As Chairman of the Partnership to Improve Patient Care (PIPC), I could not be more pleased to see the widespread emphasis among health stakeholders on advancing health equity. As stated by the Centers for Disease Control, racism is a public health crisis. It will take all facets of the health care system to address the effects of stigma and discrimination on health and access to health care.
Therefore, I am excited for a new report published by the National Minority Quality Forum, Global Liver Institute, Preparedness and Treatment Equity Coalition and the Partnership to Improve Patient Care, that provides health technology assessment (HTA) organizations, health systems, payers, and policymakers that want to center their value assessment work on health equity several recommendations from constituencies whose voices are too often omitted from their work – Black, Indigenous, and people of color (BIPOC) patients and people with disabilities. PIPC was proud to moderate the development of this report and to highlight the perspectives of leading experts on issues related to health equity and the implications of HTA on health equity.
The report is timely for many reasons. First, organizations conducting value assessments are currently engaged in their own processes for addressing the historical biases inherent in HTA methodologies. For example, the Institute for Clinical and Economic Review (ICER) received a grant from the Commonwealth Fund to “evaluate procedural and methodological changes that could further support health equity goals in health technology assessment (HTA).” As ICER updates its broader value framework, advocates hope their health equity process leads to a higher bar for inclusion in the data that informs their value assessments, better methods and a commitment to meaningful engagement from BIPOC patients and people with disabilities. Additionally, the Innovation and Value Initiative has initiated a 2-year Health Equity Initiative aimed at embedding health equity throughout its “research projects, educational offerings, and patient and stakeholder engagement activities to catalyze action in the development of methods in value assessment that promote equity in health access and outcomes.”
Second, the report is timely as the Center for Medicare and Medicaid Services (CMS) made health equity a pillar of its strategic plan and is undergoing efforts to implement a process of establishing a “fair price” for prescription drugs as required by the Inflation Reduction Act. Also, the Centers for Medicare and Medicaid Innovation (CMMI) is responding to an Executive Order calling for ideas on new health care payment and delivery models that would “lower drug costs and promote access to innovative drug therapies.” As part of these ongoing efforts, PIPC supports policies that will drive affordable access to high quality care for patients and people with disabilities in a manner that does not prioritize program savings over a patient’s affordable access to care.
For these policymakers, the report highlights how the reliability of research and value assessment are compromised for certain subpopulations omitted from the data and its implications for exacerbating health inequity. It will be essential for CMS and CMMI to establish patient-centeredness standards for the high-quality evidence the agencies will allow to be considered in making decisions about coverage and reimbursement to ensure it is centered on the value proposition of treatments for all people. Flawed HTA will work against the agencies’ health equity goals by entrenching its inherent bias into decisions impacting care access.
Third, the report is timely as states such as Oregon continue to rely on flawed sources of evidence to make decisions about access to care for Medicaid beneficiaries. The Health Evidence Review Commission (HERC) advises the Oregon Health Authority on what services are prioritized for coverage under Medicaid. Deprioritized services are not covered, regardless of medical necessity. Despite early efforts in 1992 by HHS to prevent Oregon from relying on the discriminatory metric called the quality-adjusted life year (QALY) to determine what services would be covered, the HERC now openly acknowledges how it has continued to use the metric and sought comments on a policy to embed its continued use. Throughout the states, there is evidence of Medicaid programs relying on QALY-based value assessments to make coverage and utilization management decisions, too often resulting in hurdles to affordable, quality care that exacerbate existing health disparities. The HHS Office for Civil Rights is currently considering regulations that would safeguard against the use of discriminatory metrics in value assessment as part of its Section 1557 rulemaking, potentially driving a nondiscrimination standard for the evidence that states are allowed to consider in making decisions in their Medicaid programs.
As experts in research and health economics, HTA organizations have an opportunity to work alongside other health care stakeholders in this effort to advance health equity. Doing so will require acknowledging the historical bias of value assessment methodologies, and a commitment to engaging with impacted patients and people with disabilities to do better in the future. Until then, payers and policymakers committed to health equity should avoid relying on value assessments to drive their decisions.
The report is timely for many reasons. First, organizations conducting value assessments are currently engaged in their own processes for addressing the historical biases inherent in HTA methodologies. For example, the Institute for Clinical and Economic Review (ICER) received a grant from the Commonwealth Fund to “evaluate procedural and methodological changes that could further support health equity goals in health technology assessment (HTA).” As ICER updates its broader value framework, advocates hope their health equity process leads to a higher bar for inclusion in the data that informs their value assessments, better methods and a commitment to meaningful engagement from BIPOC patients and people with disabilities. Additionally, the Innovation and Value Initiative has initiated a 2-year Health Equity Initiative aimed at embedding health equity throughout its “research projects, educational offerings, and patient and stakeholder engagement activities to catalyze action in the development of methods in value assessment that promote equity in health access and outcomes.”
Second, the report is timely as the Center for Medicare and Medicaid Services (CMS) made health equity a pillar of its strategic plan and is undergoing efforts to implement a process of establishing a “fair price” for prescription drugs as required by the Inflation Reduction Act. Also, the Centers for Medicare and Medicaid Innovation (CMMI) is responding to an Executive Order calling for ideas on new health care payment and delivery models that would “lower drug costs and promote access to innovative drug therapies.” As part of these ongoing efforts, PIPC supports policies that will drive affordable access to high quality care for patients and people with disabilities in a manner that does not prioritize program savings over a patient’s affordable access to care.
For these policymakers, the report highlights how the reliability of research and value assessment are compromised for certain subpopulations omitted from the data and its implications for exacerbating health inequity. It will be essential for CMS and CMMI to establish patient-centeredness standards for the high-quality evidence the agencies will allow to be considered in making decisions about coverage and reimbursement to ensure it is centered on the value proposition of treatments for all people. Flawed HTA will work against the agencies’ health equity goals by entrenching its inherent bias into decisions impacting care access.
Third, the report is timely as states such as Oregon continue to rely on flawed sources of evidence to make decisions about access to care for Medicaid beneficiaries. The Health Evidence Review Commission (HERC) advises the Oregon Health Authority on what services are prioritized for coverage under Medicaid. Deprioritized services are not covered, regardless of medical necessity. Despite early efforts in 1992 by HHS to prevent Oregon from relying on the discriminatory metric called the quality-adjusted life year (QALY) to determine what services would be covered, the HERC now openly acknowledges how it has continued to use the metric and sought comments on a policy to embed its continued use. Throughout the states, there is evidence of Medicaid programs relying on QALY-based value assessments to make coverage and utilization management decisions, too often resulting in hurdles to affordable, quality care that exacerbate existing health disparities. The HHS Office for Civil Rights is currently considering regulations that would safeguard against the use of discriminatory metrics in value assessment as part of its Section 1557 rulemaking, potentially driving a nondiscrimination standard for the evidence that states are allowed to consider in making decisions in their Medicaid programs.
As experts in research and health economics, HTA organizations have an opportunity to work alongside other health care stakeholders in this effort to advance health equity. Doing so will require acknowledging the historical bias of value assessment methodologies, and a commitment to engaging with impacted patients and people with disabilities to do better in the future. Until then, payers and policymakers committed to health equity should avoid relying on value assessments to drive their decisions.
