Variation in Medicaid and commercial coverage of cell and gene therapies

Growth in the availability of cell and gene therapies (CGTs) promises significant innovation in the treatment of serious diseases, but the high cost and one-time administration of CGTs has also raised concern about strain on health plan budgets and inequity in access. We used coverage information from the Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) database for 18 large commercial health plans in the US and information from state Medicaid websites to examine variation in coverage of 11 CGTs in August 2021. We found that US commercial and Medicaid health plans imposed restrictions in 53.5 % and 68.3 % of their coverage policies for the 11 included CGTs, respectively. In addition, we identified significant variation in access to CGTs across commercial plans and across Medicaid plans. Coverage restrictions for certain CGTs were more common than others; clinical requirements were often (but not always) consistent with the inclusion criteria for the clinical trial central to the drug's approval. We conclude that there is variation in access to CGTs, creating differential patient access.

Varied use of step therapy among Medicare Advantage plans

OBJECTIVES

First, to examine 7 large Medicare Advantage (MA) plans' use of step therapy. Second, to compare step therapy that health plans imposed in their MA and commercial (employer) drug coverage policies.

STUDY DESIGN

Database analysis.

METHODS

Using data from the Tufts Medical Center Specialty Drug Evidence and Coverage Database, we evaluated 7 large MA plans' use of step therapy in their Part B drug coverage policies. First, we determined the frequency with which different MA plans applied step therapy. Second, we determined the frequency with which plans imposed step therapy protocols across International Classification of Diseases, Tenth Revision, Clinical Modification categories. Third, we compared each step therapy protocol against each drug's corresponding FDA label indication. Fourth, we examined the consistency of step therapy protocols between the same insurer's MA and commercial lines of business.

RESULTS

The frequency with which the included MA plans imposed step therapy ranged from 26.1% to 63.7%. Step therapy was most common for dermatology conditions (90.2%) and least common for oncology conditions (28.6%). On average, MA plans' step therapy requirements were consistent with the drug's FDA label indication 29.0% of the time. MA plans' and commercial plans' use of step therapy differed for the same drug-indication pairs 46.1% of the time.

CONCLUSIONS

MA plans vary in the frequency with which they impose step therapy protocols in their Part B drug coverage policies. Moreover, insurers often impose different step therapy protocols in their MA plan and commercial plan offerings. Differences in plans' step therapy requirements may result in variability in patients' access to care within MA.

Follow-On Indications for Orphan Drugs Related to the Inflation Reduction Act

This cohort study assesses rates at which orphan drugs approved by the US Food and Drug Administration were also approved for supplemental (follow-on) indications.

Commercial coverage of specialty drugs, 2017-2021

Health plans guide their enrollees' access to specialty drugs through coverage policies. We examined a set of health plan policies to determine if they have become more or less stringent over time. We did so by comparing the consistency of policies with Food and Drug Administration (FDA) label indications. We considered coverage policies for the same 187 specialty drugs issued by 17 large US commercial health plans from 2017 through 2021. Overall, the proportion of policies that were consistent with the FDA label declined from 57.1% in 2017 to 45.1% in 2021; the proportion of policies that were more restrictive than the FDA label increased from 39.5% to 51.7%. The proportion of policies excluding drug coverage remained approximately constant (3.4% in 2017; 3.2% in 2021). Trends in coverage restrictiveness varied across plans. For 13 plans, the proportion of policies with restrictions increased over time, while for 4 plans it declined.

Variation in Medicaid and commercial payer coverage of aducanumab for Alzheimer's disease

INTRODUCTION

Ever since the United States Food and Drug Administration (FDA) approved aducanumab and Centers for Medicare & Medicaid Service (CMS) restricted coverage for the drug, a crucial question has been how other payers will behave. This study examined how Medicaid and commercial plans cover aducanumab.

METHODS

We created a database of aducanumab coverage policies issued by Medicaid fee-for-service programs (50 states and DC) and 35 of the largest commercial plans (covering ∼ 84% of the commercially insured population).

RESULTS

We found that only 41% of Medicaid fee-for-service plans have issued a publicly available coverage policy for aducanumab and that there is wide variation in these coverage criteria. Although the majority of included commercial plans have issued an aducanumab coverage policy, only five plans covered aducanumab for their enrollees. Available coverage polices showed little consistency in how to measure sufficient treatment response.

DISCUSSION

Differences in coverage policies mean that Alzheimer's patients' access to aducanumab may vary across jurisdictions and across commercial insurers.

HIGHLIGHTS

Less than half of state Medicaid fee-for-service plans issued a publicly available coverage policy for aducanumab. Available Medicaid coverage policies varied substantially in their coverage criteria. The majority of included commercial plans issued an aducanumab coverage policy; only five plans covered aducanumab. Available coverage polices showed little consistency in how to measure sufficient treatment response.

Specialty drug coverage varies between health plans' medical and pharmacy benefit policies

BACKGROUND: In an effort to control drug spending, health plans are increasingly shifting specialty drugs from their medical benefit to the pharmacy benefit. One consequence of this trend is that some health plans have both a medical and a pharmacy coverage policy for the same drug. OBJECTIVE: To examine how frequently health plans issue medical and pharmacy benefit policies for the same specialty drug and to evaluate the concordance between plans' medical and pharmacy policies when plans issue both policy types. METHODS: We identified specialty drug coverage policies from the Tufts Medical Center Specialty Drug Evidence and Coverage Database, which includes policies issued by 17 of the largest US commercial health plans. Policies were current as of August 2020. We determined plans that issued both medical and pharmacy policies. Next, we identified drugs with "medical-pharmacy policy pairs," ie, drugs for which a plan issued both a medical and a pharmacy policy. For these pairs, we compared the plan's policies while accounting for the following coverage criteria: patient subgroups (patients must meet certain clinical criteria), prescriber requirements (a specialist must prescribe the drug), and step therapy protocols (patients must first fail alternative treatments). We considered medical-pharmacy policy pairs to be discordant if coverage criteria differed, eg, the medical policy included a prescriber requirement but the pharmacy policy did not. RESULTS: Eight plans issued separate medical and pharmacy benefit coverage policies for the same specialty drug and indication. Among these 8 plans, we identified 1,619 medical-pharmacy policy pairs. Eighty-six percent of pairs were concordant (1,386/1,619), and 14% were discordant (233/1,619). Discordance was most often due to differences in plans' application of step therapy protocols (184/233), followed by prescriber requirements (52/233) and patient subgroups (25/233). Forty pairs were discordant in multiple ways. Of discordant pairs, medical policies were more restrictive 41% (96/233) of the time; pharmacy policies were more restrictive 54% (125/233) of the time; 5% of the time (12/233), the medical policy was more restrictive in some ways, but the pharmacy policy was more restrictive in others. Overall, plans imposed coverage restrictions in their medical and pharmacy policies with similar frequencies. CONCLUSIONS: Commercial health plans' medical and pharmacy coverage policies for the same specialty drugs tended to be concordant, although we found coverage criteria to be discordant 14% of the time. Medical and pharmacy policies that are inconsistent in their coverage criteria and restrictions complicate, and potentially hinder, patients' access to specialty drugs. DISCLOSURES: Drs Kauf, O'Sullivan, and Strand were employees of Alkermes, Inc., when the study was conducted and may own stock in the company. Mx Levine, Mr Panzer, and Dr Chambers have no conflicts of interest to disclose. This research study was supported by Alkermes, Inc.

Factors Associated with Biosimilar Exclusions and Step Therapy Restrictions Among US Commercial Health Plans

BACKGROUND

Biosimilars have been introduced with the goal of competing with high-priced biologic therapies, yet their adoption has been slower than expected and resulted in limited efficiency gains. We aimed to explore factors associated with biosimilar coverage relative to their reference products by commercial plans in the United States (US).

METHODS AND DATA

We identified 1181 coverage decisions for 19 commercially available biosimilars, corresponding to 7 reference products and 28 indications from the Tufts Medical Center Specialty Drug Evidence and Coverage database. We also drew on the Tufts Medical Center Cost-Effectiveness Analysis Registry for cost-effectiveness evidence, and the Merative™ Micromedex^® RED BOOK^® for list prices. We summarized the coverage restrictiveness as a binary variable based on whether the product is covered by the health plan, and if covered, the difference of payers' line of therapy between the biosimilar and its reference product. We used a multivariate logistic regression to examine the association between coverage restrictiveness and a number of potential drivers of coverage.

