When making coverage and reimbursement decisions, it is essential to have a complete view and a comprehensive methodology to assess value. A presentation at AMCP Nexus 2023 offered strategies, tools, and insights to help managed care professionals optimize these assessments.
The speakers encouraged attendees to consider three key things when assessing biopharmaceutical value. First, what are the specific perspectives that are most important? Different stakeholders have different priorities and opinions about biopharmaceutical value, from patients to manufacturers to employers to benefit managers to hospitals. Second, what decisions are being informed by the value assessment at hand? These may include individual patients’ treatment decisions, employer benefits decisions, coverage and reimbursement decisions, or pricing decisions. The third consideration:
What elements are being considered in the assessment of value? For example, efficacy, side effects, equity, route of administration, and others may be taken into account.
Kimberly Westrich, MA, director of value and access strategy at Cencora; Kim Riggs, MPH, vice president of value and access strategy at Cencora; and Jessica Hatton, PharmD, BCACP, associate vice president of pharmacy at CareSource, recommended a number of tools to help inform the value-assessment process, such as:
- Academy of Managed Care Pharmacy dossiers.
- American Society of Clinical Oncology’s value framework.
- Comparative effectiveness research from the Patient-Centered Outcomes Research Institute .
- Evidence reports from the Institute for Clinical and Economic Review.
- Guidelines from specialty societies.
- Innovation and Value Initiative’s Open-Source Value Project.
- International Society for Pharmacoeconomics and Outcomes Special Task Force on U.S. Value Assessment.
- National Comprehensive Cancer Network evidence blocks.
- National Health Council’s Rubric to Capture the Patient Voice.
According to the speakers, it is less clear whether the Centers for Medicare & Medicaid Services is a useful resource for value assessment. The United States does not have an official health technology assessment (HTA) body or standardized value assessment processes, although many other countries do. For example, Joint Clinical Assessment is likely to become essential in the European Union’s HTA processes in the near future. Its goal is to replace several redundant processes among member nations. The speakers suggested that U.S. entities could learn from those processes and the criteria they apply.
Reference Westrich K, Riggs K. Hatton J. Optimizing Value Assessment Tools for Coverage and Reimbursement Decisions: Promises and Pitfalls. Session M5. Presented at AMCP Nexus 2023; Oct. 16‒19, 2023; Orlando, Fla.
