Blog written by Josie Cooper, Executive Director, Alliance for Patient Access

Cute child and doctor talking in clinics

Health care providers work closely with their patients to deliver optimal, personalized care. That includes considering, alongside the patient, the range of medication options to determine the best course of treatment.

Unfortunately, a variety of factors threatens to undermine that important relationship. One growing threat is the Institute for Clinical and Economic Review, or ICER, a health economics organization whose work minimizes the patient and physician relationship and undermines shared decision-making.

Here are three things you need to know about ICER:

  1. ICER’s Approach Undercuts Patient-Centered Care
    While individual health care providers are focused on the needs of the patient in front of them, ICER’s health economists take a population health perspective. They think in cohorts, yielding solutions that are consistently one-size-fits-all. As evidence, consider ICER’s metric for assessing a drug’s cost-effectiveness. The quality adjusted life year, or QALY, measures a drug’s value by the number of years of “perfect” health it provides. The metric has raised ethical, legal and equity concerns from policymakers and health care analysts. And it’s no wonder why. Many patients, such as seniors, the disabled, and those with chronic or rare diseases, may never achieve the QALY definition of “perfect health.” Do they not still deserve the best, most personalized care? Is innovation that produces groundbreaking treatments for those communities not still valuable to these patients? A single equation simply cannot determine value for all individual patients.
  2. ICER Ignores Patients’ and Providers’ Values
    In its evaluations, ICER often omits key elements of value. These include the impact of diseases on caregivers and children, or health disparities. ICER also repeatedly fails to incorporate a disease’s effect on overall quality of life. For instance, an ICER evaluation of a new asthma medicine in 2018 determined that the treatment in review wasn’t worth its cost but failed to consider issues such as work productivity, time with family, and sleep. An ICER review of new medications to treat and prevent migraine disease had similar omissions. The assessment didn’t take into account comorbidities, variations in treatment effectiveness between patients, missed work, additional caregiver needs, and time away from family. The result? ICER’s reviews underestimate the potential value of better managing these chronic diseases, pushing the new treatment further out of reach from patients.
  3. State Legislatures Are Taking Action
    As ICER’s reach grows, its methodology is creeping into more areas of health care policy. Some states seeking to regulate prescription drug prices, for example, are looking to ICER. A bill in the New Jersey state legislature seeks to establish a prescription drug affordability board. A bill in Maine has similar aims. Both would look to ICER and its QALY methodology in determining how to assess the value of innovative medicine. As with ICER’s own reports, the outcome could well be reduced access and heightened barriers to the treatment that providers want their patients to have. Some states are taking notice and pushing back against the discriminatory nature of ICER and the QALY methodology. In May 2020, Oklahoma signed a law prohibiting state agencies from using the QALY methodology for health care decisions. In 2021, the Connecticut General Assembly reintroduced a bill that would prevent insurance companies from using QALYs. Perhaps Oklahoma and Connecticut policymakers understand that treatment decisions belong between a patient and physician, not between a patient and an ICER health economist.

For the sake of patient-centered care, advocates hope to see more policymakers catch on to this fact.

Josie Cooper is the executive director of the Alliance for Patient Access, a national network of policy-minded health care providers who advocate for patient-centered care.