Amidst debate about rising health care costs, some policy-makers have expressed renewed interest in using cost-effectiveness thresholds as the basis for setting coverage and payment policy. But a new analysis from Xcenda shows that reliance on one-size-fits-all value assessments, such as those used by the Institute for Clinical and Economic Review (ICER), could limit hundreds of thousands of Medicare Part B beneficiaries’ access to life saving medicines.
The new analysis compared ICER’s assessments regarding what treatments are of “highest value” to utilization of Medicare Part B medicines for four diseases. The data show if Medicare were to apply ICER’s determinations, which rely on cost effectiveness thresholds, as the basis for coverage policy, 62 to 93 percent of patients with rheumatoid arthritis (RA), multiple sclerosis (MS), non-small cell lung cancer (NSCLC) and/or multiple myeloma (MM) could lose access the treatments their physicians determined were best.
The analysis quantifies, for the first time, the profoundly negative impact using ICER’s assessments would have on Medicare beneficiaries. ICER’s framework poses particular risks for beneficiaries in part because it relies on conventional, one-size-fits-all thresholds to judge cost effectiveness. These thresholds ignore important differences in individual patient needs and preferences and have been widely criticized as discriminating against vulnerable groups such as the elderly and disabled.
Despite these concerns, some policymakers have persisted in pursuing them. For example, earlier this year the New York Department of Health began using ICER reviews and cost-effectiveness thresholds to set value-based prices for medicines in Medicaid, a move that has been sharply criticized by patient advocates. The decision by the Department of Veterans Affairs to use ICER in its coverage decisions provoked similar concern from patients, veterans and people with disabilities.
To measure the value of medicines, we need better tools that capture the complexity of the diseases and patients we treat. That is why our sector provides an unprecedented level of support to advance these tools. If we do not invest in better solutions to facilitate access to the treatments that patients value, there could be serious consequences for both patient health and progress against unmet medical need.
Read more about the Xcenda analysis here.
View the Xcenda analysis one pager here.
Lauren Neves
Lauren Neves is Vice President of Policy at PhRMA focusing on the value of cancer medicines, medication adherence, and payment and delivery reform. Prior to joining PhRMA, Lauren earned her law degree and worked as a market access and health policy consultant to health care and pharmaceutical clients.
Health care practitioners sound the alarm on middlemen-imposed barriers to patient care, need for policy change
The Inflation Reduction Act could increase costs and reduce access for millions of seniors
Are the IRA’s Part B inflation rebates lowering costs for Medicare patients? No.
Biosimilars continue to drive market competition and increase savings for seniors
Three things to know about the United Nations’ new HIV/AIDS report
Case study: How seniors could face access disruptions because of the IRA’s price setting provisions
ICYMI: Misaligned policies undermine patient access
New analysis: Flawed assessments of a medicine’s value jeopardize patient access
3 Takeaways from POLITICO’s Health Care Summit
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
Incomplete evaluations undermine patient access to transformational medicine
Navigating the Patient Experience Survey: Protecting Lifelines to Access and Innovation
CMS guidance on IRA price setting process doubles down on bad policy
A guide to MedPAC’s Part B vote today
MedPAC proposal threatens access to medicines in Part B
States can support access to medicine as COVID-19 Public Health Emergency ends
CMS coverage policy is detrimental to Alzheimer’s patients
How Part B’s ASP system helps control costs for the government and seniors
Medicare Part B spending in four points
Minnesota lawmakers are letting PBMs off the hook, and threatening patients’ access to medicines
In their own words: Insured Americans support policy reforms that address access and affordability concerns
Biosimilar uptake is increasing and so are health savings
CMS coverage policies restrict patient access to important treatment options for Alzheimer’s disease
The Senate’s latest price setting proposal will undermine: Patient access to medicines
New research shows competition driven by biosimilars helps control costs in Part B
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
Innovative contracts continue to gain traction and improve quality of care
Part B 101: Three charts show the program helps control costs for health care system and enrollees
PhRMA submits comments urging CMS to withdraw coverage proposal
It’s a new year, but sadly Congress is still pursuing flawed price setting policies
Post-approval research save lives. Why is Congress trying disincentivize it?
