State-based Analysis: ICER-based Formularies Could Upend Access to Current Treatments in Medicaid

By Xcenda |

Due to the mounting public pressure to reduce overall Medicaid healthcare expenditures, CMS is focused on value-based solutions that create pathways to more cost-effective treatments. Xcenda conducted an analysis based on assessing Medicaid utilization data for 5 states and found that a significant number of patients would potentially lose access to the treatments their doctors determined were best for them if Medicaid began utilizing an ICER-based formulary. 

State-based Analysis: ICER-based Formularies Could Upend Access to Current Treatments in Medicaid

As pressure on managing healthcare costs grow, the Centers for Medicare & Medicaid Services (CMS) and other payers are  focused on value-based solutions that create pathways to more cost-effective effective treatments through the use of value assessment frameworks like Institute for Clinical and Economic Review’s (ICER’s).

Xcenda conducted an analysis based on assessing Medicaid utilization data for 5 states—California, Massachusetts, Maryland, Nevada, and New York - and found that a significant number of patients with multiple sclerosis (MS), rheumatoid arthritis (RA), non-small cell lung cancer (NSCLC), multiple myeloma (MM), and psoriasis would potentially lose access to the treatments their doctors determined were best for them if Medicaid began utilizing an Institute for Clinical and Economic Review(ICER)-based formulary. For example, approximately two-thirds of prescription drugs to treat RA, NSCLC, and psoriasis would potentially be shifted to a different ICER-recommended drug. Also, 100% of patients with MS in the 5 states could be denied access to their current treatment, as ICER reported there was no utilization of the medicine it valued the highest.
 
The policy implications are severe and could impact already vulnerable patients by:
  • Restricting physicians to a limited number of treatment options eliminates flexibility that is sometimes needed to treat patients effectively; an ICER-based formulary may restrict access and lead to prescriber fatigue
  • An ICER-based formulary could negatively affect timely patient access to treatment by creating new challenges in the form of utilization management restrictions and other barriers
  • Switching patients from a self-administered drug to a physician-administered therapy could affect patients, shift utilization to another site of care, and increase the financial burden on beneficiaries; this may vary by state Medicaid and managed Medicaid plans
While there is a role for value assessment frameworks, these should be considered tools in a tool box and not one-size-fits-all mandates.