Age-Related Macular Degeneration Treatments: Determining Appropriate Use - Episode 4

Addressing Underrecognition of Wet AMD

Peter L. Salgo, MD: We’ve been discussing some of the risk factors here. We talked about gender. Is race involved? Is ethnicity involved?

Jared Nielsen, MD: People who are of European ancestry are more likely to suffer from this disease. We just don’t see it as often in patients that have non-European ancestry.

Peter L. Salgo, MD: What about other environmental factors? Is there anything that…

Jared Nielsen, MD: Smoking is the big one. Charlie also alluded to a general state of health and exercise being factors as well.

Peter L. Salgo, MD: We’ve got all these environmental factors, we’ve got genetic factors, and we’ve got age. Now, you want to approach some way to manage and to track these folks from day 1. The question is, are you paying for tracking? Are they paying for getting all of this right or is there some kind of disconnect? In your view, from the payer side, are you doing enough?

Peter Dehnel, MD: Unfortunately, in many areas, we don’t have enough emphasis on outcomes.

Peter L. Salgo, MD: What does that mean?

Peter Dehnel, MD: There may be a lot of processes that are being well taken care of. Yes, with a diabetic, you need to come in for your HbA1C every 6 months. But in terms of looking at the outcome of people who have been diagnosed with wet AMD, what happens to them over the next 1 to 2 years? Then, if we find out they’re not being well managed, what can we do upstream, at the time of diagnosis, to make sure that they are having better outcomes with their vision?

Jared Nielsen, MD: I think that’s extremely important. One of the things that I see as a great opportunity for a partnership between clinicians and payers would be to make sure that patients get frequent treatment enough. If we look at the results of these phase III trials, they’re spectacular. It’s amazing that Charlie and I can practice in the era that we do. We have a cure for neovascular, or wet, AMD, but when we look at what happens in the real world, when we look at a very influential paper in our field that was published looking at what happened in Europe, patients just don’t have the outcomes in the clinic that they do in these clinical trials.

The main underlying reason is that they don’t get treated enough, and it’s tough. It’s tough for family members to bring the patients and for patients to come on a regular basis to have these treatments in their eyes. And yet, I think it’s important. If I’m a payer and I’m paying for this, I want to make sure that my patient is going to get the best outcome possible. I’m not going to want to spend money and have a suboptimal result.

Gary L. Johnson, MD, MS, MBA: Jared, when you said they don’t get treated enough, did you mean that once diagnosed and begun on treatment, they don’t follow up in terms of intravitreal injections? That they don’t have enough or that they never start on treatment to begin with?

Jared Nielsen, MD: Just looking at patients who start on treatment, quite often, unfortunately, we find that patients just don’t get enough treatment.

Peter L. Salgo, MD: I want to hone in on this. First of all, I want to back up, because I heard a word that you rarely hear.

Jared Nielsen, MD: Is that cooperation?

Peter L. Salgo, MD: No, that’s unspoken. But the word I heard you use was “cure.”

Jared Nielsen, MD: Yes.

Peter L. Salgo, MD: Now, I’ve heard diabetic retinopathy discussed. I’ve heard AMD discussed And, in the past, it was never cure. It was always treat, it was always control. But you used the word “cure.” It’s a powerful word.

Jared Nielsen, MD: And it’s probably an overstep in the fact that, when I’m speaking with patients, one of the main discussions I have with them is that this is not a disease I can cure, but it’s one that I can manage. In the past, people would go blind, with certainty; it was going to happen. Now, we can stand in the gap and treat patients and keep people seeing. Over 90% of the time, I can maintain their vision, and more than 30% of the time, we can improve it substantially with treatment.

Peter L. Salgo, MD: So, let’s be very clear. We’re dealing with a chronic disease.

Jared Nielsen, MD: Oh, yes.

Peter L. Salgo, MD: As are many other physicians with many other diseases. But now there’s an effective treatment—not necessarily a cure.

Jared Nielsen, MD: You’re accurate.

Peter L. Salgo, MD: But if you can keep people seeing, whether or not you turn off the process, I’m not sure there’s a distinction.

Jared Nielsen, MD: And there are certain patients who respond in a way where they need less treatment. But for a majority of patients, this is a disease that lasts much longer than just a few years or a few months.

Peter L. Salgo, MD: Let me ask a provocative question: how do you track the population in the sense of how prevalent this disease is in your group—in your plan?

Peter Dehnel, MD: I couldn’t tell you, based on the information provided. I’d be interested in what Jared has to say in terms of what he would see as an active partnership. How can we better track those patients? You’re talking about a commercial population or a Medicare population, and in my organization, those are like 2 different shops. They’re 2 different areas.

Jared Nielsen, MD: It’s interesting that you bring that up. I think we’re managing a chronic disease, and I think—once you see that a patient is being treated for this and go out to educate them—yes, you need to continue to follow up with the people who are administering treatment.

Peter L. Salgo, MD: Let me throw it back. If you don’t know the prevalence in your payer group, your payee group, does that actually imply that you don’t know how important this disease is? That it hasn’t, if you will, hit the radar?

Peter Dehnel, MD: In all fairness, we do not fully understand the entire affected population for many different diseases. We’ll have claims history, but that’s oftentimes lagging in terms of the actual incidence of that disease. And we don’t have, necessarily—because people may come into our plan with a preexisting diagnosis that we don’t have—an easy way to track.

Peter L. Salgo, MD: Does this mean that it’s underrecognized not just at the payer level, but also everywhere—at the PCP level, at the payer level, and the patient level? Is it just because we’re just not paying attention?

Jared Nielsen, MD: I think that’s an accurate statement, but I do think people have a lot of things that are vying for their attention with regard to taking care of a whole patient population.

Peter L. Salgo, MD: My eyes are right at the top of importance for me.

Jared Nielsen, MD: I think, for most people, you’re correct, but they don’t always think of the primary care provider or their general doctor as somebody they can go to who has knowledgeable expertise in that area. A lot of times, they won’t even bring it up.

Peter L. Salgo, MD: But is that fair? And is that accurate? Do people think they can’t get good ophthalmologic information from their PCP because they actually can’t?

Jared Nielsen, MD: I think it’s challenging, certainly. The primary care physician often does not have the tools in their office to be able to help. I certainly work with primary care providers in my area to help as a resource for that, and, certainly, there are a lot of things within my practice of medicine that I just have to defer to other individuals, and I need their help.

Gary L. Johnson, MD, MS, MBA: We’ve spoken about primary care physicians, we’ve spoken about ophthalmologists, but we haven’t spoken about optometrists. And for many individuals, that’s the only eye care provider they go to. Many don’t even see a PCP for general medical exams, so where does the optometrist fit in all of this?

Charles Wykoff, MD, PhD: We do partner with optometry and general ophthalmologists frequently. Currently, in our country, optometrists are not providing retinal care with delivery of drugs directly inside of the eye.

Peter L. Salgo, MD: If I may, isn’t the point of the question, really, that more people see optometrists than see ophthalmologists and PCPs?

Charles Wykoff, MD, PhD: Absolutely. And that is critical for screening, for picking these patients up, and for encouraging ongoing care, because there’s a disconnect. It’s one thing to make a diagnosis, but it’s another thing to manage these patients years down the road for their active wet disease.