This week, the Institute for Clinical and Economic Review (ICER) and the U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management Services office announced a partnership to integrate ICER’s value assessment framework in the VA’s formulary management process.
While NPC supports efforts to improve veterans’ health care, enhance the use of value as the underpinnings for health care decision-making in the VA, and improve the transparency in the VA process, we have some concerns about this collaboration. Value assessment frameworks have the potential to be effective tools for advancing patient care and achieving better clinical, economic and humanistic outcomes. Used effectively, frameworks could provide transparency and enhance the use of value in the VA decision-making process. But today’s frameworks are not without their flaws. Some of these shortcomings are critical to consider, especially if they are being used to evaluate treatments for our vulnerable VA population.
To begin with, taking a “one-size-fits-all” approach and using one framework alone to evaluate a health care treatment or intervention is not sufficient to determine care for a diverse population. When considering the varied and often complex health needs of veterans, decision-makers require far more information. Utilizing multiple frameworks and other decision-making tools can provide important and different perspectives, like those of physicians, consumers and especially patients.
Payers also rely on evidence about treatments that is available at a given point in time, which can be limited to a particular population or outcome. Evidence evolves over time, providing a greater understanding of how a product works in the real world or in patients with multiple comorbidities. While payers routinely update their coverage decisions as this new evidence evolves, ICER assessments are a static representation of evidence at a point in time. ICER does not conduct routine updates to its assessments as new findings become available, in fact it has only conducted a supplemental “brief evidence update” one time. Outdated information could hurt, rather than help patients; we hope that won’t be the case in this partnership.
In addition, ICER’s framework is heavily focused on a health system perspective, as is the VA. But looking through the health system lens alone minimizes the importance of societal benefits and costs and their impact on patients’ lives. Many factors that are important to veterans and their families are not typically considered or quantified in value assessments. For veterans who are seeking treatment for PTSD or other serious conditions, the ability to manage their mental and physical health, improve their quality of lives and reduce the burden on their families and other caregivers are among their many important concerns that are not often captured in an assessment.
If the use of multiple value assessment frameworks by organizations such as the VA brings greater value to our veterans, who have given so much for their country, then this could be a positive development. But frameworks cannot be used in a vacuum. It’s incumbent upon the VA and ICER to ensure that a broad array of evidence is used and regularly updated, a variety of frameworks and stakeholder input is considered, and the factors that are important to veterans and their families are included in decision-making. We need to ensure our veterans are being provided not just with health care, but with valuable, effective health care.
For more information on value assessment frameworks, see NPC's Guiding Practices for Patient-Centered Value Assessment, our landscape assessment of value frameworks and other related resources.