Background: Worldwide, prices for cancer drugs have been under downward pressure where several governments have mandated price cuts of branded and generic products. A better alternative to mandated price cuts would be the estimation of a launch price based on drug performance, cost effectiveness and a country’s ability to pay. In this study, the development of a global pricing index for new drugs that encompasses all of these attributes in patients with metastatic colorectal cancer (mCRC) is described. Methods: A pharmacoeconomic model was developed to simulate clinical outcomes in mCRC patients receiving chemotherapy with the addition of a “new drug” that improves survival by 1.4, 3 and 6 months. Cost and health state utility data were obtained from cancer centers and oncology nurses (total n=112) in Canada (n=24), Spain (n=24), India (n=24), South Africa (n=16) and Malaysia (n=24). A price per dose was estimated for each survival increment using a target value threshold of three times the per capita gross domestic product (GDP) for each country, as recommended by the World Health Organisation (WHO). Multivariable analysis was then used to develop the pricing index, which considers survival benefit, per capita GDP and income dispersion as measured by the Gini coefficient as predictor variables. Results: Higher survival benefits were associated with elevated drug prices, especially in wealthier countries such as Canada and Spain. For a nation like Argentina with a per capita GDP of $15,000 and a Gini coefficient of 51, it is estimated that for a drug which provides a 4 month survival benefit in mCRC, the value based price would be $US 630 per dose. In contrast, the same drug in a wealthier country like Norway could command a price of $US 2,775 and still be considered cost effective according to the WHO criteria. Conclusions: A global pricing index was presented that can be used to estimate a value based price in different countries for new drugs in mCRC. The application of this index to estimate a price based on cost effectiveness would be a good starting point for opening dialogue between the key stakeholders and a better alternative to governments’ mandated price cuts.

Physicians often continue to prescribe brand-name drugs to their patients even when less expensive generic equivalents are available. In a 1994 study, Judith Hellerstein advances two hypotheses to explain this behavior. First, doctors may consciously conclude that certain brand-name drugs impart a relative therapeutic benefit that outweighs their higher cost. Second, physicians may choose to prescribe brand-name drugs without evidence of therapeutic superiority if neither they nor their insured patients bear the increased cost of these drugs. The second hypothesis implies that moral hazard is evident in physicians' prescribing behavior. Hellerstein's findings support neither hypothesis, but her estimation equation does not explicitly capture the effects of brand-name/generic price differentials and information diffusion on the probability of generic prescription. The author adapts Hellerstein's theoretical model to a modified estimation equation that incorporates these effects and uses it to create new estimates based on data on antimicrobial prescriptions from the 1994 National Ambulatory Medical Care Survey (NAMCS). Unexpectedly, the results appear to affirm both hypotheses. The evidence for moral hazard is particularly strong, as self-paying patients are significantly more likely than patients with Medicare or private insurance to be prescribed the generics that are cheapest relative to their brand-name counterparts. The author also finds that certain popular antimicrobial drugs such as amoxicillin and sulfamethoxazole/trimethoprim are prescribed in the same form (generic or brand-name) by most doctors to most patients. The market power exhibited by these preferred forms leads the author to conclude that they are "brands" in the economic sense. / Master of Arts

In the extensive literature on price dispersions that exists to date, there is a gap in the analysis of how market structure affects prices as well as the degree of dispersion in prices. Specifically, the literature is deficient in analyzing how price levels and price dispersion are affected by the number of firms operating in a market. I use secondary data to look at the prices of prescription drugs at the retail level in nine hundred and seventy pharmacies across one hundred and sixty five markets in Maryland and compare price dispersion across these brick and mortar pharmacies as well as across a separate set of pharmacies that only operate online. I compare online versus offline price dispersion, as well as price dispersion in purely offline markets from the structure of the market’s context. Stahl’s (1989) theoretical model is used to formulate and test the hypotheses that an increase in the proportion of positive search cost consumers in a market will cause price levels to rise and price dispersion to initially increase and then decrease. Furthermore, in markets with the proportion of positive search cost consumers above a threshold level, an increase in the number of firms will also lead price levels to rise and price dispersion to initially increase and then decrease. Conversely, in markets with positive search cost consumers below the threshold level, an increase in the number of firms will lead to lower price levels, i.e. the competitive outcome. For the analysis, I look at prices at the pharmacy level and price dispersion at the market level and determine the proportion of high search cost consumers for a specific pharmacy or a specific market relative to the other pharmacies and markets in the dataset. I find that a significant part of the differences in prices for a homogeneous prescription drug can be attributed to asymmetric information and that price dispersion is higher in markets with a greater number of firms, and price levels are higher in low income neighborhoods.

