Employers need confidence that their advisors are using value assessment models that account for the factors that are important to both the patient and the payer. (Image: Shutterstock)

Employers rely on their health plans and benefits consultants to advise them on coverage for a particular drug or treatment, based on data about clinical benefits as well as costs. With steadily rising prices and new therapies, however, employers face increasingly tough choices about coverage that affect both employees and company budgets. Employers have been pleased (so far) that their third-party advisors evaluate the evidence and make recommendations and decisions on their behalf.

And yet, there is growing recognition that such recommendations may not be based on fully relevant data that includes the factors that employers care most about. Beyond just clinical evidence, employers care about real-world patient experience and costs, including indirect costs like employee absenteeism. If employers are uncertain about the information their trusted advisors use to make recommendations and decisions, how can they be confident they are offering the right coverage to employees and their families?

Value assessment status quo: Limited, opaque methods

When making their recommendations and decisions about coverage, health plans and consultants rely on a combination of analyses, including value assessments published by organizations like the Institute for Clinical and Economic Review (ICER). By looking at clinical data and expected costs to assess cost-effectiveness, ICER posits a target "acceptable" launch price for a given drug/therapy.