Comparative Cost Evaluation of Managed Entry Agreement Techniques Using Real-World Data from High-Cost Anticancer Drugs in Thailand.

High-cost innovative anticancer drugs pose challenges for health systems in balancing timely patient access with long-term financial sustainability. In Thailand, reliance on Health Technology Assessment for reimbursement decisions may delay access, highlighting the potential role of Managed Entry Agreements (MEAs) as complementary policy instruments to manage uncertainty related to price, effectiveness, and use; however, MEA application remains limited and lacks an analytical framework for technique selection. This study used real-world data from Thammasat University Hospital to examine and compare the cost-saving performance of five MEA techniques-discount, free initiation treatment, utilization cap, conditional treatment continuation, and pay-by-result-across six high-cost anticancer drugs representing dominant uncertainty characteristics. Drug procurement costs were modeled over a 24-month horizon from the payer's perspective, and one-way sensitivity analyses were conducted using ±10% variation in median progression-free survival. Free initiation treatment generated the highest cost savings across uncertainty types, followed by conditional treatment continuation, while utilization cap and discount produced more moderate savings. Pay-by-result demonstrated the lowest cost-saving potential. Sensitivity analyses confirmed the robustness of comparative rankings. Overall, the findings indicate that MEA performance varies according to dominant sources of drug-related uncertainty and support a more structured, context-appropriate approach to MEA selection to strengthen market access and value-based pricing in Thailand.