Balancing Cost, Innovation, and Access: A Comparative Institutional Analysis of Pharmaceutical Pricing Tools in High-Income Health Systems

Background: Soaring drug prices threaten affordability and equity in high-income health systems. This study examines how two families of reform tools, international reference pricing (including the U.S. Most Favored Nation–type proposals and Canada’s PMPRB comparators) and value-based payment approaches, perform across four core policy goals: cost containment, innovation, equity, and implementation feasibility.Methods: Guided by institutional and governance theories, we conducted a structured comparative policy analysis of the United States, Canada, and the United Kingdom using a four-dimensional trade-off matrix. We coded 37 documents (2007–2025), including policy guidance, legislation, and empirical evaluations, to rate each country–instrument pair (1–5) on cost, innovation incentives, equity of access, and feasibility, based on design features rather than realized outcomes.Results: The U.K.’s integrated model, combining NICE’s cost-effectiveness appraisals with the voluntary scheme for branded medicines (VPAG), shows the most consistent alignment across all four dimensions. Canada’s PMPRB-based system achieves strong cost control and broad baseline access but provides weaker, indirect innovation incentives and limited outcome-linked pricing. In the U.S., MFN-type proposals and pharmaceutical value-based contracts face legal challenges, fragmented payers, and limited infrastructure, resulting in low scores on equity and feasibility despite some innovation-supportive features.Conclusions: Neither international reference pricing nor value-based payment alone is sufficient to advance Universal Health Coverage goals. A hybrid approach, anchoring negotiations in international benchmarks while linking reimbursement to therapeutic value, appears more realistic for fragmented systems such as the U.S., but only if accompanied by investments in data, governance, and federal negotiating capacity. The trade-off matrix offers a repeatable framework for assessing pricing reforms and illustrates how institutional “fit,” rather than technical design alone, shapes policy success.