Dee Anna Glaser, MD: Thinking about that, how do we take those individual patients who are in our practice, that are being presented to you, and start to try to think about insurance coverage? Where do you start?
Adelaide Hebert, MD: Well, I think patients don’t know a lot about what is covered and what is not. Understanding what’s covered under their pharmacy plan versus the part of the plan that pays me, like the portion that might be for durable goods, which would include the iontophoresis technology. All of this is extremely foreign to the patients I care for. And I understand. Insurance is very complicated. In my practice, my medical school will not allow me to treat with Botox and bill. I hope that I will get paid. I actually have to write a prescription for the patient, get that covered through their pharmacy benefits, and have it shipped to my office. There are a lot of complicated portions in this management scheme. We’re willing to do it because it offers such a favorable impact and outcome on the patients that we treat, but I don’t know that everyone is willing to undertake that. I think insurance is one of the biggest obstacles we still need to work on, and I hope that with better education for our colleagues within that realm, we’ll be able to smooth much of this out and more readily offer these options to our patients.
Dee Anna Glaser, MD: We’re actually starting to see some insurance plans that will no longer cover the drug of botulinum toxin, but will cover the injection.
Adelaide Hebert, MD: Yes, we see that, too.
Dee Anna Glaser, MD: That’s really been a new challenge. It seems like every time we move a few steps forward, we take a little step backward. We just have to keep marching on. What do you think the coverage will be for these new emerging therapies, like glycopyrronium tosylate, which will hopefully get approval soon?
Adam Friedman, MD, FAAD: I think it’s going to come down to where the company prices the drug. A lot of the onus is on us, to prove that you need it. We have wonderful data, a lot of it generated by the International Hyperhidrosis Society. We need to prove the point that this is not just a medical condition but is a disabling one. This is going to depend on a couple of different players. We’ve kind of been harping on this access to care.
I’m also worried that, let’s say, it’s not well covered. Will that stymie further innovation? Will other companies say, “If we put all of this money in and we get it out, if we get through the FDA process and those hurdles—hooray for us—will it even be covered in the sense that insurance carriers will actually put it into the standard formulary? Or will it be a second-tier type of drug, where the co-pay will be astronomical for the patient?”
Dee Anna Glaser, MD: One of the issues with this is that hyperhidrosis is a lifelong disease. We’re trying to think about management and therapy that is safe and effective over a lifetime, as physicians and healthcare providers. And, as payers, we’re also trying to think of what the cost is over the lifetime. This is not just short term, 6 months to 1 year, where you make some lifestyle changes, lose some weight, change your diet, and it’s going to be treated. This really has become an issue because it is lifelong. Andy, what are your thoughts?
Andy Szczotka, PharmD: From a payer perspective, we try to look at a population health—based approach. We look at the clinical data that’s there, the peer-reviewed literature, looking at guidelines from both a national and a local level to see what the best approach to therapy is. We look at that and try to develop and engage our local experts—people who we use internally besides those of the national associations—and develop our own pathway for determining the best way to approach it. We know it’s not going to hit 100% of all patients, but it’s going to hopefully hit the majority of those patients. We develop some kind of sequence of therapy. As you mentioned earlier, there’s always going to be additive processes or sequences that go forward, so we’re really looking at how they work. When we look at these new emerging therapies, how are we going to evaluate them? It would be very similar to what we do with any new drug that comes out, in terms of a pharmacy and therapeutic approach, but we’ll look at that data and engage our experts to determine the best positioning for it and how it will work.
As you mentioned, this is something new to us. This is not like cardiovascular disease or diabetes, in which we’ve known about forever and know how to manage. This is new. It’s additive therapy. It’s new additional cost. There really is not a direct cost offset for the payer. So, how are we going to manage this and what’s the best way to do it? We’re going to take some type of logical stepwise approach to be able to manage this therapy long term.
Dee Anna Glaser, MD: There really are not any labs to follow, right? You can’t say, “Wow, what a great success. We got that glucose or hemoglobin A1C down to this,” or whatever. I think it is going to take a new thought process from all of us to really understand how to provide safe and effective quality care for the patient that’s reasonable for society and healthcare to cover.
I look forward to the day where patients are not embarrassed to even come in and speak to their physicians or healthcare providers, right? We’re still facing that issue today, where patients are too embarrassed to talk about their sweating with their own physician. It just amazes me that this still goes on. I don’t exactly know how we’ll overcome all of that, but that really is the first step—getting people to realize that. As you mentioned, it’s not because they didn’t shower or they didn’t do something right or that they’re dirty or lazy. They’ve got this medical condition. I would imagine the future for you, in terms of prescribing therapy, might be where you don’t have to go through multiple prior authorization processes involving multiple staff.
Adam Friedman, MD, FAAD: That would be wonderful. I’m sure my staff would really appreciate that.
Andy Szczotka, PharmD: One of the gaps that we’re seeing now is that we have a lot of therapy options that have all been proven to be very effective and safe, even labeled or unlabeled. But we’re not seeing that combination of additive therapies in the literature that allows payers to evaluate and understand it. We still look at it as a silo approach, because that’s what the literature shows. As we move forward, having these types of discussions and these types of forums will allow us to be able to move in a direction where we can better treat the patient and understand the real value behind it. I think that’s where healthcare is moving toward. We’re looking at the value for the patient and what value therapies can bring, overall.
Dee Anna Glaser, MD: Yes, that is really so important. We’ve been trying to design studies that look at this, but they’re so complicated. I just spent an hour with one of our statisticians and we haven’t gotten it knocked out yet. I also think we need more assistance from our patients, to more freely verbalize how this disease affects them when they’re in the office. I know all of us have had this experience when talking to a teenager or college student. You’re asking, “How does this impact your quality of life?” And, of course, the first thing is, “I have to wear black. I can’t wear pink, or blue, or other colors.” They’re so focused on that. They are unable to really process what’s driving that, not just the end result that they are embarrassed to wear a light blue shirt.
And so, I look to the day when they can freely just tell us how it’s actually affecting their lives in the classroom, at work, and with loved ones, and for them to understand it. I usually just look at the teenager and say, “Do you think your insurance really cares what color shirt you wear? You need to think about the ways that it’s impacting your career.” I always think about all of the future little Babe Ruths who aren’t being developed because they can’t hold on to the bat or they can’t do different things, and what the world is missing from some of these very bright kids and patients with hyperhidrosis. My ongoing joke is that they all need to become swimmers. They kind of laugh.