When America Sets the Floor: Most-favoured-nation pricing and the case for a European fixed payment model

I want to make a different case, and to go back to an idea I published ten years ago: a fixed payment for innovative medicines, agreed at European level. When I first proposed it, the political appetite for this simply was not there. I think MFN has started to change that.ⁱ

“Ten years ago I argued that Europe and the pharmaceutical industry should swap the price per product for a fixed, multi-year budget. The politics were not there. Most-favoured-nation pricing may have changed that.”

Bas Amesz, Managing Partner, Vintura

Key conclusions

1. Under US most-favoured-nation (MFN) pricing, the lowest European price becomes the target for American prices; an early or cheap European launch turns into a commercial liability.
2. The effect is visible: new-drug launches in EU markets fell by around 35% within ten months, and clinical research is following the same logic out of Europe.
3. MFN exposes a weakness of Europe’s own making: twenty-seven separate national negotiations, easy to game from outside and unequal in access at home.
4. The answer: a European fixed payment model, a multi-year fixed annual payment per therapy, based on added value and population size, with access for every eligible patient from day one.
5. With no per-unit price, MFN has no published price to reference, parallel trade loses its basis, and Europe saves in the order of €35 billion a year.
6. Financing follows each country’s ability to pay, and the EU vaccine procurement shows the mechanism works. First step: a standing European taskforce with a proposal within a year.

1. What MFN actually does

On 12 May 2025 President Trump signed Executive Order 14297, “Delivering Most-Favored-Nation Prescription Drug Pricing to American Patients.”ⁱⁱ For single-source branded medicines, those without a generic or biosimilar competitor, the US price target is set to the lowest price paid in any OECD country with a GDP per head of at least 60% of America’s.ⁱⁱⁱ That basket is, in practice, wealthy Europe, plus a handful of markets such as Japan, Canada and Australia; the lowest price in it will usually be a European one. The order tells HHS to set the targets, instructs the US Trade Representative and the Commerce Department to act against countries accused of “free-riding” on American innovation, and sets up a direct-to-consumer route, TrumpRx, for patients to buy at the MFN price. If manufacturers do not move, it threatens rulemaking, drug-importation waivers, the revocation of approvals and tariffs. The reference baskets sit inside three pricing models, GENEROUS, GLOBE and GUARD, each built largely on European countries.^iv And the voluntary agreements now reach forward: under so-called prospective commitments, manufacturers agree to launch all future products at MFN-comparable prices, which puts every launch decision yet to be taken inside the policy’s reach.^v By spring 2026 the administration had signed deals with seventeen leading manufacturers, covering around 86% of the branded market.^vi

The intent is plain: “European prices are expected to become the floor under American ones.”

2. The effect: pull the launches in Europe

The consequence was easy to predict, and it is already in the data. If a low European price drags down the price in a far larger market, the rational move is to launch in the United States first and put Europe off, or skip it. GlobalData counted a fall of about 35% in new-drug launches across EU markets in the ten months after the order, and 37% in the countries that make up the US reference baskets.^vii More than nine in ten medicines approved in 2025 launched in the United States first, and most have not appeared anywhere else.^viii Stefan Oelrich, the EFPIA president and a Bayer executive, talks of the first signs of delayed introductions into Europe; another executive compared launch planning to playing chess blindfolded. France’s health authority has watched early-access applications halve, from 25 in 2024 to 10. Some companies have pulled products outright: Amgen withdrew its cholesterol therapy from Denmark, citing a changed environment. And the direction of travel is now written into policy, not just company behaviour. In December 2025 the United States and the United Kingdom agreed a deal that commits Britain to paying about a quarter more for new medicines, by lifting the threshold it uses to judge what a medicine is worth and cutting the rebates it claws back.^ix The pattern now has names attached. Insmed has held back the European launch of Brinsupri, a newly approved treatment for the chronic lung disease bronchiectasis, even with a regulatory green light, while it weighs the pricing consequences at home. Market-access advisers talk openly about MFN limiting which medicines reach the EU for years, and about American and European patients drifting towards two different standards of care.^x MFN is not working alone; the teething problems of the EU HTA Regulation and the prospect of an obligation to launch in all member states under the pharmaceutical package push the same way. Novartis, which has already signed its own deal with Washington, told investors that the real effect on European launches is “a 2027 story.”^xi Whichever way the accounting eventually falls, it is European patients who are waiting in the meantime.

