Leveraging real-world evidence to maximize reimbursement decision-making
Industry experts gathered at the TELUS Health Annual Conference to discuss the potential of real-world evidence (RWE) in improving reimbursement decision-making for private drug plans.
RWE, drawn from outside clinical trials, offers valuable insights into drug performance and cost management for payors.
Unlocking value for money
Bobby Currie, manager of Pharmaceutical Relations at Canada Life, stressed the importance of assessing drug value and effectiveness for patients. Real-world evidence fills the gap left by clinical trials, confirming a drug's efficacy and supporting value assumptions.
"When a drug is showing a lot of promise in a devastating or life-threatening condition, sometimes patients don’t really want to wait for every ‘i’ to get dotted and every ‘t’ to get crossed. As a payor, though, we really need to be thinking about [questions such as] is that drug going to live up to that promise [and] is there value for money?” said Currie. “Real-world evidence can help fill that gap. It can help us confirm effectiveness for those patients and support that assumption of value.”
Currie sees RWE as a means to improve access, lifecycle management, and health outcomes while addressing challenges such as data integration and the need for reliable data.
Expanding evidence base
Nicole Mittmann, chief scientist and vice-president at CADTH, highlighted the increasing role of RWE in healthcare decisions. She defined RWE as “evidence about the use, safety, and effectiveness of a medical product, technology or drug that is based on data from the real-world health care setting.”
According to her, while RWE fills uncertainty gaps, it does not replace clinical trials or guarantee greater access. CADTH aims to develop RWE guidance, including quality and reporting standards, for regulatory and health technology submissions in Canada.
“The work that we’re trying to do is expand the evidence base, and then [decide] how do we enhance our deliberations using that evidence at our organization [and] how do we actually start [to] build a common metric around [RWE] with respect to standards and outcomes,” said Mittmann.
RWE producer perspective
Karine Grand'Maison, vice president of access and government relations at Pfizer emphasized the complementary nature of RWE with clinical data.
She emphasized that RWE enables private payors to assess value, understand patient needs, facilitate innovative contracting, and ensure timely access to drugs. In addition, she mentioned that collaboration and early engagement among stakeholders are vital for effective RWE decision-making.
“The workforce in Canada is counting on all of us to provide timely and appropriate access to drug treatments and vaccines. In some cases, we’ll need real-world evidence to help facilitate the value assessment and the reimbursement decision,” said Grand'Maison. “The best way to make that happen is to collaborate as early as possible in the process so we can make sure that all the perspectives are taken into account.”
Consultant perspective
Catherine Beauchemin, partner at PeriPharm, highlighted how RWE addresses critical questions for payors.
Through case studies, she demonstrated the impact of RWE gaps on decision-making, underscoring the need for comprehensive evidence on therapeutic and economic value. PeriPharm's Proxy Network aims to generate patient-centered evidence, offering a new source of RWE.
“Canadian payors need comprehensive evidence on the therapeutic and economic value of a new drug,” said Beauchemin. “Although real-world evidence will never replace the randomized controlled trial, it undeniably brings value to drug assessments and helps better inform decisions. Considering the increasing cost of specialty drugs and drugs for rare diseases, real-world evidence will certainly become a pillar in health care decision-making.”
Consensus on RWE for drug plan sustainability
Despite different perspectives, the panellists unanimously agreed on the value of RWE in navigating rising drug costs.
According to the panellists, RWE was seen as part of the solution moving forward. In 2022, the top 10 most expensive drugs from the TELUS book of business had an average cost per claimant ranging from $400,000 to $1,800,000 per year. Plan sponsors recognized the importance of acquiring as much information as possible to make informed decisions and safeguard the long-term sustainability of their drug plans.
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