| Sumario: | Background: Soaring drug prices pose a significant obstacle to affordable and equitable access to medicines in high-income healthcare systems. This study compares two leading reform tool families, Most Favored Nation (MFN)/international reference pricing (IRP) and value-based contracting (VBC), across the United States, Canada, and the United Kingdom, with attention to cost containment, value-linked incentive design, equity of access, and implementation feasibility. U.S. policy developments (CMS Innovation Center's GENEROUS, GLOBE, and GUARD models) extend international benchmark-based design options beyond the 2020 MFN rule. Methods: Guided by institutional and governance theories, we conducted a structured comparative policy analysis using a four-dimensional trade-off matrix. Cases from the United States, Canada, and the United Kingdom were selected using a most-different-systems design. Documents from 2007 to 2025 were coded for cost containment, value-linked incentive design, equity, and implementation feasibility. To reduce subjectivity, scores were assigned using prespecified rubric anchors, conservative scoring rules for borderline cases, and a sensitivity check of adjacent-score judgments. Design-stage U.S. benchmark-based model materials assessed on March 5, 2026, were incorporated descriptively and not considered as outcome evidence. Results: The United Kingdom model, centered on the National Institute for Health and Care Excellence (UK NICE) and the Voluntary Scheme for Branded Medicines Pricing, Access and Growth (VPAG), was most consistently aligned across all four dimensions (design-feature alignment). Canada's Patented Medicine Prices Review Board (PMPRB) supports affordability and baseline access, with implementation variation across provinces and more limited adoption of outcomes-based contracting. U.S. MFN/IRP initiatives and VBC pilots show lower alignment on equity and feasibility in a multi-payer environment characterized by contested authority and variable data/contracting capacity. Emerging CMS Innovation Center proposals (GENEROUS, GLOBE, GUARD) indicate continued federal interest in benchmark-based designs, but empirical impacts remain to be evaluated. Conclusions: MFN/IRP anchoring and VBC are implementation-intensive tools whose performance depends on institutional fit. A hybrid approach, using international benchmarks as inputs for negotiations and expanding value-linked agreements where measurement and governance prerequisites are met, may offer a more feasible U.S. pathway. This study provides a repeatable framework for assessing drug pricing reforms and illustrates how institutional alignment conditions the implementability of tools. Design-feature scores reflect policy design and governance capacity, not realized outcomes. Plain Language Summary: Prescription medication prices are often high, making it difficult for people to access the medicines they need. This study examines how three countries, Canada, the United Kingdom, and the United States, attempt to control prices while supporting fair access and workable implementation. We focus on two main approaches: using international price benchmarks to inform pricing (international reference pricing/MFN-type designs) and paying based on a drug's clinical value or outcomes (value-based care/value-based contracting). We found that countries differ mainly because their health systems are organized differently. The United Kingdom's centralized structure supports more consistent policy implementation, while the United States' multi-payer structure creates greater legal, administrative, and data challenges. Canada shows strong price regulation and baseline access, but policies vary across provinces and outcomes-based contracting is less common. Newly assessed March 5, 2026, U.S. proposals (GENEROUS, GLOBE, GUARD) suggest continued federal interest in international benchmark-based approaches, but these are recent and do not yet have outcome evidence. We suggest a combined approach in the United States: use international benchmarks to strengthen negotiations and expand value-linked contracts only where measurement and coordination are feasible.
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