3. And then there is the research

The damage does not stop at access. Europe’s share of industry-sponsored clinical trials has already fallen from 22% in 2013 to 12% in 2023, even as the global total grew by around 40%, which works out at some 60,000 fewer trial places for European patients. For cell and gene therapies, the most advanced medicine there is, Europe’s share has dropped from a quarter to a tenth while China’s has climbed past 40%.^xii MFN pushes in the same direction. Companies run their trials where they expect to sell, so when European launch becomes a liability the studies that precede it follow the commercial logic out of the region. American biotech firms have reportedly grown wary even of licensing deals with European partners, for fear of triggering the provisions that would pull down their US price.^xiii

“A launch problem is turning into a research problem, and research is where Europe’s future medicines, jobs and know-how are decided.”

4. The deeper flaw MFN exposes

MFN did not create Europe’s weakness. It exposed it. Europe negotiates medicine prices twenty-seven times over, each country referencing the next, in a slow chain where filing in one market often waits on reimbursement in others. That makes the system easy to game from outside and unequal inside. EFPIA’s own W.A.I.T. data show a new medicine reaching patients in about 128 days in Germany and 840 days in Portugal.^xiv The same fragmentation shows up in how Europe judges value. The EU HTA Regulation was meant to assess a medicine’s clinical effectiveness once, for the whole bloc. In practice member states still bring their own national comparators: in June 2026 the joint assessment of Catequentinib, a cancer medicine from a small US biotech, was discontinued after exactly that kind of fragmented dossier process.^xv The numbers tell the same story: the first year of the regulation produced twelve joint assessments against a projection of about twenty-five, and the fifty planned for 2026 look no more likely to arrive.^xvi The fragmentation that lets Washington pick off Europe’s lowest price is the same fragmentation that ties a patient’s access to the country they happen to live in. Both problems trace back to one fact: Europe buys as a crowd, not as a single customer. Behind the fragmentation sits a quieter fact: Europe also chooses to invest less in innovative care than America does, and prices reflect that willingness to pay as much as any political negotiation.

“Europe buys as a crowd, not as a single customer”

5. A ten-year-old idea, revisited

This is where the model I set out in 2016 comes back. The idea is a multi-year agreement between industry and a payer, built not on a price per unit but on a fixed annual payment, set on the added value of a therapy and the size of the population it can help. Call it a fixed annual payment rather than a budget, if that reads better: ‘budget’ suggests a ceiling waiting to be squeezed, while the point of the model is what the payment buys. Price and volume come apart. Every patient with the right indication is treated, with no extra cost as the numbers grow, and the manufacturer is paid for the innovation rather than for the units it can push. That is not a capped budget by another name. Under a cap the manufacturer still sells per unit and repays the excess, so the volume risk stays with industry and the incentive to ration stays with the payer. Here there is no per-unit sale, no excess and no clawback: the payment is certain, and access is unconditional. My estimate at the time put the potential European saving at around €35 billion a year.^xvii

You would not do this for every product. It belongs where the medical need is high and the innovation real: new oncology and rare-disease therapies, and, at the far end, the kind of need the pandemic laid bare. The aim is not to fix a price for the whole pharmacy. It is to handle the medicines that matter most in a better way.

