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How much weight do Canada's HTA assessments carry, and could value-based tiered formularies gain traction in the US – some thoughts from ISPOR

04 June 2014 Margaret Labban

Negative recommendations don't always preclude market access in Canada I've been covering The Canadian Agency for Drugs and Technologies in Health (CADTH) assessments for a while now, but and it is always instructive to be reminded of how variable the impact of these decisions are across individual Canadian provinces, as I was today at the ongoing annual meeting of ISPOR in Montreal.

While it is common knowledge that the recommendations are not legally binding, and variations exist across the different jurisdictions on what they choose to do with these Health Technology Assessments (HTAs); ISPOR has definitely opened my eyes even more to the potential opportunities that still exist even AFTER a negative recommendation has been issued, and how it might not always be a death knell for the manufacturer.

According to a review of the most recent CADTH Common Drug Review (CDR) assessments, negative recommendations poorly predicted the availability of the drugs in Canada's largest provinces. In Ontario specifically, a large proportion of drugs with negative CADTH recommendations were available on the provincial formulary or through the special access programme. An interesting point to keep in mind is that negative decisions leave the door open to negotiations that could secure market access for a negotiated price reduction.

Value-based Tiering in the US Another interesting presentation at ISPOR described preliminary data from a pilot study, where commercial insurer Premera Blue Cross was implementing a novel value-based tiered drug plan formulary that sought to manage utilisation of drugs based on cost-effectiveness and value, rather than just cost. The drugs were placed on tiers with varying incremental cost-effectiveness ratio (ICER) thresholds, and the idea was that the increased cost-sharing from low-value drugs would work to offset any increases in expenditure from placing high-cost high-value drugs on lower tiers with little co-pay. So far, the programme seems to be working and the drug plan reported cost savings in the first year… but did this translate to improved care? Could this set the stage for more HTA-based formularies?

Most drug plans under the current system in the US have more expensive specialty drugs predominantly placed in higher tiers, with relatively high copays or coinsurance. This could mean that individuals in need of such medication may not seek out the treatment due to out-of-pocket costs, or fail to adhere to treatment, costing the healthcare system and the payer more overall, than would have otherwise been the case. Could value-based tiering improve adherence? Could it continue to produce cost-savings over the long-term? This is something we will definitely keep an eye out on in the future.

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