Post-Disaster Infrastructure Delivery for Resilience

As climate change increases the frequency and intensity of disasters and associated infrastructure damage, Alternative Project Delivery Methods are well positioned to enable innovative contracting and partnering methods for designing and delivering adaptation solutions that are more time- and cost-effective. However, where conventional “build-back-as-before” post-disaster reconstruction occurs, communities remain vulnerable to future disasters of similar or greater magnitude. In this conceptual paper, we draw on a variety of literature and emergent practices to present how such alternative delivery methods of reconstruction projects can systematically integrate “build-back-better” and introduce more resilient infrastructure outcomes. Considering existing knowledge regarding infrastructure resilience, post-disaster reconstruction and project delivery methods, we consider the resilience regimes of rebound, robustness, graceful extensibility, and sustained adaptability to present the potential for alternative project delivery methods to improve the agility and flexibility of infrastructure against future climate-related and other hazards. We discuss the criticality of continued pursuit of stakeholder engagement to support further improvements to project delivery methods, enabling new opportunities for engaging with a broader set of stakeholders, and for stakeholders to contribute new knowledge and insights to the design process. We conclude the significant potential for such methods to enable resilient infrastructure outcomes, through prioritizing resilience alongside time and cost. We also present a visual schematic in the form of a framework for enabling post-disaster infrastructure delivery for resilience outcomes, across different scales and timeframes of reconstruction. The findings have immediate implications for agencies managing disaster recovery efforts, offering decision-support for improving the adaptive capacity of infrastructure, the services they deliver, and capacities of the communities that rely on them.

Ensuring access to medicines at a fair price? Innovative contracting experiences in France

Issue Innovative contracting models are developed to ease price-setting negotiations in case an extremely expensive drug has not proven sufficient efficiency in clinical trials. As disruptive HIV treatments are expected in the near future, French patient organizations evaluated the ability of these innovative contracts to ensure accessible medicines at a fair price. Description Performance-based schemes condition prices paid by the State to the efficiency of the medicine observed through real-world data. In France, thirteen performance-based contracts have been concluded between 2008 and 2015. They are presented as a triple solution: innovative treatments are available to patients, manufacturers access markets, and states ensure healthcare within limited budgets. Establishing the added value of these models implies determining if they allow rapid access to treatments with substantial savings for payers, while ensuring rigorous price and cost transparency. Results Performance-based contracts indeed ensure patient access to treatments, but other mechanisms (such as temporary use authorizations) already serve this purpose. Regarding expenditure reduction however, these schemes have not proven their worth. The Court of Auditors' evaluation showed they do not generate substantial savings, as final prices correspond to those that would have applied with the European price guarantee. Lastly, as contracts are protected by business secrecy, the public cannot access neither to actual prices negotiated by payers, nor the amount of public investment that have been used for the research and development of the drug. Lessons The derogatory nature of performance contracts invites us to consider them on a case-by-case basis if ensuring access to a specific innovation is necessary. These contracts are certainly innovative, but they cannot be presented as technologies providing access at a fair price. Finally, their contractual and derogatory nature raises serious transparency issues. Key messages Performance-based contracts should be considered as alternatives to existing administrative channels provided that they lead to substantial savings and are drawn up in full transparency. Patient organizations need to assess innovative schemes such as performance-based contracting to ensure access to treatments without undermining historical struggles for fair and transparent pricing.

Innovative Contracting for Pharmaceuticals and Medicaid's Best-Price Rule

In recent years, drug manufacturers and private payers have expressed interest in novel pricing models that more closely link a drug's price to its value. Indication-based pricing, outcome-based pricing, drug licenses, and drug mortgages have all been discussed as alternatives to paying strictly for volume. Manufacturers and payers have complained, however, that Medicaid's “best-price rule” inhibits their ability to enter into these new pricing arrangements. This article examines the best-price rule and assesses to what extent, if any, it might frustrate the goal of paying for value. We conclude that the best-price rule is not as serious a problem as it is sometimes made out to be but that it is also not simply a convenient excuse for refusing to try something new. The law here is complex, and moving to a pay-for-value model for drugs will require close coordination among manufacturers, payers, and regulators.