By NextBestFitAccept somewhat slower adoption
Accept that negotiation and assessment delay some new treatments, as in peer countries, in exchange for lower prices.
Fast-track coverage chosen instead.
Review ledgerHow this path connects
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Require assessment before coverage
- Create an exceptional-access route
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
Accepting delays from negotiation and assessment yields the largest savings and avoids paying for unproven drugs. Some patients wait for new treatments.
- Brand-name drug prices far above production cost
Accepting negotiation and assessment delays obtains lower prices and the largest savings on new treatments.
- Low-value care and overtreatment
Assessment before coverage avoids paying for unproven drugs.
- Reduces income or business for affected groups
Negotiating lower prices and assessing new treatments reduces manufacturer revenue.
- Central coverage decisions can feel like rationing
Coverage assessment delays some new treatments while avoiding payment for unproven drugs.
3 paths soften this
Independent, transparent coverage body with appealsCentral coverage decisions can feel like rationingChosenCover everything clinically effective, without cost thresholdsCentral coverage decisions can feel like rationingRejectedClinician-led exceptions with fast reviewCentral coverage decisions can feel like rationingChosen
Who's affected
- People with unaffordable deductibles or coinsurance
- Brand-name drug prices far above production cost: Market exclusivity sustains drug prices far above production cost.
- Uninsured people
- Brand-name drug prices far above production cost: Market exclusivity sustains drug prices far above production cost.
- Health insurers, brokers, and their shareholders
- Brand-name drug prices far above production cost: Market exclusivity sustains drug prices far above production cost.
- Low-value care and overtreatment: They pay for tests and treatments with little benefit.
- Taxpayers and public budgets
- Brand-name drug prices far above production cost: Market exclusivity sustains drug prices far above production cost.
- Low-value care and overtreatment: They pay for tests and treatments with little benefit.
- Central coverage decisions can feel like rationing: Declining low-value care holds down public spending.
- People with ongoing or specialist care needs
- Low-value care and overtreatment: Low-benefit tests and treatments expose them to harm.
- Drug and device makers
- Brand-name drug prices far above production cost: Market exclusivity supports high prices and shareholder returns.
- Low-value care and overtreatment: They sell devices and tests used in low-value care.
- Central coverage decisions can feel like rationing: A declined product loses the whole national market.
- Pharmacy benefit managers and their pharmacies
- Brand-name drug prices far above production cost: High list prices generate rebates for benefit managers.
- Hospitals, clinics, and care organizations
- Low-value care and overtreatment: Per-service payments reward additional low-value care.
- People with ongoing or specialist care needs
- Central coverage decisions can feel like rationing: People needing a declined or delayed treatment have no other insurer to turn to.
- Exceptional-access route for individual patients
Where it has been tried
- Canada, Australia: New drugs often become publicly covered a year or more after U.S. launch.
- Canada: The Patented Medicine Prices Review Board's June 2025 report found that, among the 2022 new-to-Canada medicines with both Canadian and PMPRB11 sales, Canadian sales began an average of 11 months after the first international sale.