A new analysis from Xcenda found that if Medicaid were to use one-size-fits-all value assessments like the Institute for Clinical and Economic Review’s (ICER) framework as the basis for accessing a medicine, an estimated 42 to 99 percent of prescriptions to treat serious, complex conditions like cancer and multiple sclerosis may not be covered. This shows the dangerous effects using ICER’s value framework could have for some of the most vulnerable patients.
Cost-effectiveness thresholds are the wrong basis for setting policy on access to medicines. In Medicaid, these thresholds would change access to more than 820,000 prescriptions for medicines that treat patients for serious diseases like multiple sclerosis (MS), rheumatoid arthritis (RA), non-small cell lung cancer (NSCLC), multiple myeloma (MM), and psoriasis. Specifically, the study found:
- Over 99 percent of prescriptions to treat MS would be switched from the treatment their doctor prescribed to a medicine ICER deemed “high value”
- Approximately 75 percent or more prescriptions for medicines to treat RA, NSCLC and psoriasis would have to be shifted to an ICER-recommended medicine
We are particularly concerned for Medicaid patients in Massachusetts. Currently, Governor Baker has a budget proposal that would set a value for a medicine using ICER-like analyses if a certain supplemental rebate is not reached. Any government policy made using cost-effectiveness analyses will insert the government between patients and their doctors, impeding individualized treatment decision making and discouraging innovation.
The Xcenda analysis builds on previous research that shows the negative impacts ICER’s assessments would have if they were used to make coverage decisions in Medicare. ICER’s framework ignores important differences in individual patient needs and preferences, and discriminates against the elderly, the disabled and other vulnerable patients. We need to invest in better tools that capture the complexity of diseases and all the outcomes that matter to patients and families.
Read more about the Xcenda analysis here.
View the Xcenda analysis one pager here.
Katie Koziara
Katie Koziara is Senior Director of public affairs at PhRMA focusing on the organization’s executive visibility work and media relations strategy. She previously ran the social media strategy for a D.C.-based non-profit working on federal management and leadership issues. Katie earned her B.A. in Public Policy from the University of Michigan’s Ford School and is currently earning her M.A. in Fiction Writing from Johns Hopkins University.
Katie Koziara
Delivering breakthroughs and lower costs for patients
The hidden cost of 340B: A multi-billion-dollar burden on taxpayers and Medicaid
Ensuring access to affordable medicines for patients through Medicaid
Health care practitioners sound the alarm on middlemen-imposed barriers to patient care, need for policy change
CMS, don’t fall behind the rest of the medical community on obesity
The real cost of denying access to medicines in Medicaid
Three things to know about the United Nations’ new HIV/AIDS report
Medicaid by the numbers
Case study: How seniors could face access disruptions because of the IRA’s price setting provisions
ICYMI: Misaligned policies undermine patient access
Providing affordable access to medicines in Medicaid
3 Takeaways from POLITICO’s Health Care Summit
Increased use of prior authorization in Medicaid is blocking access for patients
New analysis of patient access restrictions in the United Kingdom
ICYMI: 3 takeaways on the IRA’s unintended consequences from America’s Physician Groups’ 2023 annual fall conference
Manufacturers provided $42 billion in Medicaid discounts in 2021 alone
CMS should rethink proposed changes to the Medicaid Drug Rebate Program | PhRMA
Navigating the Patient Experience Survey: Protecting Lifelines to Access and Innovation
New calculator demonstrates how improved adherence to anti-diabetic medicines can benefit people in Medicaid
States can support access to medicine as COVID-19 Public Health Emergency ends
Minnesota lawmakers are letting PBMs off the hook, and threatening patients’ access to medicines
Study finds hepatitis C cure saved Medicaid $15 billion
In their own words: Insured Americans support policy reforms that address access and affordability concerns
Busting 3 Myths About Copay Coupons
CMS coverage decision restricts access to treatments for Alzheimer’s disease
You won’t fix what you don’t value: Two reasons why traditional cost-effective analyses can perpetuate health inequities
PhRMA presents research at ISPOR 2022
Report finds PBMs are increasingly restricting patient access to medicines
Medicaid 101: Three charts on access and spending
Study finds nearly half of payers believe innovative contracts can lead to lower patient out-of-pocket costs
Getting the 340B program back on track in 2021
Insurers shift medicine costs to patients with severe chronic illnesses
Tennessee’s Medicaid demonstration fails patients
Proposed change to Medicaid line extension definition ignores importance of critical improvements in treatments
Growth in innovative, value-based contracts holds promise for the health system and for patients
Recent administration actions undermine patient assistance programs
