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Examining Payer Coverage Decision Trends Related to ICER Value Assessment Framework

April 16, 2021

By Edan Stanley

headshotsTasmina Hydery, PharmD, MBA, BCGP, assistant director, integrated technology solutions, and Linnea Tennant, PharmD, MBA, MS, assistant director, value and access strategy, both from Xcenda, discuss their recent study which examined the Institute for Clinical and Economic Review (ICER) value assessment framework (VAF), and its connection to trends in utilization and payer coverage decisions.

What existing data led you and your co-investigators to conduct this research?

Our team has consistently conducted payer research over the last several years to examine the evolving role of ICER in payer coverage decisions. Findings from prior research conducted by our team have shown that the majority of payers are using ICER reports as a secondary source of evidence to support P&T preparations, and we have seen that ICER’s influence on payer decision making has steadily increased over time. To build on our existing research, we conducted an update to our survey to assess trends over a longer period of time and to ask payers about some of ICER’s newer initiatives. ICER is consistently evolving its methodologies and assessment process, so it is important for us to continue to monitor the payer landscape to understand how these changes are impacting payer decision making.

Please briefly describe your study and its findings. Were any of the outcomes particularly surprising?

We analyzed data from double-blinded, web-based surveys that were fielded through Xcenda’s research panel, the Managed Care Network (MCN), in November 2016, November 2018, and October 2020, to assess trends in payer uptake and the impact of the ICER VAF in coverage decisions. The surveys assessed payers’ utilization of the ICER VAF in coverage decisions, and the most recent survey also assessed payer perceptions of newer ICER initiatives. The results suggest the impact of ICER’s VAF on payer decision making increased from 2016 to 2018 but has remained relatively stable from 2018 to 2020. ICER reports may be utilized more frequently in select therapeutic areas (eg, high-cost drugs or disease states) compared to others.

One of the most interesting aspects of our research examined how ICER reports have impacted coverage decisions for specific products. We found that nearly half of payers have either expanded access or restricted access to therapeutics in response to an ICER assessment.

What are the possible real-world applications of these findings in clinical practice?

These research findings highlight the evolving role of ICER in payer decision making. From the manufacturer perspective, it is important to understand how payers are using ICER reports in order to effectively navigate the ICER assessment process. From our extensive experience working with manufacturers on ICER strategy projects, we strongly encourage proactive preparation for potential ICER reviews. We have seen that manufacturers who prepare for evaluations are able to more efficiently align internally to meet short turnaround times, act more nimbly and confidently, and have more meaningful engagements with ICER throughout the evaluation process. These research findings underscore the growing relevance of ICER in payer decision and highlight the importance of proactive ICER strategy work. 

Do you and your co-investigators intend to expand upon this research?

Through annual surveys which are fielded through Xcenda’s MCN, we plan to continue evaluating payer utilization of ICER assessments to assess trends in payer uptake and impact over time. Additionally, as a part of an agreement with ICER, Xcenda’s FormularyDecisions platform will include ICER Analytics, a cloud-based tool that hosts ICER evidence reports and underlying analyses. This will allow us to track payer feedback on ICER’s economic models in the Interactive Modeler and track payer utilization of ICER reports in the Evidence Compendium and assess further trends over time.

About the Researchers

Tasmina Hydery, PharmD, MBA, BCGP, is a pharmacist by training with nearly seven years of experience as a consultant for payers prior to transitioning to Xcenda (which is a part of AmerisourceBergen) in October 2020. She has an extensive research background in retrospective claims analysis studies for high-cost therapies and evaluation of clinical and economic characteristics for novel therapies. Having reviewed ICER reports and attended ICER meetings in my previous role, Dr Hydery explained she was eager to evaluate the uptake and impact of ICER’s value assessment framework (VAF) in coverage decisions across a diverse array of payers.

Linnea Tennant, PharmD, MBA, MS, is currently an assistant director within the value and access strategy team, with 6 years of experience in health economics and outcomes research and market access consulting. She currently leads Xcenda’s value assessment frameworks team. In this role, Dr Tennant is responsible for helping manufacturers develop strategies related to emerging VAFs in the United States, including ICER, and for conducting market research to understand the growing influence of value assessment tools on payer decision making in the United States.

Choi M, Hydery T, Tan R, Tennant L. Trends in the uptake and impact of the Institute for Clinical and Economic Review value assessment framework in payer coverage decisions from 2016 to 2020. Poster presented at: AMCP 2021, April 12-16, 2021; Virtual. 

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