RESULTS

Compared with reference products, health plans imposed coverage exclusions or step therapy restrictions on biosimilars in 229 (19.4%) decisions. Plans were more likely to restrict biosimilar coverage for the pediatric population (odds ratio [OR] 11.558, 95% confidence interval [CI] 3.906-34.203), in diseases with US prevalence higher than 1,000,000 (OR 2.067, 95% CI 1.060-4.029), and if the plan did not contract with one of the three major pharmacy benefit managers (OR 1.683, 95% CI 1.129-2.507). Compared with the reference product, plans were less likely to impose restrictions on the biosimilar-indication pairs if the biosimilar was indicated for cancer treatments (OR 0.019, 95% CI 0.008-0.041), if the product was the first biosimilar (OR 0.225, 95% CI 0.118-0.429), if the biosimilar had two competitors (reference product included; OR 0.060, 95% CI 0.006-0.586), if the biosimilar could generate annual list price savings of more than $15,000 per patient (OR 0.171, 95% CI 0.057-0.514), if the biosimilar's reference product was restricted by the plan (OR 0.065, 95% CI 0.038-0.109), or if a cost-effectiveness measure was not available (OR 0.066, 95% CI 0.023-0.186).

CONCLUSION

Our study offered novel insights on the factors associated with biosimilar coverage by commercial health plans in the US relative to their reference products. Cancer treatment, pediatric population, and coverage restriction of the reference products are some of the most significant factors that are associated with biosimilar coverage decisions.

The association between US Food and Drug Administration-expedited review designations and health plan specialty drug coverage

BACKGROUND: The US Food and Drug Administration (FDA) speeds approval of important clinical advancements through 4 expedited review programs: Priority Review, Accelerated Approval, Fast Track, and Breakthrough Therapy. Whether health plans prioritize coverage of expedited drugs relative to drugs that the FDA determined did not qualify from these programs is unclear. OBJECTIVES: To investigate how fast US commercial health plans issued coverage policies for drugs included in different numbers of FDA-expedited programs. Second, to examine the association between a drug's inclusion in an FDA-expedited program and plan coverage restrictiveness. METHODS: We used a separate dataset for each study objective. For the first objective, we created a dataset of policies issued by 17 large commercial health plans for 2018 FDA-approved drugs. Included policies were active exactly 1 year following each drug's FDA approval. We investigated the relationship between the speed of policy issuance and the number of expedited programs. We controlled for cancer and orphan indication. For the second objective, we analyzed a dataset of commercial health plan specialty drug coverage policies. We categorized drugs with respect to the number of expedited programs (0, 1, or 2+ programs). Coverage policies were categorized as whether plans imposed restrictions beyond a drug's FDA-approved labeling, for example, step therapy requirements. We used regression analysis to examine the association between FDA-expedited review and coverage restrictiveness when controlling for other relevant factors (eg, availability of alternatives). RESULTS: For our first objective, plans issued 62% (742/1,190) of policies within a year of a drug's FDA approval. In unadjusted analysis, policy issuance speed increased with each additional expedited program (hazard ratio=1.15; P<0.01). After controlling for cancer and orphan status, the number of expedited programs was not associated with faster policy issuance (hazard ratio=0.95; P=0.209). For our second objective, plans imposed coverage restrictions in 33% (672/2,027) of policies for drugs the FDA included in at least 1 FDA-expedited program vs 51% (870/1,706) of policies for drugs the FDA excluded from these programs. In multivariable regression, we did not find an association between FDA-expedited review and coverage restrictiveness after controlling for other decision-making factors (including disease prevalence, annual cost, etc). CONCLUSIONS: After controlling for other decision-making factors, we did not find that FDA-expedited approval was associated with faster coverage policy issuance, nor did we find that plans covered drugs the FDA included in expedited review programs less restrictively than drugs excluded from these programs. Our findings raise questions about why plans do not also accelerate access for these clinical advancements. DISCLOSURES: This study was funded by Janssen Scientific Affairs, LLC. Mr Ingham is an employee of Janssen Scientific Affairs, LLC, and is a stockholder of Johnson & Johnson. Dr Chambers reports grants from Janssen Scientific Affairs, LLC, during the conduct of the study.

Commercial health plans use of patient subgroup restrictions: An analysis of orphan and FDA-expedited programs

BACKGROUND: Health plans apply utilization management criteria to guide their enrollees' access to prescription drugs. Patient subgroup restrictions (ie, clinical prerequisites for drug coverage) are a form of utilization management that have not been thoroughly investigated. OBJECTIVE: To examine the frequency with which large US commercial health plans impose patient subgroup restrictions beyond the US Food and Drug Administration (FDA) label in their coverage policies for orphan drugs and for drugs included in 1 or more FDA-expedited programs. To determine how consistently these patient subgroup restrictions align with eligibility criteria specified in each drug's pivotal clinical trial(s). METHODS: The Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) database was used, which includes coverage policies issued by 17 large US commercial health plans. SPEC contained 3,786 orphan drug policies and 4,027 FDA-expedited drug policies (current as of December 2020). SPEC data on plans' patient subgroup restrictions were assessed for the first objective. Each patient subgroup restriction was benchmarked against the corresponding eligibility criteria for a drug's pivotal clinical trial(s) for the second objective. To do so, the "Clinical Studies" section of the drug's FDA label was reviewed or, if necessary, the published manuscript describing the drug's pivotal trial(s). Patient subgroup restrictions were categorized as follows: (1) "consistent," the restriction and trial eligibility criterion are equivalent; (2) "same measure, more stringent," the restriction and trial eligibility criteria depend on the same measure, but the plan coverage is more restrictive; (3) "same measure, less stringent," the restriction and trial eligibility criteria depend on the same measure, but the plan coverage is less restrictive; and (4) "not consistent," the restriction and trial eligibility criteria depend on different measures. RESULTS: Health plans imposed patient subgroup restrictions in 20.2% of orphan drug policies (frequency varied by health plan, 11.7%-36.6%), and in 21.8% of FDA-expedited drug policies (frequency varied by health plan, 11.1%-47.9%). Of the 936 patient subgroup restrictions in orphan drug policies, 60.3% were categorized as consistent; 7.3% as same measure, more stringent; 12.0% as same measure, less stringent; and 20.5% as not consistent. Of the 1,070 patient subgroup restrictions in FDA-expedited drug policies, 57.5% were categorized as consistent; 6.7% as same measure, more stringent; 16.0% as same measure, less stringent; and 19.8% as not consistent. CONCLUSIONS: Patient subgroup restrictions for orphan drugs and FDA-expedited programs varied substantially across health plans, potentially resulting in inconsistent access to a given therapy across the approved patient population. Patient subgroup restrictions tend to be consistent with eligibility criteria specified in pivotal clinical trials. DISCLOSURES: This study was funded by Sarepta Therapeutics, Inc. Alexa C Klimchak and Lauren E Sedita are employees of Sarepta Therapeutics, Inc., and may own stock/options in the company.

Examining US commercial health plans' use of The Institute for Clinical and Economic Review's reports in specialty drug coverage decisions

BACKGROUND: The Institute for Clinical and Economic Review (ICER) has emerged in a visible role in US health care. However, it is unclear to what extent US commercial health plans use ICER value assessments in their specialty drug coverage decisions. OBJECTIVE: To evaluate the relationship between ICER's reported cost-effectiveness ratios (CERs) and coverage restrictiveness. Also, to examine the frequency with which plans have cited ICER in their coverage policies and to investigate how frequently health plans adjusted their drug coverage criteria in the 12 months after ICER's assessments. METHODS: We analyzed the Tufts Medical Center Specialty Drug Evidence and Coverage Database, which includes specialty drug coverage decisions issued by 17 large US commercial health plans. For ICER-assessed drugs, we recorded ICER's estimated CERs in the form of cost per quality-adjusted life-year (QALY) gained. First, we used multivariate logistic regression to examine the association between ICER's reported CERs and plan coverage restrictiveness, when controlling for other factors that were likely to affect decision-making. Next, we examined how often plans cited ICER's assessments in coverage decisions issued in years 2017-2020. Lastly, we examined whether plans added or removed coverage restrictions (eg, patient subgroup restrictions or step therapy protocols) in the 12 months following ICER's assessment. RESULTS: Plans tended to cover drugs with higher (less favorable) CERs more restrictively than drugs with CERs less than $100,000 per QALY: odds ratio (OR) = 4.48 if $100,000-$175,000 per QALY; OR = 2.00 if $175,000-$500,000 per QALY; and OR = 2.10 if $500,000 or more per QALY (all P < 0.01). Plans cited ICER in 0.8% (5/622) of coverage policies in 2017, 0.6% (5/833) in 2018, 1.7% (19/1,139) in 2019, and 2.4% (33/1,406) in 2020. For drugs with CERs less than $175,000 per QALY, plans adjusted coverage in 37% of cases: added restrictions in 20%, removed restrictions in 15%, and added one restriction but removed another in 2%. For drugs with CERs of $175,000 or more, plans changed coverage criteria in 29% of cases: added restrictions in 21%, removed restrictions in 5%, and added one restriction but removed another in 4%. CONCLUSIONS: We found that when controlling for other factors, health plans' specialty drug coverage decisions were associated with ICER's estimated CERs. Plans infrequently cited ICER value assessments. We did not observe a trend for plans more often narrowing coverage criteria for drugs with CERs $175,000 or more compared with drugs with CERs less than $175,000. DISCLOSURES: This research study was supported by a consortium of funders: Amgen, Genen-tech, Janssen Pharmaceuticals, Otsuka, and GSK.

