Diving Into the What-Ifs of ICER: Implications of Applying Cost-Effectiveness Thresholds in Medicare

October 12, 2018

Continued concerns about rising healthcare costs have prompted renewed proposals for use of a single value threshold (eg, cost-effectiveness threshold or similar approaches) as the basis for setting coverage or payment policy.

To further inform debate about the role and implications of value standards in healthcare policy, Xcenda examined the potential impact if ICER’s value assessment framework was applied across 4 conditions in the Medicare Part B program. Xcenda selected ICER’s framework because it appears to be designed for use at the policy level, was referenced in Medicare Payment Advisory Commission (MedPAC) deliberations, and was cited by CMS in its controversial 2016 Part B Drug Payment Model proposal.

Our study looked at the over 200,000 Medicare Part B fee-for-service beneficiaries with RA, MS, NSCLC, and/or multiple myeloma who used a physician-administered product evaluated by ICER. If the Medicare program was to adopt an ICER-based formulary, 59% to 93%, or nearly 140,000 of these patients, could lose access to their physician’s treatment of choice and could be forced to switch to a therapy deemed cost-effective.

Our results underscore the importance of ensuring that value assessments are used in ways that do not prevent patients and doctors from making informed choices about care options and the need for alternatives that are more physician- and patient-centered. Ideally, current or alternative tools could be tailored and supported to encourage informed, individualized decisions at the physician and patient level.
Read the report to learn more.

Health Policy Weekly is written by Xcenda, a consultancy and business unit of AmerisourceBergen Specialty Group. Visit Xcenda’s online archive to access more health policy news.

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