CVS Caremark’s misguided cost-effectiveness model has the potential to harm patients

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Recent news from CVS Health and their Pharmacy Benefit Manager (PBM) CVS Caremark has patients across Connecticut and across the nation on edge — worrying that medications they need — in some cases, life-saving medications — may not be available to them.

While the Epilepsy Foundation and its local affiliate Epilepsy Foundation of Connecticut (EFCT) appreciate the need to reign in healthcare costs, the formulas that determine what medications could be on the insurance company’s formularies simply don’t add up for patient health.

The epilepsy community is deeply concerned that CVS Caremark will offer clients the option of formularies that rely on assessments from the Institute for Clinical and Economic Review (ICER).

The new proposals would deny coverage of drugs if they do not meet a subjective “quality-adjusted life-year” (QALY)- based threshold.

Among the many troubling aspects of the CVS announcement, EFCT is concerned about the deep flaws in ICER’s cost-effectiveness analysis. In particular, CVS’s erroneous policy decisions based on cost-effectiveness ignore important differences between people with epilepsy and instead rely on a single, one-size-fits-all assessment.

Epilepsy is a unique condition and individuals respond differently to medications. A number of factors, including age, gender, daily routine, and type of seizure, can change the medication plan from one individual to another.

For some, a medication may help control seizures, but the side effects stand in the way of adherence and productivity by impacting cognitive ability, mood, and memory. While their seizures may be under control, they are not able to lead prolific lives due to the debilitating side effects of that specific medication.

This is why EFCT advocates for access to all therapeutic options for people with epilepsy and insists that an individual’s needs and preferences be taken into account — with their treating physician being the final arbiter of the appropriate medication.

For an already vulnerable population, it is also troublesome that this value framework would calculate the lives of people with disabilities and chronic diseases like epilepsy as “worth less” when compared to people that are younger or/and non-disabled. In the past, the United States has taken a strong stance against such measures as unacceptable discrimination against people with disabilities. It is essential that such measures continue to be rejected at the federal level.

CVS Health needs to stand by its stated purpose which is “helping people on their path to better health.” However, by relying on cost-effectiveness thresholds as the sole factor when determining value, they are doing the exact opposite and actually jeopardizing patients’ care.

We urge CVS Health to stay true to their purpose by abandoning this subjective QALY-based threshold measure which ignores the unique nature of epilepsy and peoples’ personal preferences, as well as makes already discriminated against populations, like the epilepsy community, susceptible to further, unnecessary adversity.

Linda Wallace is the Executive Director and Michael Finley the Connecticut Government Relations Director of the Epilepsy Foundation of Connecticut in Middletown.


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