State-Level Variation In Low-Value Care For Commercially Insured And Medicare Advantage Populations

Low-value care is a major source of health care inefficiency in the US. Our analysis of 2009-19 administrative claims data from OptumLabs Data Warehouse found that low-value care and associated spending remain prevalent among commercially insured and Medicare Advantage enrollees. The aggregated prevalence of twenty-three low-value services was 1,920 per 100,000 eligible enrollees, which amounted to $3.7 billion in wasteful expenditures during the study period. State-level variation in spending was greater than variation in utilization, and much of the variation in spending was driven by differences in average procedure prices. If the average price for twenty-three low-value services among the top ten states in spending were set to the national average, their spending would decrease by 19.8 percent (from $735,000 to $590,000 per 100,000 eligible enrollees). State-level actions to improve the routine measurement and reporting of low-value care could identify sources of variation and help design state-specific policies that lead to better patient-centered outcomes, enhanced equity, and more efficient spending.

Characterizing health plan evidence review practices

BACKGROUND: Health plans guide enrollees' access to specialty drugs through coverage policies. Practice guidelines recommend that the evidence supporting drug coverage policies should be comprehensive and routinely updated to reflect evidence-based medicine. OBJECTIVE: To examine the frequency with which health plans update their coverage criteria and supporting evidence and to determine the pattern with which plans cited relevant literature in their coverage policies. METHODS: Coverage policies from 17 large US commercial health plans were retrieved from the Tufts Medical Center Specialty Drug Evidence and Coverage database for August 2017 and August 2019. We identified drug-indication pairs (eg, infliximab for rheumatoid arthritis) for which plans had issued coverage policies in August 2017 and August 2019. We examined the frequency with which plans reissued these policies (ie, issued a new coverage document) between these 2 time points and the frequency with which plans altered coverage criteria or updated the cited evidence. A random sample of 20 drug-indication pairs was chosen to determine the comprehensiveness of cited evidence from the Specialty Drug Evidence and Coverage database. For each pair, a systematic literature search was conducted to identify relevant clinical and economic studies. A comparison of the systematic literature search with the evidence cited in each drug-indication pair's coverage policy was conducted to determine the comprehensive nature of each coverage policy's evidence. RESULTS: We identified 4,597 instances of plans issuing a coverage policy for the same drug-indication pair in both August 2017 and August 2019. Of those 4,597 instances, plans reissued an updated coverage document in 4,468 (97%). Fifteen percent of reissued policies revised both their coverage criteria and the evidence cited, 2% only their coverage criteria, 69% only the cited evidence, and 14% made no change. A total of 2,760 literature documents were identified relevant to at least one of the 20 drug-indication pairs, of which at least one plan cited 146 of these documents at least once (5.3%). Plans cited health technology assessments, randomized controlled trials (RCTs), systematic reviews/meta-analyses, and clinical guidelines most comprehensively. CONCLUSIONS: Health plans reissued most of their specialty drug coverage policies over a 2-year period. When plans revised their drug coverage criteria, they also tended to revise the evidence cited in their coverage polices. Of all the evidence found in our systematic review, plans more comprehensively cite health technology assessments, RCTs, and systematic reviews/meta-analyses. DISCLOSURES: This study was funded by the National Pharmaceutical Council.

Patients' access to 2018 FDA-approved drugs 1 year post approval

OBJECTIVES

To examine US commercial health plans' adoption of 2018 FDA-approved drugs.

STUDY DESIGN

Database analysis.

METHODS

We identified novel drugs that the FDA approved in 2018 and categorized them as follows: cancer treatment, orphan drug, included in an expedited review program, and biosimilar. Using a data set of 17 large health plans' drug coverage policies and formularies, we examined coverage 1 year following FDA approval.

RESULTS

The FDA approved 66 drugs in 2018 (5 were not yet marketed 1 year following approval). For 60 of 61 drugs, some plans issued coverage policies whereas other plans included the drug in their formularies. Plans imposed restrictions (eg, step therapy) in 37% (275/742) of coverage policies. Plans covered biosimilars, orphan drugs, and cancer treatments more generously than drugs not in those categories (P < .05). Plans imposed restrictions in their policies with different frequencies (range, 7%-52%). Plans imposed utilization management (UM) in 82% (3837/4697) of formulary entries. Of those entries, plans required prior authorizations in 98%, included drugs on the highest patient co-payment tier in 70%, and imposed step therapy in 3%. Plans most often placed orphan drugs and cancer treatments on the highest cost-sharing formulary tiers (68% and 64% of the time, respectively). Plans imposed UM in their formularies with different frequencies (range, 62%-100% of entries).

CONCLUSIONS

Health plans imposed fewer coverage restrictions on cancer treatments, orphan drugs, and biosimilars than on drugs not in those categories. Some plans covered 2018 FDA-approved drugs more generously than others, which has implications for patients' access to innovative therapies.

Are Medical Devices Cost-Effective?

OBJECTIVE

Medical devices can offer important therapeutic advances but, as for any medical interventions, there are questions about their costs and benefits. We examined health benefits and costs for pre-market approved (PMA) devices approved by the US Food and Drug Administration (FDA) (1999-2015), grouping them by generic category (e.g., drug-eluting stents) and indication.

METHODS

We searched PubMed for incremental health gain estimates [measured in quality-adjusted life-years (QALYs)] and incremental costs for each device category compared to previously available treatments. We calculated incremental cost-effectiveness ratios by dividing the average incremental costs by the average incremental QALY gains. In sensitivity analysis, we repeated the analysis when excluding industry-funded studies.

RESULTS

We identified at least one relevant cost-utility or comparative-effectiveness study for 88 devices (15.9% of non-cosmetic devices approved from 1999 to 2015), and at least one device across 53 (26.2%) generic categories. The median (mean) incremental cost across generic device categories was $1701 ($13,320). The median (mean) incremental health gain across generic device categories was 0.13 (0.46) QALYs. We found that cost-effectiveness ratios for 36 of 53 (68%) and 43 of 53 (81%) device categories fell below (were more favorable than) $50,000 and $150,000 per QALY, respectively. Results were roughly similar when we excluded industry-funded studies.

CONCLUSIONS

We found that roughly one-quarter of the major PMA medical device categories have published cost-effectiveness evidence accessible through a large, publicly available database. Available evidence suggests that devices generally offer good value, as judged relative to established cost-effectiveness benchmarks.

Patients’ access to rare neuromuscular disease therapies varies across US private insurers

Background

The extent to which different US private insurers require their enrollees to meet the same coverage criteria before gaining access to treatment is unclear. Our objective was to scrutinize the patient access criteria imposed by US private insurers for a set of rare neuromuscular disease (NMD) disease-modifying therapies (DMTs).

Methods

We examined coverage policies issued by 17 large US private insurers for the following NMD treatments: nusinersen and onasemnogene abeparvovec for spinal muscular atrophy, edaravone for amyotrophic lateral sclerosis, and eteplirsen for Duchenne muscular dystrophy. We reviewed the plans’ coverage policies and identified the patient access criteria, including clinical prerequisites, step therapy protocols, and prescriber requirements. We compared the plans’ patient access criteria with the therapies’ US Food and Drug Administration (FDA)-labeled indications.

Results

The included insurers issued 65 coverage policies for the included therapies. Plans imposed coverage restrictions beyond the FDA-approved indications in 60 coverage policies; plans did not cover eteplirsen in five policies. No therapy was covered the same way by all insurers. Plans applied clinical criteria beyond the FDA label indication in 56 policies and step therapy protocols in three policies. Plans required that a neurologist prescribe the therapy in 37 policies, 22 of which required the neurologist to have expertise in the particular disease. Plans often required patients to suffer from symptoms of particular severity; e.g. for eteplirsen, plans differed in their 6-min walk test requirements; for edaravone, some plans required that patients had normal respiratory function, while others required only that patients did not require ventilation; for nusinersen and onasemnogene abeparvovec, plans differed in the number of SMN2 gene copies they required patients to have (SMN2 copy number is correlated with disease severity).