A price control by any other name would still put patients at risk and threaten innovation
Making medicines more affordable: Modernizing Medicare
ICYMI: New study confirms policies like H.R. 3 could significantly reduce drug development
Recent polling misrepresents public support for Medicare “negotiation”
What they’re saying: Patient advocates want to protect Medicare from government interference
Study finds nearly half of payers believe innovative contracts can lead to lower patient out-of-pocket costs
The ABCs (and Ds) of Medicare
Getting the 340B program back on track in 2021
New analysis finds stark difference in coverage of breast cancer medicines for seniors in the United States and England
No matter how you look at it, the Most Favored Nation rule is bad policy
Growth in innovative, value-based contracts holds promise for the health system and for patients
Innovative contracts drive access for patients and value for the system
PhRMA submits comments to CMS on policy changes for in-home care under Part B during COVID-19
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
Three reasons the Administration should abandon its International Pricing Index proposal
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
New analysis: Government intervention in Part B threatens patient access to medicines
Setting the record straight on international reference pricing
No matter how you structure it, government arbitration is wrong for Medicare drug coverage
5 Ways to improve ICER’s value assessment framework
What you should know: Government arbitration is the wrong way to change Medicare
By the numbers: A look at the Part B International Pricing Index Model
Assessing value top of mind at ISPOR 2019
Event tomorrow: Improving access and affordability for America’s seniors
Fact Check: How the Part B International Pricing Index Model replaces market competition with government-set prices
340B continues to drive shift in site of care for physician-administered medicines to more expensive hospital settings
Fact Check: How the Part B International Pricing Index model threatens patient access
New analysis shows 820,000 prescriptions would be in jeopardy if ICER’s value framework is used in Medicaid
New analysis finds Average Sales Price system has led to significant cost savings for Medicare and seniors
New “Prescription for Medicare” campaign focuses on impacts of wrong and right solutions for Medicare
Value assessments should include all the outcomes that matter to patients and families
In survey, PhRMA member companies highlight impact of IPI on R&D
PhRMA comments to administration on Medicare Part D proposed rule
ICYMI: New study reinforces dangers of proposed IPI model
PhRMA comments to administration on International Pricing Index Model
10 things you should know about medicine spending and costs
ICYMI: WSJ and NYT highlight concerns with Part B International Pricing Index 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
PhRMA comments in response to request for information on competitive bidding program in Medicare Part B
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
Fact Check Friday: Getting the facts straight about negotiation in Medicare Part B
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
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
Medicare Monday: New Xcenda white paper looks at four strengths of Part B
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
Medicare Monday: Moran finds Part B medicine prices are stable, not a key driver of Medicare costs
Improving care quality by engaging patients in shared decision making
ICYMI: Research shows promise of innovative payment arrangements in reducing costs, improving access
Copay coupons can help ease patients’ out-of-pocket costs
PhRMA launches new consumer-facing Let’s Talk About Cost website
Guess what? Part B drug spending remains stable share of Medicare spending
Clarity around anti-kickback statute needed to promote innovative payment arrangements
Video: What is a results-based contract?
Medicare Monday: CMS withdraws Part B demo, takes positive step forward on CMMI
How much are hospitals marking up the price of medicines? The answer may surprise you.
PhRMA Foundation recognizes inaugural Challenge Award recipients
Johnson & Johnson, Pfizer, Walgreens and other CEOs discuss value in the future of health care
The journey to better health care requires a holistic view
Medicare Monday: Medicare turns 52!
Medicare Monday: How Part B has evolved over the years
Medicare Monday: It is Medicare’s birthday month!
Medicare Monday: New report highlights progress in fighting cancer with new physician-administered medicines
Modernizing FDA regulations to advance a value-driven health care system
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
ICYMI: Avalere and FasterCures develop new value framework from patient perspective
Medicare Monday: Catch up on MedPAC and its Part B recommendations
Medicare Monday: Did you know Medicare Part B uses a market-based system to pay for 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
Medicare Monday: Stakeholders raise concern with MedPAC’s proposed changes to drug purchasing program
Medicare Monday: What they are saying about MedPAC’s Part B recommendations
RA medicines often demonstrate far greater benefits to patients than initially understood
Medicare Monday: A guide to MedPAC’s Part B vote this week
New analysis: More than half of patients’ out-of-pocket spending for brand medicines is based on full list price
Medicare Monday: Billing code basics for biologics in Part B
Medicare Monday: A closer look at Part B spending
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
Medicare Monday: How Medicare helps beneficiaries access needed medicines
Medicare Monday: A closer look at Medicare Part B
Medicare Monday: Kicking off 2017 with Medicare resources
New analysis shows negative impact of ICER’s value framework on patient access in Medicare Part B
Access
Part B
The Value Collaborative
Value-Driven Health Care
New analysis shows negative impact of ICER’s value framework on patient access in Medicare Part B
New analysis shows negative impact of ICER’s value framework on patient access in Medicare Part B