Reflections from my conversation with Patti Peeples on international pharmaceutical pricing, market access, and the importance of looking beyond national policy debates.

I recently had the opportunity to join Patti Peeples on her Patti’s People podcast to discuss Most-Favored-Nation (MFN) pricing and what the renewed debate in the United States could mean for pharmaceutical companies, healthcare systems, and ultimately patients.

It was an enjoyable conversation because Patti brought us beyond the headlines and into some of the practical questions that are often missing from discussions about pharmaceutical pricing.

The idea behind MFN pricing sounds relatively simple: why should the United States pay more for a medicine than other countries?

It is a legitimate question. But having worked across different healthcare systems, I have learned that comparing pharmaceutical prices internationally is rarely as straightforward as it appears.

A medicine’s price is not determined in isolation. It reflects a country’s healthcare priorities, reimbursement arrangements, negotiating processes, and sometimes its willingness to accept uncertainty about the evidence. Even within Europe, where countries operate under a common regulatory framework, approaches to pricing and reimbursement remain remarkably different.

And that is where the discussion becomes more interesting to me.

What happens when a pricing decision in one country starts influencing access decisions in another?

International reference pricing is not new. What makes the current MFN debate particularly relevant is the scale of the US market and the potential consequences of linking prices across countries.

If a price negotiated in a smaller European market has implications for the United States, manufacturers may reconsider when and where they launch a medicine, or how they approach national negotiations.

This does not mean those consequences will necessarily occur. Much depends on how a policy is designed and implemented. But they are precisely the kinds of questions that should be considered before assuming that lower reference prices automatically translate into better access.

For me, the distinction between price and access is essential. A lower price is meaningful, but so is whether a medicine becomes available, how long patients wait for it, and whether the healthcare system can actually deliver it.

Another part of our conversation focused on something I have encountered repeatedly throughout my career: the tendency to treat market access as a problem to solve shortly before launch.

By that point, many of the decisions that determine the strength and relevance of the evidence have already been made.

Which comparator was selected? Were the outcomes relevant to patients and healthcare decision-makers? How will uncertainty be addressed? Will the evidence generated for regulatory purposes also answer the questions that HTA bodies and payers are likely to ask?

These are not simply reimbursement questions. They are questions about how we plan evidence generation and understand value throughout development.

The introduction of joint clinical assessments under the EU HTA Regulation makes this discussion even more relevant. Greater coordination in clinical assessment is an important development, but it does not mean that national differences in value assessment, pricing, or reimbursement will disappear.

During the podcast, we also found ourselves discussing my experience coaching CrossFit, which might seem an unusual connection to pharmaceutical market access.

Yet there is something useful in the way we teach: explain, demonstrate, practice, and correct.

I see a parallel with communicating scientific evidence. We can develop sophisticated models and generate increasingly complex evidence, but if we cannot explain what that evidence means for a particular decision, we have not completed the job.

That does not mean simplifying the science to the point of losing its meaning. It means understanding who needs the evidence, what decisions they are making, and how to communicate uncertainty without obscuring it.

I came away from the conversation thinking that the MFN debate is another reminder of how interconnected pharmaceutical policy has become.

Pricing, evidence generation, HTA, and patient access are often discussed separately. In practice, decisions in one area influence all the others, sometimes across national borders.

And perhaps that is the question worth keeping at the center of the discussion: not only how much we pay for medicines, but how our policies influence who can access them, where, and when.

Thank you, Patti, for the opportunity to explore these questions.

Watch the interview: Patti’s People — Patti Peeples Speaks with Ramiro Gilardino