Muristek
In Reply In response to my recent Viewpoint, the comments from Dr Gusmano and colleagues appear to abide by the principle that for every complex and challenging problem, there is a response that makes the problem even more complex and more challenging. Here, the challenge is that the extent of evidence of the clinical benefit of a drug often is limited at the time of initial launch and then increases and improves over time. My Viewpoint proposal was to begin with a low price of the drug at the time of market launch and then raise (or lower) the price commensurate with the evolution of the evidence. In contrast, Gusmano and colleagues suggest that before this can be done, there needs to be agreement on how to define and measure value (suggestions include clinical indicators, effects on productivity, reductions in other forms of care, composites, indexes, and surrogates); agreement on how much agreement counts; agreement on decisions about who gets to decide, who gets to finance clinical research, how studies can be held “accountable to the public”; and, last but not least, agreement on how to take into account “societal factors and institutions.” This proposed list of required agreements is well intentioned but would ensure stasis and protect the dysfunctional status quo of pharmaceutical pricing.
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