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Special Considerations in HIV Management

Determining Cost-Effectiveness of Newer HIV Therapies

Michael G. Sension, MD; Peter L. Salgo, MD; Jeffrey D. Dunn, PharmD, MBA; and Elly Fatehi, PharmD, MPH, offer their perspectives on the challenges with determining the cost effectiveness of newer HIV therapies versus existing therapies.


Michael G. Sension, MD: It’s interesting. We’ve been talking a lot about the perspectives of managing HIV. But along the lines of what you’re talking about, with all of our advances in technology and pharmaceutical improvements, we’re still at between 40,000 and 45,000 new cases of HIV every single year. As a payer realizing that every year you’re going to have 40,000 to 50,000 new entries into the consumer market of HIV products, that is as much a concern: reducing the number of new infections. That’s in part getting more people on therapy, virologically suppressed—treatment is prevention—but also along the lines of the other preventive efforts that you’re adopting and seeing in New York.

Peter L. Salgo, MD: But he’s not denying payment. He’s not saying, “I’m not going to pay for anybody.” He just wants to be prudent. Is there a difference?

Jeffrey D. Dunn, PharmD, MBA: Well it may be that I am not seeing the big picture. Are you seeing payers say no a lot?

Michael G. Sension, MD: I’ll tell you, what’s frustrating to me is if I have a single-tablet regimen and I have a payer who says, “We won’t pay for that, but we’ll pay for each of the 3 components separately.” That has happened to me. I’ve actually chosen one of the recommended regimens for most patients’ drugs, and I’ve had a payer come back and say, “We don’t want you to give that one, we want you to give another one.” I’ve had good reason to not want to give the alternative one. It’s not even alternative: They’re all on the same page. But they’ve done exactly that. It’s been very frustrating when I felt that the best option for that patient was the particular choice.

Jeffrey D. Dunn, PharmD, MBA: When you go back and say, “Based on X, Y, and Z, I want to do this,” outside of just, “I like it,” or compliance, do they still push back?

Michael G. Sension, MD: It’s a challenge. Some do. Some say, “We’ll only give you the one that you want if they fail the other one.” But in that case, that’s not an indication. You wouldn’t sequence somebody from one to another in the setting of failure. It wouldn’t be appropriate.

Peter L. Salgo, MD: But that would be a step there.

Michael G. Sension, MD: Right. And that wouldn’t have been appropriate in that particular scenario. So, I’m a bit sensitive to that because it’s frustrating. I’ve experienced that frustration.

Peter L. Salgo, MD: That’s some of your cynicism. When he says, “We’re going to pay for everything,” you say, “Wait a minute.” You’ve seen the other side.

Michael G. Sension, MD: I’ll go back. I think the DHHS guidelines are good. I can say 90% of my patients are treated with medicines I can count on 1 hand. I think that is very much a part of the DHHS guidelines, but even then the decisions I make are not necessarily driven by cost but by what I think drugs within each class have proven themselves to be. They have advantages over others. I’ll keep coming back to darunavir within the class of protease inhibitors because I think that’s a very good example.

Peter L. Salgo, MD: But is there a significant difference between good and good enough if there’s a significant price difference?

Michael G. Sension, MD: I would challenge that. I think you have to look at the specific case. I think it’s hard to generalize. I would say within the protease inhibitor class, again going to darunavir, I really would not go to an alternative. I think that for almost everyone, it would be the preferred protease inhibitor if it has advantages. In other words, if it has a higher genetic barrier to resistance. If it has less toxicity. If it has less drug-drug interactions. Those are the things that I would try to wrap my head around as you negotiate cost and choose something. My concern is that as weaker drugs, or drugs that don’t have the advantages we see in newer products that have come out, they will say, “Aha, I’m going to go to Jeff and I’m going to cut my price so that I can still maintain my market share.” That’s where I have concern. As newer drugs are developed with improvements, the older drugs will lower their price to get your attention.

Jeffrey D. Dunn, PharmD, MBA: I think we’d have to have conversations about specifics looking at drugs. What is a clinically meaningful improvement versus the cost? I think it’s a little bit unfair in this situation without looking at that level of specificity. But I think that’s legitimate as these new drugs come out and we say they’re better. Let’s have a conversation about what that means clinically in terms of “better,” and don’t dismiss cost.

Peter L. Salgo, MD: Before we go, I think everybody should have an opportunity to give just some sort of bullet point as to what you’d like our viewers to really take away and remember. So, why don’t we start with you, Dr. Dunn?

Jeffrey D. Dunn, PharmD, MBA: I think it’s awesome, the progress we’ve made in the last decade or 20 years in terms of having better outcomes and better drugs. Patients are living normal lives. There’s no argument in that we’ve made a lot of progress. I do think there’s still a huge opportunity for the different stakeholders to have a little bit of a different conversation. I will just say I think payers are viewed—and sometimes rightfully so, but sometimes not fairly—as doing things strictly for cost.

I do think that we have an opportunity to bring a lot of things to the table around data management and care management, looking at helping manage the patient more holistically. But it’s unfortunate. I still think it’s a little bit of an antagonistic relationship. My hope would be that we’re not just completely dismissive of cost and that we can have a conversation about doing the right thing for the patient, but hopefully doing it in a way that is sustainable for the people who are paying for insurance.

Peter L. Salgo, MD: Dr. Fatehi?

Elly Fatehi, PharmD, MPH: I think it’s amazing that we’ve come this far with HIV. It’s a manageable chronic condition. We have amazing drugs that work and can get individuals to undetectable levels, and if we can help drive adherence to maintain those undetectable levels, I think it would be great for all of us in society.

Peter L. Salgo, MD: Dr. Sension?

Michael G. Sension, MD: I see the advances as really being a win-win situation for patients. I look to where we were 20 or 25 years ago and where we are today. Even the debates around all the different recommended regimens and the different options all really represent easier to administer, better tolerated, and simpler regimens that affect higher rates of virologic suppression.

Peter L. Salgo, MD: I don’t often give my own opinion at the end of these things, but having been in this business from the beginning of the AIDS epidemic to now, I’m going to tell you what I think. I think that everybody at this table should be proud to be in a profession—whether on the financial side or the medical side—in which we’ve gotten to this spot. I look back over 30 years of triumph. We are here. We are arguing over dollars and cents as opposed to funeral costs. When I think back as to how I’ve spent my life in this profession with people such as you, all of whom I admire, I just think that they’re the best 30 years of my life. It’s wonderful that I look forward to more. This is remarkable stuff. Everybody out there in this business can give yourself a round of applause, too. All of us have been part of this journey, which is insanely great. This is just one example of it, but it’s a heck of a great one.

With that, I want to thank all of you for your contributions, and I want to thank you of course for joining us out there. I hope you found this AJMC® Peer Exchange® to be informative. I’m Dr. Peter Salgo, and I’ll see you next time.

 
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