Conclusions

The evaluated large US private insurers tended to impose coverage restrictions beyond the FDA label indication for the included set of rare NMD DMTs. Plans rarely applied the same patient access criteria in their coverage policies for the same products. Inconsistent coverage criteria mean that patients with different insurers have variable access to the same therapies across insurers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02182-3.

Is an Orphan Drug's Cost-Effectiveness Associated with US Health Plan Coverage Restrictiveness?

BACKGROUND AND OBJECTIVES

Orphan drugs' high prices raise questions about whether their costs are worth their benefits. We examined the association between an orphan drug's cost-effectiveness and health plan coverage restrictiveness.

METHODS

We analyzed a dataset of US commercial health plan coverage decisions (information current as of 2019) for orphan drugs (n = 3298). We used multi-level random-effect logistic regression to examine the association between orphan drug cost-effectiveness and coverage restrictiveness. We identified cost-effectiveness estimates from the Tufts Medical Center Cost-Effectiveness Analysis Registry, and from the Institute for Clinical and Economic Review's value assessments. We included only cost-effectiveness studies not funded by product manufacturers. We included the following independent variables: cancer indication, availability of alternatives, pediatric population, number of years since US Food and Drug Administration (FDA) approval, disease prevalence, annual cost, additional non-orphan indication, safety, and inclusion in a FDA expedited review program.

RESULTS

Plans restricted drug coverage in 29.7% (n = 981) of decisions. Plans were more likely to restrict drugs with incremental cost-effectiveness ratios of $50,000-$175,000 per quality-adjusted life-year [QALY] (odds ratio = 1.855, p < 0.05), $175,000-$500,000 per QALY (odds ratio = 1.859, p < 0.05), and >$500,000 per QALY/dominated (odds ratio = 2.032, p < 0.01), compared to drugs with incremental cost-effectiveness ratios <$50,000 per QALY. Plans more often restricted drugs with non-cancer indications, having available alternatives, with more recent approval, in an FDA expedited review program, and for which the FDA additionally issued approval for a non-orphan disease. Plans more often restricted drugs with higher annual costs, and drugs indicated for higher prevalence diseases. All findings p < 0.05.

CONCLUSIONS

Among other factors, an orphan drug's cost-effectiveness was associated with health plan drug coverage restrictiveness.

Use of prescriber requirements among US commercial health plans

BACKGROUND: Prescriber requirements are a form of utilization management (UM) in which health plans require that a certain type of physician (eg, a rheumatologist) prescribe a drug. OBJECTIVE: To examine how a set of US commercial health plans impose prescriber requirements in their specialty drug coverage decisions. METHODS: We identified specialty drug coverage decisions from the Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) Database. SPEC includes coverage information issued by 17 large US commercial health plans. We categorized prescriber requirements as the following: (1) the drug must be prescribed in consultation, supervision, or coordination with a specialist; (2) the drug must be prescribed by a specialist (eg, a neurologist); or (3) the drug must be prescribed by a specialist with particular expertise (eg, a neurologist with expertise in spinal muscular atrophy). First, we examined how often each plan imposed prescriber requirements. Second, we determined the degree of specialization that plans required prescribing physicians to have. Third, we used Pearson's chi-square tests to examine the association between plans' use of prescriber requirements and the following drug characteristics: cancer treatment, orphan indication, pediatric indication, drug approved in the last year, black box warning, and self-administered formulation. RESULTS: Overall, health plans imposed prescriber requirements in 22.0% (1,844/8,383) of their coverage decisions, although the frequency that they did so varied (range: 0.8%-86.0%). Of prescriber requirements, 79.1% (1,459/1,844) required that the drug be prescribed in consultation, supervision, or coordination with a specialist; 18.3% (338/1,844) required that the drug be prescribed by a specialist; and 2.6% (47/1,844) required that the drug be prescribed by a specialist with particular expertise. Plans were more likely to impose prescriber requirements for drugs with the following characteristics: indicated for a pediatric population, black box warning, self-administered, and noncancer treatments (all P < 0.001). CONCLUSIONS: Health plans varied in the frequency that they imposed prescriber requirements in their specialty drug coverage decisions and with respect to the degree of specialization they required prescribing physicians to have. DISCLOSURES: This study was funded by the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center. The center receives funding from a variety of sources, including government agencies, foundations, and pharmaceutical and device companies. The SPEC Database, which provided data for this study, is funded in part through a data subscription program to which a number of pharmaceutical companies subscribe. All authors are employed by the Center for the Evaluation of Value and Risk in Health. In addition, Chambers reports speaker fees from Astellas and consulting fees from Biogen and Lundbeck. The other authors have nothing to disclose. An earlier version of this study was presented as a poster at the AMCP 2021 Virtual Meeting, April 12-16, 2021.

Variation in market access decisions for cell and gene therapies across the United States, Canada, and Europe

Transformative cell and gene therapies have now launched worldwide, and many potentially curative cell and gene therapies are in development, offering the prospect of significant health gains for patients. Access to these therapies depend on decisions made by health technology assessment (HTA) and payer organizations. We sought to describe the emerging cell and gene therapies market access landscape by analyzing 17 US commercial payer medical policies, and HTA reports from five European countries and Canada. We found that some US health plans applied coverage restrictions more often than others (four plans applied restrictions in all decisions, while four plans applied restrictions in <30% of decisions). The European and Canadian HTA bodies recommend access to fewer therapies than US health plans, reflecting a more stringent approach in the context of limited evidence and high scientific uncertainty that is commonly associated with these treatments. Our findings suggest that patient access to approved cell and gene therapies is restricted in all regions studied, though the nature of these restrictions differs between US health plans and the European/Canada HTA recommendations. Payers, HTA groups, pharmaceutical companies, and other stakeholders should collaborate to more clearly define the "uncertainties" and develop market access policies that balance benefits of early access with ongoing data collection to close evidence gaps over time.

Variation In Use And Content Of Prescription Drug Step Therapy Protocols, Within And Across Health Plans

Insurers limit the use of certain prescription drugs by requiring step therapy-that is, by allowing access only after alternatives have been tried and have failed. Using data from seventeen of the largest US commercial health plans, we examined step therapy protocols that determined patients' eligibility for specialty drugs and identified ten diseases that are often subject to that requirement. Overall, plans applied step therapy in 38.9 percent of drug coverage policies, with varying frequency across plans (20.6-57.5 percent). Of the protocols for the ten diseases, 34.0 percent were consistent with corresponding clinical guidelines, 55.6 percent were more stringent, and 6.1 percent were less stringent. Trials of alternatives not included in the clinical guidelines were required in 4.2 percent of protocols, and the consistency of protocols varied within and across plans. These findings raise questions about potentially overly restrictive step therapy protocols, as well as concerns that variability across health plans makes protocols onerous for patients and practitioners alike. The findings thus suggest the need for state and federal legislative initiatives to help ensure appropriate prescription drug use.

An Evidence Review of Low-Value Care Recommendations: Inconsistency and Lack of Economic Evidence Considered

BACKGROUND

Low-value care, typically defined as health services that provide little or no benefit, has potential to cause harm, incur unnecessary costs, and waste limited resources. Although evidence-based guidelines identifying low-value care have increased, the guidelines differ in the type of evidence they cite to support recommendations against its routine use.

OBJECTIVE

We examined the evidentiary rationale underlying recommendations against low-value interventions.

DESIGN

We identified 1167 "low-value care" recommendations across five US organizations: the US Preventive Services Task Force (USPSTF), the "Choosing Wisely" Initiative, American College of Physicians (ACP), American College of Cardiology/American Heart Association (ACC/AHA), and American Society of Clinical Oncology (ASCO). For each recommendation, we classified the reported evidentiary rationale into five groups: (1) low economic value; (2) no net clinical benefit; (3) little or no absolute clinical benefit; (4) insufficient evidence; (5) no reason mentioned. We further investigated whether any cited or otherwise available cost-effectiveness evidence was consistent with conventional low economic value benchmarks (e.g., exceeding $100,000 per quality-adjusted life-year).

