OBJECTIVES: Global medicines expenditure is forecast to hit $1.4 trillion annually by 2020 (private / public sources, USD, source: IMS Institute), an increase of approximately 30% from current levels. To manage global medicine spend, it is likely that payers and pharmaceutical companies will need to expand innovative contracting, with increased reliance on mechanisms that share risk and ensure predictable patient costs. Payer preferences and perceptions of implementation hurdles across types of innovative agreements are currently not well understood, leading to a potential disconnect between pharmaceutical manufacturers and payers which may ultimately reduce timely patient access to medicines. METHODS: To understand stakeholder preferences in EU5 markets, a two-stage research approach was used. In a pilot focus group (n=5), payer stakeholders from each market were asked to estimate national preference ranks for innovative agreements, defined as performance-based (individual patient response), evidence development (e.g. patient registries), or financial-based risk-sharing (such as patient capitation). This pilot was followed by an online best-worst scaling exercise (N=66, EU5 participants) to generate net preference scores across product / agreement scenarios. RESULTS: Average preference rank (1 = not preferred, 5 = most preferred) for financial-based risk-sharing was 3.5, followed by performance-based (2.6) and evidence development (1.8). Evidence development was ranked highest in France but lowest in all other markets. Only the UK ranked performance-based schemes as the most-preferred option (4/5). Mandatory in-market negotiations (such as in Germany) were seen as a barrier to innovative contracting, through achieving a lowest acceptable price as a condition of reimbursement. CONCLUSIONS: In order to manage public medicine expenditure, innovative contracting may represent a better alternative to simple discounts or rebates, but uptake requires acceptance from stakeholders. Results indicate that in-market preferences vary across the EU5, and that existing pricing/access policies may act as a disincentive to innovation. Funded by Mundipharma International Limited