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Managed Care's Role in Future Treatment of PAH


Derek van Amerongen, MD, MS: There are many conditions, such as PAH, which have seen some pretty significant evolution in the last 5 to 10 years in terms of their treatment paradigms. This is an exciting time in medicine in terms of our increasing understanding of how to manage these extremely difficult and complex conditions, the role of genetics, and the role of combination therapy. All of these are now really remaking how we approach so many conditions and diseases. They create significant challenges in terms of how we as a society and we as a healthcare system maximize access to these expensive yet important therapies.

And I think, going forward, managed care is always going to do everything possible to make sure that individuals who have conditions like PAH can get the drugs they need, and get access to the proper specialists and tertiary care centers that are designed to treat them. The challenge, of course, is always going to be: how do we make sure that we do this in a medically responsible way, in a way that avoids unnecessary costs and that protects patients in terms of making sure that they are not being exposed to treatments or therapies that might have safety or significant tolerability issues?

But, I believe that as we understand more medically, as we continue to move our entire system towards a more value-based model—which is part of the transition we’re seeing with healthcare reform and will continue to see over the next 5 to 10 to 15 years—I actually am very optimistic about the ability to maximize treatment for conditions like PAH, and actually improve and expand access to therapies that many people even just a few years ago might not have been able to obtain.

Clinical trials are tremendously important in all conditions, especially in rare diseases such as PAH. The challenge for managed care, to a certain degree, has always been that coverage of clinical trials has typically been an exclusion from insurance, because insurance was never designed to fund experimental trials and innovative research. At the same time, one of the things that health plans are doing more and more, especially with conditions like PAH, is helping to connect individuals to clinical trials, which may be funded by the NIH and pharma companies.

We have a very robust case management process within our health plan, and most health plans do as well. And one of the things that we want to do is help connect people as we identify them with PAH, as we line them up with the clinicians and the sites of care that are going to do the best job of taking care of them. We also want to make sure we’re connecting those individuals with trials that may exist, and helping the healthcare providers in our networks who are interested in getting access to those patients in order to bring them into trials, to facilitate that as well.

So, I think it’s a great opportunity for us to collaborate not only with providers and research institutions, but with pharma as well to make sure that patients are getting access to trials, that they’re having the ability to participate in moving the entire area forward, and, at the same time, make sure that we as insurers are being proper stewards of the premium dollars that we’re given. We are funding care, but not underwriting experimental research, while, at the same time, helping to draw those connections so that that research can move forward.

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