Understanding the National Institute for Health and Care Excellence Severity Premium: Exploring Its Implementation and the Implications for Decision Making and Patient Access

Martin W Njoroge; Matthew Walton; Robert Hodgson

doi:10.1016/j.jval.2024.02.013

Understanding the National Institute for Health and Care Excellence Severity Premium: Exploring Its Implementation and the Implications for Decision Making and Patient Access

Value Health. 2024 Mar 4:S1098-3015(24)00085-8. doi: 10.1016/j.jval.2024.02.013. Online ahead of print.

Authors

Martin W Njoroge¹, Matthew Walton¹, Robert Hodgson²

Affiliations

¹ Centre for Reviews and Dissemination, University of York, York, England, UK.
² Centre for Reviews and Dissemination, University of York, York, England, UK. Electronic address: rob.hodgson@york.ac.uk.

PMID: 38447743
DOI: 10.1016/j.jval.2024.02.013

Abstract

Objectives: This study aimed to evaluate the impact of the National Institute for Health and Care Excellence's (NICE) new severity modifier, which has replaced the end-of-life (EoL) premium, on future NICE recommendations, considering past decision-making patterns.

Methods: NICE technology appraisals (TAs) published between January 2020 and December 2022 were reviewed. Summary statistics were generated to assess how the new severity modifier might affect hypothetical decision making in historical TAs.

Results: A total of 138 data points were identified from 132 TAs. Although the EoL premium was applied in 46 appraisals (33%), 57 (39%) qualify for a severity-based quality-adjusted life-year (QALY) multiplier. Only 19 appraisals (14.6%) not receiving an EoL premium met the severity criteria, the majority (17) qualifying for a 1.2× multiplier. In appraisals predicted to meet the severity criteria, 45 (79%) were in oncology, making them 4.04 times (95% CI 1.91-9.02) more likely to qualify for a severity modifier than nononcology indications. Among historically EoL indications, 42 (91%) were predicted to meet the severity criteria, making them 14.8 times (95% CI 6.37-37.6) more likely to qualify for a severity modifier.

Conclusions: The new severity modifier will predominantly benefit oncology indications, continuing their previous explicit prioritization under the EoL decision modifier. However, the new severity modifier is harder to achieve and less generous; only a fraction of appraisals qualify for the highest effective £51 000 per QALY threshold. The vast majority of indications previously approved at £50 000 per QALY would now need to meet a cost-effectiveness threshold of <£36 000. This may necessitate greater pricing flexibility from manufacturers and increase the likelihood of negative recommendations.

Keywords: NICE; decision making; end of life; reimbursement; severity modifier.