RESULTS

Of the identified low-value care recommendations, Choosing Wisely contributed the most (N=582, 50%), followed by ACC/AHA (N=250, 21%). The services deemed "low value" differed substantially across organizations. "No net clinical benefit" (N=428, 37%) and "little or no clinical benefit" (N=296, 25%) were the most commonly reported reasons for classifying an intervention as low value. Consideration of economic value was less frequently reported (N=171, 15%). When relevant cost-effectiveness studies were available, their results were mostly consistent with low-value care recommendations.

CONCLUSIONS

Our study found that evidentiary rationales for low-value care vary substantially, with most recommendations relying on clinical evidence. Broadening the evidence base to incorporate cost-effectiveness evidence can help refine the definition of "low-value" care to reflect whether an intervention's costs are worth the benefits. Developing a consensus grading structure on the strength and evidentiary rationale may help improve de-implementation efforts for low-value care.

Variation in health plan coverage of ESAs for anemia due to chronic kidney disease

BACKGROUND: Because health plans each issue their own policies, drug coverage can vary. This variation can result in patients having unequal access to treatment. In this study, we evaluate commercial health plans' coverage policies for erythropoiesis-stimulating agents (ESAs) for patients with anemia resulting from chronic kidney disease (CKD). OBJECTIVES: To assess how a set of US commercial health plans cover ESAs for patients with anemia due to CKD. Our second objective was to examine the evidence that the plans reviewed when formulating their coverage policies. METHODS: We used the Tufts Medical Center Specialty Drug and Evidence and Coverage Database to identify coverage policies issued by 17 of the largest US commercial health plans for ESAs. The following drugs were indicated for anemia due to CKD: darbepoetin alfa, methoxy polyethylene glycol-epoetin beta, epoetin alfa (available as two brands), and epoetin alfa-epbx. Coverage policies were current as of May 2019. We determined whether the health plans applied any restrictions, such as step therapy protocols or patient subgroup restrictions, in their coverage policies. We categorized the evidence that plans cited to support their policies into seven categories: randomized controlled trials (RCTs), real-world evidence (RWE) studies (studies based on data collected in a real-world setting), other clinical studies (eg, single arm trials), systematic reviews and/or meta-analyses, clinical or treatment guidelines, health technology assessments, and economic evaluations. RESULTS: We categorized 72.5% of coverage policies (58/80 policies) as equivalent to the FDA label and 27.5% (22/80 policies) as more restrictive. In restricted policies, plans most often applied step therapy protocols (18/22 policies), followed by prescriber requirements (4/22 policies), and patient subgroup restrictions (3/22 policies). Five health plans applied restrictions in at least half of their coverage policies; seven plans did not apply restrictions in any policy. Plans that cited evidence reviewed an average of 10 citations across their ESA coverage policies, ranging from one to 29 studies. Plans varied with respect to the types of cited studies: at least 50% of evidence cited by five health plans was RCTs, while half or more of the evidence cited by four health plans was clinical or treatment guidelines. CONCLUSIONS: Health plans varied in how they covered ESAs for patients with anemia due to CKD and in the evidence cited in their coverage policies. Inconsistencies in plans' coverage policies may have implications for patients' access to ESAs. DISCLOSURES: This study was funded by Otsuka Pharmaceutical Development and Commercialization. Sanon, Redmond, and Mogahadam are employed by Otsuka Pharmaceutical. Michalopoulos was employed by Otsuka Pharmaceutical at the time of this study. Margaretos, Panzer, and Chambers are employed by Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Center for the Evaluation of Value and Risk in Health. Lai was with Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Center for the Evaluation of Value and Risk in Health at the time of this study.

Limited role of patient input in specialty drug coverage policies

BACKGROUND: Despite increased financial contributions towards care, consumers' role in shaping their insurance benefits is unclear. OBJECTIVE: To examine the role played by patient input when US commercial health plans formulate specialty drug coverage policies, along with the benefits and challenges of considering this input. METHODS: We employed a parallel, mixed-methods approach. First, we reviewed health plans' policy development processes as reported on their websites. Second, we reviewed a data set of private health plan coverage decisions for specialty drugs and examined whether the evidence cited in policies included patient-reported outcomes (eg, health-related quality of life endpoints) and patient-based methodological designs (eg, interviews or surveys of patients). Third, we performed a survey (N = 21 respondents) and interviews (N = 5 interviewees) with plan decision-makers to determine the current role of patient input in plan decision-making, and the benefits and challenges of incorporating this data when formulating specialty drug coverage policies. RESULTS: We found that plans do not commonly solicit patient input when developing coverage policies, with only two instances of limited interaction between plans and patients or members. 1,316 (9%) of the studies plans cited in their specialty drug coverage policies included at least one patient-reported endpoint, and 0.4% (N = 62) used a patient-based methodological design. Of studies with patient-based designs, 40 used interviews, 26 included surveys/questionnaires, and one concerned shared decision-making (design categories not mutually exclusive). Almost half of the survey respondents reported having never engaged with patients or members when developing coverage policies. Among respondents who had engaged with patients or members, most reported doing so only rarely. The survey and interviews highlighted various benefits of soliciting patient input, including the value of obtaining a humanistic perspective, and several challenges, including resource requirements and the quality of obtained information. CONCLUSIONS: We found a notable lack of patient and member engagement by commercial health plans when formulating drug coverage policies. Survey respondents and interviewees identified benefits of accounting for patients' and plan members' values and preferences in specialty drug coverage policies, but also reported a number of important challenges to doing so. DISCLOSURES: National Pharmaceutical Council provided funding for this research.

Variation in access to hemophilia A treatments in the United States

BACKGROUND

US commercial health plans have been found to vary in how they cover specialty drugs indicated for a range of diseases. In this study, we examined patients' access to hemophilia A (HemA) treatments across a set of large commercial health plans.

OBJECTIVE

To examine variation in health plans' coverage policies for HemA treatments.

METHODS

We reviewed HemA treatment coverage policies (current as of August 2019) issued by 17 commercial health plans primarily using the Tufts Medical Center Specialty Drug Evidence and Coverage Database. We categorized policies as: covered without conditions (coverage consistent with the FDA label); covered with conditions (conditions on coverage beyond the FDA label); broader coverage (coverage for a broader patient population than the FDA label); and mixed (conditions on coverage beyond the FDA label in one way, but coverage was broader than the FDA label in another).

RESULTS

We identified 296 coverage policies for 26 HemA treatments, including 15 short half-life factor VIII (FVIII) products, five extended half-life FVIII products, three bypassing agents, two desmopressin products, and emicizumab. We classified 36% of policies as coverage without conditions, 50% as covered with conditions, 7% as broader coverage, and 7% as mixed. Plans applied conditions on coverage with different frequencies: two did not apply conditions in any policies; ten applied conditions in ≥50%; four applied conditions in <40%. One plan did not publish coverage policies for any HemA products. Conditions on coverage most often related to bleeding frequency (36%), although specific requirements varied. Plans applied step therapy protocols in 17% of policies.

CONCLUSIONS

How health plans covered HemA treatments varied. Plans added conditions on coverage beyond the FDA label roughly half the time. Conditions most often related to bleeding frequency. Variable coverage affects patients' access to treatment, and potentially has clinical implications on disease management and disease progression.

Coverage for Biosimilars vs Reference Products Among US Commercial Health Plans

This study uses US commercial health plan insurance data to characterize coverage for biosimilar drugs compared with reference products.

What types of real-world evidence studies do U.S. commercial health plans cite in their specialty drug coverage decisions?

PURPOSE

To examine the RWE U.S. commercial health plans cite in their specialty drug coverage decisions.

METHODS

We used the Tufts Medical Center Specialty Drug Evidence and Coverage Database to identify specialty drug coverage decisions (n = 7267) issued by 17 large commercial health plans. We categorized the clinical evidence plans cited in these coverage decisions (n = 5227) as randomized controlled trials (RCTs), RWE studies, and other clinical studies (studies other than RCT or RWE study). We categorized RWE studies with respect to study type, for example, case series, studies based on medical records, and so on. We compared the frequency that plans cited different categories of RWE, cited RWE for different diseases, and cited RWE for drugs on the market for different time periods.

RESULTS

RWE comprised 16% of cited clinical studies. Health plans cited RWE with different frequencies (5%-31% of the cited clinical evidence). Overall, plans cited RWE categorized as medical records most often (26% of cited RWE studies). Plans varied in the frequency they cited different RWE categories. Plans most frequently cited RWE for gastroenterological diseases (35% of clinical study citations) and least frequently for respiratory diseases (11% of clinical study citations). Plans cited RWE more for drugs that have long been on the market.

