Objectives
A current challenge in the US health care system is to meet simultaneous goals of sustained innovation, cost control, and improved quality. This study investigates the current US payer landscape for achieving value in the use of pharmaceuticals and how it differs from payers outside the US.
Methods
In-depth phone interviews with 13 executive-level US managed care representatives and 6 health technology assessment (HTA) advisors (1 each in Australia, Canada, France, Germany, Italy, and the United Kingdom) were conducted in September–November 2017. Interviewees were provided with discussion questions and background information on value frameworks.
Results
Stakeholders throughout the health care continuum are seeking more value for pharmaceuticals; however, explicit mechanisms for US payers to use value-based concepts (e.g., cost per quality adjusted life-year or budget impact) in coverage and reimbursement decisions are limited. US payers must cover Food and Drug Administration–approved products if there is no therapeutic alternative and have little ability to control pharmaceutical prices in these instances. Mechanisms US payers use to enforce value-based reimbursement can involve denying coverage if therapeutic alternatives exist, increasing patient co-payments, establishing treatment-sequencing, requiring prior authorization, competitive bidding for preferred status among therapeutically equivalent products, and leveraging public opinion and media mobilization. Payers view outcomes-based contracting to offer uncertain savings and do not consider it a broadly applicable solution to achieving value because of operational difficulties. All 13 US payers interviewed use published value assessments (e.g., Institute for Clinical and Economic Review [ICER] reports) as a reference, but only 2 have formal economic value assessment processes. HTA advisors interviewed outside the US assess value using cost-effectiveness thresholds and/or evidence of patient-relevant benefits compared with predefined comparators.
Conclusions
Value needs to be considered in pharmaceutical decision making to manage budgets going forward. Implementing value-based decision making in the US remains a challenge.
