Managing ILD Treatment: Utilization Tools vs Self-Regulation

Kristin Highland, MD, and Ryan Haumschild, PharmD, MS, MBA, compare management tools to self-regulation for the best ILD treatment outcome, as well as patient access to nintedanib, pirfenidone, and tocilizumab through special pharmacies.

Ryan Haumschild, PharmD, MS, MBA: When we talk about the management of treatment, I think it's important for us just to call out utilization tools that we have by payers, because I think a lot of times these medications can be higher cost. Not all of them; some of the immunosuppressants aren't, but when you start to look at some of the agents that are now having more robust data, like tocilizumab, there tends to be a payer management strategy around them. As we look to it, the question [that] always comes up is, should there be prior authorizations and pre-certification data? Or should we just allow some specialists to self-regulate? I think that's always an important consideration. We talk about these therapies because you want to make sure that the specialists that are treating these patients can take a unique approach. It's really hard sometimes to create definitive pathways when you're looking at combination therapy, or if you mix in any type of pulmonary hypertension. With these patients it becomes even that much more complex. So as we look through it, when we [are] looking at it from a payer’s lens, the ultimate goal is to provide good clinical efficacy, preserve cost, and reduce any unnecessary excess spending. I think what we recognize is when specialists are managing these patients we're able to preserve quality of life, reduce any chance of nonadherence, and also detect any type of side effects in case there needs to be any transition or duplicative therapy added to the patient's regimen. So that's one of the things that I [think] through, especially when we think about some of these patients who have idiopathic pulmonary fibrosis and they can have worsening lung damage, all of a sudden they have acid reflux on top of it, all of a sudden they're abandoned in therapy and they're not being monitored. How do we get the provider or specialist in right away and reduce the amount of step-through therapies to ultimately get [patients] on the most efficacious therapy? So those are some of the things I want to add in as we start to think about the payer management process. And I wouldn't be able to [talk about] the payer management without talking about the mandating of specialty pharmacy use. And I know the 3 of you are really familiar with this, so Dr Highland I'm going to come to you as we think about nintedanib, pirfenidone, and tocilizumab. I know you utilize these agents for your patients. How has your experience been getting these medications from specialty pharmacy, and really when we talk about patient access, because we know time to treatment is so important, especially when we rely on adherence.

Kristin Highland, MD: I actually have had a reasonably good experience with specialty pharmacies. I've been using specialty pharmacies for years in the context of pulmonary hypertension. So in this transition to interstitial lung disease, it was not anything new for me. I actually feel that specialty pharmacies often are better at navigating the prior authorization process along with us and with the patient, as well as hav(ing) assistance in getting patients enrolled in patient assistance programs when there is a copay that maybe they can't afford, and are also quite useful at helping to monitor toxicities of these drugs, particularly drugs that have a REMS [risk evaluation and mitigation strategy] associated with them. So there's a patient education piece that you can get from a specialty pharmacy. Most of the time I'm quite happy. There's always a glitch in January when everybody has to get reauthorized and that process is a little bit disastrous. And so, since we're talking to payers, one of the things I would plead for is that these drugs shouldn't require reauthorization year in and year out. Once they're on a drug, they probably should be able to stay on the drug. Their diagnosis of interstitial lung disease hasn't changed. So I'd like to put a plug in for not having to redo the prior authorization every January, that would save us all a lot of gray hair.

Ryan Haumschild, PharmD, MS, MBA: I appreciate your plea, I agree with your plea, and it is really important in the specialty pharmacy to have close collaboration with clinic, and with the patient. Also, financial toxicity, we've got to make sure patients actually get access to these medications to see improvement. We're thinking about patient assistance programs, we think about grants and foundations, having someone that can facilitate that connection and get access is really important.

This transcript has been edited for clarity.

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