Peter Salgo, MD: Do you see yourself as a patient advocate? “Come hell or high water, I’m going to do what’s necessary for my patient?”
 
Howard Weintraub, MD: Yes.
 
Peter Salgo, MD: Even if it bankrupts their insurance companies?
 
Gary L. Johnson, MD, MBA: This may surprise you, but I also consider what we do as being a patient advocate.
 
Peter Salgo, MD: I was going to ask you the same question. You answered it.
 
Gary L. Johnson, MD, MBA: Very good.
 
Howard Weintraub, MD: The answer is yes.
 
Peter Salgo, MD: Okay, but aren’t there ridiculously expensive therapies that might be useful, but are simply so many standard deviations out of the box that you couldn’t possibly afford them? Would you recommend them if your patient could benefit from them?
 
Seth J. Baum, MD: If you have a single patient sitting in front of you in your office and that patient can benefit from a medication or a procedure, then you recommend that medication or procedure regardless of cost. It’s not in the purview of the clinician, I think, to make that distinction.
 
Peter Salgo, MD: But that’s their call, and that’s what you’re ganging up on them about it, no? What do you think?
 
Jennifer Strohecker, PharmD, BCPS: Well, I think that’s the hard piece of it, because if I was looking at the patient to the face, I want to offer them the safe therapies. I want to provide the life-saving resource today if I had that in my power. That’s not the hat I’m wearing working for the insurance company. I’m not. So, we have to make sure that our resources are allocated properly, and, unfortunately, that does tend to be jumping over…
 
Howard Weintraub, MD: We’ve been very fortunate to get samples from the companies, and we will support patients with samples while they’re waiting for their approval.
 
Peter Salgo, MD: Okay, but that’s not going to work long term.
 
Howard Weintraub, MD: What it does is it says there’s a commitment to getting this done. And that’s one way it should be solved, in their favor.
 
Peter Salgo, MD: Let me put this out to the payers, first, because you do have a view of the landscape that the individual practitioner does not. The individual practitioner sees 1 patient at a time and sees an individual's risk. And you, although you have to pay individually, also see the bigger landscape because you know what your budget is. How do you determine whether these agents are being used appropriately?
 
Gary L. Johnson, MD, MBA: Again, and I think the insurance industry, being very highly regulated and subject to both internal and external appeals process, my view is that, in general, we’re very permissive in terms of coverage of expensive agents. We want to make sure that they’re used in appropriate patients. We want to make sure that they’re being used according to FDA or compendia citations. That’s our obligation. We had a system back in the 50s and 60s, called indemnity insurance, where there was no managed care. Whatever the doctor wrote, prescribed, wanted to do, they just sent in a claim and it got paid. Well, that was an unsustainable system. That’s why we are where we are today. So, it is also our job. That’s why I said I also feel like I am an advocate, for not only the clinical care that our members, our insured patients, receive, but also their financial interests.
 
Peter Salgo, MD: What about you? Do you think that these agents are being used appropriately? And what do you mean by “appropriately” anyway?
 
Jennifer Strohecker, PharmD, BCPS: First of all, I think the next question will be, do patients have access? And I think by using them appropriately, it means the right patients do have access.
 
Peter Salgo, MD: Okay, but who determines who’s right? Is it you or him?
 
Jennifer Strohecker, PharmD, BCPS: I think it’s a partnership.
 
Peter Salgo, MD: Do you see them partnering with you or do you see them being adversarial?
 
Howard Weintraub, MD: The latter.
 
Peter Salgo, MD: The latter.
 
Jennifer Strohecker, PharmD, BCPS: Yes, I understand.
 
Peter Salgo, MD: But why are you agreeing so quickly? Are you adversarial?
 
Jennifer Strohecker, PharmD, BCPS: Because I can understand. I can understand, from both sides of the fence, where there’s challenges and where we’re going to have to come to better agreement to offer new therapies to patients who really derive great benefit from them. But there’s also the cost challenge that the payer has to constantly weigh and is accountable for. So, I understand both viewpoints and I understand where I’m a barrier to you providing great care for your patient. I can see where that can exist, and I think there has to be greater dialogue. Also, I think that the manufacturer has to come to the table to be cost competitive.
 
Peter Salgo, MD: Okay, the manufacturer, I’ll be the manufacturer. I just spent 2 trillion gold grinkles developing this drug. Along the way, 1.5 billion gold grinkles were spent on blind alleys. If I’m going to be sustainable and provide new pharmaceuticals for the world, I’ve got to charge what I’m charging. Otherwise we stop, no?
 
