Will New Value Assessments Lead to Care Rationing?

by Amanda Conschafter, blog editor

For patients, the immense value of a life-changing medication can be difficult to quantify. Yet as drug prices rise, more health insurers and policy analysts are trying to do just—create a price point based upon a medical therapy’s clinical effectiveness. But when market price doesn’t conform to analysts’ value assessment, effectiveness data can be used to justify limiting patients’ access to breakthrough treatments. Such could be the case with a new study from the Institute for Clinical and Economic Review, which considers the value two new drugs for treating high cholesterol.

As ICER’s study reports, newly approved PCSK9 inhibitors alirocumab‎ and evolocumab‎ can reduce LDL cholesterol by 55-60 percent—welcome news for millions of Americans. The study’s analysts suggest that expected patient improvements correspond to a price that’s 67 percent less than the therapies’ listed market price. But a significant portion of American patients need cholesterol-lowering medication, analysts reason, suggesting that the price of the medication be reduced still further to roughly one seventh of the list price.

The study is part of an ICER series analyzing FDA-approved drugs, designed to offer “benchmark prices” that fuel price negotiations and justify coverage decisions by insurers. The organization’s efforts have also given rise to its new Value Assessment Framework. Stakeholders have expressed concerns, however, about the effect that such value assessments have on patient access. Data points intended to minimize health care costs can instead be used to deny coverage for patients, limiting access to necessary therapies. As ICER’s founder explained, if the cost of new LDL cholesterol-lowering medications proves to be higher than the benchmark created by ICER, “doctors, insurers, and other parties may need to work together to determine ways to limit the use of these drugs.”

Analytics for assessing medications’ values can also overlook the cornerstone of quality health care—the physician-patient relationship. Statistics by nature generalize patients into types instead of individuals, considering measures such as net health benefit and long-term cost instead of value for an individual patient’s course of treatment. Should insurers lean too heavily on value assessments in determining coverage policies, physicians may find their ability to guide patient care very limited.

ICER welcomes public comment on its study until September 22.


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