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Under the Inflation Reduction Act, government bureaucrats will unilaterally decide how much a treatment selected for price setting is worth. To make matters worse, the price setting process is a black box. No one knows how exactly the government is determining the value of medicines selected for price setting or how much input it will use from patients, providers and other stakeholders — but, alarmingly, we do know they expressed significant interest in using flawed cost-effectiveness metrics. In the 2023 final guidance for the first year of the price setting process, CMS stated that it: “…will review and consider cost-effectiveness measures and studies that use such measures for initial price applicability year 2026.”

Concerningly, one organization eager to weigh in is the Institute for Clinical and Economic Review (ICER). The group holds itself out as an expert in assessing the value of medicines despite relying on outdated and discriminatory cost-effectiveness metrics. And, as patient advocates and others have warned, ICER’s one-size-fits-all approach that ignores the unique needs of different patient populations can lead to discriminatory outcomes. Government adoption of flawed value assessments like these could be devastating for patients.

A recent analysis by Cencora (formerly Xcenda) looked at treatment options for five serious, complex medical conditions that are covered by Medicare Part B and have been evaluated by ICER. Cencora considered what would happen if the government adopted ICER’s value assessments as the basis for its coverage decisions. The results were startling:

• In 2020, nearly 185,000 Medicare Part B beneficiaries with multiple myeloma, asthma, multiple sclerosis, non-small cell lung cancer and rheumatoid arthritis used a physician-administered product evaluated by ICER.
  
  
• If the government adopted an ICER-based formulary for the Part B program, 63% of these Part B beneficiaries, or nearly 117,000 individuals, could lose access to their current treatment.
  
  
• The results were even worse for certain diseases, including 99% of Part B patients with multiple sclerosis losing access to their preferred treatment, 85% of Part B patients with non-small cell lung cancer and 83% of those with multiple myeloma.

“If the government used ICER-like assessments to set prices for medicines, many patients could lose access to the treatments that they and their physicians had previously determined were best for them based on individual needs and preferences, after careful consideration of the nuances of a patient’s condition,” explained Cencora.

Government shouldn’t interfere in decisions best left to patients and their doctors. The Inflation Reduction Act already threatens seniors’ access to care. Injecting ICER’s flawed value assessments to an already flawed government decision making about drug payment could further jeopardize patients’ ability to get the lifesaving treatments they need. 

Nicole Longo

Nicole Longo is Deputy Vice President of public affairs at PhRMA focusing on Medicare, 340B, importation and more. She previously worked for a D.C.-based public affairs firm where she assisted a wide range of clients with communications efforts on everything from trade policy to agriculture policy to health care policy. Outside the office, Nicole can be found trying new restaurants (usually Italian), taking an occasional barre class and cheering on the Cincinnati Bengals.

Nicole Longo

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