingpushincentivesforpre-clinicalR&Dtoaddressthethreatsofantimicrobialresistance.LaunchedonAugust1,2016,CARB-Xhasnowraised$455.5millioninfundingfromBARDA,NIAIDandtheWellcomeTrust.Thefirst11awardswereannouncedinMarch2017(http://www.carb-x.org/portfolio),andthreeoftheseinitialprojectsrepresentnewantibioticdrugclassesagainstGram-negatives,sevenhavenewmoleculartargets,fourarenon-traditionalapproaches,andalltargetCDCandWHOprioritypathogens.Theseprojectswereawardedalmost$24Minitiallyanduptoanother$24Mifmilestonesarehit.Allawardedfundsarematchedwithprivatemoney,with30-50%cost-sharing.
CARB-XwillonlyfundprojectsthroughphaseIclinicaltesting,leavingsignificantscientificandfinancialhurdlestoclearpriortoapproval.Manyofthesecompanieswillrelyonfundingfrominvestors,whichwillonlybeavailableifthereisaclearandpredictablepathtoROI.ImplementationofthePAVEAwardwouldprovideapredictablereturn,makingtheinvestmentinantimicrobialsmoreattractive.LikeCARB-X,thePAVEAwardwillsupplementpublicfundswithprivatepayers,leveragingbothtosupportinnovation.
Value-basedStrategiesforEncouraging NewDevelopmentofAntimicrobialDrugs
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ontheuseofnovelantibiotics,outcomes(includingsafetyoutcomes),canbenefitthehealthcarecommunityinbetterunderstandingtheuseinclinicalsettingsandsupportsustainableuse.Thus,idealperformancemeasuresinthesecontractswouldbebasedonevidenceofadrug’savailability,supportforsustainableuse,andcontinueddatacollection.
TheCenterrecommendsthat,asinotherareasofhealthcareperformancemeasurement,measuresrelatedtothevalueinpracticeofapriorityantimicrobialdrugshouldbuildonmeasuresavailabletoday.Therearesomeavailablemeasuresthatcouldbeusedasastartingpoint,includingmeasuresthatwouldpertaintoongoingavailabilityandutilityaccessmeasuresandusedata,allofwhichcanhelptotrackappropriatestewardship.TheCDC’sAntimicrobialUseOptionoftheNationalHealthcareSafetyNetworkisalreadyavailabletohospitalstoreportantibioticusedataandcouldbeusedtotrackusenationally.PairingtheAntimicrobialUseoptionwithitscompanionAntimicrobialResistanceOptioncouldprovidethetypeofdatathatwouldassistinmonitoringnewantibiotics.36Asecondsetofmeasurescouldberelatedtodatacollectionandevidencedevelopment,andcouldincludeexecutionofstudiesthatbetterdefinesafetyandutilizationpatternsofanantimicrobialdrug.Specifically,thesemeasurescouldincludetheperformanceofpatientpopulationandsusceptibilitystudiesandcost-effectivenessstudiesthatestimatecoststothepayerifthedrugwerenotavailable.Finally,contractswilltakeintoconsiderationthesupplychainandavailability.
Effectivestewardshipmeasuresarecriticalforthesuccessofdevelopersunderthesecontracts.ProviderswillneedtocollaboratewithmanufacturerstodemonstrateadequateperformanceonstewardshipmeasureswithinproviderAPMs.APMcontractscanbedesignedtobalanceover-andunder-useincentives,forexample,throughacombinationofper-memberper-monthpaymentsandpaymentsforactualuse.SolongasthepaymentswereasignificantshiftawayfromFFSpayments,manufacturersandpayerscouldnegotiatemixedmodels,wheremanufacturersandpayersbothfacefinancialrisk(e.g.,apartialcapitationpayment,withsomeadjustmentsbasedonvolumeandperformance).Indeed,afurtheradvantageofthePAVEAwardmodelisthatthesamekindsofappropriateusemeasurescanbeusedbypayerstosupportaligned,value-basedpaymentsforbothmanufacturersandproviders.Thispaymentalignmentcansupportdevelopersinworkingcollaborativelywithprovidersandpatientstopromoteandensureappropriateuse,whichiscriticalforthelong-termsustainabilityoftheantimicrobialsupplyandpublichealth.
