{"entity":{"id":"idea-cost-value-scale-in-coverage","kind":"idea","name":"Tie coverage and copays to the ESMO benefit scale","aka":[],"tldr":"Oncology has two respected scales that grade how much a drug helps in each indication; payers could set low copays for high-grade uses and require a conversation for low-grade ones instead of blanket prior authorisation.","summary":"The ESMO Magnitude of Clinical Benefit Scale grades each indication from 1 to 5 (palliative) or A to C (curative); the ASCO Value Framework produces a net health benefit score; ICER publishes cost-effectiveness reviews. Value-based insurance design lowers cost sharing for high-value care. Applying the scales to oncology formularies (zero copay for ESMO-MCBS 4 and 5 indications, standard review for 1 and 2) would target scrutiny where benefit is smallest and remove it where the case is clear, without any payer inventing its own scoring.","asOf":"2026-09-10","links":[{"label":"ESMO-MCBS","url":"https://www.esmo.org/guidelines/esmo-mcbs"},{"label":"ICER","url":"https://icer.org/"}],"tags":[],"related":[],"cancers":[],"sections":[],"technologies":[],"targets":[],"drugs":[],"companies":[],"institutions":["esmo","asco"],"pathways":[],"terms":["icer-value-assessment"],"trials":[],"people":[],"bottlenecks":["b-drug-pricing","b-incentive-misalignment","b-knowledge-diffusion"],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"Value-tiered oncology formularies will cut prior authorisation volume for high-benefit indications by more than 80% and shift prescribing away from ESMO-MCBS grade 1 and 2 indications without reducing use of grade 4 and 5 treatments.","rationale":"The scales are public, peer-reviewed and updated; using them costs a payer nothing and is more defensible than proprietary criteria.","test":"A payer pilot applying value tiers to checkpoint inhibitor and targeted therapy indications, measuring approvals, prescribing by grade, spend and appeals.","maturity":"early-clinical","actor":"payer","cost":"small","horizonYears":2},"route":"/ideas/idea-cost-value-scale-in-coverage/","neighbours":{"institution":[{"id":"asco","kind":"institution","name":"American Society of Clinical Oncology (ASCO)","route":"/institutions/asco/"},{"id":"esmo","kind":"institution","name":"European Society for Medical Oncology (ESMO)","route":"/institutions/esmo/"}],"term":[{"id":"icer-value-assessment","kind":"term","name":"ICER and health technology assessment","route":"/terms/icer-value-assessment/"}],"bottleneck":[{"id":"b-incentive-misalignment","kind":"bottleneck","name":"Incentives reward me-too drugs and marginal gains","route":"/bottlenecks/b-incentive-misalignment/"},{"id":"b-knowledge-diffusion","kind":"bottleneck","name":"Knowledge reaches practice too slowly","route":"/bottlenecks/b-knowledge-diffusion/"},{"id":"b-drug-pricing","kind":"bottleneck","name":"Prices and value","route":"/bottlenecks/b-drug-pricing/"}]}}