Survey: ICER Assessments Impact Payer Decision-Making

An Xcenda survey of payers found that cost-effectiveness analyses from the Institute for Clinical and Economic Review (ICER) are used in price negotiations and to implement prior authorizations.

Payers see value in the cost-effectiveness analyses and policy reports conducted by the Institute for Clinical and Economic Review (ICER), according to a recent survey conducted by Xcenda and presented at the annual meeting of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) in May 2022.

In fact, three quarters of the surveyed payers noted that ICER reports are at least somewhat impactful in their decision-making process.

“The assessments are most commonly used as a supporting source, but rarely the main source for coverage or formulary decision. In terms of formulary management, the results from ICER assessments are most often used in pricing negotiations, and to implement prior authorizations,” Daniel Faraci, research associate intern, market research, at Xcenda, said in an interview.

Xcenda researchers conducted a double-blind, web-based survey of 50 of the company’s advisory group of payer experts, which represented health plans, integrated delivery networks, and pharmacy benefit managers.

About half of the respondents surveyed indicated using findings from an ICER assessment in pricing negotiations, and about half implemented a prior authorization as a result of an ICER assessment. Of those surveyed, 62% said they use ICER analysis for supporting economic data; 56% said they used these reports as a source of clinical information, and 38% said they used ICER analysis in contracting negotiations.

“Payers are looking at the clinical evidence rating, the comparative effectiveness data, and the cost-effectiveness data that ICER is putting together and they’re looking at the core evidence generation package to inform their decision making,” said Erika Wissinger, Ph.D., director of evidence synthesis and modeling at Xcenda.

Most of the time, ICER’s reviews align with payers’ own internal review, but when they don’t, payers consider making adjustments to formularies. In fact, 56% of respondents said they are somewhat likely to expand formulary coverage if ICER found a therapy to be cost-effective after their organization had said it was not cost-effective. And 58% of respondents reported that their organizations are at least somewhat likely to restrict formulary coverage for a product ICER found not to be cost-effective after their organization had previously deemed it cost-effective.

Previous surveys conducted by Xcenda have found that two thirds of payers said that ICER at least occasionally influences their recommendations, said Kimberly Westrich, director of value & access strategy at Xcenda. “There is a trending influence of ICER from what we see over three surveys, particularly between 2016 and 2018,” she said.

These early surveys also found that ICER reports may be used more frequently in select therapeutic areas compared with others, especially with high-cost drugs or rare/orphan diseases.

In a broader sense, Westrich pointed out that there’s uncertainty with all health technology assessments, including ICER’s. “The people conducting the assessments need to make assumptions about what information to use and what goes into the model. That has an impact on certainty. In any health technology assessment, there is a wide breadth of possible answers,” she said.

Xcenda researchers noted the most recent survey reflects the perspectives of a select group of formulary decision makers in the United States and were derived from a relatively small sample size. Additionally, respondents had greater representation from health plans compared with integrated delivery networks and PBMs, and this could affect the generalizability of results across payer types.

They suggested future research should investigate in greater detail whether particular groups of payers are more likely to use ICER assessments in decision making and whether ICER assessments of certain therapeutic areas or drug classes have greater influence on payers than others