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Government and Physicians May Disagree on Rx Value

Government-negotiated prices for certain Medicare drugs could go into effect as soon as 2026. But what happens when the government officials setting the price and the physicians prescribing the drugs don’t see eye to eye on the question of value?  

A new policy paper from the Alliance for Patient Access explores the challenges that lie ahead. 

About the Research 

To examine discrepancies in medication value, researchers asked 350 U.S. physicians to respond to a European government’s assessments of certain drugs for three conditions: ulcerative colitis, psoriatic arthritis and multiple myeloma.  

The research used metrics from Germany’s Federal Joint Committee, or G-BA, the centralized decision-making body in Germany’s health care system. 

Key Findings 

Only 10% of U.S. physicians agreed with the G-BA’s negative assessments of the innovative medications. And the overwhelming majority – 90% — said the medications had additional benefits for patients.  

The gap suggests that physicians and government agents approach the question of value differently, the paper explains. For instance, the research confirmed that physicians are likely to also consider real-world factors such as:  

  • Unmet needs  
  • A medication’s ability to prolong life expectancy until the next treatment is available  
  • The method and frequency of drug administration  
  • Indirect benefits, such as allowing patients or caregivers to continue working 

The research echoes similar findings from 2019, when 89% of surveyed U.S. physicians disagreed with the G-BA’s negative evaluation of innovative diabetes medications and 97% said the medications offered additional value for patients. 

A Difference in Perspective 

Government agents and physicians likely arrive at different value estimates because they approach the subject from vastly different perspectives. 

Physicians treating patients consider the nuances of the patient’s diagnosis, comorbidities, health history and lifestyle. They weigh these factors to make individualized treatment decisions, the paper notes. When government agents define medication value, however, they take a systemwide, population health approach.  

Implications for Patient Care 

Establishing drug prices based solely on a government definition of value could create challenges for patients, such as: 

  • Inability to access new treatment. Insurance plans could make certain drugs harder to access. 
  • Less personalized care. Physicians may feel compelled to make treatment decisions based primarily on cost.  
  • More frequent non-medical switching. Health plans may switch patients from effective treatment to a more profitable alternative, triggering side effects and re-emerging symptoms.  
  • Less research and medical innovation. Experts predict that 135 fewer new drugs will come to market over the next two decades.  

To ensure that patients continue to receive optimal and personalized care, government organizations must find ways to incorporate the views of physicians when establishing Medicare drug price.

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