RSV diagnosis can lead to an array of financial complications.
Adam C. Welch, PharmD, MBA, FAPhA: Let’s shift to talk about some of the financial burden and future considerations of RSV here on this agency payer perspective. My first question: What are some of the strategies that we can implement to help ensure that families have access to RSV [respiratory syncytial virus] prevention and try to minimize some of that administrative burden that we spoke about earlier?
Kimberly C. Chen, DO, MSHLM: It’s very important to differentiate between commercial payer and Medicare compared with Medicaid. For Medicare, I think the guideline is much more straightforward right now because the ACIP [Advisory Committee on Immunization Practices] recommendations basically allow the provider, the physician, and the patients to have a shared decision of figuring out who can get [a] vaccination. It makes it much easier; it does not require [preoperative care]. Meanwhile, for commercial and Medicaid populations, more likely the state will still need to make some decisions. The commercial payers, Medicare, and Medicaid are still sitting tight to wait on the ACIP decision. So with that, [preoperative care] will continue to be required. So ways we can decrease that turnaround time [for preoperative care] are very important. As we talked about earlier, for the therapeutics, that’s 40 days right now. And part of that is that specialty pharmacy fulfillment takes about 21 days. So ways to get that decrease are also important to making sure that maybe the specialty medication can be available in pharmacy [in] your neighborhood as well as…where the patients can actually get it from their providers. Those are ways that we can improve access and make sure that some of those socially disadvantaged neighborhoods will get their medications more easily.
Adam C. Welch, PharmD, MBA, FAPhA: Dr Boyer, as a clinician, how do you triage these families and think about who needs RSV preventive measures and who does not?
Debra Boyer, MD, MHPE: The guidelines are helpful. And there are those patients who clearly fall within the recommended groups. It’s remembering as a clinician that those patients need this and to start that process as early as possible for all the reasons that Dr Chen mentioned. There are all those kids that fall within that considered group, and as a clinician, we need to make decisions for each of those patients and then work with the payers to…hopefully get permission if it should be indicated to pay for it. So it can be a challenge, but it is awareness both for the clinicians and one for the payers to be able to easily approve when they’re needed.
Transcript edited for clarity.