ICER Misses…Again

The latest Unsupported Price Increase Report from ICER lacks balance, uses flawed methods and may harm patients.

The Institute for Clinical and Economic Review today released another edition of their deeply flawed Unsupported Price Increase (UPI) Reports in a strained narrative to keep drug prices front and center for policymakers and the press. The incomplete data and arbitrary methodology behind this report should give anyone pause before using this report for decisions on patient access. 

ICER describes itself as an independent source that transparently reviews all available evidence to help align a treatment’s price with how well it improves the lives of patients and families.1 The UPI reports do none of these things. Using ICER’s brand to suggest independence and credibility for a misleading report with a subjective and ever-shifting methodology is problematic. Collaborating with those who prioritize price over value to “minimize administrative burden” and “generate adverse publicity” exposes the motivation of these reports.2  Relying on these reports could lead to oversimplified pricing policies and limited patient access.

The report’s flaws begin with its premise. Government data, researchers, and PBMs all agree that drug prices have been flat or falling for several years. Multiple studies have demonstrated this, including recent IQVIA reports which note that net manufacturer prices for brand medicines — the cost of medicines after all discounts and rebates have been paid — declined 2.9% in 2020 and rose only 1% in 2021, continuing a 5-year trend with net prices below the CPI. 

Starting on that very shaky ground, the flaws of the UPI reports go much deeper. Considering the data selectively used by ICER – and the valuable evidence that is excluded – these reports are not powered to inform good policy:

  • ICER’s report will be used by others to encourage state action based on their findings, though ICER’s findings are already two years old when published. The “Report Year” is based on prices from the previous year and published the following year.
  • ICER only considers data during one- or two-year periods, which ignores the effects of medicines on patients’ well-being over a longer period of time, as well as fluctuations in costs and health spending.
  • The net price data ICER uses suffers from several limitations that call into question any analyses based on estimated prices of specialty, injectable, or oncology drugs3  – which account for the majority of the products ICER evaluates. In the past, ICER has acknowledged this limitation. This year, ICER sweeps it under the rug by no longer listing all drugs that they have selected for evaluation and highlighting the few for which they have good data. This decreased transparency leaves the reader wondering just how bad the data gaps are.
  • The Appendix of ICER's UPI report is rich with peer-reviewed publications submitted by manufacturers supporting the value of their products, much of which is used by payers and cited by FDA guidance on communicating health care economic information. But ICER rejects this evidence and then concludes the price increase “unsupported by evidence.” A 2021 ICER literature review accepted only 8 of 548 identified studies related to the targeted drugs.
  • ICER doubles down on their lack of patient-centeredness. ICER’s methodology rules out considering evidence related to indications for products that account for less than 10% of drug utilization. This effectively ignores the voice of patients with rare diseases and the value of effective treatments.

Hand-picking the data to arrive at a convenient narrative – like ICER does in this report – should not be mistaken for good research. To effectively address health spending, examination of all health spending drivers is essential. Selective takes and a narrow focus on medications are not conducive to having a broader dialogue or getting to the root of health spending issues.  

What will advance the debate is an emphasis on paying for value. Value is the fundamental issue regarding patient access to effective medicines: are we improving and saving lives with the investments made? The measurement of value should include a broad array of benefits that are important to patients and society. There is clear consensus on best practices for value assessments, including the principle that evaluations should focus broadly on all aspects of the healthcare system, not just on medications. ICER’s UPI methods violate this principle.

ICER’s UPI reports fall tragically short of their own goals. They often state that “Policymakers and the public in general can decide for themselves whether they feel that when the most expensive drugs in the US raise prices there should be new high-quality evidence of benefits not previously known.”4  Excluding good evidence, moving the goalposts, and ignoring overall drug and health spending trends suggests ICER has already decided for them.