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Coverage Considerations for Novel Agents in Diabetes
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June 12, 2019

Coverage Considerations for Novel Agents in Diabetes

Considerations for the coverage of new higher-cost drugs by health insurance plans for the treatment of diabetes and prevention of kidney disease.


Peter Salgo, MD: I read the newspaper, I’m a patient. I say, I hear that there [are] GLP-1s [glucagon-like peptide-1 receptor agonists], and DPP-4s [dipeptidyl-peptidase-4 inhibitors], and SGLT2s [sodium-glucose cotransporter 2 inhibitors]. And the paper says they’re great, and the paper that I read, I believe. I want it. Why shouldn’t I have it?

Om P. Ganda, MD: Yeah, but I think it’s always nice to really document the feeling that you might have. I mean, we really—obviously cardiologists more than us—are very excited, and they want to treat their patients before they get any cardiovascular event such as heart attack or [need a] stent or bypass. But you know, I think we’ll have to do those kinds of studies. Already there are studies in progress in people without diabetes who have a high risk of heart failure or who already have heart failure, and we want to prevent the further episodes. So those kinds of studies are currently in progress. So we really can’t. Amid all our excitement, we still need to wait for some of those studies to be completed, and several of such trials are continuing. And you might raise the question, What about people without diabetes with kidney disease? Now that comes up as the next question and... [Cross-talk.]

Peter Salgo, MD: Because he’s not going to approve it, that’s why.

Om P. Ganda, MD: Well, we have to. Our job is to convince him eventually, right?

Peter Salgo, MD: I mean, OK, I come to you. I’ve got a patient with kidney disease. These drugs clearly, in the diabetes studies, show a desirable impact on the progression of renal failure. Can I have it if my patient doesn’t have diabetes?

James T. Kenney, RPh, MBA: Well, it’s a good question.

Peter Salgo, MD: Deafly silence here.

James T. Kenney, RPh, MBA: Well, it depends on the design. In some cases, if there’s a prior [authorization] on it that requires diabetes as the indication, then you’re going to get an initial no. And then the physician has to make his or her case to say we want to use it in this particular patient with chronic kidney disease because here [are] the data to support that. And if they make a good case typically, you do get coverage.

Om P. Ganda, MD: And that’s what we need to do, Jim, because I think we should really be looking at the long-sighted view, not the shortsighted view of just controlling the proteinuria or controlling the blood glucose. And you know that you’ll be saving a lot of money by paying a little bit ahead and preventing these complications—dialysis, transplantation.

Peter Salgo, MD: He’s got to make his fourth quarter. You’ve got to make your fourth.

Om P. Ganda, MD: This is the debate that’s been ongoing for years, right?

James T. Kenney, RPh, MBA: Absolutely. You hear a lot of commentary on our side. Well, we don’t want to treat the patient today because that complication is not going to occur for 20 years. That’s a bunch of baloney.

Om P. Ganda, MD: But if we can tell you, 1 of those 3 people will get kidney failure.

James T. Kenney, RPh, MBA: Right. But if you think about it, if we treat everybody the same, when the patient switches health plans, Helena is still her doctor, so she’s still treating her the same way. So if we’re sitting there saying, well, we’re going to try to exclude this coverage and not allow access to these drugs and so forth, [that] makes no sense. You want to use the best choices. You want to use the most cost-effective choices, from the plan perspective, because we don’t have unlimited resources. And then when we start to see the positive results, it’s also incumbent on the manufacturers to come in and share that information. Get that clinical information to us sooner, so that we understand the potential additional role of these drugs. And maybe we’d be less restrictive.

Peter Salgo, MD: Let me mention something so horrible that I’m almost going to have to whisper it. If you’re telling me that all the plans have to have the same criteria and have to pay for the same drugs, why are there different plans? Why not just a single payer?

James T. Kenney, RPh, MBA: That’s 1 for the politicians.

Peter Salgo, MD: I tried. I just tried.

Om P. Ganda, MD: Thank you for doing that.

Peter Salgo, MD: I mean, what you’re really saying is there’s no uniformity across plans.

James T. Kenney, RPh, MBA: But there’s also not uniformity around the country. You have different practice standards, you have different preferences among different categories of drugs. And when you think about [it], you’ve got 4 or 5 different categories or drug or therapeutic classes of drug within diabetes space, it may be very different practice in California than it is in the Southwest than it is in the Northeast. So that makes a big difference as well. There isn’t [a] universal consensus, and then the pricing is different, right? If somebody gets a drug on formulary on plan A, then the company that lost out is now going to competitively bid to try to get it on plan B. So now you’re got 2 different drugs, 2 different formularies because everybody wants a piece of the business.

 
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