It is worth setting out where that saving comes from. The arithmetic runs as follows. Over the next five years more than 200 new active substances are due to come to market; whether they all reach Europe is exactly what MFN has put in doubt, and securing that cohort is what the model is for. Gross spending on these new medicines is projected in the order of $45 billion a year by 2029, though the net effect on Europe’s total bill is far smaller, since older products lose patent protection and some are displaced by the newer ones over the same period. It is this gross launch cohort, not the net increase, that the fixed payment would cover, and that is the scope of the model.^xviii

Selling them the conventional way is expensive. The largest manufacturers spend roughly a quarter of revenue on sales and marketing, and the launch window is the most commercially intensive phase of a product’s life.^xix On top of that sits the access machinery: pricing and reimbursement dossiers, HTA submissions and negotiations repeated in up to twenty-seven national systems. A fixed payment removes most of this work. There is one negotiation with one counterparty, no per-unit volume to drive, and access is settled in the contract rather than won country by country. Take commercial and access spend at 25% of sales for a launch cohort, and assume 70% of it falls away, with medical affairs, education and pharmacovigilance retained. The retained part matters: medical affairs becomes more central under this model, not less, since it is the function that makes sure doctors have the rigorous, up-to-date scientific evidence they need to inform their clinical decisions. What falls away is promotion and the duplicated country-by-country access effort, not the exchange of scientific information. That is roughly 17% of the cohort’s revenue: in the order of €8 billion a year on a €45 billion cohort, recurring, and compounding as each new wave of launches enters the model. This is money now spent on persuasion and process rather than on discovery or treatment. In the negotiation it is room that payer and manufacturer can share, on top of a gain that is harder to price: revenue certainty lowers the risk premium investors demand. The model also removes the machinery of parallel trade almost as a side effect. Because a fixed payment has no per-unit price, it takes away the price differences between member states that parallel trade feeds on. This does not lower the cost of the medicines themselves, which are bought either way; what falls away is the apparatus built around the arbitrage, the traders, the extra logistics, and the repackaging and relabelling of leaflets from one market to another. Parallel trade shifts a large volume of product, around €6.5 billion at ex-factory prices in 2023 by EFPIA’s estimate, and diverts money from innovation without benefiting patients; taking away the price gap removes the reason for that whole layer of activity to exist.^xx

What I could not see in 2016 is the virtue this design now has. A fixed payment has no per-unit price to point at, which turns out to be its most useful feature. A determined administration can always construct a number, dividing whatever Europe pays by the patients treated. But MFN as designed references per-unit prices in named countries; a confidential, multi-year lump sum for a portfolio of medicines gives it no published price to point at, and any constructed average is a different, contestable figure rather than a benchmark. Harder to anchor is not impossible to attack, but it is a much weaker handle than twenty-seven list prices. And because the payment guarantees treatment for every eligible patient in the countries that join, it closes the gap in access at the same time. It also ends the sequencing of launches: a medicine under the model arrives in every participating country at once, and the design can go a step further, with the medicine made available on EMA approval while the negotiation runs in parallel, so patients see no delay at all. One design answers both the external and the internal problem.

The design separates access from financing, and it needs to, because a single European payment appears to treat unequal countries equally: GDP per head varies several-fold across the Union, and the ability to pay varies with it. Access under the model is uniform, every eligible patient in every participating country, because that is the point of it. Financing is not. Each country contributes to the fund according to its ability to pay, with GDP per head as the obvious key, much as the Union’s own budget is financed on gross national income. The equity question is settled where it belongs, in the contributions rather than in the price. The alternative route to the same fairness, prices tied to each country’s GDP per head, would reintroduce exactly what the model removes: a per-unit price in every market for Washington to reference and for parallel traders to arbitrage. Scaled contributions deliver the fairness without the exposure, and they are fairer than the status quo, in which the patients of the poorest countries wait longest for the medicines everyone else already has.