CONCLUSIONS

Health plans varied with respect to the number and types of RWE studies they cited in their specialty drug coverage decisions. Plans cited RWE more often for some diseases than others, and cited more RWE for older drugs.

Little Consistency In Evidence Cited By Commercial Plans For Specialty Drug Coverage

We found wide variation in the evidence that US commercial health plans reported reviewing in their specialty drug coverage policies. There was little consistency in the numbers or types of studies cited by health plans. On average, only 15 percent of health plans' coverage policies cited the same study evaluating a specific drug for a specific indication.

Variation in US private health plans' coverage of orphan drugs

OBJECTIVES

To compare coverage of orphan and nonorphan drugs, to examine variation in orphan drug coverage across the largest US private plans, and to evaluate factors influencing coverage decisions.

STUDY DESIGN

Database and regression analyses.

METHODS

We analyzed a data set of private health plan coverage decisions for specialty drugs (N = 5000) in 3 ways. First, we compared the frequency with which plans applied restrictions in their decisions for orphan and nonorphan drugs. Second, we examined variation in the frequency with which 17 of the largest 20 private plans applied coverage restrictions for orphan drugs. Third, we used multivariate regression to examine factors associated with restricted orphan drug coverage.

RESULTS

Health plans are less likely to restrict orphan drugs compared with nonorphan drugs. Of orphan drug decisions (n = 2168), plans did not apply coverage restrictions in 70% of cases, applied restrictions in 29%, and did not cover in 1%. In contrast, of nonorphan drug decisions (n = 2832), plans did not apply coverage restrictions in 53% of cases, applied restrictions in 41%, and did not cover in 6%. The frequency of restrictions for orphan drugs varied from 11% to 65% across plans. The attributes of orphan drugs that were more likely to be associated with restrictions than others included drugs for noncancer diseases, drugs with alternatives, self-administered drugs, drugs indicated for diseases with a higher prevalence, and drugs with higher annual costs (all P <.05).

CONCLUSIONS

Health plans restrict access to orphan drugs approximately one-third of the time, and restrictions vary considerably across plans. Plans more often add restrictions for orphan drugs that are indicated for diseases with a higher prevalence and that have higher annual costs.

Specialty Drug Coverage Varies Across Commercial Health Plans In The US

We analyzed specialty drug coverage decisions issued by the largest US commercial health plans to examine variation in coverage and the consistency of those decisions with indications approved by the Food and Drug Administration (FDA). Across 3,417 decisions, 16 percent of the 302 drug-indication pairs were covered the same way by all of the health plans, and 48 percent were covered the same way by 75 percent of the plans. Specifically, 52 percent of the decisions were consistent with the FDA label, 9 percent less restrictive, 2 percent mixed (less restrictive in some ways but more restrictive in others), and 33 percent more restrictive, while 5 percent of the pairs were not covered. Health plans restricted coverage of drugs indicated for cancer less often than they did coverage of drugs indicated for other diseases. Using multivariate regression, we found that several drug-related factors were associated with less restrictive coverage, including indications for orphan diseases or pediatric populations, absence of safety warnings, time on the market, lack of alternatives, and expedited FDA review. Variations in coverage have implications for patients' access to treatment and health system costs.

Discrepancies Between FDA-Required Labeling and Evidence that Payers Cite in Drug Coverage Policies

BACKGROUND

FDA-required labeling summarizes certain data that the FDA relies on in its drug approval process. However, when determining coverage of specialty drugs, health care payers may consider dissimilar evidence.

OBJECTIVE

To compare evidence cited by the largest U.S. commercial payers in their specialty drug coverage policies with evidence featured in the labeling of the indicated drugs.

METHODS

We used the Tufts Medical Center Specialty Drug Evidence and Coverage Database (SPEC)-a database of specialty drug coverage policies issued by 17 of the 20 largest U.S. commercial health care payers-to identify coverage policies for drugs indicated for multiple sclerosis, rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, and non-small cell lung cancer (NSCLC). These disease categories were selected because each was represented by multiple drugs. For each drug, we identified endpoints included in the clinical studies presented in the FDA-required labeling. Using SPEC, we identified randomized controlled trials (RCTs) and other clinical studies that at least 1 payer cited in its coverage policies for the included drugs. We reviewed the full text of each study to identify the endpoints reported. We categorized endpoints as identical to endpoints in the FDA-required labeling of the drugs; similar (e.g., a different measurement scale was used to evaluate the same endpoint); and different (the endpoint was not featured in the FDA-required labeling).

RESULTS

We included 41 drugs and reviewed 348 studies (246 RCTs and 102 other clinical studies). Of 2,237 endpoints, 63% were categorized as identical, 26% as similar, and 12% as different. Rheumatoid arthritis was the indication with the largest proportion of endpoints categorized as identical (74% of endpoints in the RCTs cited by payers; 59% of endpoints in the other clinical studies cited by payers). NSCLC was the indication with the largest proportion of endpoints categorized as different (33% of end-points in the RCTs cited by payers; 37% of endpoints in the other clinical studies cited by payers).

CONCLUSIONS

Payers often report reviewing clinical evidence that goes beyond information included in FDA-required labeling. Our findings suggest that the FDA should continue engaging with the manufacturer and payer communities to appropriately facilitate communication of information necessary to allow for informed coverage decisions.

DISCLOSURES

This study was funded by an unrestricted grant from the Pharmaceutical Research and Manufacturers of America. The authors work with The Center for the Evaluation of Value and Risk in Health, which is partially supported through the CEA Registry Sponsorship program; the CEA Registry has received funding from the National Science Foundation, National Library of Medicine, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, and a variety of pharmaceutical and device companies that subscribe to the data. Chambers reports personal fees from Health Advances, Ernst & Young, Magellan Health, Summit Therapeutics, and Sanofi-Aventis, unrelated to this study. Neumann reports past advisory board work with Amgen, Avexis, Axovant, Bayer, Bluebird, Congressional Budget Office, Janssen, Merck, Novo Nordisk, Pacira, Paratek, and Sage; consulting work for Boston Health Economics, GSK, Precision Health Economics, Veritech, and Vertex; speaker fees from AbbVie, Celgene, and Roche; and grants from the Alzheimer's Association, Amgen, Gates, Lundbeck, NIH, NPC, and Sage, all unrelated to this study. The other authors have nothing to disclose.

Hemophilia Burden of Disease: A Systematic Review of the Cost-Utility Literature for Hemophilia

BACKGROUND

Prophylaxis with clotting factor replacement products is recommended by the Medical and Scientific Advisory Council of the National Hemophilia Foundation as the optimal therapy for the prevention of bleeding episodes in individuals with severe hemophilia A or B (< 1 IU per dL endogenous factor VIII or factor IX activity, respectively). Prophylaxis is associated with an improved health-related quality of life and has been shown to be cost-effective compared with on-demand therapy. However, the overall cost of treatment remains high, particularly among patients with a greater propensity to bleed. The overall value of hemophilia treatments and their associated benefits, measured in quality-adjusted life-years (QALYs), and dollar costs compared with other interventions can be evaluated through the use of cost-utility analyses (CUAs). Previous CUA studies in hemophilia have focused primarily on patients with more severe forms of hemophilia and on prophylaxis compared with on-demand treatment. However, to our knowledge, no studies to date have utilized QALYs as a standardized outcome measure to systematically evaluate the relative cost-effectiveness of current hemophilia treatment options.

OBJECTIVE

To systematically review the CUA literature of hemophilia treatments and demonstrate the challenges in producing cost-utility evidence compared with other rare diseases.

METHODS

We conducted a systematic literature review using the Tufts Medical Center Cost-Effectiveness Analysis Registry and the National Health Service Economic Evaluation Database for English-language CUAs published from 2000 through 2015 with the search terms hemophilia, haemophilia, factor VIII, or factor IX. Two trained reviewers independently reviewed every study to extract relevant data. Incremental cost-effectiveness ratios were converted to 2014 U.S. dollars using exchange rates for currency conversion and the Consumer Price Index to adjust for inflation.

RESULTS

Our search yielded 52 studies, 11 of which met our inclusion criteria. The cost-effectiveness of hemophilia treatments varied widely based on variations in the study designs, including differences in time horizon, discount rates, and medical interventions.

CONCLUSIONS

We found the cost-effectiveness of hemophilia treatments to be broadly comparable to that of other orphan drugs. Improved standardization of future CUA studies will be important for further evaluation of the cost-effectiveness of hemophilia treatments.