The thesis deals with economic theory and research of the drug markets. Analysis of the literature compares individual approaches to theories by present authors, including their conclusions on data for the U.S. Established hypotheses based on the conclusions of analyzed literature are tested mainly using regression analysis on the available Czech data, where data on marihuana markets have high interdependency. The effects of selected variables on the price of drugs, which is a key characteristic of drug markets, are tested on data for the EU-27. The work describes trends in European drug markets and provides evidence on the influence of the variables on the price of drugs.

Cette thèse étudie deux facteurs majeurs pour le bien-être individuel, la qualité de l'emploi et l'accès aux soins. Dans le premier chapitre, nous étudions l'effet de la perte d’emploi suite à une fermeture d’usine sur un large panel d’indicateurs mesurant la qualité de l'emploi retrouvé. Nous utilisons une stratégie d’appariement exact par tranche qui prend en compte les inobservables fixes dans le temps. Nos résultats principaux montrent une dégradation de la qualité de l’emploi suite au licenciement, dont la durée et l’ampleur dépendent de la dimension considérée. Le second chapitre étudie l'impact d'une assurance maladie publique plus généreuse sur la consommation de soins de santé. Nous utilisons la coexistence de deux systèmes d'assurance maladie en France, tous deux publics et obligatoires : le système national, et le régime local d'Alsace Moselle, donc les taux de remboursement sont plus élevés. Nous évaluons comment les personnes déménageant en Alsace Moselle modifient leur consommation de soins, en utilisant les personnes déménageant entre d’autres régions françaises comme groupe de contrôle. En étudiant plusieurs postes de santé, nous trouvons qu’au total, le régime d’Alsace Moselle n’engendre pas de hausse des dépenses. Le dernier chapitre s'intéresse à l'effet de l'achat groupé sur les prix des médicaments dans les hôpitaux français, en utilisant les créations de groupements entre 2009 et 2014. Nos données contiennent les prix d’achat des médicaments innovants dans les hôpitaux publics. Nos résultats montrent que l'achat groupé baisse les prix des médicaments en oligopole, mais n'a aucun impact sur les prix des médicaments qui n'ont pas de concurrents. / This thesis focuses on two major aspects of individual well-being : job quality and the availability of medical care. We first investigate the long-term effects of job displacement on several dimensions of job quality. We use a coarsened exact matching method that takes into account time-invariant unobservables. Our main findings point to a deterioration of job quality after displacement. The magnitude and duration of the observed negative impact depends on the dimension considered. The second chapter studies the impact of a more generous public health insurance. We use the coexistence of two compulsory public health insurance systems in France, the national system, and the Alsace Moselle local system, which offers higher reimbursement rates. We investigate how moving to Alsace Moselle affects healthcare consumption, taking individuals who move between other French regions as a control group. Overall, we show that the Alsace Moselle local system does not increase healthcare consumption. The third chapter estimates the impact of group purchasing on medicine prices in French hospitals. We take advantage of the creation of regional purchasing groups between 2009 and 2014. We use a unique database that provides information on the average annual prices paid by public hospitals for all innovative medicines. Using a fixed effects model controlling for medicine-specific bargaining abilities of hospitals and medicine-specific price trends, we find that group purchasing reduces prices of medicines in oligopoly markets, but has no impact on prices of medicines for which there exist no competitors.

Pochi studi hanno analizzato I prezzi delle droghe in Europa nonostante I risultati forniti da questo tipo di analisi in altri paesi. In America, l’analisi sui prezzi delle droghe costituisce la base dell’attuale conoscenza su domanda e offerta del mercato delle droga e dell’effetto delle forze di polizia. Questa tesi analizza il prezzo delle droghe illecite (eroina e cocaina) in Europa. In particolare questo studio ha due obiettivi 1) identificare quali fattori influenzano i prezzi delle droghe; 2) identificare quali fattori hanno portato al declino dei prezzi delle droghe negli ultimi venti anni. In linea con la precedente letteratura, questo studio ha impiegato un’analisi della variazione geografica e temporale dei prezzi, un “Risk and price model” ed una analisi panel. I risultati mostrano che le forze di polizia e il livello di violenza hanno un effetto marginale sul prezzo delle droghe e non sono capaci di spiegare il loro declino negli anni. La globalizzazione sembra la principale spiegazione. La globalizzazione ha tagliato i costi nel traffico di droga, riducendo le inefficienze causate dalla sua illegalità (per esempio nel trasporto). Di conseguenza la globalizzazione può essere considerata la componente principale nello spiegare il declino dei prezzi delle droghe in Europa. / There are few studies on drug prices in Europe, despite the insight this type of analysis has provided in other countries. In the USA, the examination of drug prices has improved the knowledge of the demand and supply in drug markets and the impact of law enforcement. The dissertation aims to analyze the prices of illicit drugs (heroin and cocaine) in Europe. The study has two objectives: (1) identifying which factors affect drug prices; (2) analyzing which factors drove the price decline in the last twenty years. In line with the previous literature, the methods include the analysis of the trends of prices over time and across countries, a risk and price model, and a panel regression. The results show that law enforcement and violence have marginal impact on drug prices and they are unable to explain the decline over time. In fact, globalization is the key explanatory factor. Globalization has likely cut the costs of the drug trade, reducing the inefficiencies caused by illegality (e.g. transportation). As a result, it may be regarded as the most important factor in the price decline in European drug markets.

