Patient Access Withers Under ICER’s Influence

August 28, 2018

Patients’ prescription drug options are getting slimmer.

CVS Health recently announced that employers who use its pharmacy benefit management services can cut certain medications from their plan’s formulary of approved drugs.  Which drugs? Those that exceed a cost-effectiveness threshold established by ICER, the Institute for Clinical and Economic Review.  

ICER is a controversial health economics organization that evaluates new drugs based on price and efficacy.  The organization, whose funders include health insurers and their foundations, routinely suggests aggressive price cuts on breakthrough medicines.

What happens when manufacturers can’t meet ICER’s demands?  CVS’ new plan tells the story.

Patients who have waited for breakthrough drugs to treat conditions that defy existing therapies may find treatment out of reach.  Patients who are stable on advanced medicines may lose access to their treatment. Chronic disease patients for whom one drug doesn’t work may discover they have no other viable options.

And it’s not just CVS Health that’s limiting patient access to boost its bottom line.  

Express Scripts announced this month that it will drop 242 prescription drugs from its formulary.  The exclusions, which take effect January 2019, include antiretrovirals, drugs for hepatitis C, growth hormones and HIV medications, among others.  Express Scripts projects that it will save $3 billion (read: raise profits) in 2019 by implementing these changes.

Will either pharmacy benefit managers’ savings trickle down to patients?  That detail remains hazy.

Pharmacy benefit managers have come under scrutiny for pocketing rebates provided by drug manufacturers.  Some, in turn, have attempted to defend their use of rebates.  The move is part of a broader attempt to combat bad press, including growing public awareness about practices such as gag clauses – where pharmacy benefit managers prohibit pharmacists from telling patients when it would be cheaper to buy their prescription drug out of pocket than to use their insurance.

One thing is clear: Pharmacy benefit managers’ restrictive formularies, including those based on ICER’s controversial calculations, mean fewer treatment options.  Patients in the United States could have a rocky 2019 ahead of them.

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