Influence of Institute for Clinical and Economic Review (ICER) Reports in Formulary Decision Making

BACKGROUND: The Institute for Clinical and Economic Review (ICER) is a non-profit organization which conducts evidence-based reviews of health care interventions. The ICER Integrated Evidence Rating™ assesses the comparative clinical effectiveness and comparative value based on price expectation to arrive at an overall rating. This method for rating the clinical effectiveness is modeled on the “Evidence-Based Medicine (EBM) matrix.”

OBJECTIVES: To assess the influence of ICER ratings on formulary decision making process

METHODS: Data from ICER Reports outlining the EBM ratings published from 2015-2022 was extracted and categorized by rating. The data were then matched with the respective therapeutic formulary coverage. The findings were confirmed in primary research with US payers

RESULTS: A total of 71 ICER reports were analyzed. The ratings based on the EBM matrix for approximately 236 products were reported and grouped. Our analysis found that 86 products received a rating of either A (Superior) or B (Incremental), 44 received a rating of B+ (Incremental or better) and 85 received a rating of C- (Comparable or inferior), P/I (Promising but inconclusive) or I (Insufficient). Furthermore, looking at the key formulary management, there was no correlation between ICER rating and formulary status. Based on primary research, Payers believe that ICER ratings play little-to-no role in most formulary decisions, as plans tend to carry out their own assessment of product value with a clinical evaluation similar to current ICER protocols. ICER reports are, however, frequently used in contract negotiations wherein positive ratings do not guarantee price premiums and easier access, but negative ratings can drive lower prices and restricted access.

CONCLUSIONS: Managed care organizations (MCO) evaluate products according to their formulary positions irrespective to ICER ratings. The ICER reports are frequently used in contract negotiations, especially in cases where a novel therapy has received a negative rating.