Expanding the Use of Real- World Evidence in Regulatory and Value-Based Payment Decision-Making for Drugs and Biologics July 2019 LEADERSHIP William H

Expanding the Use of Real- World Evidence in Regulatory and Value-Based Payment Decision-Making for Drugs and Biologics July 2019 LEADERSHIP William H. Frist, M.D. Mark McClellan, M.D., Ph.D. Former U.S. Senate Majority Leader Robert J. Margolis Professor of Business, Medicine, Senior Fellow, Bipartisan Policy Center and Policy, Duke University Founding Director, Duke-Margolis Center for Robert Califf, M.D., Ph.D. Health Policy Professor of Medicine, Donald F. Fortin, M.D., Former Administrator, Centers for Medicare and Professor of Cardiology, Duke School of Medicine Medicaid Services Member, Duke Clinical Research Institute Former Commissioner, Food and Drug Administration Former Commissioner, Food and Drug Administration Andrew von Eschenbach, M.D. President, Samaritan Health Initiatives Former Commissioner, Food and Drug Administration Former Director, National Cancer Institute Senior Fellow, Bipartisan Policy Center STAFF G. William Hoagland Janet M. Marchibroda Senior Vice President Fellow, Bipartisan Policy Center CONSULTANTS Gregory Daniel, Ph.D., R.Ph. Morgan Romine Deputy Director, Duke Margolis Center for Research Director, Duke Margolis Center for Health Policy Health Policy Clinical Professor, Fuqua School of Business, Mark Segal, Ph.D., FHIMSS Duke University Principal, Digital Health Policy Advisors ACKNOWLEDGMENTS The Bipartisan Policy Center would like to thank the Jayne Koskinas Ted Giovanis Foundation for Health and Policy for their generous support for this project. BPC would like to thank the leadership of this effort, including Senator Bill Frist, Dr. Rob Califf, Dr. Mark McClellan, and Dr. Andrew von Eschenbach, for their guidance, as well as Morgan Romine, Gregory Daniel, Mark Segal, and Ann Gordon who contributed to the development of this report. BPC would also like to thank several members of the BPC and Duke-Margolis Center for Health Policy staff, including Anand Parekh and Katherine Hayes of BPC and Marianne Hamilton-Lopez, Christina Silcox, and Nirosha Mahendraratnam Lederer of the Duke-Margolis Center for Health Policy, who reviewed and provided input to the report. Finally, BPC would like to extend its gratitude to the number of individuals—listed in the acknowledgments section—who participated in roundtable discussions, interviews, and meetings, to inform the development of report. DISCLAIMER The findings and recommendations expressed herein do not necessarily represent the views or opinions of the Bipartisan Policy Center’s founders or its board of directors. 2 bipartisanpolicy.org Letter from the Former FDA Commissioners Exciting progress has been made in recent years in the discovery and development of new therapies and treatments, particularly for patients fighting diseases thought to be incurable just a generation ago. Scientific breakthroughs coupled with a faster, more streamlined process for the development of novel drugs and biologics is accelerating the pace at which patients are receiving new, more effective treatments. But this acceleration is also enabling market entry based on biomarkers and surrogates rather than definitive information about risks and benefits in practice. These advances are set against the backdrop of continually rising health care costs, declining life expectancy, and ongoing concerns about affordability and disparities in the U.S. health care system. Efforts to shift from volume-based to value-based payment for care delivery are showing promise and providing lessons that can inform new models of payment for medical products that can help address these concerns. Just as the life cycle of drug development is being modernized through the use of real-world data and real-world evidence, so too can new models of value-based payment benefit from data generated through care processes and by patients themselves. Real-world data and evidence can improve regulatory and payment decision-making. It can also provide generalizable knowledge to support clinician and patient decision-making. We have already made significant progress in creating a framework for the use of real-world evidence in regulatory decision-making, but there is more work to do. This report examines both the progress so far and the barriers we must address if we are to meaningfully expand the role of real- world data and evidence to inform the discovery, development, and delivery of new therapies for patients, provide high-quality evidence about risks and benefits in practice, and inform which therapies are best for which patients. The report’s recommendations focus on clearing barriers to the access and use of real-world data to provide an evidence base for regulatory evaluation and value-based payment programs, expanding opportunities to use