It is worth being clear about the kind of measure this is. Most cost-control tools in Europe work by subtraction: faster generic and biosimilar entry, reference-price cuts, tighter cost-effectiveness thresholds. They lower spending by squeezing the innovator and do little to get new medicines to patients sooner; easing generic entry, in particular, rewards the copy rather than the discovery. A fixed payment works the other way. It pays for genuine innovation with predictable, multi-year income, opens access to every eligible patient, and still brings total cost down. Stimulating innovation, improving access and reducing spend at the same time is the test a serious proposal should meet, and subtraction, by its nature, cannot.

“Stimulating innovation, improving access and reducing spend at the same time is the test a serious proposal should meet, and subtraction, by its nature, cannot.”

6. The criticism to expect

One line of attack is worth meeting head-on. In the first years of a launch, when only a handful of patients are treated, a fixed payment divided by that handful gives a cost per patient that looks higher than the American price. Critics will reach for that number, but it misreads the model, because paying more in the early years is deliberate rather than a flaw. The payment is front-loaded, money paid now is worth more than money promised later, and patients get full access from year one instead of after a slow ramp. The figure makes the trade plain: the manufacturer accepts a lower total in return for certainty and earlier cash, while the payer accepts a higher early outlay in return for a capped, predictable bill and immediate access for everyone who needs the medicine. The early-year comparison only holds if you insist on comparing two things the model was built to keep apart. For medicines that launch on immature evidence, as rare-disease and many oncology therapies do, the contract can carry the uncertainty: part of the multi-year payment tied to confirmatory data, agreed at the outset, so it is managed inside the agreement rather than through a price fight in every country. The model also disarms a concern payers know well: the population that looks conveniently small at launch, justifying a high price per patient, and then grows once reimbursement is secured. Under a fixed payment that growth costs the payer nothing extra, and with no per-unit price the incentive to underestimate the population disappears.

Industry will raise two further objections, and they deserve straight answers. The first is that a European fund would behave the way national payers do today: a budget eroded over time, never adjusted for inflation, clawed back when finance ministries get nervous. The risk is real, and the answer is contractual. Multi-year terms, indexation and the absence of clawbacks are not decoration; a model sold on certainty is dead the first time certainty is broken. The second is governance: who decides for Europe, and how fast? The vaccine work gives the outline, a steering board of participating states and a small standing negotiating team. And if medicines are available on EMA approval while the negotiation runs, the model beats the current system on speed instead of adding a layer to it.

7. This is now industrial policy

None of this is only health economics any more. After social media, artificial intelligence and defence, life sciences is the next field where industrial policy is being set rather than argued over. The United States has put MFN alongside tariffs; the EU has accepted a 15% tariff on pharmaceutical exports to America, ending a thirty-year run of zero tariffs on medicines.^xxi In April 2025 the chief executives of Europe’s research-based companies warned the Commission of a risk of exodus, with as much as €103 billion of planned investment for 2025 to 2029, around 85% of capital spending and half of R&D, possibly moving to the United States.^xxii Those numbers deserve a sceptical read: moving production takes years and a great deal of money, and the industry is using the moment to push for the higher European prices it has long wanted.^xxiii But the direction is real. A payment agreed at bloc level is more than a pricing tool. It lets Europe negotiate as one buyer, with prices the United States cannot anchor, instead of handing over twenty-seven separate concessions.

“It lets Europe negotiate as one buyer, with prices the United States cannot anchor, instead of handing over twenty-seven separate concessions.”

