Patient groups rebuke CVS on ICER, saying cost-effectiveness reviews discriminate

CVS last month made waves in pharma with a plan to allow clients to exclude drugs based on guidance from drug cost watchdog ICER. Now, patient advocacy groups are hitting back at the decision, urging CVS to reconsider and saying the cost-effectiveness calculations at ICER discriminate against the chronically ill, the elderly and others.

In a letter (PDF) to CVS CEO Larry Merlo, members of the Partnership to Improve Patient Care urged the PBM giant to reconsider its decision to allow reviews by the Institute for Clinical and Economic Review to affect coverage decisions. The patient advocates wrote that they “support access to high-quality, affordable care, but CVS’ reliance on a cost-effectiveness threshold is profoundly misguided.”

In their view, if CVS allows clients to make policy decisions based on the cost-effectiveness reviews, that would ignore “important differences among patients” and instead rely on a “one-size-fits-all" approach. They said cost-effectiveness analyses discriminate “against the chronically ill, the elderly and people with disabilities, using algorithms that calculate their lives as 'worth less' than people who are younger or non-disabled." PIPC counts PhRMA and BIO, two biopharma industry trade groups, among members of its steering committee.

A representative for CVS said because ICER's quality-adjusted life years "standard applies uniformly across all health conditions and plan members, our benefit design will not be discriminatory and, in fact, will improve the chances that patients with disabilities and serious illness will be able to get the treatments they need at a price they and the health system can afford." CVS will meet with patient advocates to discuss their concerns, she added.

ICER VP of communications and outreach David Whitrap said the QALY metric "is recognized as the gold standard for measuring how much a treatment improves patients’ lives, and it effectively rewards innovative medicines that significantly improve the lives of patients most in need."

"Patient populations that start off with a lower quality of life—whether because of a serious chronic illness or disability—actually represent the greatest opportunity for treatments to achieve a significant improvement in QALYs," he added.