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Value Framework Initiatives Not Yet Used in Health Plan Decision Making


While in theory value frameworks are beneficial, a survey from Avalere Health found that not many health plans are actually using them.

Value frameworks are a relatively new concept for the healthcare industry. They are a tool that helps health plans asses the value of prescription drugs and other treatments based on clinical benefit, side effects, cost, and overall improvement in the patient’s quality of life. While in theory value frameworks are beneficial, a survey from Avalere Health found that not many health plans are actually using them.

Last year, the American Society of Clinical Oncology (ASCO), Institute for Clinical and Economic Review (ICER), Memorial Sloan Kettering Cancer Center, and National Comprehensive Cancer Network (NCCN) each launched their own value framework initiatives. The new report found that all of the survey respondents acknowledged the launch of these frameworks but reported that they were not implementing them into their coverage decision-making process. The survey participants reported that while these initiatives help to open the door to conversations about the prices of prescription drugs, they are still in an early development phase and they would like to see the frameworks first tested in a provider community.

Additionally, the participating health plans said that they don’t even foresee using value frameworks as a part of coverage decision making in a year from now, suggesting that perhaps these initiatives still have a long way to go. During his time with Aetna’s oncology program, Michael Kolodziej, MD, now the national medical director of managed care strategy at Flatiron Health, had expressed a similar view.

“… speaking from the insurance company point of view, I don't see a way that the insurance company is going to use them,” he said. “But I do see a way that they are going to become an important component of shared decision making at the physician-patient level.”

Kolodziej added that there are 2 important missing elements: real-world evidence and the patient voice. (Watch the full video interview with Kolodziej.)

“Integrating broader perspectives of value—especially the patient’s view—may help value frameworks garner greater acceptance,” said Josh Seidman, senior vice president of Avalere’s Center for Payment and Delivery Innovation, in a statement. “While current frameworks lay the ground work for the continued push toward value, there’s still room for improvement.”

Avalere interviewed various medical and pharmacy directors from 11 health plans, 3 of which were large, national health plans and the remaining participants were mid-sized to smaller regional health plans, and all of the payers offered services across the Medicare, Medicaid, commercial and exchange markets. The survey was conducted from June to July 2016.

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