Whether you realize it or not, many of these insurance barriers started with the Institute for Clinical and Economic Review.
Known as ICER, the self-appointed cost appraiser has a major impact on our ability to access the treatments prescribed by our doctors. Private and unregulated, ICER reports are often considered by both private insurers and state health systems to decide which treatments get covered and which patients are denied access to care.
“When ICER determines a treatment is too expensive, the insurance companies use that report as the basis to deny treatment,” explains Terry Wilcox, executive director of Patients Rising, a national patient advocacy non-profit organization that helps patients overcome insurance barriers to access.
She adds, “Big Insurance and Pharmacy Benefit Managers
are actively using ICER to advance their anti-patient agenda in which
algorithms, formularies and numerical calculations determine what treatments we
get, and when we get them.”
ICER Patient Denial Agenda Gets Worse
If you thought ICER’s agenda couldn’t get any worse,
think again. Now, ICER is floating a power grab at the Food and Drug
“It’s bad enough that ICER reports are used to deny
patients access to treatment,” warns patient advocate Terry Wilcox. “Their continued
rise in prominence could end medical innovation as we know it, especially for
patients living with rare or ultra-rare conditions. ICER is sending a signal to
small biotech companies that a commitment to rare disease patients might not be
worth it because their incremental innovation is too costly. For these patients
and their families, ICER is killing hope in the process.”
In a recent opinion-piece featured at the Philadelphia Inquirer, a proponent of patient denials lays out the agenda to incorporate ICER appraisals into FDA decision-making.
“Importantly, CVS Caremark, a major pharmacy benefits
manager, has announced that it will permit its customers to refuse coverage of
any medicine where ICER data shows it is not cost-effective,” writes Arthur
Garson Jr., director of the Health Policy Institute at the Texas Medical Center
“We could take this a step further. The government,
specifically the Food and Drug Administration, could refuse to approve new
drugs that are less cost-effective than the status quo.”
ICER Threat to Patients
In addition to the blatant ethical violations with
insurance companies deciding government policy, incorporating ICER’s
decision-making would block medical innovation into treating rare and chronic
diseases. That’s because ICER uses something called a Quality Adjust Life Year,
or QALY, to deny patients access. It’s a math formula that compares the life of
a person battling a disease with that of a healthy person, plus the cost of the
The proposal to give insurance-backed ICER control of
FDA decision-making has drawn fierce criticism from patient advocates.
“We don’t approve drugs on the basis of cost,” explains patient advocate Tayjus Surampudi, who fights for patients living with Duchenne Muscular Dystrophy. “When it comes to orphan disease drugs, we reward those drug companies that can save lives and offer individuals and their families some semblance of hope.”
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