FINANCINGMECHANISMS
BoththeAMRReviewandDRIVE-ABhavesuggestedtheuseofpublicfundstofinanceMERs.Suchfundscouldcomefromgeneralgovernmentrevenues,butdedicatedfundingsourceshavealsobeenproposedtobestreflectthepublicgoodofthesedrugs.TheAMRReviewsuggesteda“payorplay”model,inwhichmanufacturersthatarenotinvestedinantimicrobialdevelopmentwouldbechargedafee.Manytherapeuticareas(includingchemotherapyandsurgery)aredependentoneffectiveantimicrobials;consequently,drugmanufacturersshouldcontributetoantimicrobialdevelopmentthroughinvestmentintheirownantimicrobialR&Dorbypayingafee.Anotherproposedfundingmechanismisataxonallantibioticuse,effectivelya“userfee”foraccesstoantibiotics.37,38Thepurposeofthistaxwouldbetonotonlygeneratefundstorewardantimicrobialdevelopment,butalsotodiscourageinappropriateuseofcurrentantimicrobialsbyincreasingthecostofuse.Theentryrewardcouldalsobefundedthroughayearlypermemberfeeforallhealthcareplans,whichwouldservetodistributethecostofdevelopmentacrosssociety.
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AnalternateapproachintheU.S.torelyingsolelyontaxesandfeeswouldbetorelyonthesaleoftransferableexclusivityvouchers(TEVs),eitheraloneorincombinationwithasmallertax,asdescribedabove.Insteadofbeingawardedtomanufacturerswhobringpriorityantimicrobialstothemarket,TEVscouldbeanexpedientmethodforprovidingpublicfundingforantimicrobialdevelopment.Asdescribedabove,therearesomeundueconsequencesthatcouldarisefromsuchincentives,whichcouldpotentiallybeaddressedbyestablishingguardrailstopromoteefficiency.Appropriatelimitsonthetimeand/orrevenuegeneratedbytheTEV,alongwithsufficientsupportforpatientassistanceprograms,wouldeasesomeofthenegativeimpactsofshiftingthefinancialburdenfromantimicrobialdrugstootherdiseaseareas(Table2).Additionally,thevoucherrecipientshouldbeobligatedtoprovidenoticeofwhichdrugwillbereceivingtheextensionfouryearspriortoexpirationofthatdrug’sexclusivity,whichshouldbesufficientnoticetoalleviatetheimpactongenericmanufacturers.32
Table2.Proposed“guardrails”foranantimicrobialtransferableexclusivityvoucherprogram32
Challenges Potentialsolutions
Increasescostinotherareasofhealthcare Capvoucher(invalueorduration)
Cannegativelyaffectthegenericmarket • Voucherwillonlybeawardedtonewdrugs(notapplicableforpreviouslyapproveddrugs)
• Companythatwillbeusingthevouchermustdeclarewhichdrugthevoucherwillbeusedonatleast4yearspriortoexclusivityexpiration
Doesnotencouragestewardship Linkqualityreportingrequirements(e.g.,efficacy,lengthofhospitalstay)toreceiptofvoucher
Couldbepoorlytargetedtoneededantibiotics Limiteligibilitytodrugsthatmeetcriteriasetbypublic/privatepartnershipgroup,whichwillidentifyunmetneedbasedonperiodicreviewsofinfectionrate,resistance,andthedrugpipeline
Tenyearsafterimplementationofvoucherprogram,theGAOcouldconductastudytodeterminetheeffectivenessofthevouchersandwhetherthevoucherprogramshouldcontinue
Whateverfinancingmechanismisused,publicinvestmentisneededtosupportthepublichealthbenefitsofantimicrobialdrugdevelopmentandavailabilitythatarenotcapturedwellinpaymentsforactualuseofthedrug.Whilethispublicinvestmentwouldsupportabenefittoallofsociety,givenincreasingfiscalpressures,itiscriticaltoleverageanypublicfundingtominimizethecostsoftheseeffortstothepublic.Themarketentryrewardproposedherebuildsonratherthanreplacesexistingfundingstreamsforantimicrobials,limitingtheneedforpublicfunds.
