The Rise of ICER - The Payer Perspective

Payers reveal where ICER is really impacting pharma/payer relations

How is the Institute for Clinical and Economic Review (ICER) influencing payer behavior? ICER's evidence and price benchmarking data are valued by payers but, for now, are not central to their decision making. For some, ICER's methodology is seen as a blunt instrument which fails to take into account the real-world commercial complexities of drug pricing and reimbursement. Nevertheless, payers are not slow to bring into play ICER's assessments if it suits their purpose. So how can pharma respond when ICER's assessments are referenced by payers?

ICER is becoming a force in pharma/payer relations and manufacturers need clear policies and procedures for responding to their influence. To help shape your strategy we interviewed experienced US payers with direct ICER experience. In The Rise of ICER - The Payer Perspective they outline the key issues and attitudes that shape payer thinking and thereby reveal the proactive steps pharma can undertake to mitigate risk from a negative ICER assessment, or make the most of a positive one.

Payers explore key questions such as:

• How valuable are ICER assessments in helping payers make coverage decisions and identifying product formulary placement?

• How influential is ICER's wider work, such as on unsupported price increases and real-world evidence?

• To what degree are payers influenced by ICER and how might this change in the future?

• How useful are ICER assessments for helping payers find data and information for their own drug information/review processes?

• Are ICER's choice of thresholds to inform value-based price benchmarks important to payers?

• What data and information would payers like to see included in ICER assessments?

What payers say:

"We hear more about ICER's reports from the manufacturers than we do from anybody else. I've had manufacturers come to me and say 'Hey, ICER just put out a report for this drug, but we did our own cost-effectiveness, our own version of ICER's evaluation, and we come up with a much different number.' Well, of course they did. ICER's reports seem to be more for manufacturers, because what I think they are trying to do is to come up with their own evaluation to dispute the numbers that ICER is putting out. I've had that happen a couple of times. Where they would say, 'Oh well, ICER looked at this but they should have looked at that. We looked at this, but they didn't." Pharmacy Director.

"From what I understand with value-based contracts, they often sound better than they are in reality; they're often very hard to operationalize. It's possible that ICER could help that if they were able to include very objective endpoints that would be noncontroversial for either party, and agreed upon as acceptable endpoints for that drug to reasonably meet in order to be performing the way it should. So then it might make it easier to operationalize because one of the reasons that I think we see fewer value-based contracts is oftentimes it's very hard to come up with endpoints that both parties accept as a fair result as a consequence of the particular drug, and not other confounding factors that could improve that outcome." Medical Director, Health insurer.

"We put together everything that is available: all the clinical information, all the economic information, we put that together in-house for the P&T materials. We don't base our economic discussions based on the quality-adjusted life year. We just don't look at the economics that way; we look at what's the weighted average cost, the cost per month, the cost per year." Pharmacy Director.

What to expect

A detailed report exploring payer attitudes to ICER, the value they perceive in their work and how it is influencing their relationship with manufacturers:

• An examination of 14 key issues that shape payer thinking about and attitude to ICER

• 13 targeted questions put to payers with ICER experience

• Their responses which provided 40 insights supported by 94 directly quoted comments

  Expert contributors

  Experts contributing to this report have been screened to ensure they:

• Currently hold or recently left a role working in a payer organisation in the US, including health plans and pharmacy benefit managers (PBMs)

• Have direct experience of informing, supporting and/or making coverage decisions on medicines

Experts interviewed included

• A Manager of Pharmacy Contracts at a not-for-profit PBM serving over a million members.

• A Vice President of Clinical Strategy and Programs with responsibility for formularies at a pharmacy benefit manager.

• A recently retired Physician Director of Pharmacy and Therapeutics and Medication Safety, and Chair of the formulary committee for a multi-specialty medical group and regional health plan (an Integrated Care Consortium or ICC) caring for about 750,000 members.

• A Medical Director working at a health insurance company with more than ten million members.

• A Pharmacy Director for a regional payer that covers commercial and Medicare lives. He runs a Pharmacy and Therapeutics (P&T) committee and is directly involved in formulary and coverage decisions for oncology products.

• A Medical Director at a not-for-profit PBM serving over a million members.

• A Vice President with responsibility for pharmacy at a not-for-profit health plan serving around a million members.

Experts provided their own individual views, which do not necessarily reflect the views of the organizations they work for.

Why choose FirstWord ExpertViews?

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• Are based on primary research with experts whose knowledge and current experience is proven

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