ICER Counts Lung Cancer Patients as 2/3 of a Healthy Person

  • by: Robert Goldberg |
  • 10/26/2016
ICER released a report claiming that at retail prices,  immunotherapies (Tecentrig, Keytruda and Opdivo)  for non small cell lung cancer (after a first line of treatment) are not worth using compared to a 20 year old drug (docetaxel) that is 3-4 times less likely to help patients and when it does work, is half as effective in extending life and generating a treatment response.   The table below shows the significant clinical benefits of new drugs that block PDL-1 and PD-1 protein expression, 
Drug Ratio of Patients Likely to    Benefit from Immunotherapy Compared to Docetaxel Expected Survival in Months Differnce in Duration of Response in Months
Docetaxel   8.5  
Acentriq 3.4 14.8 7.2
Opdivo 4.0 11.1 11.6
Keytruda 3.8 19.4 Not reached
  Source: Institute for Clinical and Economic Review, Evidence Report - Non-Small Cell Lung        Cancer, Table 6 page 36 and Table 10 page 45

ICER determined that the maximum amount of money to be spent on an additional year of life in perfect health -- a quality adjusted life year (QALY) is $150K.   Which means that most of the new drugs developed and to extend the life of lung cancer patients over the past ten years would not be used. 

Applying the ICER QALY calculations to lung cancer patients over the past ten years, I found that if ICER had its way 10 years ago, and denied access to new lung cancer drugs, today the death rate from lung cancer would be 23 percent higher.  And the cost of care will be more expensive, increasing hospital related costs by $3 billion a year.

ICER ignores indirect costs, such as lost productivity and caregiver salaries or the productive possibilities of being able to make plans to marry, raise kids, compose music, travel, go to school. ICER ignores the value of two additional years of life to a patient who has run out of options.

But the worst element of the ICER framework is how it devalues the additional months and years of life people with advanced lung cancer can get from newer medicines.  

At face value ICER’s QALY standard of value is arbitrary. Patients who live twice as long as those taking a generic drug should be credited with the total years of extended life.  ICER believes that an additional year of life for a lung cancer patient is really worth two-thirds of an additional year of life for a healthy person.  


Where has this metric been used before?    Article 1, Section 2, Paragraph 3 of the United States Constitution, which allowed slave states and their collective slave drivers to count each of their slaves as 3/5 of a white man.  

To mind the use of a QALY in determining access and drug prices violates the spirit, if not the letter of the Equal Protection Clause.

Worse (perhaps)ICER uses that same discriminatory rationale by assigning a lower value to patients and a higher value to insurers.   When it comes to patients, ICER uses the retail price of the drug to determine a QALY   When it comes to payors,  ICER uses the price or cost of the drug LESS any cost savings generated. 
Immunotherapy  Payer Cost per patient 
net of drug generated savings 
Cost used for patient QALY  
Tencentriq       39000   102519    
Keytruda 73900 108841  
Opdivo  44500 180489    

ICER is the worst example of how economic analysis has been applied to health care.  In the end, it is not about numbers. It is about people and the additional years and vitality medical innovation generates.  ICER is not alone in failing to factor in the economic value of hope or the virtue of forward looking, of having a project.

Modern medicines are extending lives, improving lives and saving lives. Setting an arbitrary limit on what that is worth is simply closing the door on medical progress, increasing the death rate and driving up costs at the same time.  And it also forecloses the possibilities of life that, while intangible or uncounted, adds more to our well-being than consumption.  As the great economist Irving Fisher noted: The true “wealth of nations” is the health of its individuals. And greater health through the diffusion of medical innovation is the most important way to eliminate inequality and eliminate barriers to people battling disease. ICER's value framework diminishes the value of longer life as part of an effort to show most new drugs are NOT cost effective.   In doing so, it is violating the civil rights of people because they have lung cancer.   


Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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