Presentation (CTI)

OBJECTIVES: Healthcare systems and governments globally are shifting from reactive treatment to proactive disease prevention. The long-term and broader societal value of preventative therapies may not be adequately captured in current HTA frameworks. We assess how differences in HTA methodological approaches, particularly adopting a societal perspective, could influence reimbursement decisions, focusing on calcitonin gene-related peptide (CGRP) therapies for migraine prevention as a case study.
METHODS: Published evaluations for six CGRP therapies (galcanezumab, erenumab, fremanezumab, eptinezumab, atogepant and rimegepant) were identified for HTA bodies focused on cost-effectiveness: NICE, SMC, ICER, CDA-AMC, PBAC and ZIN. Key methodological characteristics, decision-making metrics and reimbursement outcomes were extracted.
RESULTS: Of 32 appraisals, productivity costs were included in six base case analyses, all conducted by ZIN. Of these, four were reimbursed for the manufacturer-defined population albeit narrower than the licensed population; separately, four required reassessments after initial evidence was insufficient for decision-making, with key uncertainties around estimation and substantiation of productivity costs. Scenario analyses including productivity costs were explored in eight appraisals, but had limited influence on outcomes despite ICER reductions: CDA-AMC did not comment on these scenarios; broader uncertainty drove a decrease in the willingness-to-pay threshold for NICE; similarly, perceived long-term value for money was reduced by uncertainty for ICER. Reimbursement rates were similar between appraisals assessing productivity losses (base case or scenario) and those that did not (100% vs 94.4%, excluding ICER assessments), although 6% fewer appraisals assessing productivity losses were recommended for the full manufacturer-defined population. This likely reflects differences in manufacturer-defined populations across HTA bodies rather than a direct effect of including productivity costs.
CONCLUSIONS: Despite widespread acknowledgement of productivity losses, a societal perspective was rarely adopted. Where adopted, including productivity costs reduced ICERs but these reductions were generally not reflected in final decision-making, with evidence uncertainty remaining a key barrier to demonstrating value.