Managed Care Perspectives: Optimizing Women’s Reproductive Health - Episode 10
Payer decision-makers discuss defining value among agents for unintended pregnancy, uterine fibroids, and endometriosis.
Neil Minkoff, MD: Let me bring in both Kevin and Maria. As we talk about these things, we have a wide range of options that are being discussed. There are traditional oral contraceptives, progesterone-only contraceptives, different forms of IUDs [intrauterine devices], and things like Orilissa [elagolix], Oriahnn [elagolix with estradiol and norethisterone acetate], and Myfembree [relugolix].
One of the things that becomes a challenge on the payer side is trying to figure out how to manage all of that in figuring out what’s first-line, second-line, and third-line. Does a patient have to fail drug A to get to drug B? Are the oral contraceptives all highly generic, so they’re all available? When you get to figuring out Myfembree vs Oriahnn, maybe there’s an either-or type of scenario there. [What] are you guys doing in terms of this? You don’t necessarily have to tell me what you’re doing to manage, as much as you can tell me philosophically how you decide to manage in this state, especially as it’s grown beyond oral contraceptives and IUDs to have these newer types of molecules.
Maria Lopes, MD, MS: The answer for payers is a relatively easy one. We have contraceptive benefits under ACA [Affordable Care Act], and with that, contraception is free. We talked about IUDs, progesterone, and oral contraceptives. The path of least resistance for physicians and patients at $0 cost-share is to initiate a frontline option that when you get into higher cost drugs essentially allows justification to a payer for what else has already been tried. Typically, we’re not defining how long you need to be on a frontline option. But the fact that they’re low cost, if not free, incentivizes the system and members to perhaps consider 1 of those options first.
With some of the newer agents, there’s very exciting innovation in terms of additional treatment options. They’re oral. They’re easy to administer. There’s risk-benefit to different forms of contraceptive options. Not everybody is going to be appropriate for oral contraceptives. Not everyone is going to be appropriate for an IUD or progesterone. But usually, when it comes to higher-cost products, payers are looking at perhaps a step approach, so prior authorization, which gets into the label indication for the drug, postmenopausal vs perimenopausal or women of childbearing years. That’s so we’re at least ensuring appropriate use with a consideration for what else—at least maybe 1 other option—has been tried.
Fairly loose, but the other issue is what patients are going to face in terms of costs. Because a lot of these drugs are going to end up in the specialty tier, prior authorization and patient cost-share is a real issue. Then affordability for some, especially some who can at least afford medications at a high cost, becomes a real issue for compliance.
Kevin Stephens, Sr MD, JD: I agree 100%. Just to backtrack a bit, 1 of the things we look at is when you go to [the] emergency department, get a CT scan, and get some type of ultrasound or pelvic ultrasound. Neil, I believe you said that at 3 o’clock in the morning, it may not be as readily available as one would like to make the diagnosis. That brings up another point. We also look at the site of care as a big cost driver, too. We realize that having an ultrasound in the emergency department in the middle of the night by an emergency room physician may not be the most cost-effective place and way to get that care done. Give them something for the pain, show a stop in the bleeding, give them adequate care and those kinds of things to make sure that the patient is stable.
We also look at things like whether the pelvic ultrasound could be a transvaginal ultrasound ordered on an outpatient basis and not in the hospital with an ultrasound technician coming in the middle of the night and those kinds of things. Those are things that even when you have to have a laparoscopic myomectomy or whatever the procedure may be, we look at ambulatory surgical centers as opposed to being inpatient because we know that site of care is a driver for costs. We try to get the best care at the best place and to take care of the patient.
Going back to what Dr Lopes said, we have a lot of stuff to do. Technology has advanced tremendously over the last couple of years. We all have to work together. Perhaps my take-home message for all of us would be that we all have to sit down and get together and look at the data, because we have to start with the studies and see what the indications are. We have to look at what the complications are, and maybe look at quality also. Not just quality in terms of quality outcomes, but also quality of life. Nowadays, we have to pay attention to quality of life. That’s a big driver for many people. We have to put that into our equation and come up with the best algorithm to achieve all of those things, realizing that it may be trial and error. We may not get it right the first time. We just have to be committed to the process. At the end of the day, we’ll all get to a better space.
Transcripts edited for clarity.