Underestimating the Value of an Intervention – The Case for Including Productivity in Value Assessments and Formulary Design

Authors: Karmarkar T, Graff J, Westrich K.
Publication: Journal of Managed Care & Specialty Pharmacy, May 2020

Research published in the Journal of Managed Care and Specialty Pharmacy demonstrates that including non-health care costs like productivity in value assessment frameworks (VAF) can change the value assessment of interventions, impact on coverage decisions and subsequent patient access.
 
Value assessments, including cost-effectiveness analyses, are one method to compare the value of a health intervention to treatment alternatives. However, for value assessments to comprehensively capture value, experts have recommended that value assessments must include the full balance of costs and benefits to patients and society. This includes work productivity because any loss (or improvement) in productivity due to health comes at a cost (or benefit) to the individual, employer and society.

The researchers asked three main questions:

1. Is productivity included in value assessment reports? If it is included, is it included in the main results (e.g., co-base case analysis) or in secondary analysis (e.g., scenario analysis)?
2. When it is included, how much does productivity change the assessment of value?
3. Would including productivity potentially change health care decisions and patient access to treatments?

To answer these questions, the researchers reviewed value assessment reports of pharmaceutical interventions published between March 2017 and July 2019 by the Institute for Clinical and Economic Review (ICER). The analysis shows several key points on the inclusion of productivity in value assessment frameworks:

• Productivity was included in most, but not all, value assessment reports issued by ICER (18/19 reports, 94.7%). Only two reports (11%) included productivity in the main results as a co-base case analysis; 16 (88%) included productivity in a scenario analysis.
• Excluding productivity underestimated the value of an intervention for 90% of the treatment comparisons. However, the magnitude of the change in value varied. The change in value across all comparisons ranged from an 80.1% improvement in value to a decrease in value by 6.8%.
• Productivity could change health care decisions and patient access to medications, but the extent depends on how a payer chooses to use value assessment reports and whether they use commonly used thresholds to determine which treatments are “good value.” Across the 75 treatment comparisons the researchers studied, payers’ decisions to cover or exclude certain treatments could change between 1%-10% of the time based on the threshold for value the payer references.

Methods:

• The NPC researchers searched all value assessment reports for pharmaceuticals issued by ICER between March 2017 and July 2019.
• Within each report, researchers identified unique treatment comparisons and noted if productivity was included and whether it was reported as a main result (as a co-base case) or a secondary result (as a scenario analysis).
• Value was categorized using ICER’s willingness to pay thresholds for both non-orphan and orphan diseases.
• They assessed the direction and magnitude of change in value when productivity was included or excluded.