Innovative contracts drive access for patients and value for the system
Manufacturer cost-sharing assistance programs can save chronically ill patients hundreds to thousands of dollars annually
PhRMA submits comments to CMS on Medicaid proposed rule
ICYMI: Patients saved nearly $800,000 out of pocket through innovative contracting arrangements
PhRMA comments on HHS proposed rule on manufacturer cost-sharing assistance and accumulator adjustment programs
Low-value health care costs $345B each year and provides little benefit
Addressing barriers that inhibit value-based contracts
Guest post: Value-based agreements can improve outcomes and even save patients money at the pharmacy counter
New data show how ICER’s value framework could prevent or delay access to treatments for Medicaid patients across the country
Guest Post: Following my stroke, having access to ground-breaking medical innovation has never been more important
Setting the record straight on international reference pricing
5 Ways to improve ICER’s value assessment framework
Assessing value top of mind at ISPOR 2019
Fact Check: How the Part B International Pricing Index model threatens patient access
Value assessments should include all the outcomes that matter to patients and families
PhRMA comments to administration on Medicare Part D proposed rule
ICYMI: New study reinforces dangers of proposed IPI model
Groups sound the alarm on administration’s new Part B proposal
4 things you need to know about the administration’s latest Part B proposal
PhRMA submission to the 2019 National Trade Estimate Report urges action to protect U.S. biopharmaceutical innovation
Event tomorrow: Leaders convene to discuss solutions to advance value-driven health care
New whitepaper identifies reasons why ICER’s cost-effectiveness analyses are not useful for payers
Guest post: Developing new payment models to ensure patients have access to high-investment therapies
Number of value-based contracts continues to rise
How much do you know about Medicare Part B?
ICER’s budget impact threshold: Sounding a false alarm on affordability and access
PhRMA submission to HHS on blueprint to lower drug prices and reduce out-of-pocket costs
Event next week: Supporting the next generation of lifesaving medicines
How ICER’s assessment of a new class of migraine treatments fails patients
Guest post: Excellent care for LGBTQ patients requires cultural humility and specific medical knowledge
Aspen Spotlight Health: Discussing the forefront of innovation
New analysis shows that more medicines worldwide are available to U.S. patients
New analysis shows that HTA organizations may frequently restrict access to cancer treatments
New analysis shows negative impact of ICER’s value framework on patient access in Medicare Part B
ICYMI: Recent survey adds to growing body of research on barriers to innovative payment approaches
Event tomorrow: Improving patient access to lifesaving medicines
Event tomorrow: Making the biopharmaceutical supply chain work for patients
Reality check: Value-based contracts are good for patients
Video: Barriers to results-based contracts
PPA celebrates 13 years of helping patients access their medicines
Improving care quality by engaging patients in shared decision making
ICYMI: Research shows promise of innovative payment arrangements in reducing costs, improving access
ICYMI: Two PBM reports show dramatic slowdown in medicine spending growth
Copay coupons can help ease patients’ out-of-pocket costs
PhRMA launches new consumer-facing Let’s Talk About Cost website
Clarity around anti-kickback statute needed to promote innovative payment arrangements
New report shows better diabetes management saves money and improves patient outcomes
Video: What is a results-based contract?
How much are hospitals marking up the price of medicines? The answer may surprise you.
Johnson & Johnson, Pfizer, Walgreens and other CEOs discuss value in the future of health care
Foreign government price setting by any name harms innovation and access to medicines
PhRMA CEO in Forbes - How to negotiate better deals for prescription medicines
Compulsory licensing: A misused and abused international trade law
Government-imposed price controls threaten innovation and access
ICYMI: Innovative payment models helping provide patient access to new medicines
RA medicines often demonstrate far greater benefits to patients than initially understood
Stakeholders Agree: Modernize the legal framework to support move to value-driven health care
How do multiple sclerosis patients define value?
Biopharmaceutical industry’s success reducing disparities for African Americans
Medicare Monday: What is IPAB, and why is it bad for patients?
PhRMA CEO talks White House meeting, innovation & jobs with POLITICO’s Pulse Check
VIDEO: PhRMA CEO discusses #GOBOLDLY campaign and White House meeting with CNNMoney’s Maggie Lake
The Value Collaborative: Advancing private market solutions to achieve better health, lower costs
"New analysis shows 820,000 prescriptions would be in jeopardy if ICER’s value framework is used in Medicaid"
Access
Medicaid
The Value Collaborative
New analysis shows 820,000 prescriptions would be in jeopardy if ICER’s value framework is used in Medicaid
"New analysis shows 820,000 prescriptions would be in jeopardy if ICER’s value framework is used in Medicaid"