DISCLOSURES

This research was funded by Biogen, which provided an unrestricted research grant to the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center. Biogen and Sobi reviewed and provided feedback on the manuscript. The authors had full editorial control of the manuscript and provided final approval of all content. The authors report no conflict of interest regarding the material discussed in this article. Neumann and Chambers are employed at the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center. Thorat was an employee of Center for Evaluation Value and Risk in Health, Tufts Medical Center when the analyses were carried out. Chambers has participated on advisory boards for Sanofi and Astellas Pharma.

Drugs Cleared Through The FDA's Expedited Review Offer Greater Gains Than Drugs Approved By Conventional Process

We investigated whether drugs approved by the Food and Drug Administration (FDA) through expedited review have offered larger health gains, compared to drugs approved through conventional review processes. We identified published estimates of additional health gains (measured in quality-adjusted life-years, or QALYs) associated with drugs approved in the period 1999-2012 through expedited (seventy-six drugs) versus conventional (fifty-nine) review processes. We found that drugs in at least one expedited review program offered greater gains than drugs reviewed through conventional processes (0.182 versus 0.003 QALYs). We also found that, compared to drugs not included in the same program, greater gains were provided by drugs in the priority review (0.175 versus 0.007 QALYs), accelerated approval (0.370 versus 0.031 QALYs), and fast track (0.254 versus 0.014 QALYs) programs. Our analysis suggests that the FDA has prioritized drugs that offer the largest health gains.

Variation in Private Payer Coverage of Rheumatoid Arthritis Drugs

BACKGROUND

Payers in the United States issue coverage determinations to guide how their enrolled beneficiaries use prescription drugs. Because payers create their own coverage policies, how they cover drugs can vary, which in turn can affect access to care by beneficiaries.

OBJECTIVE

To examine how the largest private payers based on membership cover drugs indicated for rheumatoid arthritis and to determine what evidence the payers reported reviewing when formulating their coverage policies.

METHODS

Coverage policies issued by the 10 largest private payers that make their policies publicly available were identified for rheumatoid arthritis drugs. Each coverage determination was compared with the drug's corresponding FDA label and categorized according to the following: (a) consistent with the label, (b) more restrictive than the label, (c) less restrictive than the label, or (d) mixed (i.e., more restrictive than the label in one way but less restrictive in another). Each coverage determination was also compared with the American College of Rheumatology (ACR) 2012 treatment recommendations and categorized using the same relative restrictiveness criteria. The policies were then reviewed to identify the evidence that the payers reported reviewing. The identified evidence was divided into the following 6 categories: randomized controlled trials; other clinical studies (e.g., observational studies); health technology assessments; clinical reviews; cost-effectiveness analyses; and clinical guidelines.

RESULTS

Sixty-nine percent of coverage determinations were more restrictive than the corresponding FDA label; 15% were consistent; 3% were less restrictive; and 13% were mixed. Thirty-four percent of coverage determinations were consistent with the ACR recommendations, 33% were more restrictive; 17% were less restrictive; and 17% were mixed. Payers most often reported reviewing randomized controlled trials for their coverage policies (an average of 2.3 per policy). The payers reported reviewing an average of 1.4 clinical guidelines, 1.1 clinical reviews, 0.8 other clinical studies, and 0.5 technology assessments per policy. Only 1 payer reported reviewing cost-effectiveness analyses. The evidence base that the payers reported reviewing varied in terms of volume and composition.

CONCLUSIONS

Payers most often covered rheumatoid arthritis drugs more restrictively than the corresponding FDA label indication and the ACR treatment recommendations. Payers reported reviewing a varied evidence base in their coverage policies.

DISCLOSURES

Funding for this study was provided by Genentech. Chambers has participated in a Sanofi advisory board, unrelated to this study. The authors report no other potential conflicts of interest. Study concept and design were contributed by Chambers. Anderson, Wilkinson, and Chenoweth collected the data, assisted by Chambers, and data interpretation was primarily performed by Chambers, along with Anderson and with assistance from Wilkinson and Chenoweth. The manuscript was written primarily by Chambers, along with Wilkinson and with assistance from Anderson and Chenoweth. Chambers, Chenoweth, Wilkinson, and Anderson revised the manuscript.

The Decline in Vitamin Research Funding: A Missed Opportunity?

Background: The National Nutrition Research Roadmap has called for support of greater collaborative, interdisciplinary research for multiple areas of nutrition research. However, a substantial reduction in federal funding makes responding to these calls challenging. Objectives: The objectives of this study were to examine temporal trends in research funding and to discuss the potential consequences of these trends. Methods: We searched the NIH RePORTER database to identify NIH research grants and USASpending to identify National Science Foundation and USDA research grants awarded from 1992 to 2015. We focused on those that pertained to vitamin research. For the years 2000 to 2015, we examined funding trends for different vitamins, including vitamins A, B (one-carbon B-vitamins were considered separately from other B-vitamins), C, D, E, and K. Results: From 1992 to 2015, total federal research spending increased from ∼$14 to $45 billion (2016 US dollars). Although vitamin research spending increased from ∼$89 to $95 million, the proportion of grants awarded for vitamin research declined by more than two-thirds, from 0.65% in 1992 to 0.2% in 2015. Federal agencies awarded 6035 vitamin research grants over the time period, with vitamin A associated with the most research projects per year on average (n = 115) and vitamin K the fewest (n = 8). Vitamin D research projects were associated with the greatest average yearly project value ($34.8 million). Conclusions: Vitamin research has faced a disproportionate decline in research funding from 1992 to 2015. Insufficient federal research funding streams risk stalling progress in vitamin research and leaving important advancements unrealized.

A Review of Empirical Analyses of Disinvestment Initiatives

BACKGROUND

Disinvesting in low-value health care services provides opportunities for investment in higher value care and thus an increase in health care efficiency.

OBJECTIVES

To identify international experience with disinvestment initiatives and to review empirical analyses of disinvestment initiatives.

METHODS

We performed a literature search using the PubMed database to identify international experience with disinvestment initiatives. We also reviewed empirical analyses of disinvestment initiatives.

RESULTS

We identified 26 unique disinvestment initiatives implemented across 11 countries. Nineteen addressed multiple intervention types, six addressed only drugs, and one addressed only devices. We reviewed 18 empirical analyses of disinvestment initiatives: 7 reported that the initiative was successful, 8 reported that the initiative was unsuccessful, and 3 reported that findings were mixed; that is, the study considered multiple services and reported a decrease in the use of some but not others. Thirty-seven low-value services were evaluated across the 18 empirical analyses, for 14 (38%) of which the disinvestment initiative led to a decline in use. Six of the seven studies that reported the disinvestment initiative to be successful included an attempt to promote the disinvestment initiative among participating clinicians.

CONCLUSIONS

The success of disinvestment initiatives has been mixed, with fewer than half the identified empirical studies reporting that use of the low-value service was reduced. Our findings suggest that promotion of the disinvestment initiative among clinicians is a key component to the success of the disinvestment initiative.

Estimating Population Health Benefits Associated with Specialty and Traditional Drugs in the Year Following Product Approval

OBJECTIVE

Compared to traditional drugs, specialty drugs tend to be indicated for lower prevalence diseases. Our objective was to compare the potential population health benefits associated with specialty and traditional drugs in the year following product approval.

METHODS

First, we created a dataset of estimates of incremental quality-adjusted life-year (QALY) gains and incremental life-year (LY) gains for US FDA-approved drugs (1999-2011) compared to standard of care at the time of approval identified from a literature search. Second, we categorized each drug as specialty or traditional. Third, for each drug we identified estimates of US disease prevalence for each pertinent indication. Fourth, in order to conservatively estimate the potential population health gains associated with each new drug in the year following its approval we multiplied the health gain estimate by 10% of the identified prevalence. Fifth, we used Mann-Whitney U tests to compare the population health gains for specialty and traditional drugs.

RESULTS

We identified QALY gain estimates for 101 drugs, including 56 specialty drugs, and LY gain estimates for 50 drugs, including 34 specialty drugs. The median estimated population QALY gain in the year following approval for specialty drugs was 4200 (IQR = 27,000) and for traditional drugs was 694 (IQR = 24,400) (p = 0.245). The median estimated population LY gain in the year following approval for specialty drugs was 7250 (IQR = 39,200) and for traditional drugs was 2500 (IQR = 58,200) (p = 0.752).

CONCLUSIONS

Despite often being indicated for diseases of lower prevalence, we found a trend towards specialty drugs offering larger potential population health gains than traditional drugs, particularly when measured in terms of QALYs.