CARESETTINGS
Marketchallengesforantimicrobialdevelopmentspantheinpatientandoutpatientsettings,butmostnovelantimicrobialsunderdevelopmentandespeciallythoseintendedtotreatthemosturgentinfectionsthatwouldqualifyforthePAVEAwardwouldbeusedintheinpatientsetting.However,thePAVEAwardcouldpotentiallybeappliedovertime,ifneededtodrugsintheoutpatientsetting.Productdevelopers,payers,andprovidersareenteringintomorerisk-sharing,outcomes-basedmodelstohelpaddressproductperformanceuncertaintyandtohelpensurebettervaluefordollarsspent.FuturepaymentapproachesforantimicrobialsinthissettingcouldleverageCDCtrackingsystemsaswellasappropriateuseguidelinesthathavebeenissuedbyCDCandothergroupstoensureappropriateprescribingandstewardship.Theguidelinesandoutcomesgoverningthevalue-basedpaymentmodel
Value-basedStrategiesforEncouraging NewDevelopmentofAntimicrobialDrugs
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forhigh-priorityinpatientantimicrobialsmayneedadjustmentstobeapplicableintheoutpatientsetting.Butweexpectthatthesameprinciplesandapproachcanbeapplied.
DRUGSFORRAREINFECTIONS
Someantimicrobial-resistantinfectionsareextremelyrare.Newantimicrobialsthattreattheseinfectionsareunlikelytogeneratesignificantcostsforpayers—andpayersmaynotseethevalueinhavingcontractsinplacefortheiruse.Creatingvalue-basedpaymentcontracts—oranypayercontracts—maynotbeworthwhile.Inthesecaseswherenoconsequentialprivatemarketexists,aswithdrugsneededascountermeasures,aMERmightbelinkedtoappropriateaccessandcontinuedevidencedevelopment.Ofcourse,itwillgenerallybeinthemanufacturer’sinteresttoworkoutvalue-basedcontractsforpriorityantimicrobialswheneverfeasible,toprovideadditionalrevenuestreams.
TRANSITIONTOROUTINEUSEOFVALUE-BASEDPAYMENTSFORANTIMICROBIALS
Thepresentationofourmodelfocusesonthecurrentstatusoffee-for-servicepaymentsforantimicrobials,recognizingthatitmaytakeseveralyearstophaseintheuseofAPMsbasedonvaluenotvolumeofsales.Withtheincentivesandmomentumcreatedbyourproposedapproach,theaimistomakevalue-basedpaymentthenormforantimicrobialrevenues.Asthesemechanismsbecomemoreroutine,alargershareofrevenuesfromvalue-basedpaymentsshouldbeexpectedearlierafterlaunchofanewpriorityantimicrobialthatqualifiesforthemarketentrypayment.Legislationsupportingthisapproachmightevenspecifyatransitionpathtothepredominantorfulluseofvalue-basedpaymentsforantimicrobials,suchthatantimicrobialslaunchedin,forexample,2027,wouldbeexpectedtohaveahighshareofvalue-basedpaymentcontractsinplacefromlaunchonwards.
ConclusionRecognizingtheimportanceofarobustpipelineofantimicrobialdrugcandidatestomaintainingpublichealth,theproposaldescribedhereisdesignedtoprovideastrong,leveragedfinancialincentiveforpriorityantimicrobialdevelopmentwithintheU.S.ThePAVEAwardandsubsequentvalue-basedcontractswouldbuilduponpaymentstructuresthatarecurrentlyinplacetoshiftthefocusfromsalesvolumetooutcomesandappropriateuse.Thisproposalwillrequirecollaborationacrossarangeofstakeholders,allofwhomwillstandtobenefitfromtheavailabilityofeffective,high-priorityantimicrobials.Whileitmaytakeseveralyearstofullyimplementthisproposal,thePAVEAwardcouldbeginmakingamajorcontributionnowtotheglobalefforttocreateandsustainarobustpipelineofantimicrobialstoaddressurgentandgrowingpublichealthneeds.Inparticular,PAVEcouldbeintegratedwithcurrentlegislativeproposalsforTEVandDISARM,usingtheTEVasthefundingmechanismforthePAVEAwardandimplementingDISARMinawaythatsupportsthetransitiontobetterpaymentmodelsforavailabilityanduseofpriorityantimicrobialsinhospitalizedpatients.Withthegrowingthreatofantimicrobialresistance,andtheurgentneedtodevelopamoresustainablewayofassuringtheavailabilityandappropriateuseofpriorityantimicrobialsintheUnitedStates,thetimeforimplementationisnow.
