Long-Term Outcomes and Managing PAH Costs

Derek van Amerongen, MD, MS: As we look at the pivotal trials that come to us about a given drug at the P&T committee at the health plan, one of the things that we’re always very interested to see is—has there been any work done on understanding the longer term impact of the use of a given therapy? And a great example of that is, is a therapy actually reducing, for example, the need for hospitalization? If a person needs to go into the hospital, then that indicates that there’s a problem with the clinical management, that the outcomes are not where anyone, either the doctor or the patient, want them to be. Certainly, hospitalization can be quite expensive, and can lead to a lot of additional complications and adverse events that would hopefully be avoided if we could keep the individual out of the hospital.

So, understanding the potential for a therapy to avoid those types of complications is very, very important. Part of the challenge that we have in managed care, and I would say in the medical literature in general, is that we regularly do not find that information in pivotal trials. It would be great if that was something that researchers would routinely include. Because, it would help us understand not only how we forecast the impact of a given therapy, especially if we’re talking about a new therapy moving from, say, the current standard of care to a new option. And also, how do we counsel individuals? How do we counsel those patients, in terms of what they can expect as they move from the therapy they were on to perhaps a new therapy?

This becomes much more than a cost issue. Although, certainly, the cost is important in order to make sure that we keep a handle on healthcare costs, and keep medical coverage affordable for individuals. It really becomes, I think, even more importantly a clinical issue. How do we understand which therapies are really going to give us the best outcome, and get us to that end point that both doctors and patients really want to achieve?

Managed care has always been focused on how we maximize clinical outcomes. The two reasons for that are number one, that we get an optimal patient-centered outcome. And number two, we can hopefully avoid unnecessary cost to the system. One of the exciting things that’s happened with the advent of the Affordable Care Act and healthcare reform is that there is, today, a much greater alignment than ever between providers, including hospitals and clinicians and health plans and other stakeholders, on how we can avoid those preventable readmissions. And not only the cost that that engenders, but I think even more importantly the stress and potential risk that that poses to patients who have conditions like PAH for whom another hospitalization is potentially a very deleterious event.

So, one of the things that we do at health plans is make sure that anyone coming out of the hospital has the support of our nurse case managers. And that we work very closely with the discharge planners from the hospital, to make sure that that individual has all of the support he or she needs. When you look at the data as to why people get readmitted to the hospital within, say, 14 or 30 days after admission, it frequently boils down to very basic things. They did not get their medications; they did not get a follow-up visit with their clinician; they did not have a clear understanding of their discharge instructions; they did not perhaps have the logistic support to get from their home back to their doctor’s office, or to another place of care that might have been necessary.

Those are all issues that we at the health plan focus on. And I think that what we’re trying to do is take a lot of the nitty-gritty things, a lot of the logistic issues, and complement that with the care being provided by the clinicians to make sure that the patients have all of the resources and support they need to avoid that 1 in 5 individuals who gets readmitted to the hospital within 30 days.