TOWARDS IMPLEMENTING NEW PAYMENT MODELS FOR THE REIMBURSEMENT OF HIGH-COST, CURATIVE THERAPIES IN EUROPE: INSIGHTS FROM SEMI- STRUCTURED INTERVIEWS
Desmet T, Michelsen S, Van den Brande E, Van Dyck W, Simoens S, Huys I. Front Pharmacol. 2025 Jan 20;15:1397531. Doi: 10.3389/ fphar.2024.1397531.
MARC CZARKA
CEO. EuroPharMedTech (EPMT)
SUMMARY
The article explores how Europe- an healthcare systems, specifically Belgium, could adopt new ways to pay for very expensive, one- time treatments like gene and cell therapies. These advanced therapies can offer long-term or even curative benefits, but their high upfront costs create major challenges for public health budgets. Traditional payment systems aren’t built to handle this kind of financial burden, which is why alternative models, like out- come-based spread payments (OBSP), are being discussed. In these models, payment for the treatment is spread out over time and tied to how well the treatment actually works for patients.
The goal of the study is to understand what’s needed to make these kinds of payment models a reality. More concretely, it aimed to elicit opinions on and insights into the governance aspect of implementing OBSP in Belgium for the reimbursement of innovative therapies. To get a clear picture, the authors conducted 33 in-depth interviews with a wide range of stakeholders, including doctors, hospital pharmacists, health system managers, policymakers, legal experts, patient representatives, pharmaceutical company staff, and people from Belgium’s public health insurance system. These conversations took place between July and October 2020 and were analyzed using a structured approach that allowed the team to identify key themes and challenges. Statements were allocated into six main topics: payment structure, spread payments, outcome-based agreements, governance, transparency, and regulation.
Seven key conditions must be met for OBSP models to succeed, from robust data to transparency and external governance
Interviews revealed the necessary conditions that, fulfilled together, are seen to be sufficient for the successful implementation of OBSP, including consensus on pricing, payment logistics, robust data infrastructure and financing, clear agreement terms (duration, outcome parameters, payment triggers), long-term patient fol- low-up solutions, an external multi-stakeholder governance body, and transparency regarding agreement types. From the interviews, the authors found that seven conditions need to be in place for OBSP models to work properly.
- Everyone involved needs to agree on the price of the therapy and how its value is assessed.
- The way payments are broken down over time has to be carefully planned.
- Strong systems need to be in place to collect and analyze data about patient outcomes, since payments depend on whether the treatment is effective.
- The contracts that govern these agreements have to be clear, especially about how long payments last, what counts as a successful outcome, and when payments should stop or be adjusted.
- There must be systems to follow up with patients over the longterm, which is often difficult in real-world settings.
- An independent organization should be responsible for overseeing the process, to make sure it runs smoothly and fairly.
- Transparency is essential, stakeholders emphasized that the terms of these agreements, and how decisions are made, should be open and clearly communicated.
Even though there is strong interest in implementing OBSP models, the study shows there are still a lot of barriers. For example, there’s no agreement yet on who should take responsibility for different parts of the process, like managing the data or covering financial risks if the therapy doesn’t work. There are also technical and legal challenges when it comes to tracking patient outcomes over time, especially if patients change healthcare providers or move between regions. In addition, there is no central authority currently in place to coordinate these efforts, and many existing agreements are kept confidential, which makes it harder for others to learn from past experiences or build better systems.
To help move things forward, the authors propose a roadmap or checklist based on the seven key conditions mentioned above. This framework can help policymakers and other actors understand what pieces need to be in place before an OBSP model can be successfully launched.
COMMENT
Thomas Desmet’s 2025 article explores the barriers to implementing outcome-based spread payments for high-cost therapies in Europe. While the topic is timely and relevant in light of rising pharmaceutical expenditures, the article ultimately offers limited novel insight and leaves several critical issues unaddressed.
Strengths
- The authors rightly recognize OBSP as a potential tool to increase access to innovative therapies while possibly mitigating financial risk for payers.
- The use of semi-structured inter- views allows for a diversity of stakeholder perspectives, touching on pricing, governance, and infrastructure challenges.
Critical Shortcomings
- Delayed Publication Timeline. The interviews were conducted in 2020, yet the article appeared only in 2025, a five-year gap that raises legitimate concerns about the relevance and currency of the In a field characterized by rapid policy developments, particularly around gene therapies and payment innovation, such a delay undermines the practical utility of the study’s conclusions. No explanation is given for this timeline.
- Response Rate and Representativeness. Although 90 stakeholders were contacted, only 33 agreed to be interviewed (a ~37% response rate). The article does not specify how respondents are distributed across stakeholder categories — a major omission given the potential for imbalanced representation. Without such information, the findings risk reflecting a non representative or skewed sample, especially in a setting where perspectives can vary dramatically between industry, regulators, and healthcare providers.
- Linguistic and Cultural Bias. All interviews were conducted in Dutch or This choice systematically excludes participants with limited proficiency in these languages, most notably native French speakers in Belgium. Given that language proficiency in professional contexts varies across regions and sectors, this methodological decision introduces a significant linguistic bias. The absence of French-language participation is neither acknowledged nor critically examined, undermining the inclusivity and national representative ness of the analysis.
- Lack of Theoretical or Policy Innovation. While the article reiterates well-known challenges, such as the need for data infrastructure, transparency, and governance, these insights are not new to the literature. Nor does the study offer concrete policy solutions, implementation strategies, or comparative insights from jurisdictions where OBSP has been piloted. As such, the article contributes more as a consolidation of stakeholder sentiment than as a springboard for action or reform.
- Identified weaknesses. The author’s level of introspection is limited but not non-existent. He acknowledges certain weaknesses himself including variability in responses and lack of “generalizability” to other countries.
Desmet’s study engages with a real and pressing policy issue, but its limited originality, methodological blind spots, and much delayed publication dilute its impact. One is left with the impression of a paper that fulfills a publication requirement more than it drives the discourse forward. While it gathers useful quotes and clusters familiar themes, it does not significantly advance the conversation around sustainable reimbursement models.
