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Aligning Treatment Goals With Payer Considerations


Dr Lopes leads a discussion surrounding payer considerations with an emphasis on patient-centered care in endometriosis management.

This presentation is brought to you by Myovant Sciences.

Maria Lopes, MD, MS: How do you work to set individual goals and approach some of these challenges around the patient side, including symptom relief, alternative treatment options, patient preference, and shared decision-making? This takes so much time. Are there tools that can be considered or deployed that may assist in this shared decision-making process?

Eric Surrey, MD: A fact of life and modern medicine is that there are very few clinicians who have an hour to spend with the patient. I’ll do an hour-long new-patient consultation, but my field is a bit of a niche field. The average clinician may have 15 or 20 minutes for a new patient. There are several ways of managing that initial problem. One is to have questionnaires for pelvic pain. The patient could fill it out at home, and then you have a huge amount of information to start. If you know that she’s coming in with pelvic pain as a chief complaint, you can focus your pre-office visit in a different way so that you’re more prepared.

If you think, “I need to spend more time with this patient. We aren’t going to get this accomplished today,” I don’t think any patient is going to be upset if you say, “I want to have you come back, and I want to be able to book a little more time for you in 2 weeks so that we can address this 1 issue.” That isn’t a problem. The patient is going to appreciate that. Say, “I want to have more time for you.”

I agree completely with the idea of shared decision-making. There are some things in medicine that aren’t shared decision-making, but those are usually critical illness, emergency, bleeding to death type of things. This isn’t that problem. I’ve always felt that in any field of medicine, if any clinician feels there’s only 1 way to treat a problem, then that doctor has a very small toolbox, and I’d consider talking to somebody else, because there are lots of ways of dealing with any one problem.

It’s critical to find out what’s important for the patient and what their primary concern is. It may not be what you’re thinking. If it turns out that they only want to get pregnant, that’s a whole different form of therapy. In terms of dealing with payers, you have to have ancillary staff who are going to help with letter writing. You may have physician extenders in your practice who have particular interest in pelvic pain whom you can train and can spend time with the patients. “I want you to talk with this person, this PA [physician assistant] in my practice. I have all my patients with pelvic pain talk with her.” I don’t think the patient is going to feel shunted. They’re going to feel like they’ve got a real interest in this.

There are ways of doing this if that’s an interest that one has in one’s practice. Using your time appropriately and effectively [is important]. There’s that old study that showed how long it took for a doctor to interrupt a patient after they asked, “What brings you in today?” I’m making up this number, but it was about 20 seconds before the patient would get interrupted. You need to keep your mouth closed and listen.

Maria Lopes, MD, MS: Sometimes less is more. Tara, let me bring you into the fold. Have you come across tools? These days, there seem to be apps for every disease that can assist with how patients are doing, even on treatment. How do you determine what success looks like? To Dr Surrey’s point, physicians aren’t going to have more time, so how do you maximize that time in terms of patient wishes and how they’re doing on therapy or perhaps consideration for the next step and the approach?

What does treatment success look like from a payer perspective? From a payer perspective, we usually have claims. Treatment success is when you aren’t visiting the ED [emergency department], and when we’re avoiding surgery and looking at polypharmacy, including opioid use. There’s tremendous focus around opioids and avoiding opioids. But avoiding procedures [is important].

There are a lot of good data that show that, in the years preceding a diagnosis—this is common in many other conditions—health care resource utilization is very high. Then once you have a diagnosis, there’s resolution of the uncertainty in terms of what you have. Hopefully, if you’re on the right treatment, the total cost of care should be contained. That’s what a payer’s looking for: “Are you on effective treatments?” Even if we’re increasing pharmacy spending, we’re looking to reduce spending from a total-cost-of-care perspective. Technology and apps may be part of the solution, along with how we can interact with patients and how we’re managing symptoms around pain and improving function. Those ultimately lead to greater patient satisfaction with the care that they’re receiving.

Transcript edited for clarity.

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