La thèse vise à analyser la structure des échanges transnationaux de cocaïne, d’héroïne et de marijuana. Partant de la perspective des systèmes-mondes, l’hypothèse que le trafic de drogues forme un système inverse au commerce légal est développée. Les outils de l’analyse de réseaux sont appliqués aux échanges de drogues entre pays. La thèse s’appuie sur deux sources de données complémentaires. La première est une banque d’informations uniques compilées par l’United Nations Office on Drugs and Crime (UNODC) sur les saisies d’importance effectuées dans le monde entre 1998 et 2007 (n = 47629). Ces données sont complétées par les informations contenues dans une dizaine de rapports publiés par des organismes internationaux de surveillance du trafic de drogues. Les réseaux d’échanges dirigés construits à partir de ces données permettent d’examiner l’étendue du trafic entre la plupart des pays du monde et de qualifier leur implication individuelle. Les chapitres 3 et 4 portent sur la structure du trafic elle-même. Dans un premier temps, les différents rôles joués par les pays et les caractéristiques des trois marchés de drogues sont comparés. Les quantités en circulation et les taux d’interception sont estimés pour les 16 régions géographiques définies par l’UNODC. Dans un deuxième temps, leurs caractéristiques structurelles sont comparées à celles des marchés légaux. Il en ressort que les marchés de drogues sont beaucoup moins denses et que les pays périphériques y jouent un rôle plus prononcé. L’inégalité des échanges caractérise les deux économies, mais leurs structures sont inversées. Le chapitre 5 propose une analyse de la principale source de risque pour les trafiquants, les saisies de drogues. Les données compilées permettent de démontrer que les saisies policières de drogues agrégées au niveau des pays sont principalement indicatrices du volume de trafic. L’éventuel biais lié aux pressions policières est négligeable pour les quantités saisies, mais plus prononcé pour le nombre de saisies. Les organismes de contrôle seraient donc plus à même de moduler leurs activités que les retombées éventuelles. Les résultats suggèrent aussi que les trafiquants adoptent des stratégies diverses pour limiter les pertes liées aux saisies. Le chapitre 6 s’attarde à l’impact de la structure sur le prix et la valeur des drogues. Le prix de gros varie considérablement d’un pays à l’autre et d’une drogue à l’autre. Ces variations s’expliquent par les contraintes auxquelles font face les trafiquants dans le cadre de leurs activités. D’une part, la valeur des drogues augmente plus rapidement lorsqu’elles sont destinées à des pays où les risques et les coûts d’importation sont élevés. D’autre part, la majoration des prix est plus prononcée lorsque les échanges sont dirigés vers des pays du cœur de l’économie légale. De nouveau, les rôles sont inversés : les pays généralement avantagés dépendent des plus désavantagés, et les pays pauvres en profitent pour exploiter les riches. / This dissertation proposes an analysis of the structure of transnational drug trafficking. Based on the world-system perspective, it is hypothesized that cocaine, heroin and marijuana form separate markets that are opposite to other legal trades in many ways. The analysis relies on two data sources. The first is a unique compilation of seizures gathered together by the United Nations Office on Drugs and Crime (UNODC). The seizures were made between 1998 and 2007 (n = 47629). It is completed by intelligence published by various agencies across the world. The dataset allows the construction of directed networks of drug trade between most countries of the world. Chapters 3 and 4 analyze the structure of the trade itself. Firstly, the roles played by the countries in each market are described and compared. The flow of drugs and interception rates are estimated for each 16 geographic areas defined by the UNODC. Secondly, several structural characteristics of the drug markets are compared to other legal trade, namely coffee and chocolate. It is shown that drug trade networks are less dense and that peripheral countries play more important roles. While inequality is characteristic of both legal and illegal economies, their structure is reversed. In chapter 5, it is demonstrated that seizure data are mostly indicative of drug trafficking within a country. The expected law enforcement bias is negligible for quantities seized but more apparent when we look at the number of seizures. Thus, law enforcement agencies are better at planning operations against drug trafficking than at predicting their outcomes. The results presented in chapter 5 also suggest that traffickers use counter-strategies to reduce losses caused by drug seizures. The price and value of drugs show significant variations among countries. Those variations are usually explained by varying costs and pressures suffered by traffickers. Chapter 6 seeks to measure the impact of structural features on wholesale price and value. The value of drugs increases more sharply when the drugs are bound to countries where the risks of seizures are higher. Furthermore, price mark-ups are higher when the trade is directed to core countries. Again, the situation is reversed: richer countries that generally control all economic activities rely on peripheral countries to be supplied in drugs.