Medicare is scrutinizing evidence more tightly for national coverage determinations

We examined Medicare national coverage determinations for medical interventions to determine whether or not they have become more restrictive over time. National coverage determinations address whether particular big-ticket medical items, services, treatment procedures, and technologies can be paid for under Medicare. We found that after we adjusted for the strength of evidence and other factors known to influence the determinations of the Centers for Medicare and Medicaid Services (CMS), the evidentiary bar for coverage has risen. More recent coverage determinations (from mid-March 2008 through August 2012) were twenty times less likely to be positive than earlier coverage determinations (from February 1999 through January 2002). Furthermore, coverage during the study period was increasingly and positively associated both with the degree of consistency of favorable findings in the CMS reviewed clinical evidence and with recommendations made in clinical guidelines. Coverage policy is an important payer tool for promoting the appropriate use of medical interventions, but CMS's rising evidence standards also raise questions about patients' access to new technologies and about hurdles for the pharmaceutical and device industries as they attempt to bring innovations to the market.

Despite high costs, specialty drugs may offer value for money comparable to that of traditional drugs

Specialty drugs are often many times more expensive than traditional drugs, which raises questions of affordability and value. We compared the value of specialty and traditional drugs approved by the Food and Drug Administration (FDA) in the period 1999-2011. To do this, we identified published estimates of additional health gains (measured in quality-adjusted life-years, or QALYs) and increased costs of drug and health care resource use that were associated with fifty-eight specialty drugs and forty-four traditional drugs, compared to preexisting care. We found that specialty drugs offered greater QALY gains (0.183 versus 0.002 QALYs) but were associated with greater additional costs ($12,238 versus $784), compared to traditional drugs. The two types of drugs had comparable cost-effectiveness. However, the distributions across the two types differed, with 26 percent of specialty drugs--but only 9 percent of traditional drugs--associated with incremental cost-effectiveness ratios of greater than $150,000 per QALY. Our study suggests that although specialty drugs often have higher costs than traditional drugs, they also tend to confer greater benefits and hence may still offer reasonable value for money.

Mapping US commercial payers' coverage policies for medical interventions

OBJECTIVES

To examine coverage policies for medical interventions issued by the largest US commercial payers.

STUDY DESIGN

Review of publicly accessible coverage policies for medical interventions.

METHODS

We categorized the 20 largest commercial payers' medical benefit coverage policies for medical technologies-current as of August 1, 2014-with respect to technology type (eg, medical devices, pharmaceuticals, surgeries). We identified the interventions most commonly subject to coverage policies and compared payer coverage determinations in terms of whether they covered the intervention and the evidence they reported reviewing.

RESULTS

Eighteen payers made their coverage policies publicly available and 17 reported the evidence they reviewed in formulating policies. The types of technologies considered varied across payers, although most focused on devices and diagnostics. Of the 28 interventions most commonly subject to coverage policies, the coverage of 9 varied (ie, some payers covered the intervention and others did not). On average, payers reported reviewing clinical studies in 87% of coverage policies (range = 25%-100%). Two payers did not report reviewing systematic reviews or meta-analyses in any coverage policies, and 9 reported reviewing such evidence in at least half of their policies. Fourteen payers reported reviewing cost-effectiveness analyses at least some of the time, with frequency ranging from 8% to 43%. Commercial payers' coverage decisions did not appear to reflect direct input from patients or patient advocates, at least as stated in published coverage policies.

CONCLUSIONS

Coverage of medical interventions varies across US private payers. Payers often report reviewing different evidence when formulating coverage policies, but do not report considering input directly from patients in evidence assessments.

The impact of formulary drug exclusion policies on patients and healthcare costs

OBJECTIVES

In an attempt to increase the efficiency of their drug benefit policies, insurers are increasingly excluding drugs from their formularies that they deem to be of low value. Our objective was to identify and review empirical evaluations of drug exclusion policies and examine how they affected patients and healthcare costs.

STUDY DESIGN

Literature review.

METHODS

We performed a literature search to identify empirical studies that evaluated drug exclusion policies. We reviewed each study to determine how the policy impacted patients (ie, if disease control or frequency, or severity of symptoms, were affected) and if healthcare costs (eg, drug expenditures and costs associated with physician office visits, hospitalizations, laboratory tests) changed.

RESULTS

We included 26 studies pertaining to 27 drug exclusion policies. Twenty studies reported the impact of 21 drug exclusion policies on patients: 6 (28.6%) policies were reported to have had a positive impact, 6 (28.6%) to have had a negative impact, and 9 (42.8%) to not have impacted patients. Eighteen studies reported the impact of 19 drug exclusion policies on overall healthcare costs: 14 (73.7%) policies were reported to have reduced costs, 1 (5.3%) to have had a neutral impact on costs, and 4 (21.1%) to have increased costs.

CONCLUSIONS

Although there were important exceptions, most studies found that drug exclusion policies reduced costs and did not negatively impact patients.

The Role of Decision Models in Health Care Policy: A Case Study

BACKGROUND

In 2009, the Centers for Medicare and Medicaid Services (CMS) underwent a National Coverage Determination on computed tomography colonography (CTC) to screen for colorectal cancer. The Cancer Intervention & Surveillance Network developed decision models to inform this decision. The purpose of our study was to investigate the role of models in this decision.

METHODS

We performed a descriptive case study. We conducted semistructured telephone interviews with members of the CMS coverage and analysis group (CAG) and Medicare Coverage and Analysis Advisory Committee (MEDCAC) panelists. Informed by previously published literature, we developed a coding scheme to analyze interview transcripts, MEDCAC meeting transcripts, and the final CMS decision memo.

RESULTS

Four members of the CAG and 8 MEDCAC panelists were interviewed. The total number of codes across all study documents was 772. We found evidence that decision makers believed in the adequacy of models to inform decision making. In interview transcripts, the code Models Are Adequate to Inform was more frequent than the code Models Are Inadequate to Inform (47 times v. 5). Discussion of model conceptualization dominated the MEDCAC meeting (Model Conceptualization assigned 113 times) and was frequently discussed during interviews (Model Conceptualization assigned 84 times). We also found evidence that the models helped to focus the policy discussion. Across study documents, the codes Focus on Cost, Focus on Clinical-Health Impact, and Focus on Inadequacy of Evidence Base were assigned 99, 98, and 97 times, respectively.

CONCLUSIONS

Decision makers involved in the CTC decision believed in the adequacy of models to inform coverage decisions. The model played a role in focusing the CTC coverage policy discussion.

Thirty Years of Media Coverage on High Drug Prices in the United States--A Never-Ending Story or a Time for Change?

In recent years drug prices have increasingly become a topic of debate for patients, providers, payers and policy makers. To place the current drug price debate into historical context, we searched the New York Times and Wall Street Journal from 1985 - 2015 and found that concerns about drug prices have commonly featured in the press over the study period with recently stronger calls for change. Price levels, types of innovations, stakeholder responses, and strategies to address high prices discussed in the media suggest that concerted efforts are required to enable affordable and high-value innovations.

How Do Payers Respond to Regulatory Actions? The Case of Bevacizumab

PURPOSE

In February 2008, the US Food and Drug Administration (FDA) granted accelerated approval for bevacizumab for metastatic breast cancer. After public hearings in July 2010, and June 2011, the FDA revoked this approved indication in November 2011, on the basis of additional evidence regarding its risk/benefit profile. The Centers for Medicare and Medicaid Services, local Medicare contractors, and commercial payers varied in their stated intentions to cover bevacizumab after FDA's regulatory actions. We examined payer-specific trends in bevacizumab use after the FDA's regulatory actions.

METHODS

We used outpatient medical claims compiled by IMS Health to evaluate trends in bevacizumab use for breast cancer for Medicare-insured and commercially insured patients (N = 102,906) using segmented regression. Given that Medicare coverage policies may vary across regional contractors, we estimated trends in bevacizumab use across 10 local coverage areas. In a sensitivity analysis, we estimated trends in bevacizumab use for breast cancer compared with trends in use for lung cancer using difference-in-differences models.

RESULTS

Among chemotherapy infusions for breast cancer, bevacizumab use decreased from 31% in July 2010, to 4% in September 2012. Use decreased by 11% among commercially insured and 13% among Medicare-insured patients after July 2010 (interaction P = .68) and continued to decline by 9% per month (interaction P = .61). We observed no contractor-level variation in bevacizumab use among Medicare beneficiaries. During the same period, bevacizumab use for lung cancer was stable.

CONCLUSION

Although insurers varied in public statements regarding coverage intentions, bevacizumab use declined similarly among all payers, suggesting that provider decision making, rather than payer-specific coverage policies, drove reductions.