Impact Analysis of ICER Formulary Implementation in Medicaid

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Margaret Harper
5 years ago
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1 Impact Analysis of ICER Formulary Implementation in Medicaid

2 Key Findings A significant number of patients with multiple sclerosis (MS), rheumatoid arthritis (RA), non-small cell lung cancer (NSCLC), multiple myeloma (MM), and psoriasis would lose access to the treatments their doctors determined was best for them if Medicaid began utilizing an ICER-based formulary Over 99 percent of prescriptions to treat MS would be switched from their current treatment to a medicine ICER deemed high value Approximately three-fourths or more of prescriptions for medicines to treat RA, NSCLC, and psoriasis would have to be shifted to an ICER-recommended drug Psoriasis 73% Multiple Myeloma 42% Non-Small Cell Lung Cancer 78% Multiple Sclerosis 99% RA 87% 0% 20% 40% 60% 80% 100% Not

3 Methodology Methodology & Limitations Xcenda selected product classes evaluated by ICER 1 that would be covered under state and managed Medicaid programs for this analysis. We assessed the impact of shifting prescription volume to therapies deemed most cost-effective by ICER. Xcenda used the Centers for Medicare & Medicaid Service (CMS) 2017 Medicaid State Drug Utilization Data to conduct the analysis. 2 Limitations Patient-level detail (e.g., number of beneficiaries, diagnoses) was not provided; therefore, utilization was assessed per product and not per product and indication. We were unable to identify patients using multiple prescriptions in a calendar year. This analysis only spans one calendar year. We did not account for differences in how medicines may be covered in different Medicaid plans and what access restrictions may exist. 1. Institute for Clinical and Economic Review Medicaid. Accessed July 12, 2018.

4 Estimated Impact of ICER-based Formulary in Medicaid, by Condition

5 Rheumatoid Arthritis The therapies ICER determined were of high value for the treatment of rheumatoid arthritis accounted for only 13% of treatments. 87% of prescriptions could be different in an ICER-based formulary. 13% 87% Not N= 429,495

6 Multiple Sclerosis The only medicine ICER determined was of high value for the treatment of multiple sclerosis accounted for only 0.4 percent of prescriptions. Essentially all Medicaid patients with MS could be forced to switch treatments under an ICER-based formulary. 1% 99% Not N=203,149

7 Non-Small Cell Lung Cancer In 2017, Medicaid covered 52,185 prescriptions for treatments included in ICER s NSCLC assessment. Under an ICER-based formulary, 78 percent of the prescriptions to treat NSCLC could be different. 22% 78% Not N= 52,185

8 Multiple Myeloma In 2017, Medicaid covered 18,810 prescriptions for treatments included in ICER s multiple myeloma assessment. Under an ICER-based formulary in Medicaid, 42 percent of prescriptions to treat myeloma could be different. 42% 58% Not N= 18,810

9 Psoriasis In 2017, Medicaid covered 257,134 prescriptions for treatments included in ICER s psoriasis assessment. The therapies ICER determined were of high value accounted for just over one-third of treatments, meaning nearly two-thirds of prescriptions could be different. 27% 73% Kyprolis, 79% Not N= 257,134

10 Policy Implications Restricting physicians to a limited number of treatment options eliminates flexibility that is sometimes needed to treat patients on an individual basis; an ICER-based formulary ignores these clinical considerations. An ICER-based formulary could negatively impact timely patient access to treatment by creating new challenges in the form of UM restrictions and other barriers. Switching patients from a self-administered drug to a physician-administered therapy could impact patients, shift utilization to another site of care, and increase the administrative burden on beneficiaries; this may vary by state Medicaid and managed Medicaid plans.

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