What is ICER and how does it promote discriminatory drug ...

The Institute for Clinical and Economic Review (ICER) produces reports, known as “cost effectiveness analyses” or “value assessments” on how much it thinks ... Skiptomaincontent Returntotopofpage WhatisICERandhowdoesitpromotediscriminatorydrugpricing? TheInstituteforClinicalandEconomicReview(ICER)producesreports,knownas“costeffectivenessanalyses”or“valueassessments”onhowmuchitthinksnewdrugsshouldcost.ICERmetricsvaluetreatingyoungindividualsingoodhealthasmorecost-effectivethantreatingolderadults(65andolder)orpeoplewithdisabilities.Insurancecompaniesusethesevaluestodecidewhetherit’sworthpayingforacertaintreatmentortest.Sickandolderpatientsaremorelikelytobedeniedaccesstomedicationsthatcouldhelpimprovetheirconditionorqualityoflife. JoinUs Ageorpossibledisabilitydoesnotimpactthevalueofahumanlife.However,theInstituteofClinicalandEconomicReview(ICER)producesrecommendationsonhowmuchnewdrugsshouldcostbasedonthesesameconsiderations. Theresult?Reportsthatsaythelivesofolderadultsandindividualswithdisabilitiesorchronicconditionsarelessvaluablethansomeoneyoungerorin“perfecthealth.”Insurancecompaniesandgovernmentsinothernationsoftenusetheseanalysestodeterminewhethertheywillpayforspecifictreatmentsortests.However,ICERandothersarepushingforMedicareandMedicaidtousethesesamediscriminatoryreports. Itistimeforpatientstosay “enoughisenough” andstandagainstdiscriminationinhealthcare.SignuptodaytoreceivenewsupdatesonICER’sactivityandopportunitiestoconnectwithelectedofficialsontheimportanceofprotectingpatients’rights. HowdoesICERdecidewhichmedicinesareworththeircost? ICERlooksattwometricswhenitdeterminesadrug’sworth:thevalueoftreatingthetypeofpatientforwhichthedrugisdesigned,andhowmuchitcoststhehealthsystem. Theorganization’sanalysiscomparesthecostofanewdrugagainstotherexistingtreatments,thelikelihoodofsideeffects,andadrug’sshort-termbenefits.Longer-termbenefits,suchasfewerhospitalvisitsorimprovedqualityoflife,arenottakenintoconsideration.Unfortunately,thereislittletransparencyintoexactlywhatgoesintoICER’sformulationsorhowtheyarriveattheirconclusions.ThismeansotherresearchersandeveninsurancecompaniesareunabletoanalyzeandreplicateICER’sresults. Theorganizationalsodeterminesadrug’svaluebasedonquality-adjustedlife-years(QALYs).Thismeasurementputsadollarvalueononeyearofthepatient’slifetoestimatejusthowcost-effectiveamedicaltreatmentis.ICER’sdescriptionofits“equalvalueoflifeyearsgained”metric,whichissimplerthanQALYs,statestheydonotadjustforqualityoflifedifferencesarisingfrom“age,severityofillness,orlevelofdisability.”Fortwopatientsreceivingequalcare,itmeanscoveringtreatmentfortheyoungerandhealthieroneisamorecost-effectivemoveforaninsurancecompanythantreatingtheolderandsickerone. WhatistheproblemwithQALYs? SincetheQALYmeasureisarbitrary(ICERvaluesoneyearofperfecthealthat$100,000to$150,000),itsoutcomeisinconsistent.QALYsplacealowervalueonthelifeofpatientswithseriousillnesses,whomaybeexpensivetotreatintheshorttermbutmightotherwisebenefitfromalong-termcureorgreatlyimprovedlifeexpectancyorqualityoflife.Thevalueshavesevereconsequences,sinceinsurerscouldusethemtodenyhigh-costdrugstocertainpopulationsorpatientsincertaindiseasestages. Perhapsmostimportant,theuseofQALYsandsimilarassessmentsasthebasisfordrugcoverageandreimbursementdecisionsisconsidereddiscriminatoryunderU.S.Federallaw,includingtheAmericanswithDisabilitiesAct(ADA).ThegoverningbranchoftheEUhasalsocriticizedtheUnitedKingdomforusingQALYstodeterminedrugpricing.QALYsoriginatedinthe1960sandfoundapplicationwhentheBritishgovernmentwassearchingforwaystorationhealthcareforitsNationalHealthService. WhataretheconsequenceswithICER’scurrentmethodology? ICER’smethodologycanmeanolderadults,peoplewithdisabilitiesandveteransaredeemed“tooexpensive”toreceivecare.Butithasbroaderconsequencesaswell. Drugsdevelopedtotreatrareormorecomplexdiseasesmayonlybebeneficialtoasmallnumberofpatientsortakelongertodevelop,whichmeanstheirpricestendtobehigher.IfICERreportsdeterminethatpatientssufferingfromthesediseasesaretoosicktotreat,orthetreatmentistoocostlyintheshort-term,insurancecompanieswilllikelyshyawayfromcoveringthesenoveldrugs.Notonlydoesthecost-prohibitivenatureofpayingfordrugsthatacoveredbyhealthinsurancelimittheiravailability,butitwillalsodissuadepharmaceuticalcompaniesfromresearchingcuresforlessprevalentdiseases. ICER’sdiscriminatorytacticsaregainingsteamwithsomebigplayers.CVSHealthlastyearannounceditsintentiontoemployICER’sframeworksothatpayerclientscanexcludesomemedications;andtheDepartmentofVeteransAffairspartneredwithICERfordrug-pricenegotiationsin2017. CoordinatedLegislativeEffort Thereisacoordinatedstatelegislativecampaign,pushedbytheNationalAcademyforStateHealthPolicy(NASHP)andrelyingexclusivelyonICER,thatwouldrecklesslycutaccesstoprescriptiondrugsforseniorsbasedonanarbitrarydeterminationthatthosedrugshad“unsupportedpriceincreases”inagivenyear.Suchdrugscouldvaryfromyeartoyearandincludemedicationsforwhichnoothertreatmentcurrentlyexists.ICERcreatescostanalysisreportsthathealthinsurancecompaniesusetodenypatientsaccesstoinnovativemedicaltreatments. InJanuary2021,ICERreleasedthesecondeditionofitsreport,unimaginativelycalledUnsupportedPriceIncreaseReport,whichfocusesonahand-picked,narrowgroupofmedicines.Thisreportincludesahighly-criticizedanalysis.ICERevenadmitsitsreportisflawedandthatit“doesnotcurrentlyhavethecapacitytoperformfulleconomicanalysesinconjunctionwiththeevaluationofclinicalevidenceforthedrugsinitsUPIReports.”Thepressrelease fortheirreportiscandidaboutcoordinationwith NASHP’spushforstatelaws.Despitetheseconcernsandtheshorttrackrecordofthisreport,ICERandNASHPcontendthatthereportisvalidasasolitarysourceformakingpricingdeterminations.NongovernmentalentitiesshouldnotbegivensolepowertodriveprescriptiondrugaccessdeterminationsinMedicaid.  Accordingto a DrugChannels analysis ofdatafromSSRHealth(anindependentorganizationthatcollectsandreportsdataonpharmaceuticalprices),growthinprescriptiondrugpricesslowedsignificantlyoverthepastfiveyears,withnetprices declining by-2.2% in2020alone.Additionally,whilepriceshavefallen, utilization hasincreased,whichmeansthatmorepatientsareusingmoremedicines,whichincreasesoverallhealthspending. Forhealthinsuranceproviders,ICER’scontroversialmethodologyservesasthebasisforperverseincentives.PayersareusingICERreportstodenycoverageorpreferredformularyplacementwhenthereasoningbehindthosedecisionscannotevenbereplicated. Ultimately,thefactthatdrugsareinaccessibleandunaffordabletomanyseniorsisduetoprivatePartDinsurersandPBM’sdemandinghigherrebatesfrompharmacompanies(whichdriveuplistprices)andthenimplementingaggressivecost-sharing.Thispracticemakesolderadultspaymorefordrugstheirphysiciansprescribeandsetspatientsuptofailtostickwiththeirphysicians’recommendedcourseoftreatment. LearnMore DiscriminationhasnoplaceinAmericanprescriptiondrugcoverage–TheTennessean Governorsshouldrejectunscientificanddiscriminatoryapproachestodrugpricing–TheHill Cost-effectivenessinhealthcareisracist–MorningConsult TheeducationaleffortsofthiscampaignaresupportedbyGileadSciences,EliLilly,Merck&Co.,Inc.,PhRMA,andPfizer,Inc. Search: Go Closemenu Welcome!Pleaseprovideyourinformationtogetstarted. CLOSE