new data sources and approaches, and advancing new models of collaboration among payers, manufacturers, regulators, clinicians, and—most importantly—patients. We are living in an age of remarkable scientific progress. We owe it to the patients we serve to support that progress by continually examining and improving our processes to deliver new, effective therapies to them as fast as is safely possible. We believe the recommendations in this report are important steps toward reaching that critical goal. Sincerely, Robert Califf, M.D., Ph.D. Andrew von Eschenbach, M.D. Mark McClellan, M.D., Ph.D. Professor of Medicine, Donald F. Fortin, M.D., President, Samaritan Health Initiatives Robert J. Margolis Professor of Business, Professor of Cardiology, Duke School of Medicine Former Commissioner, Food and Medicine, and Policy, Duke University Member, Duke Clinical Research Institute Drug Administration Founding Director, Duke-Margolis Center for Former Commissioner, Food and Former Director, National Cancer Institute Health Policy Drug Administration Former Administrator, Centers for Medicare and Medicaid Services Former Commissioner, Food and Drug Administration bipartisanpolicy.org 3 5 Executive Summary 10 Introduction 12 Using Real-World Evidence to Support Value-Based Payment 14 Using Real-World Evidence to Support Regulatory Evaluation 17 Policy Recommendations Assuring Adequate Funding of Real-World Evidence Activities Improving Regulatory Clarity Improving Access to Data Improving Reliability and Relevance of Data Leveraging Technology to Gain Input Directly from Patients Expanding Efforts to Leverage Artificial Intelligence Accelerating Pilots and Demonstration Projects for New Data Sources and Additional Medical Products Assuring Privacy and Confidentiality Advancing Innovative, New Models of Drug Development Addressing Regulatory Barriers Expanding CMS Workforce to Support Evaluation of New Emerging Therapies Promoting Cooperation and Collaboration 39 Conclusion 40 Acknowledgments 41 Endnotes 4 bipartisanpolicy.org Executive Summary The amount of electronic health care data is increasing at unprecedented rates, due to the now widespread adoption of electronic health records (EHRs) and other technology in health care, as well as the significant increase in the number of patients that are now using technologies—such as wearables, biosensors, apps, and other digital health tools—to track their activities and health status and connect with the health system. These real-world data sources provide the opportunity to improve the evidence base for the development of new drugs and biologics, regulatory evaluation by the Food and Drug Administration (FDA), and new value-based payment arrangements, which align pricing or payments with outcomes. Real-world data and evidence have significant bipartisan support. Several provisions related to real-world evidence were contained in the 21st Century Cures Act passed and signed into law in December 2016, as well as the FDA Reauthorization Act of 2017 and other user fee legislation passed in 2017. The FDA has taken several steps to advance the generation and use of real-world evidence for regulatory decision-making, including the publication of the Framework for FDA’s Real-World Evidence Program (FDA Framework) in December 2018. While there are many opportunities to leverage these new data sources as real-world evidence to support regulatory efforts and new value-based payment arrangements for drugs and biologics, there are also barriers to their use. The recommendations below are expected to advance the generation and use of real-world evidence for regulatory evaluation and value-based payment decision-making. 1. ASSURING ADEQUATE FUNDING OF REAL-WORLD EVIDENCE ACTIVITIES 1.1 Fully Fund the FDA’s FY2020 Budget Request for the Creation of a New Medical Data Enterprise to Advance the Use of Real-World Evidence As it finalizes appropriations for FY2020, Congress should fully fund the FDA’s $60 million budget request for a Medical Data Enterprise to advance the use of real-world evidence to evaluate both effectiveness and safety of drugs, biologics, and devices. 2. IMPROVING REGULATORY CLARITY 2.1 Continue and Expand Upon Efforts to Improve Regulatory Clarity The FDA should build on the recent momentum related to real-world evidence and rapidly develop and publish guidance—as required by the 21st Century Cures Act—regarding the circumstances under which sponsors and the FDA may rely on real-world evidence to help support the approval of a new indication for an existing drug, as well as to help support or satisfy post-approval study requirements. Such guidance should address key issues raised within the recently released FDA Framework. The guidance should be informed not only by the FDA Framework, but also by insights gained from

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