New tools for assessing drug value haven’t caught on with payers — yet

Print 29 July 2016
Ed Silverman / STAT

As prices for prescription drugs keep rising, several organizations have developed different ways to assess the value of new medicines based on such attributes as cost, quality of life, and effectiveness. But a new survey finds that even as health plans continue to criticize drug prices, they have not yet embraced these new tools.

None of the 11 plans queried actively rely on these new methods and a majority do not expect to do so next year either, according to the survey conducted by Avalere Health and released today. The tools are being developed by four groups — the American Society of Clinical Oncology, the Institute for Clinical and Economic Review, the National Comprehensive Care Network and Memorial Sloan Kettering Cancer Center.

The plans are “anxious to get better comparative information on the value of different therapies, but are also concerned these tools are somewhat nascent and not robust enough,” said Josh Seidman, an Avalere vice president. He noted that most respondents work as either medical director or pharmacy directors, and all but one serves on a committee that recommends prescription drug coverage.

For now, Seidman explained that the plans would like to see physicians and other health care providers more readily embrace the value tools before formally incorporating them into any decision-making procedures. The health plans, by the way, sell coverage across various markets — commercial, Medicare, Medicaid, and the health care exchanges. And the survey was conducted over the past several weeks.

The results come as payers — both public and private — grapple with rising costs for medicines, as well as increasingly higher price tags for newly launched treatments. The pharmaceutical industry has argued that rebates and discounts lower costs, but these numbers are never released. Meanwhile, payers are moving to tighten coverage when a lack of competitive medicines reduces their bargaining power.

Each of the four groups is seeking to fill an information void by providing ways for payers to evaluate new prescription drugs. Over the past two years, they have either released or begun developing tools that payers and physicians — and in some cases, patients — can use to assess value. These are still early days, of course, but one of the groups has met with some controversy.

Notably, ICER has been criticized by the pharmaceutical industry for its methodology. Last spring, Amgen openly challenged the nonprofit’s review of bone cancer drugs. In a nod to the criticism, the group two weeks ago openly began soliciting suggestions for ways to improve its approach. The survey found that 64 percent do not plan to rely on ICER next year.

But Dr. Steve Pearson, who heads ICER, wrote us that he is aware of some payers that are already using “elements of our work. Both the clinical effectiveness and the cost effectiveness results are being used both as input when they make their own coverage decisions and when they enter into negotiations” with drug companies.

Meanwhile, Dr. Peter Bach, who helped develop the Abacus tool at Memorial Sloan Kettering, told us that he was not discouraged by the survey results, despite findings that 64 percent of the plans do not expect to rely on his Abacus next year, while 27 percent may use the tool and another 9 percent reported that they are very likely to do so.

“I think this constitutes substantive progress. It’s only been 13 months since we launched. I’m buoyed by seeing the interest,” said Bach, who heads the Center for Health Policy and Outcomes at the cancer center. “I think it’s going to take a while for payers to get used to the idea of paying drugs based on benefit, because it’s a different way of thinking about allocating drug spending.”

A spokeswoman for America’s Health Insurance Plans, an industry trade group, said that health plans already use value tools to assess new medicines. “These are more focused on identifying and implementing specific benchmarks and protocols for measuring medication adherence and health outcomes,” she told us.

But she said the new tools are filling a void by comparing the value of existing medicines with new ones coming to the market to gauge cost effectiveness. However, she pointed out the ASCO and NCCN tools differ slightly from the others by orienting the assessment toward physicians and patients. In fact, 82 percent of plans do not expect to use the ASCO tool next year compared with 64 percent for NCCN.

In a statement, ASCO chief medical officer Dr. Richard Schilsky noted the organization has revised its tool and is currently in the process of updating software to provide information more quickly to doctors and patients. We also asked NCCN for comment and will update you accordingly.

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