PNS136 ICER AND THE USE OF MEDICAID DATA

Abstract

ICER (Institute for Clinical and Economic review) is an independent, non-profit research institute that seeks to establish the clinical effectiveness and value of drugs. ICER has committed to use Real World Evidence (RWE), such as payer reimbursement data, to quantify the burden of illness on the US overall health system. Commercial claims studies are now commonly cited sources, however there is a lack of RWE based on reimbursement data for Medicaid and other government programs. Medicaid is a federal-state assistance program that serves low-income individuals of all ages, as well as about half (47%) of the 13.3 million children with special health care needs. In particular, many children with high cost rare diseases would be eligible for Medicaid and this cost of care would comprise a large proportion of the overall health system spending. Thus, Medicaid RWE data is necessary to accurately evaluate the potential cost offsets of new drugs on the health system as a whole, especially in the cases of rare diseases. We reviewed all completed ICER assessments (N=40, as of January 15, 2020) and identified the data sources for the cost-related model inputs. We flagged reviews utilizing Medicaid RWE to quantify the existing burden on the US health system. Of the 40 completed ICER reports, 4 (10%) utilized any Medicaid data. This is likely attributable to a lack of published data analyses that incorporate Medicaid data. 9 of the 40 reviewed ICER reports were for rare diseases (<200,000 cases per year in the US), but none of these utilized Medicaid data. The majority of ICER assessments do not include the healthcare costs currently paid for by Medicaid, so may underestimate the value of new drugs to the US overall health system, particularly in the case of high-cost rare diseases.