At the American College of Cardiology 66th Scientific Session, Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC, president of the American Society for Preventive Cardiology, discussed why insurers are so reluctant to approve coverage of PCSK9 inhibitors and how this hesitance could harm patients who are denied access to the cardiovascular drugs.
At the American College of Cardiology 66th Scientific Session, Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC, president of the American Society for Preventive Cardiology, discussed why insurers are so reluctant to approve coverage of PCSK9 inhibitors and how this hesitance could harm patients who are denied access to the cardiovascular drugs.
Transcript (slightly modified)
Why are payers reluctant to approve coverage of PCSK9 inhibitors?
Well we know from the beginning, when the PCSK9 inhibitors were approved, there was pushback immediately, and the pushback was always a financial pushback. These are very expensive drugs, are they cost effective? A number of different studies were published utilizing QALYs [quality adjusted life years] to estimate the cost-effectiveness of drugs. QALYs, by the way, most people don’t know this, the Affordable Care Act actually banned the use of QALYs in economic determinations like this, pharmacoeconomic decisions, so they really shouldn’t be used in any of these papers, yet they are.
So it looks as though it’s strictly financial. Now, periodically, the insurers will say people are writing off-label. To my knowledge, it’s not generally true. Obviously, you’re going to find some outliers, always are going to, but the PI [prescribing information] for these drugs is very, very clear.
However, a group of us just published a paper that’s coming out the 20th [of March] from Clinical Cardiology, which has a prior authorization that can be used for everyone but also defines the 5 elements of the PI with a 6-member coauthor group from varying groups and organizations. It’s a very simplified, very clear, very pragmatic product that defines these 5 elements and also employs a simple prior authorization, so hopefully the payers will embrace this and it will make the clinicians’ lives easier and it’ll make the patients healthier, so that’s the ultimate goal.
Do you think we will see insurers ease up on their requirements for approving these drugs?
We hope that payers will become less stringent with these requirements. FOURIER came out at this meeting. It was a very powerful outcomes trial that demonstrated the efficacy of PCSK9 inhibitors in a very short period of time, in just a 2-year trial, at reducing heart attack and stroke.
This is all about the patients. Patients have contracts with their insurance companies, and when a PCSK9 inhibitor is on formulary with those insurance companies and the patient is prescribed the PCSK9 inhibitor on label, they really are obligated to provide it.
I am hopeful that it will change. People are literally dying waiting for these drugs. That is not hyperbole. They are literally dying on line waiting for the drugs, so that has to come to an end.
ATS 2024: Bridging the Past, Present, and Future of Respiratory Care
May 16th 2024The application of artificial intelligence in medicine is anticipated as a highlight of ATS 2024, with sessions exploring its applications in research, radiological interpretation, and pediatric pulmonology.
Read More
The Importance of Examining and Preventing Atrial Fibrillation
August 29th 2023At this year’s American Society for Preventive Cardiology Congress on CVD Prevention, Emelia J. Benjamin, MD, ScM, delivered the Honorary Fellow Award Lecture, “The Imperative to Focus on the Prevention of Atrial Fibrillation,” as the recipient of this year’s Honorary Fellow of the American Society for Preventive Cardiology award.
Listen
Looking Back on ISPOR 2024: Hot Policy Topics, Welcome Focus on Employers, and More
May 10th 2024Kimberly Westrich, MA, chief strategy officer of the National Pharmaceutical Council, reflects on the most valuable learnings from the 2024 meeting of ISPOR—The Professional Society for Health Economics and Outcomes Research, including lively discussions of the Inflation Reduction Act and workshops on value assessment.
Read More
Promoting Equity in Public Health: Policy, Investment, and Community Engagement Solutions
June 28th 2022On this episode of Managed Care Cast, we speak with Georges C. Benjamin, MD, executive director of the American Public Health Association, on the core takeaways of his keynote session at AHIP 2022 on public health policy and other solutions to promote equitable health and well-being.
Listen
Posters Characterize DMD Caregiver Experiences, Impact of Gene Therapy on Caregiving Demands
May 10th 2024Posters presented at the ISPOR—The Professional Society for Health Economics and Outcomes Research meeting explored Duchenne muscular dystrophy (DMD) caregiver experiences and gene therapy’s impact on work opportunities for caregivers.
Read More
A Focus on Women: AUA Best Posters Highlight Female Athletes, Prenatal Care, and Women in Urology
May 9th 2024Three posters from the American Urological Association (AUA) 2024 Annual Meeting focused on urinary incontinence in female athletes, prenatal care for fetuses with spina bifida in California, and the experiences of women residents at the Brady Urological Institute.
Read More