Jim McGrath
Director of Commercial Policy, IPHA
Clinicians are increasingly realising the potential of combination therapies to address high unmet medical needs across several disease areas.
Combination treatments are where two or more individual medicines are combined into a single treatment regimen. They represent an immediate wave of advances in pharmaceutical medicine. They have shown strong potential to improve patient outcomes by targeting different disease pathways synergistically — preventing tumour growth or the spread of cancer throughout the body.
Challenges in launching combination therapies
Combination therapies will hopefully become the norm in cancer treatments while benefits will also accrue in many other therapy areas. More than 50 combination medicines will be launched in Ireland between now and the end of the decade. However, making these medicines available to patients brings with it many challenges.
For the most part, the systems of assessing medicines throughout Europe were initially designed around single-therapy treatments (monotherapies). The loose working theory of many reimbursement systems is that if — when assessed — a medicine meets the relevant pricing criteria, it will then secure reimbursement. Each use of a single medicine is based on the same price. In Ireland, this criterion typically — but not always — hinges on a pricing threshold of €45,0000 per quality-adjusted life year gained (QALY).
Systems should have the flexibility to implement discounts on combination usage.
Adjusting prices for different uses
Advances in combination treatments, however, present significant challenges to health systems and pharma companies. If one therapy in a combination is priced at or above €45,000 per QALY, then any combination of treatments above that value would exceed the pricing threshold. This is even if one of the medicines were to be given away free of charge.
The method around this is to set different prices for different uses of the medicine. To reduce health system expenditure and to maximise the use of combination therapies for patients, systems should have the flexibility to implement discounts on combination usage. Otherwise, there will be no incentive to bring the combination medicine to market — and ultimately to the patient. However, in Ireland, we currently do not have the systems to monitor different uses of the same medicine at different prices based on their indication.
Making combination therapies accessible
Companies could get around this by coordinating a price for their combination treatments. However, competition law prevents such cooperation currently. The best solution is for HSE, the pharmaceutical industry and competition authorities to develop a framework for appropriate collaboration. All sides owe it to patients to make sure the Irish health system realises these benefits.