The ICER Value Framework: Integrating Cost Effectiveness and Affordability in the Assessment of Health Care Value

What should be the relationship between the concepts of cost effectiveness and affordability in value assessments for health care interventions? This question has received greater attention in recent years given increasing financial pressures on health systems, leading to different views on how assessment reports and decision-making processes can provide the best structure for considering both elements. In the United States, the advent of explicit value frameworks to guide drug assessments has also focused attention on this issue, driven in part by the prominent inclusion of affordability within the value framework used to guide reports from the Institute for Clinical and Economic Review. After providing a formal definition of affordability for health care systems, this article argues that, even after using empirical estimates of true health system opportunity cost, cost-effectiveness thresholds cannot by themselves be set in a way that subsumes questions about short-term affordability. The article then presents an analysis of different approaches to integrating cost effectiveness and budget impact assessments within information to guide decision making. The evolution and experience with the Institute for Clinical and Economic Review value framework are highlighted, providing lessons learned and guiding principles for future efforts to bring measures of affordability within the scope of value assessment.