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Appendix1.U.S.NetSalesofNew-Molecule,Brand-NameAntibioticDrugsApprovedafter2000,inU.S.dollars(millions)
BrandName MoleculeName Owner ApprovalYear
SALES
2011 2012 2013 2014 2015
Avycaz ceftazidime/avibactam Allergen 2015 Productnotyetlaunched 35.8
Sivextro tedizolidphosphate Merck 2014 Productnotyetlaunched 2.4 37
Dalvance dalbavancin Allergen 2014 Productnotyetlaunched 14.6 20.3
Orbactiv oritavancin MedicinesCo. 2014 Productnotyetlaunched 0.8 9.1
Dificid fidaxomicin Merck 2011 24.4 74.4 51.6 47.7 39.8
Teflaro Ceftarolinefosamil Allergen 2010 2.7 22.4 44 70.3 118.5
Vibativ Telavancin Theravance 2009 10.0 0.0 0.0 4.4 9.4
Doribax Doripenem J&J(divested) 2007 Marketinganddevelopmenthaltedin2010
Tygacil Tigecycline Pfizer 2005 148 152 150 112 110
Ketek Telithromycin Sanofi(divested) 2004 Offthemarket
Cubicin Daptomycin Merck 2003 698.8 809.2 908 977 1127
Factive Gemifloxacin Vansen(Divested) 2003 6.3 0.36 -0.12 Divestedthedrugin2012.
Spectracef Cefditorenpivoxil Vansen(Divested) 2001 8.1 0.33 -0.72 Divestedthe
drugin2012.
Invanz Ertapenem Merck 2001 406 445 488 529 569
Zyvox Linezolid Pfizer 2000 640 665 688 680 457.8
Value-basedStrategiesforEncouraging NewDevelopmentofAntimicrobialDrugs
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References1. CentersforDiseasesControlandPrevention.AntibioticResistanceThreatsintheUnitedStates,2013.114
(2013).
2. AntimicrobialResistance:Tacklingacrisisforthehealthandwealthofnations.(TheReviewonAntimicrobialResistance,2014).
3. GetSmartAboutAntibiotics|MeasuringOutpatientPrescribing|CDC.Availableat:http://www.cdc.gov/getsmart/community/programs-measurement/measuring-antibiotic-prescribing.html.(Accessed:29thNovember2016)
4. Fleming-Dutra,K.E.etal.PrevalenceofInappropriateAntibioticPrescriptionsAmongUSAmbulatoryCareVisits,2010-2011.JAMA315,1864(2016).
5. AvoidableCostsinU.S.Healthcare.62(IMSInstituteforHealthcareInformatics,2013).
6. AntibioticResistantThreatsintheUnitedStates,2013.(U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention,2013).
7. WHOpublisheslistofbacteriaforwhichnewantibioticsareurgentlyneeded.(2017).Availableat:http://www.who.int/mediacentre/news/releases/2017/bacteria-antibiotics-needed/en/.(Accessed:1stMarch2017)
8. Shore,C.TrackingthePipelineofAntibioticsinDevelopment.Availableat:http://bit.ly/1x8YgVA.(Accessed:5thJanuary2017)
9. Hay,M.,Thomas,D.W.,Craighead,J.L.,Economides,C.&Rosenthal,J.Clinicaldevelopmentsuccessratesforinvestigationaldrugs.Nat.Biotechnol.32,40–51(2014).
10. MedicinesinDevelopmentforDiabetes-AReportonDiabetesandRelatedConditions.4(PharmaceuticalResearchandManufacturersofAmerica,2016).
11. MedicinesinDevelopmentforCancer.4(PharmaceuticalResearchandManufacturersofAmerica,2015).
12. DiMasi,J.A.,Grabowski,H.G.&Hansen,R.W.Innovationinthepharmaceuticalindustry:NewestimatesofR&Dcosts.J.HealthEcon.47,20–33(2016).
13. OfficeoftheAssistantSecretaryforPlanningandEvaluation(ASPE).PrescriptionDrugs:Innovation,Spending,andPatientAccess.(2016).
14. AylinSertkaya,JohnEyraud,AnnaBirkenbach,CalvinFranz,NyssaAckerley,ValerieOverton,KevinOutterson.AnalyticalFrameworkforExaminingtheValueofAntibacterialProducts.(OfficeoftheAssistantSecretaryforPlanningandEvaluation,2014).
