George Gibbs Center for Economic Prosperity

Make Cer⁠t⁠a⁠i⁠n All Pa⁠t⁠⁠i⁠en⁠t⁠s Can Access Necessary Med⁠i⁠ca⁠t⁠⁠i⁠ons

By: Sal Nuzzo / 2020

by  | Mar 30, 2020

In the wake of attempts to curb the spread of COVID-19, it’s vital to take every opportunity to examine the impact of healthcare policies on our state’s elderly population. As the virus’ impacts are most concerning in older individuals, the fact that more than 20 percent of Florida’s population is over 65 makes this especially important as the Sunshine State manages both the containment as well as treatment protocols. At a time like this, we want to make certain every patient has access to treatment.

It isn’t as straightforward a concept as one might think.

The Boston-based Institute for Clinical and Economic Review (ICER) has been promoting “cost-effectiveness” reviews that contain an inherent bias against providing necessary medicines to seniors.   Commercial health plans, the Veterans Administration, and some state Medicaid programs use these ICER reviews to rate the value of certain drugs.  Not surprisingly, since ICER was created by health insurance plans, many drugs are found not to be “cost-effective.”

Given the Centers for Disease Control and Prevention has warned that seniors are more likely to get very sick from the COVID-19 virus, health plans across the nation should immediately suspend the use of ICER cost-effectiveness reviews to decide their drug formularies.   This is the wrong time to recommend the denial of treatments to seniors based upon a biased model, particularly in a senior-heavy population like Florida.

Why are ICER reviews biased against seniors?  ICER utilizes a methodology, common in Europe, called Quality-Adjusted Life Years (QALYs), that assigns a score to medicines based upon their ability to prolong and increase quality of life.  The bias against seniors is prominent because seniors have fewer “life years” to give.  For example, a medicine that will allow a 30-year old to live until he or she is 80 will be assigned a higher “life years” score than a medicine that will allow a 75-year old to live to 80.   While ICER claims they use certain methods to mitigate this obvious anti-senior bias, they refuse to renounce the use of QALYs, arguing that this model is the “gold standard” for cost-effectiveness reviews. 

ICER’s defense of QALYs rings as hollow as the model itself, which values medicines based upon the number of years of life they may provide, will always tilt the playing field against seniors.  Medicines that only provide a “few years” of life will inevitably rate a lower score than medicines that provide many years to younger people. 

While this model was always morally dubious, its use during the COVID-19 pandemic is particularly unsupportable.   This is a time when we should expand seniors’ access to medicines, not reduce it.  Co-pays should be waived for seniors, co-insurance should be reduced, and bureaucratic hurdles to providing drugs recommended by a physician should be eliminated.  The QALY model is designed to do precisely the opposite: to make it harder for seniors to get access to the medicines their doctors recommend.

Other vulnerable populations should also be shielded from these dangerous ICER reviews.  In New York, the state Medicaid program utilized such a review to argue that cystic fibrosis patients should not receive the latest treatment because ICER concluded that the drug, Orkambi, was not cost-effective. 

Cystic fibrosis is a serious lung disease that can lead to respiratory failure in young people.  Are we seriously going to deny cystic fibrosis patients the latest treatments during the COVID-19 respiratory pandemic because some health economist up in Boston says it is not worth the money?

The Institute for Clinical and Economic Review may have been launched with good intentions but, during a global pandemic, its attempt to limit the use of new medicines is a genuine threat to public health.  Private and government health plans that utilize ICER reviews should cease and desist immediately and the institute should close its doors until this pandemic subsides.

Florida should pay attention – almost five million Floridians over 65 are counting on it.

Sal Nuzzo is Vice President of Policy at The James Madison Institute

William Smith, PhD, is Visiting Fellow in Life Sciences at the Pioneer Institute in Boston


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