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ICER: Payer Perspectives on the Use and Usage of ICER Reports

February 28, 2019

Presented By

Moderator: Jackie GladmanVice President, Sales and Marketing, Dymaxium

Elizabeth Sampsel, PharmD, MBA, BCPS Vice President, Payer Strategy and Relations, Dymaxium

John Watkins, PharmD, MPH, BCPSFormulary Manager, Premera Blue Cross

James Kenney, RPh, MBAConsultant, JTKENNEY, LLC

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Webinar Objective

• To provide insights on the US payer and decision maker perspective regarding the use, usage and quality of ICER reports for use in the P&T review process• Based on current responses (2018-19) from syndicated survey responses from the

FormularyDecisions.com® community

• Provide payer perspective using ICER, citing overall strengths and challenges

• Discussion of the use of ICER reports and implications for payers and manufacturers

Syndicated Survey Review -FormularyDecisions.com®

Elizabeth Sampsel, PharmD, MBA, BCPSVice President, Payer Strategy and RelationsDymaxium

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Central platform connecting health care decision makers to the evidence, resources, and their peer community, so they can work more effectively and collaboratively.

Data collected on:• 1900+ US PAYERs/HCDMs• 900+ organizations• 86% of covered lives (MCO)• Includes all top PBMs• 150,000 + evidence links• 2300 + products

Active evidence review and assessment to make informed formulary and reimbursement

decisions.

A closed payer only environment.

Relationships

FormularyDecisions.com®

Overview

Purpose: To better understand the payer perspective on the use, usage and quality of ICER reports for use in the P&T review process.

Data Results:• 614 syndicated survey responses

reviewed• 6 month timeframe:

Aug 13, 2018 – Feb 14, 2019

76.22%

24.34%

7.12% 5.24% 1.69% 0.37%0%

20%

40%

60%

80%

100%

ICER NCCN ASCO AHA DrugAbacus Avalere

Use of Value Frameworks n = 534

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69%of evidence access came from MCOs and PBMs

15%of evidence access came from Hospitals and IDNs

Usefulness of Value Frameworks

5%7%

1%3%

63%

21%

% Payer Feedback For Value Frameworks (n=550)

AHA ASCO Avalere DrugAbacus ICER NCCN

3.50

3.60

3.70

3.80

3.90

4.00

4.10

4.20

AHA ASCO NCCN ICER DrugAbacus

4.11 4.08

4.03

3.83

3.76

Weigh

ted AVerage

Usefulness of Value Frameworks (n=550)

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61.9%

Use and Usefulness of ICER Reports

Used or will use ICER reports in their P&T review n = 614

4.2

4.3

4.4

4.4

4.5

4.5

4.6

4.7

4.8

0 1 2 3 4 5

Payer Letters and Comments

Comparative Value – incremental budget impact

Comparative Value – value-based benchmark prices

Manufacturer Letters and Comments

Comparative Value – incremental per outcomes achieved

Reference Sections

Summary of Coverage Policies

Comparative Clinical Effectiveness

Executive Summary

Average Rating

Ratings on ICER Sections Based on Usefulness n = 22

Usage and Quality of ICER Reports

1.2%

9.0%

18.4%

27.4%

35.0%

35.9%

40.8%

60.0%

0% 20% 40% 60% 80%

Other

Support risk based contracting

Support pricing/listingnegotiations

Primary source of evidence

Inform/validate my own researchand analysis

Support development of tierplacement

Assists in determining productaffordability

Secondary source of evidence

Usage of ICER Reports n = 363

4.5 4.5 4.3 4.3

0

1

2

3

4

5

ReportSatisfaction

Report Quality Model Quality ModelSatisfaction

Aver

age

Rat

ing

Quality and Level of Satisfaction on ICER Report / Model n = 117

13.7%

86.3%

Recommendation of ICER n = 117

Not Sure Yes

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Keywords Associated with ICER

Payer Reasons for Not Using ICER Report

Primary reason ICER reports are not used are availability in time for P&T review. Other reasons are not able to extrapolate to payer population and time constraints.

45.2%

36.5%

10.3%

4.0% 4.0%

0%

10%

20%

30%

40%

50%

The ICER report was notavailable in time to prepare

for P&T decision

I do not use ICER reports aspart of my formulary

evaluation

Other ICER organization bias The ICER report methodologywas not easy to understand

Reasons for Not Using ICER Reports n = 252

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Summary

• Payers and other health care decision makers (HCDMs) are using ICER reports and finding them useful for formulary decision making.

