A little known group is making decisions about which Orange County lives are worth living
The affordability and accessibility of health care coverage continues to be a kitchen-table concern for Orange County residents and their families. The California legislature in 2018 took important steps to introduce transparency to the health care system and reduce what patients pay out-of-pocket for their medications. Unfortunately, a little-known Boston-based organization is making determinations right now about which Orange County lives are more valuable than others and who should have access to the medical care they need.
The Institute for Clinical and Economic Review (ICER) is a research organization and medical review board that makes recommendations about whether new medications are “cost-effective” and whether insurance companies should cover those treatments. To arrive at its recommendations, ICER uses a complicated mathematical formula called a “value framework,” which determines how much an insurance company should spend on any given person.
The problems with ICER’s research and methodology are legion, but the fundamental problem is this: ICER is making decisions about the value of a human life – about what a life is worth and whose life is worth saving – based only on financial considerations. If you are an Orange County resident living with a life-threatening or chronic disease, such as cancer, cystic fibrosis, arthritis, or many others, ICER’s formula is likely to determine that your life is worth less than that of a healthy person.
Simply because a patient has the misfortune to get a disease does not make his or her life any less valuable than that of a healthy person.
Another deficiency in ICER’s approach is that they fail to give meaningful consideration to what patients living with the affected conditions say about what improves their quality of life. There is little transparency into what goes into ICER’s formulations or how they arrive at their conclusions, which means other researchers are unable to analyze and replicate ICER’s results. Finally, in addition to being cruel and punitive, ICER’s one-size-fits-all approach to insurance coverage is likely to discourage efforts to develop innovative new treatments for many chronic and life-threatening conditions. It’s just a bad model.
If ICER were simply a research organization publishing reports that collected dust on a shelf, the stakes would not be nearly so high for California patients. However, payers have recently begun to use ICER’s assessments to deny patients access to treatments.
Pharmacy benefit manager (PBM) CVS Health recently announced a new prescription drug management program that would exclude from its coverage some new treatments that do not meet ICER’s cost-effectiveness benchmarks. Earlier this year, the state of New York decided to cap Medicaid spending for a cystic fibrosis treatment based on ICER’s research. This happened without public comment, which makes the precedent even more dangerous.
The conclusions that ICER reaches are less surprising given that ICER is backed by the insurance industry. Blue Shield of California and Kaiser are both funders of ICER. Steve Pearson, the founder of ICER, is a former insurance executive and has worked for the health insurance industry lobby group America’s Health Insurance Plans (AHIP). The board of ICER includes representatives from Blue Shield, Kaiser and UnitedHealth. Former Enron trader John Arnold, a prominent funder of insurance industry interests through his foundation, has given ICER $19 million.
It is time that we stop pretending that ICER is a neutral arbiter of the value of medicine and instead recognize them for what they are: an insurance industry-funded PR machine whose goal is to drive up insurer profits at all costs, even at the expense of patients.
Physicians are in the best position to know how to treat a patient. He or she knows the patient’s medical history, how the patient responds to treatment, and any other biological factors that could impact the success or failure of a medication. Decisions about how to treat patients should not be made based on an algorithm or what is most profitable for a health insurance company. No two patients are alike and so the ICER one-size-fits-all approach does not work.
The rising cost of health care is perhaps the most critical health care issue facing Californians. As we continue the conversation about meaningful solutions, California policymakers should consider the full range of cost drivers, look at who is funding attempts to influence policy, and be wary of health insurance company interests making recommendations about what an Orange County life is worth.
Chris Buchanan is on the board of the Neuropathy Action Foundation, an Orange County-based patient advocacy organization.
Filed under: General Problems
Leave a Reply