8. We have done this before: vaccines

The EU has already run a version of this, under far harder conditions, and it held. In 2020 the European Commission acted as the single buyer for the bloc, signed advance purchase agreements and, by November 2021, had committed around €71 billion for up to 4.6 billion vaccine doses, one of the largest joint purchases in the Union’s history.^xxiv The aim was to stop member states bidding against each other and to keep smaller countries from being charged more or left out, by pooling the Union’s buying power.^xxv It ran through a steering board of every member state and a negotiating team drawn from seven. It was not clean. The transparency failures and the early supply shortfalls are on the record. But those are lessons in how to run it better, not reasons to drop the idea. The pricing design was different, a price per dose under advance purchase agreements rather than a fixed budget, so the parallel is not the price model. It is the mechanism: the Union negotiated once, on terms that bound everyone, and every member state, large or small, was served on the same footing. The principle held: when the Union pools demand and shares risk, it gets different terms. The honest caveat is that it took a pandemic to get there. A health emergency without precedent overrode the usual reflexes of national control and unanimity almost overnight. Absent that kind of shock, the political will to pool procurement is far harder to summon, and it would be naive to pretend otherwise. That is the real obstacle here, not the economics.

Europe/the EU must demonstrate a collective willingness to act decisively. The crisis stemming from inaction is significant and is set to intensify further!

9. What would it take – and what is the alternative?

There are plenty of reasons this could fail. Unanimity. National control of health budgets. Control on exports to countries outside of the EU. An industry wary of price controls, and a Commission with a mixed negotiating record. All true. The more useful questions are what it would take to make it work, and whether anything better is on the table.

On the first: a standing, expert team to negotiate for medicines, a permanent version of the vaccine negotiating team rather than a committee assembled in a hurry; a clean interface with the internal market, which may prove easier than it looks: with no per-unit price there is no reference price to copy and no arbitrage to trade on, and a single European pack with an electronic patient leaflet would remove what is left of the parallel-trade logic; a value-assessment method agreed openly and in advance, building on the joint clinical assessments the HTA Regulation has already created rather than on twenty-seven national thresholds, which takes the early-year cost argument off the table; a coalition of willing countries rather than a wait for all twenty-seven; and a frame that treats fair access and Europe’s strategic position as one question, not two. The funding side need not be invented from scratch either: health economists have proposed a Pan-European Solidarity Fund (PANSOL) for pooled financing of high-cost innovation, with contributions scaled to each country’s ability to pay, and the two ideas fit together naturally.^xxvi

On the second: look at what doing nothing already costs. Innovative medicines are reaching European patients later, or not at all. Patients carry the consequences. And the research base, with the investment and the jobs attached to it, is drifting towards the United States. Against that, a fixed payment for the medicines that matter most is not the risky option. The risk sits with the path we are already on. I have no illusion that the Union will reach for this easily. Twenty-seven health systems, unanimity, and national control of budgets make bold collective moves rare, and it may well take a shock of its own before the appetite is there. But the direction of loss is not in doubt.

Ten years ago the timing was wrong, and I said so. The model has not changed; the world around it has. Most-favoured-nation pricing, tariffs and an America-first line on life sciences have made standing still the expensive choice. The EU’s real question is not whether a bloc-level payment is hard. It is whether it is willing to act together before the alternative decides for it: the slow loss of access, of patients’ timely treatment, and of the research base and the jobs that come with it. Europe pulled together once, under a crisis, and it worked. The question is whether we can do it this time by choice rather than emergency. If we do not learn to act as one buyer, we will lose this industry the way we have lost others. If someone has a better design, let them put it forward; what Europe cannot afford is to have none. A first step needs no treaty change: a standing European taskforce, mandated now, with a proposal on the table within a year, as the vaccine work showed we can do. This is a call to work together, and the time to start is now.

At Vintura we spend our days helping pharmaceutical companies make their organisations future-proof, which increasingly means preparing them for exactly the kind of shift MFN represents. The model in this piece is one answer; the harder work is building the commercial, access and organisational capabilities to operate in whatever system emerges.

If you would like to know how we approach that, I would be glad to hear from you at bamesz@vintura.com.

About the author

Bas Amesz is Managing Partner at Vintura, where he brings over 25 years of experience in strategy consulting. He has worked extensively with leading pharmaceutical companies to shape effective, future-proof organisations equipped to navigate a fast-changing market landscape.

References

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