Presentation (CTI)

OBJECTIVES: Navigating the public payer hurdle is becoming increasingly challenging for developers of new medicines, as healthcare systems respond to increasing demand amidst budgetary challenges. Manufacturers are increasingly exploring opportunities beyond the traditional public payer routes to secure patient access. This research evaluated private healthcare insurance (PHI) and out of pocket (OOP) access in three major European markets.
METHODS: Three private healthcare payer experts were interviewed alongside supplementary desk research to evaluate the market size, coverage and trends of PHI and OOP access in Italy, UK, and France.
RESULTS: 22% of the UK population is covered by some form of PHI (total value: £11.4bn [2022], with over half (£6 billion) being acute hospitals offering in- and out-patient services, £2.5bn of which is PHI-covered, £1.8bn NHS-covered, and £1.6bn OOP. PHI does not typically cover primary care nor outpatient medicines, but does cover inpatient drugs. However, these tend to be broadly aligned to NICE recommendations. The exception is within oncology, where some PHIs have specialist policies offering access to non-NICE-recommended therapies. In Italy, ~10% of the population have complementary/supplementary PHI, typically provided through employer plans but most programs do not cover pharmaceuticals. Nevertheless, around 25% of the total drugs budget spend is OOP, typically for Class C products (that are not publicly-reimbursed but require a prescription). In France, everyone is covered by supplementary health insurance, mandatory by law. ~80% covered by Mutuelles and ~20% by PHIs. Most pharmaceuticals are only partially publicly-reimbursed, this insurance covers such copayments but do not cover drugs not publicly reimbursed.
CONCLUSIONS: The role that PHI and OOP plays in pharmaceutical market access can vary dramatically, even within the three markets assessed in this research. Manufacturers looking to leverage pathways outside those of traditional public reimbursement need to have a strategy that is highly tailored to individual markets.