Peter L. Salgo, MD: If you were left to your own devices and you were left to write the way you would like to have reimbursement regulations, would you go to step therapy prior to authorization? Would you rather see somebody start on a less expensive drug and move up to a more expensive one only if required?
Jeffrey D. Dunn, PharmD, MBA: It’s not necessarily that I’m just picking the least expensive medication. I want to pick the most cost-effective medication. I’m not saying to start with the lousy drugs from 20 years ago and go through those. I’m saying that if we have 4, 5, 6, or 7 options and future single-tablet regimens—and there are maybe subtle differences between them, but generally speaking, they’re all very effective—is there an opportunity to at least have a conversation of, “Well, instead of 7, we’re going to cover 4 for starters,” and then go from there?
We’re more likely to be incentivized to build other supportive programs around that if we have some collaboration around managing the utilization costs of the medications. Because right now, we do some things, but there are more things that we could be doing. I think there’s just a perception that we’re leaving it up to the providers because if we talk about this, we’re going to get beat up.
Peter L. Salgo, MD: You’d like tighter management.
Jeffrey D. Dunn, PharmD, MBA: It’s semantics. Tighter, not necessarily, but maybe more of an emphasis around not just efficacy but efficacy, safety, cost, utilization, and the other factors that go into this.
Peter L. Salgo, MD: Does that worry you? Does it worry you if they could control it?
Michael G. Sension, MD: Yes, it worries me.
Peter L. Salgo, MD: Why does that worry you? He’s not a bad guy; I’ve talked with him.
Michael G. Sension, MD: No, but it takes away my ability to practice medicine, and I feel like the payer then is taking over my role and telling me what I need to prescribe.
Peter L. Salgo, MD: They do it in lots of areas. They seem to have accommodated to it.
Michael G. Sension, MD: Yes. And again, I would just ask that you follow current, progressive, state-of-the-art therapies. For example, in the next year, we’re expecting new treatments to come out.
Peter L. Salgo, MD: We’re going to get to that.
Michael G. Sension, MD: I think that we need to be ready to adopt these.
Jeffrey D. Dunn, PharmD, MBA: I think we’re on the same page. If you look at the escalating specialty drug trend, all the other categories are managed. Even oncology is being somewhat managed right now. The only category that’s not being managed is HIV. My fear is, if we don’t have better conversations with the payer and the providers and the guideline bodies and everybody else around this, then payers are just going to start doing something that’s going to be worse.
Peter L. Salgo, MD: What do you mean by that?
Jeffrey D. Dunn, PharmD, MBA: They’ll start putting in step therapy and prior authorizations, limiting access, and doing things just based on their perspective.
Peter L. Salgo, MD: But you’ve said you can’t do that. Why can’t you do that?
Jeffrey D. Dunn, PharmD, MBA: Historically, it has been political. But the environment is subtly changing. More and more, in an employer’s health plans, people who are paying for this are getting beat up in double-digit trends year over year. It’s affordability and access to insurance. And so, the environment is changing. Categories that we weren’t managing historically—hemophilia, oncology—we’re managing now. This is one that I think is heading in that direction. My only comment is that I would like to do it collaboratively, and I would like to have some conversations about what’s appropriate and what’s not rather than just saying, “You can’t tell me how to practice medicine.” At some point, payers are going to say, “This is what I’m doing,” and it might not be good for everybody if there’s not some collaboration.
Peter L. Salgo, MD: That’s more than just a veiled warning here. It’s coming. What I hear him saying is, “You better get your opinions in now and work with us collaboratively because it’s coming anyway.”
Michael G. Sension, MD: You don’t have to reinvent the wheel either, because it’s already happening. I’ll tell you that in South Florida, there are 2 Medicaid HIV disease state-managed entities. We have 2 HMOs (health maintenance organizations) for HIV in the Medicaid arena, and we have 1 in the Medicare arena, and they are HIV managed care. So, it’s already happening in those arenas. We’re doing it in Ryan White ADAP (AIDS Drug Assistance Program) arenas. I think that it’s rather successful so far, and I’m just concerned about restrictive formularies that handcuff me.
There’s a new form of tenofovir, a nucleoside/nucleotide reverse transcript ACE inhibitor, that has been shown to have less toxicity on kidney and bone. Not surprisingly, that is under patent, and the old form of tenofovir is going off-patent and would presumably be potentially cheaper, but that carries with it more morbidity along the lines of kidney and bone toxicity. So, I am concerned when I hear talks of adopting generics, which in my mind means older drugs that carry with them more potential problems but are cheaper. That’s my fear when I start to hear these types of discussions.