A shared commitment to value

Last week, the New England Journal of Medicine published a perspective from PhRMA’s Dr. Bill Chin alongside a counterpoint by Dr. Peter Bach, and I was struck by the extent to which both pieces illustrated, in different ways, the importance and complexity of supporting value in health care. Dr. Chin noted some of the historical challenges with advancing value-based care (e.g., variability in perspectives in value among stakeholders and among patient populations, changes in value over time and shortcomings in our ability to accurately measure value) and called for a “shared commitment to value” that is focused on the patient. Dr. Bach seemed to suggest going beyond traditional value assessment standards and imposing even blunter budget caps. In doing so, Dr. Bach misses the bigger picture on cost and affordability in cancer care and promotes a fundamentally flawed policy standard.

While he identifies affordability as a key issue for patients and recognizes the cost reductions that occur when medicines face competition from generics or biosimilar versions of biologics, he fails to acknowledge that patient affordability extends far beyond medicines and biologics. Conversations about cost and affordability need to look at spending across the health care system and not just at the share of spending that goes toward life-changing medicines.

Dr. Bach also endorses the use of rigid budget caps, which would limit patient access to needed medicines. In so doing, he highlights a fundamental problem with the Institute for Clinical and Economic Review’s (ICER) so-called value framework. This model isn’t about value, it’s about halting innovation. If newer, less toxic, but more expensive cancer medicines can keep patients out of the emergency room and hospital or give them the option of being able to work while undergoing treatment; shouldn’t we allocate a greater proportion of health care dollars to these advances? According to ICER, which is espoused by Dr. Bach, the answer is a resounding “No.”

In fact, the ICER model would work to exacerbate the very concern Dr. Bach raises on the relative value of advances compared to current care. Setting an arbitrary threshold for spending on treatment advances but giving a pass to existing items and services punishes innovation while allowing current wasteful practices to continue. While this point is technical, it highlights a critical limitation of the type of policy supported by Dr. Bach.

As underscored by Dr. Chin’s article, PhRMA has long supported the appropriate use of evidence assessments in health care decision-making, but it’s important to get them right. Dr. Bach’s commentary highlights just how complicated it is to define value, but that’s no reason to replace it with simplistic cost controls.

Read more about PhRMA’s key concerns with the ICER framework here.