La thèse vise à analyser la structure des échanges transnationaux de cocaïne, d’héroïne et de marijuana. Partant de la perspective des systèmes-mondes, l’hypothèse que le trafic de drogues forme un système inverse au commerce légal est développée. Les outils de l’analyse de réseaux sont appliqués aux échanges de drogues entre pays. La thèse s’appuie sur deux sources de données complémentaires. La première est une banque d’informations uniques compilées par l’United Nations Office on Drugs and Crime (UNODC) sur les saisies d’importance effectuées dans le monde entre 1998 et 2007 (n = 47629). Ces données sont complétées par les informations contenues dans une dizaine de rapports publiés par des organismes internationaux de surveillance du trafic de drogues. Les réseaux d’échanges dirigés construits à partir de ces données permettent d’examiner l’étendue du trafic entre la plupart des pays du monde et de qualifier leur implication individuelle. Les chapitres 3 et 4 portent sur la structure du trafic elle-même. Dans un premier temps, les différents rôles joués par les pays et les caractéristiques des trois marchés de drogues sont comparés. Les quantités en circulation et les taux d’interception sont estimés pour les 16 régions géographiques définies par l’UNODC. Dans un deuxième temps, leurs caractéristiques structurelles sont comparées à celles des marchés légaux. Il en ressort que les marchés de drogues sont beaucoup moins denses et que les pays périphériques y jouent un rôle plus prononcé. L’inégalité des échanges caractérise les deux économies, mais leurs structures sont inversées. Le chapitre 5 propose une analyse de la principale source de risque pour les trafiquants, les saisies de drogues. Les données compilées permettent de démontrer que les saisies policières de drogues agrégées au niveau des pays sont principalement indicatrices du volume de trafic. L’éventuel biais lié aux pressions policières est négligeable pour les quantités saisies, mais plus prononcé pour le nombre de saisies. Les organismes de contrôle seraient donc plus à même de moduler leurs activités que les retombées éventuelles. Les résultats suggèrent aussi que les trafiquants adoptent des stratégies diverses pour limiter les pertes liées aux saisies. Le chapitre 6 s’attarde à l’impact de la structure sur le prix et la valeur des drogues. Le prix de gros varie considérablement d’un pays à l’autre et d’une drogue à l’autre. Ces variations s’expliquent par les contraintes auxquelles font face les trafiquants dans le cadre de leurs activités. D’une part, la valeur des drogues augmente plus rapidement lorsqu’elles sont destinées à des pays où les risques et les coûts d’importation sont élevés. D’autre part, la majoration des prix est plus prononcée lorsque les échanges sont dirigés vers des pays du cœur de l’économie légale. De nouveau, les rôles sont inversés : les pays généralement avantagés dépendent des plus désavantagés, et les pays pauvres en profitent pour exploiter les riches. / This dissertation proposes an analysis of the structure of transnational drug trafficking. Based on the world-system perspective, it is hypothesized that cocaine, heroin and marijuana form separate markets that are opposite to other legal trades in many ways. The analysis relies on two data sources. The first is a unique compilation of seizures gathered together by the United Nations Office on Drugs and Crime (UNODC). The seizures were made between 1998 and 2007 (n = 47629). It is completed by intelligence published by various agencies across the world. The dataset allows the construction of directed networks of drug trade between most countries of the world. Chapters 3 and 4 analyze the structure of the trade itself. Firstly, the roles played by the countries in each market are described and compared. The flow of drugs and interception rates are estimated for each 16 geographic areas defined by the UNODC. Secondly, several structural characteristics of the drug markets are compared to other legal trade, namely coffee and chocolate. It is shown that drug trade networks are less dense and that peripheral countries play more important roles. While inequality is characteristic of both legal and illegal economies, their structure is reversed. In chapter 5, it is demonstrated that seizure data are mostly indicative of drug trafficking within a country. The expected law enforcement bias is negligible for quantities seized but more apparent when we look at the number of seizures. Thus, law enforcement agencies are better at planning operations against drug trafficking than at predicting their outcomes. The results presented in chapter 5 also suggest that traffickers use counter-strategies to reduce losses caused by drug seizures. The price and value of drugs show significant variations among countries. Those variations are usually explained by varying costs and pressures suffered by traffickers. Chapter 6 seeks to measure the impact of structural features on wholesale price and value. The value of drugs increases more sharply when the drugs are bound to countries where the risks of seizures are higher. Furthermore, price mark-ups are higher when the trade is directed to core countries. Again, the situation is reversed: richer countries that generally control all economic activities rely on peripheral countries to be supplied in drugs.