New analysis shows 820,000 prescriptions would be in jeopardy if ICER’s value framework is used in Medicaid

Katie Koziara
Katie Koziara March 20, 2019


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PhRMA_Value_Collaborative_Reversednew analysis from Xcenda found that if Medicaid were to use one-size-fits-all value assessments like the Institute for Clinical and Economic Review’s (ICER) framework as the basis for accessing a medicine, an estimated 42 to 99 percent of prescriptions to treat serious, complex conditions like cancer and multiple sclerosis may not be covered. This shows the dangerous effects using ICER’s value framework could have for some of the most vulnerable patients.

Cost-effectiveness thresholds are the wrong basis for setting policy on access to medicines. In Medicaid, these thresholds would change access to more than 820,000 prescriptions for medicines that treat patients for serious diseases like multiple sclerosis (MS), rheumatoid arthritis (RA), non-small cell lung cancer (NSCLC), multiple myeloma (MM), and psoriasis. Specifically, the study found:

  • Over 99 percent of prescriptions to treat MS would be switched from the treatment their doctor prescribed to a medicine ICER deemed “high value”
  • Approximately 75 percent or more prescriptions for medicines to treat RA, NSCLC and psoriasis would have to be shifted to an ICER-recommended medicine


We are particularly concerned for Medicaid patients in Massachusetts. Currently, Governor Baker has a budget proposal that would set a value for a medicine using ICER-like analyses if a certain supplemental rebate is not reached. Any government policy made using cost-effectiveness analyses will insert the government between patients and their doctors, impeding individualized treatment decision making and discouraging innovation.

The Xcenda analysis builds on previous research that shows the negative impacts ICER’s assessments would have if they were used to make coverage decisions in Medicare. ICER’s framework ignores important differences in individual patient needs and preferences, and discriminates against the elderly, the disabled and other vulnerable patients. We need to invest in better tools that capture the complexity of diseases and all the outcomes that matter to patients and families.

Read more about the Xcenda analysis here.

View the Xcenda analysis one pager here

Topics: Access, Medicaid, The Value Collaborative