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Examining Definition Discrepancies for Curative Therapies From a Payer Perspective

Coverage decisions for curative therapies can vary greatly due to their extended benefit/risk profiles and differing definitions by payers, according to research presented at AMCP Nexus 2020. 

“Curative therapies are generally described as one-time, or short-term, treatments for patients with diseases that would otherwise require treatment for the duration of a patient’s life,” explained Anuja Kanaskar, PharmD, MS, formerly with Xcenda at time of abstract submission, and colleagues in a poster presentation. 

Dr Kanaskar and co-researchers conducted a study in which coverage decision patterns for curative therapies were examined, and surveyed US payers on the Institute for Clinical and Economic Review’s (ICER) recently published report:“Value Assessment Methods and Pricing Recommendations for Potential Cures: A Technical Brief,” which outlines considerations for the assessment of potential curative therapies.

The researchers surveyed a final total of 152 payers from national and regional health plans, integrated delivery networks, and pharmacy benefit managers via the platform FormularyDecisions. This online platform was designed to support a bidirectional exchange between payers and manufacturers and facilitate access to critical product evidence and includes more than 2100 registered health care decision makers.

From the survey conducted in March 2020, 83% of respondents reported having some familiarity and knowledge regarding curative therapies but only 5% said their organizations had a standard definition for curative therapies. 

The highest reported decision-making drivers for curative therapies included cost-effectiveness data (77%), comparator data (75%), and post-launch real-world evidence (72%). In terms of payment models, outcomes-based payments were the most frequently considered (53%) and implemented (20%) by organizations to mitigate the high costs of curative therapies.

“When asked about familiarity with ICER’s brief, 62% were not at all or not very familiar; however, a majority (88%) were at least somewhat likely to consider utilizing it to assess the value of curative therapies,” said researchers.

 “Manufacturers should work closely with payers to better define curative therapies, since these definitions may impact payer coverage decisions, development of alternate payment models, and value assessment methods,” concluded the poster presenters. “With an increasing number of curative therapies in the pipeline, future research should examine factors that impact payer decision making for curative therapies.”

The authors of the study noted that caution should be taken when generalizing results from this survey as results are based on a small sample of recruited health care decision makers and are primarily qualitative in nature. —Edan Stanley

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