• Payers/HCDMs are rating ICER reports as high quality.

• Payers/HCDMs are accessing ICER reports through the FormularyDecisions.com platform®.

• Payers/HCDMs are using ICER primarily as a secondary source of evidence, but there is now a shift in using them for determining product affordability and to support tier placement development.

• A continued deterrent to ICER report use is availability of reports in time for P&T review.

John Watkins, PharmD, MPH, BCPSFormulary Manager Premera Blue Cross

Premera Uses ICER Reports

Special thanks to:Emily Tsiao, PharmD, PGY1 Managed Care Pharmacy Resident, Premera Blue Cross

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Premera Blue Cross

2 million members

1 million pharmacy lives

Home States: Washington, Alaska

Commercial, insurance exchange, and Medicare

Evidence‐based P&T process established in 2001

Formulary review includes pharmacoeconomic analysis 

Member‐centric approach

Challenges at Premera

Fewer staff

Reduced administrative budget

Increased workload Asked to incorporate patient voice into 

formulary process

Maintain value‐based formulary

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Alignment of Mission and Value Framework

Premera

•Mission: Improve our members lives by making healthcare work better

•Value framework: Considers clinical benefit, cost‐effectiveness, contextual factors, and budget impact

ICER

•Mission: Conduct evidence‐based reviews that help the health care system know what works 

•Value framework: Considers comparative clinical effectiveness, incremental cost‐effectiveness, contextual considerations, other benefits or disadvantages, and budget impact

ICER Report Sections of Value to Premera  

Executive Summary

Introduction

Summary of Coverage Policies 

and Clinical Guidelines

Comparative Clinical 

Effectiveness

Long‐Term Cost‐Effectiveness

Other Benefits and Contextual 

Considerations 

Potential Budget Impact

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Using ICER Reports: Challenges

Timing

P&T Committee Member and Internal Stakeholder 

Education: How to effectively analyze and interpret ICER reports

P&T Committee Feedback

“Information from ICER on complex disease states has been helpful” ‐Premera P&T Committee Member

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Summary: Why Premera Uses ICER Reports

Provides information Premera is unable to obtain using internal resources

Provides information that helps Premera debate the value of a therapeutic agent with internal and external stakeholders

Estimated savings to Premera per quarterly P&T committee meeting: $10,000 ‐ $35,000 

Premera Uses ICER Reports

John Watkins, PharmD, MPH, BCPSFormulary ManagerPremera Blue Cross

Emily Tsiao, PharmDPGY1 Managed Care Pharmacy Resident

Premera Blue Cross

© 2018 Premera. Proprietary and Confidential.

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James Kenney, RPh, MBAPresidentJTKENNEY, LLC

Health Plan Perspective on Value-Based Contracts and ICER

Value-Based Contracts

A value-based contract is a written contractual agreement in which the payment terms for

medication(s) or other health care technologies is tied to agreed-upon clinical circumstances, patient

outcomes, or measures.*

*AMCP Value Based Partnership Forum June 2017

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Design Model

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Key Drivers for Health Plans

Proof of Efficacy with Outcomes Performance

Limit Products to a Specific Population

Reduce Financial Risk

Insurance for Poor Real World Experience

Increase Rebates/Savings

Reduce Overall Costs

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Key Drivers for Manufacturers

Improved Product Access

Market Share Growth

Reduce Resistance to New to Market Agents Develop Concepts Pre-launch

Include Outcomes in Clinical Trial Design

Restrictive Plan Designs/Formularies

Gain a Competitive Advantage

ICER Role

Formulary review Determine Fair Value of Product Includes Contracted Rates Compares Competing Products

ICER Informs Assessment of Initial Launch Price of a Product

Potential Plan Benefit with Impact on Manufacturer List Price Examples Tymlos®

Entresto®

Aimovig™

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Short/Long Term Goals

Get Value in Return for Pharmaceutical Dollar Spend

Use Results to Make Formulary Decisions/Changes

Assess True Benefit of Treatments

Multiple Outcomes Contracts for Competing Therapies

Include ICER or Other Value Framework

Discussion & Questions

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Thank you for participating!For further information on the AMCP eDossier System contact esampsel@dymaxium.com

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