Drug pricing and reimbursement systems vary widely between countries, leading to different price levels for the same medications. For example, in the United States and Germany, there is a free drug pricing system and the price set by manufacturer (in case of Germany, during the first year after a drug's registration). In contrast, many European Union countries use external price referencing (EPR), which set the drug prices in one country on the prices in other countries. However, while the EPR can serve as the primary method for setting drug prices, it can also be used as a complementary tool and is used differently across health systems. Some of the strictest systems include those that set maximum allowable prices based on the lowest prices found in a reference basket of countries aiming to keep control on drug expenditures and ensure stability of healthcare budgets.
To analyze the impact of diverse pricing systems, an analysis was conducted on 10 selected drugs (except vaccines), which include Humira, Keytruda, Eliquis, Biktarvy, Dupixent, Eylea, Opdivo, Ozempic, Stelara, and Revlimid in selected 37 countries. These drugs are the ones with highest reported global sales in 2023 (1). The prices of these drugs were obtained using the Ex-Price application that provides information on drug prices from more than 50 countries and allows an accurate comparison of drug prices worldwide. As different size and strengths of drugs are available in various countries, the price of the drug was calculated as the average price per one unit (e.g. milligram). To compare prices of drugs across countries, the Z-score, a measure of price deviation, were calculated for each drug across different countries, allowing for a standardized comparison of price levels.
The scatter plot bellow presents the distribution of Z-scores for each 10 selected drugs, indicating the variation in price levels across countries, as of December 2023. According to this graph, the highest prices of drugs were seen in the USA, where EPR is not implemented. In several other countries, especially those where drug prices are referenced to other countries, the dispersion is smaller. Countries that don’t use EPR or use it as a complementary method (e.g. Hungary, Denmark, Russia or Belgium), tend to experience greater price dispersions compared to those that use EPR as the primary approach (e.g. Slovakia, Czech Republic, Romania or Cyprus).
Figure: The variation in price levels of 10 selected drugs across countries according to Z-scores
Comments: The prices were transformed to Z-score by the formula: 
, where zi: Z-score, x_i: original values of the sample, x: sample mean, S: standard deviation of the sample).
This analysis highlights the necessity of ongoing analysis of drug prices to ensure that they correspond to their added clinical value. There is an urgent need for tools like Ex-Price, which provide a comprehensive view of drug prices across different markets, aiding policymakers in making informed decisions. Ultimately, finding the right balance between drug affordability, accessibility, and the sustainability of healthcare budgets remains a critical challenge for global health systems. Implementing pricing regulations that reflect clinical benefits, and cost-effectiveness is essential to maintaining a fair and sustainable healthcare system.
Sources:
1. Top 20 Drugs in 2023 by 2022 Sales Statistics. Available at: https://xtalks.com/top-20-drugs-in-2023-by-2022-sales-statistics-3645/