Seth J. Baum, MD: Absolutely. I don’t think this is a partnership decision. I think this is a physician–patient decision regarding what medicine to use.
 
Peter Salgo, MD: But they’ve got the money.
 
Seth J. Baum, MD: It doesn’t matter. I think the decision is the physician–patient decision. Now, they can then come down on us and say, “No, we’re not going to do it.” But we’ve made the decision, and I think that’s really important. For some reason, in this conversation, the pharmacy benefit managers (PBMs) have not come up.
 
Peter Salgo, MD: Here they are.
 
Seth J. Baum, MD: Okay, here they are, and they’re the intermediary for companies grossing $400 billion a year or so in hidden negotiations without any transparency. I don’t think we know what the true cost of drugs is. The list price of a drug is definitely not the price that the PBMs pay, so we need to bring them into the conversation.
 
Peter Salgo, MD: Payers certainly look at the list price, or the cost that you actually can get the drug for, as 1 factor in prescribing this drug. And need is another. Do you meet criteria? But what about the long-term effects on America? That is to say, if you start approving these fairly expensive drugs, down the line, 10, 15, 20 years from now, the heart attack rate is going down, the CABG (coronary artery bypass grafting) rate is going down, the stent rate is going down, the stroke rate is going down, and your out-of-pocket is going to be way down compared to where you are now without these drugs. Do you factor that in?
 
Gary L. Johnson, MD, MBA: Well, I mean you’re talking about HEOR data—Health Economics Outcomes Research.
 
Peter Salgo, MD: Yes.
 
Gary L. Johnson, MD, MBA: Maybe what you say is true, but maybe not. Again, that’s where we get into the more technical analysis—number needed to treat, calculations like that.
 
Peter Salgo, MD: By the way, that’s not true. If what I proposed does not pan out, then what are we doing anything for?
 
Gary L. Johnson, MD, MBA: I can tell you that it’s not true because if it were true, that providing all the medicines and the care that we provide is lowering costs, we would see premiums going down every year. But we see a huge increase in premiums every year. We’re paying more for medical services. We’re getting some marginal improvements in event rates. But the cost is still going up.
 
Howard Weintraub, MD: Where is that cost? Is it technology? Is it medicine? It’s certainly not personnel.
 
Peter Salgo, MD: Is the cost for heart disease or is it for everything else that comes with these heart patients? It’s always appeared to me that preventive care is very expensive because people live longer and use more healthcare.
 
Howard Weintraub, MD: Right.
 
Peter Salgo, MD: Is that what’s going on or are people simply dying of heart disease at the same rate and these things have no impact at all?
 
Seth J. Baum, MD: No, but they’re not. We know that.
 
Gary L. Johnson, MD, MBA: We know that they have an impact. Clearly, they have an impact.

PCSK9 Inhibitors: Cost Concerns and Access

In this segment, Seth J. Baum, MD; Gary L. Johnson, MD, MBA; Peter Salgo, MD; Jennifer Strohecker, PharmD, BCPS; and Howard Weintraub, MD, share their views on health plan coverage criteria and appropriate access for PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor therapies in lipid management.
Published Online: May 18, 2017
View More From This Discussion
Episode 1 Current CVD Prevention and Management Challenges
Episode 2 Managed Care Decision Making in CVD and Lipid Control
Episode 3 Early Detection of Risk and Familial Hypercholesterolemia
Episode 4 Cholesterol Goals in Primary Cardiovascular Disease Prevention
Episode 5 Coverage of Statins/Nonstatins in Lipid Management
Episode 6 Lipid Management: Coverage Criteria vs FDA Labeling
Episode 7 Efficacy and Safety of PCSK9 Inhibitors
Episode 8 Management of High-Risk Populations With Hyperlipidemia
Episode 9 Candidacy for Later-Line Cholesterol-Lowering Therapies
Episode 10 Alternate Mechanisms of Action for Cholesterol Management
Episode 11 Clinical Experience With PCSK9 Inhibitors
Episode 12 PCSK9 Inhibitors: Cost Concerns and Access
Episode 13 Cholesterol Management and Long-Term Cardiovascular Disease Prevention
Episode 14 The Future of Lipid Management
Episode 15 Unmet Needs in Cholesterol Management
$vacMongoViewPlus$