OBJECTIVES: Headlines for new pharmaceutical products often emphasize product list prices as ‘too high’ to support cost-effectiveness, citing ICER appraisals as evidence, which perpetuates an impression that price is the key driver of results. This review of ICER assessments seeks to understand the extent to which product list price is the key driver of cost effectiveness ratios in ICER assessments.

METHODS: Publicly available ICER reports from January 2021 to December 2023 were reviewed, pertaining to 47 therapies across 24 conditions. One-way sensitivity analyses from the reports were catalogued to understand which model parameters had the largest impact on cost-effectiveness ratios. ICER responses to public comments were also utilised to further understand analytical context.

RESULTS: A total of 47 therapies were reported across 24 conditions, with 6 stating price as the primary cost-effectiveness driver, and 41 other primary drivers not related to therapy pricing.

43% (n=20) of treatments were for chronic, widespread conditions representing a high disease burden in the US (e.g. hypercholesterolemia, obesity, type 2 diabetes). 11/20 chronic therapies listed utility costs as a main driver for cost-effectiveness. 34% (n=16) represented progressive atypical disorders (e.g. ALS). 10/16 atypical therapies were primarily driven by either the hazard ratio of progression, or progression free survival. 23% (n=11) were indicated for rare disease, with a variety of primary influences, including health state associated costs and risk of hospitalization.

CONCLUSIONS: Headlines skew perceptions about pharmaceutical price as the key driver of cost-effectiveness in the US. In the majority of ICER reviews, sensitivity analysis endorsed by the organization show that price is not the primary driver of results. This is true for progressive conditions that will be costly over time, and for chronic conditions with inadequate standard care. Early cost-effectiveness modelling can identify these alternative drivers to price prior to clinical trial and commercialization strategy.