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Considerations for Optimal Management of Patients With Pulmonary Arterial Hypertension: A Multi-Stakeholder Roundtable Discussion
Sean M. Studer, MD, MSc; Martha Kingman, FNP-C; DNP; Luis Calo, MD, MMM, FAAFP; H. Eric Cannon, PharmD, FAMCP; Jeffrey D. Dunn, PharmD, MBA; Thomas James III, MD; Sonya J. Lewis, PharmD, MBA; Robert J

Considerations for Optimal Management of Patients With Pulmonary Arterial Hypertension: A Multi-Stakeholder Roundtable Discussion

Sean M. Studer, MD, MSc; Martha Kingman, FNP-C; DNP; Luis Calo, MD, MMM, FAAFP; H. Eric Cannon, PharmD, FAMCP; Jeffrey D. Dunn, PharmD, MBA; Thomas James III, MD; Sonya J. Lewis, PharmD, MBA; Robert J
Stakeholders, including national and regional managed care decision makers and providers, met to discuss the clinical background, health economics, and management strategies for pulmonary arterial hypertension (PAH) at a roundtable meeting on December 10, 2016, in Dallas, Texas.
Dr Calo:  “Although there are relatively few patients with PAH, if a patient with the condition is not diagnosed until a late stage, “It’s going to be bad for that person and for the healthcare system, because the costs are going to go up as the patient progresses through the levels of classification from I through IV. Therefore, it is very important that primary care physicians order the appropriate workup when confronted with a patient with the associated history and complaints.”

Dr. Lewis: “I will go back to my specialty team and ask them if we’re missing anything in coordination of care. If practitioners are not hearing much from our case managers, there could be something missing.”

Dr Cannon: “Hearing different viewpoints and understanding more of the thought process around patients reinforces the need for us to continually and openly have dialogue with the people who are providing care for the members we provide coverage for.” There could be opportunity in PAH to become “more aligned with data” and have better “coordination across the system.”

Dr Dunn: PAH “has been off the radar screen for a while,” but it seems to be coming back, so there should be preparation, including “working towards better collaboration, both in terms of formularies and care coordination.” He also noted the importance of having a “clear understanding” of physician-directed prescribing or physician-directed therapeutic decisions.

Dr James: The concept of slowing down the progression of functional decline is “a whole wellness concept. Wellness is a concept for people with chronic conditions to make them feel better. How do we go about having the right kinds of social, pharmacologic, medical, and, to a certain extent, financial interventions that will help improve the outcome of individuals with chronic disease?”

Dr Kingman: “I hope, moving forward, that we’re all able to collaborate on a nice, even playing field,” rather than being faced with “denial after denial.” There is “a lot of common ground where we could work together and collaborate more and make the right decisions financially and clinically.”

Dr Studer: “Better upfront dialogue makes it smoother for the individual patient down the road.” For a patient who is on 1 drug and remains at FC IV, “If you were the payer, you should say [to the provider], ‘What’s your plan here?’ You’re either gaining no ground and you should consider stopping [the drug], or you may need to escalate. When the desired outcomes are clear, the treatment plan should be focused on achieving them.”

The Importance of Open Access to Treatment

The health-plan participants at the roundtable meeting said they were given a deeper understanding of PAH from the expert practitioners, including details of the burden on patients living with the disease and the impact on the healthcare system, along with the importance of facilitating access to treatment options to provide appropriate care for individual patients. In turn, the practitioners gained insights into factors that health plans consider in making decisions on medications and other aspects of care. Stakeholders agreed that working together to ensure that patients with PAH are diagnosed correctly and receive appropriate treatment will result in the best outcomes for patients and optimal utilization of healthcare resources.

Conclusion

PAH is a rare, chronic, progressive, and ultimately fatal disease that affects an estimated 12 to 50 cases per million individuals. Available PAH-specific treatments include a variety of agents covering multiple mechanisms of action: prostacyclins, IP receptor agonists, endothelin-receptor antagonists, soluble guanylate cyclase stimulators, and phosphodiesterase-5 inhibitors. With the available mechanisms of action and data supporting the use of combination therapy, more attention is likely to come from managed care because of potential cost concerns. However, when treatments are used appropriately, clinical deterioration can be avoided or delayed. It is important to recognize the unique pharmacologic characteristics of agents within each class and the specific evidence supporting use of each treatment. It is also important to consider the administration characteristics of each medication and the effect of administration characteristics on patients. Because each patient with PAH has a unique set of circumstances, patients with PAH need access to individualized care. PAH specialists have the expertise to assure that the right patient gets the right drug at the right time when they have timely access to all available options. Managed care decision makers and providers can partner in the care of patients with PAH by ensuring the correct diagnosis, primarily through right heart catheterization, and facilitating the best outcomes for patients through physician-directed prescribing based on guidelines and real-world evidence. n

Author affiliations: Actelion Pharmaceuticals, US, Inc., South San Francisco, CA (JAP); Baptist Health Plan, Lexington, KY (TJ); Filias Healthcare Marketing Strategy Group, LLC, Williamstown, NJ (RJG); Luis Calo MD PA, Harlingen, TX (LC); New York University, Brooklyn, NY (SMS); Select Health, Murray, UT (HEC); University of Colorado School of Pharmacy, Denver, Colorado (SJL); University of Texas Southwestern Medical Center at Dallas, Dallas, Texas (MK); Veridicus Health, Salt Lake City, UT (JDD).
Funding source: This supplement was sponsored by Actelion Pharmaceuticals, US, Inc.
Author disclosures: Dr Calo, Dr Cannon, Dr Gilkin, Dr James, and Dr Kingman report serving as a paid advisory board member for Actelion Pharmaceuticals US, Inc; Dr Cannon also reported serving as a paid advisory board member for Gilead and Sanofi, and having obtained lecture fees from AbbVie. Dr Dunn and Dr Lewis reported that they have no relevant financial relationships with commercial interests to disclose. Dr Kingman also reported having received lecture fees and honoraria from Bayer, Gilead, and United Therapeutics. Dr Pruett reports serving as a full-time employee with and owner of stock from Actelion Pharmaceuticals US, Inc. Dr Studer reports having served as a consultant or paid advisory board member for Bayer, and for receiving lecture fees for speaking for Actelion Pharmaceuticals US, Inc, Bayer, Gilead, and United Therapeutics.
Authorship information: Concept and design (HEC, JDD, RJG, TJ, MK, JAP, SMS); acquisition of data (TJ, SJL, JAP, SMS); analysis and interpretation of data (HEC, TJ, MK, SJL, JAP, SMS); drafting of the manuscript (LC, JDD, RJG, JAP, SMS); critical revision of the manuscript for important intellectual content (HEC, JDD, RJG, JAP, SMS); expert opinion on discussion (LC); participation (SJL); supervision (HEC).
Address correspondence to: sean.studer@woodhullhc.nychhc.org
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