Jay Weaver, MD, highlights MDS treatment strategies driven by optimal health resource management.
Ryan Haumschild, PharmD, MS, MBA: As we talk about total cost of care and health resource utilization, I’m going to pivot to Dr Weaver, our in-house expert, to talk to us. Dr Weaver, we talked about a lot of context in treatment. We talked about the unique needs of this patient population. From your perspective, what are the drivers of health care resource utilization in patients with MDS [myelodysplastic syndrome]?
Jay Weaver, PharmD, MPH: We’ve touched on the clinicians. I spoke to several of those. One is obviously the symptomatic treatments, which aren’t inexpensive. You think about factors. You think about giving growth factors, transfusions, anti-infective agents for some of the infections that occur, clotting factors, and anticlotting factors. Some patents are hypercoagulable. Some aren’t coagulating at all. There’s so much supportive medical care for that.
When we think about the treatments, if you were fortunate enough to be a candidate for a bone marrow transplant, it’s not only a costly endeavor but also a risky treatment. Sometimes we’re wiping out somebody’s bone marrow and putting them at increased risk for infection and all sorts of things while we’re hoping for the graft to take. These are all considerations as we think about benefit design, which we’ll talk a little about later.
As we think about the cost of providing benefits for folks, sometimes our dilemma in helping employers or helping health plans figure out their premiums is that we have things adding to 1 side of the equation—costs and whatnot—and then we have needs for affordability. We need to make health care premiums affordable enough for people to buy the insurance so that it’s going to be of use. If you buy something and you have no coverage, then what did you really buy? Balancing those things are important.
Our biggest challenge sometimes is homing in on the right population for the right interventions. As we talked about, this condition appears often in the seventh decade of life and beyond, so it’s largely a Medicare conversation. As many of the managed care experts will tell you, Medicare is a very prescriptive benefit. They’re very specific about what’s covered, how it’s covered, the benefit levels, the cost sharing—all those things. As I talk with physicians who treat patients who have either managed Medicare plans or traditional fee-for-service, they talk about how hard it is for many patients to afford some of the therapies because the cost share can’t be subsidized. There’s no offsetting from coupons or things from manufacturers. There are very few relief mechanisms in our health care system to help people on Medicare who have a condition like this that has a very high resource utilization.
Plans find themselves in the dilemma that they can’t offer more than they’re allowed to offer. They can cover things only as CMS [Centers for Medicare & Medicaid Services] says they can cover things, and then they have very specific limits to stay within in terms of running a profitable health plan. The Centers for Medicare & Medicaid [Services] won’t let you run a health plan that isn’t profitable. If you’re in the business to run a health plan, you better run it within the means that you can. If you’re losing money, they’re going to say that probably isn’t the best thing. You’re going to have your own problems whether you’re making too much money or not enough. Trying to stay within those boundaries and create something of use that’s also helpful and affordable for patients is always tough.
Transcript edited for clarity.