Treating Wet Age-Related Macular Degeneration and Diabetic Macular Edema - Episode 3
Kevin U. Stephens, Sr., JD, MD, leads a discussion exploring the key drivers of cost for patients with wet age-related macular degeneration (AMD).
Jim Kenney, RPh, MBA: Thank you. Dr. Stephens, I’ll get you on the conversation now that we’ve covered the clinical information.I wasn’t going to ask you any of those tough vision questions or ophthalmic questions.
Kevin U. Stephens, Sr., JD, MD: Thank you.
Jim Kenney, RPh, MBA: What are the key drivers of cost for patients with wet AMD [age-related macular degeneration] from the health plan perspective?
Kevin U. Stephens, Sr., JD, MD: Well, there are 2 primary drivers. First and foremost, potentially, is the pharmaceutical cost. We have the anti-vascular endothelial growth factor agents, and they can be very expensive. Secondly, many times, and our experts can chime in also, if they have laser therapy for whatever reason, they may not be a candidate for the pharmaceutical intervention. Then the laser cost could be significant. Those are the 2 primary drivers. It’s primarily the pharmaceutical interventions, and secondary, I think the surgical interventions, even though they are less frequent, they still are cost drivers. This is not counting the disability and the social impact of vision loss. As I think someone mentioned earlier, the ability to drive, the ability to function, to see and to do, find things, and that kind of thing. It can be very debilitating particularly if blindness would occur.
Jim Kenney, RPh, MBA: Do you find patients are typically required to pay a flat co-pay? Or is coinsurance at play, which obviously makes the trip to the doctor a bit of an adventure because you don’t really know what the out-of-pocket cost might be?
Kevin U. Stephens, Sr., JD, MD: Now, that is a tough question because our health care delivery system is pretty complicated. You have Medicaid, which is for typically younger people. You have Medicare for those who are over 65. Then you have commercial insurance. For each one of the payers, there is a different fee schedule, co-payment, as an out-of-pocket expense. For instance if you’re in a commercial plan, then you may have a deductible, a co-payment, or something. If you have Medicaid, typically they do not have co-payments or deductibles. And Medicare depends on if you’re a Medicare Advantage member and that kind of thing, the formulary. It’s very complicated how we navigate through this space in terms of expenses, particular for the patient. In each particular situation, they all are different. And if you have no insurance, it’s even more problematic.
Jim Kenney, RPh, MBA: That’s a great answer. I’m going to turn it now to Dr. Anderson and ask if you have experience with patients who struggle with the out-of-pocket piece of this, the various treatment options in these conditions?
Nicholas G. Anderson, MD: Absolutely. I completely agree with Dr. Stephens on a lot of these points. We do in the United States have a very complicated health care payment system, and there are a lot of factors at play as Dr. Stephens alluded to. This is a very expensive disease to manage, and it’s a disease that for many patients we have to manage for a long time. At the patient level, they have frequent doctor visits, as often as every month, with associated costs and co-pays, frequent treatments. We’re doing the anti-VEGF therapy sometimes every month, sometimes a bit longer than that. These medications are typically very expensive.
Almost none of my patients could afford this treatment without insurance. Even my patients with insurance still have very significant co-pays. And so a number of the pharmaceutical companies have worked with charitable organizations to put together co-pay assistance programs to assist patients with the expensive co-pays. There are also ancillary costs for the patients. Again, most of these patients are elderly, they can’t drive. Just today I had several patients who were paying a significant cost to have a driver get them to the office. They were trying to expedite their visit because they were essentially paying by the minute for that driver and the caregiver. For the health care system at large, it’s just a massive expenditure when you look at ophthalmology compared to some other specialties. Again, we have very frequent doctor visits, and we have these very expensive and long-term medical treatments that the health care system needs to find a way to pay for.
Jim Kenney, RPh, MBA: That’s great information. I think from the health plan perspective, we need to be very much aware of that as we set the formularies up and put in the criteria to get access to these drugs and determine what tier they might be on, if these things are tiered, or what benefit or coinsurance might exist. Because clearly if the patient can’t afford the drug, we’re going to have a problem. Now obviously the co-pay assistance programs work well for commercial. For the Medicare population, they aren’t eligible for the standard co-pay assistance programs, so they have to rely on foundations or other sources of assistance. And those can be means-based, which can be challenging certainly for those patients. I think we all have challenges on all sides of this equation to make sure that the patient has access, but also that they can afford the medications they need to treat these conditions.
One other question, Dr. Niles, to you. Dr. Anderson indicated he does get referrals often from another ophthalmic professional, if you will. Do you get referrals often from primary care or other family practice, traditional providers, internal medicine doctors, as opposed to the patient being referred from another eye care professional?
Philip Niles, MD, MBA: A great question. I would say 95%-plus of our referrals come from other eye care professionals.
Jim Kenney, RPh, MBA: Thank you very much.
Transcript Edited for Clarity