The Rise of Health System-Led Value Frameworks

For a long time, the U.S. value assessment landscape had a recognizable shape. ICER (the Institute for Clinical and Economic Review) played the role of the independent watchdog, publishing cost-effectiveness analyses that payers loved to cite, and manufacturers loved to criticize. Professional associations and medical societies developed guidelines that governed clinical decision-making. Manufacturers built their evidence dossiers around these external frameworks because that’s where the conversations were happening.

That is no longer the whole picture. Value assessment frameworks have evolved to include more stakeholders, each applying different criteria to assess product value and determine how therapies fit into everyday clinical and operational workflows. Increasingly, large IDNs and health systems, including Kaiser Permanente, Intermountain, Cleveland Clinic, Mass General Brigham, Providence, Geisinger, Ascension, and a growing list of regional systems, are building their own internal value frameworks. These are not just clinical pathways. They are full economic models that factor in each system’s patient population, payer mix, site-of-care economics, and growing downside risk exposure under value-based contracts.

Why These Frameworks Are Different

• They’re built around population-level needs, not contractual economics. ICER asks: “Is this drug cost-effective for society at a $100K-$150K per QALY threshold?” An IDN/Health System framework asks: “Does this drug help us manage our total cost of care and hit our risk arrangements as the diversity of payers we are contracted with all have unique payment mechanisms?” Completely different question. Completely different answer.
• They incorporate site-of-care and operational realities. Traditional frameworks did not account for where a drug is being administered, however IDN/Health System frameworks scrutinize this data. The same drug can be a winner or a loser depending on where it’s administered and who’s paying.
• They weigh real-world evidence differently. NCCN and ICER privilege randomized controlled trial data. IDN/Health System frameworks increasingly want to see improvement in patient outcomes and reduction in unnecessary utilization to indicate evidence on how a drug performs in their population. This outcomes focus is why partnerships with systems on RWE generation have become so strategically valuable.
• They’re often tied to specific contracts. Some IDN/Health System frameworks are essentially translation layers between manufacturer contracts and internal clinical decisions. A drug with an outcomes-based contract may rank differently than a drug at the same net price without one.

What This Means for Manufacturers

A few hard truths:

• Your global value dossier isn’t enough. You need to develop IDN/Health System-specific value narratives that speak to their population health outcomes and their contracts.
• Medical affairs teams need IDN/Health System-fluency. MSLs who can only discuss pivotal trial data don’t stand a chance in this evolving landscape. The conversation has moved to finding shared priorities around high-risk patient populations tied to budget impact within the system’s specific risk arrangements.
• HEOR teams need to engage population health and quality roles directly. These are active health system roles, often serving as influencers or key decision makers, and they’re open for credible partnerships around the quintuple aim.
• One-size-fits-all account plans don’t work. Strategies must be tailored to each system’s decision-making model, site-of-care dynamics, and priorities.

The implication is clear: value is no longer adjudicated at a distance. It is built, tested, and decided within the walls of the IDN/Health Systems. Manufacturers who continue to anchor their strategy in global narratives alone will find themselves misaligned with the decisions that actually matter. Success now depends on the ability to meet each system on its own terms, with data, economics, and partnerships that reflect its reality.