Use of Net Monetary Benefit Analysis to Comprehensively Understand the Value of Innovative Treatments

Many countries use cost-effectiveness analysis to assess the value of new biopharmaceuticals and inform coverage decisions. To understand the full value of innovative treatments, comparing cost-effectiveness results from different perspectives is paramount. However, comparisons of the incremental-cost effectiveness ratios (ICER) are not suited to describing the increase in value resulting from an expansion of the analysis from the payer to the societal perspective. To address this limitation, we describe an alternative cost-effectiveness measure: net monetary benefit (NMB). Using NMB, we estimate payer and non-payer perspectives on the value of nivolumab, a novel immuno-oncology treatment for patients with pretreated advanced non-small cell lung cancer (NSCLC). NMB is calculated as the benefit of a therapy expressed in monetary terms net of all costs. Components of value considered included: (i) direct health costs and benefits (e.g., survival improvements, treatment cost), (ii) indirect health costs and benefits (e.g., caregiver burden, productivity), (iii) patient-centered value components (e.g., value of hope) and (iv) value components for patients without NSCLC (e.g., insurance value). Only direct costs are routinely included in cost-effectiveness assessments, thus excluding important value components. NMB is positive if the ICER is below the willingness to pay threshold of a quality-adjusted life-year. When the same value components are included in both approaches, these two metrics produce consistent decision-making guides. However, in our nivolumab case study, we found that a large share of the NMB was derived from indirect, patient-centered, and non-NSCLC patient value components. The NMB approach provides a useful framework that not only summarizes a therapy’s overall value, but also clearly calculates the share of a treatment’s value derived from different value components. Limiting a cost-effectiveness evaluation to the traditional payer perspective may understate the true value of immuno-oncology treatments.