15. InfectiousDiseasesSocietyofAmerica.NoNewDrugstoCombatAntimicrobialResistantBugs.IDSAAntimicrobialResistanceInfographics2016(2016).Availableat:https://www.idsociety.org/uploadedFiles/IDSA/Policy_and_Advocacy/Current_Topics_and_Issues/Advancing_Product_Research_and_Development/Bad_Bugs_No_Drugs/Press_Releases/IDSA%20Antibiotic%20Incentives%20Infographic%202016%20Final.pdf.
16. MurrayAitken,MichaelKleinrock,KimPennente,JenniferLyle,DeannaNass,LaurenCaskey.MedicinesUseandSpendingintheU.S.AReviewof2015andOutlookto2020.(IMSInstituteforHealthcareInformatics,2016).
17. Towse,A.&Sharma,P.IncentivesforR&DforNewAntimicrobialDrugs.Int.J.Econ.Bus.18,331–350(2011).
Value-basedStrategiesforEncouraging NewDevelopmentofAntimicrobialDrugs
20
18. Rex,J.H.etal.ProgressintheFightAgainstMultidrug-ResistantBacteria2005–2016:ModernNoninferiorityTrialDesignsEnableAntibioticDevelopmentinAdvanceofEpidemicBacterialResistance.Clin.Infect.Dis.(2017).doi:10.1093/cid/cix246
19. CoreElementsofHospitalAntibioticStewardshipPrograms.(2017).Availableat:https://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html.(Accessed:20thMarch2017)
20. AstraZenecatosellsmallmoleculeantibioticsbusinesstoPfizer.(2016).
21. DamianGarde.Merckdumps120Cubistresearchersafterits$9.5Bmerger.FierceBiotech(2015).Availableat:http://www.fiercebiotech.com/r-d/merck-dumps-120-cubist-researchers-after-its-9-5b-merger.
22. ChathamHouseWorkingGrouponNewAntibioticBusinessModels.TowardsaNewGlobalBusinessModelforAntibiotics.(ChathamHouse).
23. O’Neill,J.TacklingDrug-ResistantInfectionsGlobally:FinalReportandRecommendations.(TheReviewonAntimicrobialResistance,2016).
24. Incentivestostimulateantibioticinnovation:ThepreliminaryfindingsofDRIVE-AB.(DRIVE-AB,2016).
25. IndustryRoadmapforProgressonCombattingAntimicrobialResistance-September2016.(2016).
26. SelmaSternetal.BreakingthroughtheWall-ACallforConcertedActiononAntibioticsResearchandDevelopment.84(BostonConsultingGroupfortheGermanFederalMinistryofHealth,2017).
27. NicholasBagley&KevinOutterson.WeWillMissAntibioticsWhenThey’reGone.TheNewYorkTimes(2017).
28. JimenaS.Ferraro,AdrianTowse&JorgeMestre-Ferrandiz.IncentivesforNewDrugstoTackleAnti-MicrobialResistance.(TheOfficeofHealthEconomics,2017).
29. TheU.S.HouseofRepresentatives,21stCenturyCuresAct.
30. Sen.AlFranken.ImprovingAccessToAffordablePrescriptionDrugsAct.(2017).
31. Rep.JaniceSchakowsky.ImprovingAccesstoAffordablePrescriptionDrugsAct.(2017).
32. Outterson,K.&McDonnell,A.FundingAntibioticInnovationWithVouchers:RecommendationsOnHowToStrengthenAFlawedIncentivePolicy.HealthAff.(Millwood)35,784–790(2016).
33. AlternativePaymentModelFrameworkandProgressTracking(APMFPT)WorkGroup.AlternativePaymentModel(APM)Framework.(2016).
34. Cromwell,J.,Dayhoff,D.A.&Thoumaian,A.H.CostsavingsandphysicianresponsestoglobalbundledpaymentsforMedicareheartbypasssurgery.HealthCareFinanc.Rev.19,41–57(1997).
35. Rex,J.H.&Outterson,K.Antibioticreimbursementinamodeldelinkedfromsales:abenchmark-basedworldwideapproach.LancetInfect.Dis.16,500–505(2016).
36. AntimicrobialUseandResistance(AUR)Module.(2017).
37. Hollis,A.&Ahmed,Z.PreservingAntibiotics,Rationally.N.Engl.J.Med.369,2474–2476(2013).
38. InfectiousDiseasesSocietyofAmerica(IDSA).CombatingAntimicrobialResistance:PolicyRecommendationstoSaveLives.Clin.Infect.Dis.52,S397–S428(2011).