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Integrative Review of Managed Entry Agreements: Chances and Limitations


Background and Objective

Managed entry agreements (MEAs) consist of a set of instruments to reduce the uncertainty and the budget impact of new high-priced medicines; however, there are concerns. There is a need to critically appraise MEAs with their planned introduction in Brazil. Accordingly, the objective of this article is to identify and appraise key attributes and concerns with MEAs among payers and their advisers, with the findings providing critical considerations for Brazil and other high- and middle-income countries.


An integrative review approach was adopted. This involved a review of MEAs across countries. The review question was ‘What are the health technology MEAs that have been applied around the world?’ This review was supplemented with studies not retrieved in the search known to the senior-level co-authors including key South American markets. It also involved senior-level decision makers and advisers providing guidance on the potential advantages and disadvantages of MEAs and ways forward.


Twenty-five studies were included in the review. Most MEAs included medicines (96.8%), focused on financial arrangements (43%) and included mostly antineoplastic medicines. Most countries kept key information confidential including discounts or had not published such data. Few details were found in the literature regarding South America. Our findings and inputs resulted in both advantages including reimbursement and disadvantages including concerns with data collection for outcome-based schemes.


We are likely to see a growth in MEAs with the continual launch of new high-priced and often complex treatments, coupled with increasing demands on resources. Whilst outcome-based MEAs could be an important tool to improve access to new innovative medicines, there are critical issues to address. Comparing knowledge, experiences, and practices across countries is crucial to guide high- and middle-income countries when designing their future MEAs.

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Availability of Data and Material

Further data will be available on request.


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CZD, BG, LPG, PSA, MMG, MSC, LLNP, ALP, FAA, JA-T and AAG-J participated in the conception of the paper, design of the search strategy, data and information collection including the systematic review, writing of the first and subsequent drafts, as well as endorsing the content of the submitted paper. RI, TP, RCH, CV, TLL, SS, S.M, CG, LV, GWS, LG, HYK, JG, AL, MP, LM, JF, RG, CHO, DVA and VC work for health authorities and/or are advisers to them as well as engaged in implementing/reviewing managed entry agreements in their countries. They all contributed to the writing and design of the section “Key considerations for MEAs from a payer’s perspective” and commented on successive drafts. They also endorsed the final submission. In addition, RCH, DVA and VC also participated in the conception of the paper. VEA, NGR-J, IFZ and MCB contributed to the design and conduct of the search strategy, successive drafts and the final review of the paper. All the authors endorsed the final version of the paper.

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Correspondence to Augusto Afonso Guerra-Junior.

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Conflicts of interest/competing interests

Carolina Zampirolli Dias, Brian Godman, Ludmila Peres Gargano, Pâmela Santos Azevedo, Marina Morgado Garcia, Maurílio de Souza Cazarim, Laís Lessa Neiva Pantuzza, Nelio Gomes Ribeiro Junior, André Luiz Pereira, Marcus Carvalho Borin, Isabella de Figueiredo Zuppo, Roberto Iunes, Tomas Pippo, Renata Curi Hauegen, Carlos Vassalo, Tracey-Lea Laba, Steven Simoens, Sergio Márquez, Carolina Gomez, Luka Voncina, Gisbert W. Selke, Livio Garattini, Hye-Young Kwon, Jolanta Gulbinovic, Aneta Lipinska, Maciej Pomorski, Lindsay McClure, Jurij Fürst, Rosana Gambogi, Carla Hernandez Ortiz, Vânia Canuto, Denizar Vianna Araújo, Vânia Eloisa Araujo, Francisco de Assis Acurcio, Juliana Alvares-Teodoro and Augusto Afonso Guerra Junior have no conflicts of interest that are directly relevant to the content of this article. However, most of the co-authors are employed by health authorities or are advisers to health authorities.


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Zampirolli Dias, C., Godman, B., Gargano, L.P. et al. Integrative Review of Managed Entry Agreements: Chances and Limitations. PharmacoEconomics 38, 1165–1185 (2020).

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