Health insurers searching to lower costs and maximize profits have begun to limit patients’ access to innovative drugs.  Most physicians, however, realize that this is a terrible idea.  Patient health suffers, particularly if patients don’t respond to existing treatments. The potential of breakthrough drugs to better treat chronic and life-threatening diseases goes untapped.  And physicians like me lose the ability to make crucial decisions about our patients’ care. No longer “my” patients, these men and women are more accurately under the care of the health insurers who dictate treatment options. 

Nevertheless, a nonprofit known as the Institute for Clinical and Economic Review is playing right into the hands of insurers who want to cut drug costs, even if it means cutting patients’ best interests and personal safety out of the equation.

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ICER, as the group is called, issues reports that present a “value-based price” for breakthrough drugs.  Voted on by its panel of experts, some of whom have never treated the disease for which the treatment is prescribed, the reports effectively give insurers an artificial price point to justify limiting patient access.  “ICER says we shouldn’t pay more than ‘X’ for this drug,” they can argue, “so we won’t.”

Consider ICER’s recent position on breakthrough asthma drugs. Through one of the organization’s core programs, the California Technology Assessment Forum, the group issued a report suggesting that the medication should cost roughly 70% less than its current list price—an unlikely discount. 

The FDA-approved, once-monthly biologic injection was designed for patients with severe asthma, not ordinary asthma.  These patients don’t respond to standard treatment, and ineffective medications predispose them to repeated acute exacerbations.  That explains why they represent only about 5-10 percent of the 26 million Americans with asthma but contribute to 80 percent of the health care costs.  The biologic treatment can cut these patients’ symptoms and acute exacerbations in half, also reducing the need for oral steroids. 

ICER acknowledges the breakthrough drug’s effectiveness.   The group’s January 2016 report notes the “clinical benefits in terms of reduced rates of exacerbation and improved quality of life.” 

But the drug’s price does not conform to ICER’s arbitary cost threshold. 

That’s a problem because public and private insurers across the country will use this recommendation and future recommendations to justify their coverage decisions.  Some already are: Blue Shield of California, Express Scripts and the Centers for Medicare & Medicaid Services, to name a few.  As a result, we can expect payers to shrink their lists of approved drugs, raise patient cost-sharing requirements and impose more of the onerous prior authorization procedures that delay patients from getting their medication.

Let’s be clear, today’s physicians and patients are not blind to the challenges of rising health care expenses.  We marvel at what advanced medicine has produced – a long-awaited cure for hepatitis C, cancer treatments that rally the body’s immune system to stop the disease’s spread.  But we shudder at these treatments’ cost.

Patients, health care providers, industry, market forces, insurers and regulators must pause and listen to each other.  We must come to solutions through common sense and aim to better the health of each patient by protecting choice.  We cannot – we must not – cut patients out of the equation and treat this challenge as a purely mathematical one.

Yet ICER, I fear, takes us dangerously to the brink, a tipping point none of us can afford. Artificial price points meant to bully the pharmaceutical industry will instead undermine patient health.  Patients will discover that the medicine that is right for them, that they and their physicians choose, is out of reach.  New health care disparities will emerge.

In this political season, we can see an obvious parallel between election politics and health care insurance enrollment. Once they have your vote or your premium, the government and company can do what they please, often for their own interests. 

Rising health care costs will continue to perpetuate this kind of behavior, breeding so-called experts who do statistical acrobatics to justify health care economics.  But policymakers must remember this: good medicine is now, as it ever was, personal, patient-specific and guided not by statistics but by the physician-patient relationship.  This is the model that physicians hold fast to, the one that allows patients to access drugs they need to live better lives. 


Samuel Louie, MD, is Professor of Medicine at the University of California, Davis, a practicing pulmonologist and a member of the Alliance for Patient Access.