Dr Haumschild leads a discussion surrounding patient and provider collaboration to avoid clinical inertia in MS treatment pathways.
Ryan Haumschild, PharmD, MS, MBA: One of the things I see is, pharmacists play an important role in treatment recommendations and follow-up as well. A lot of times when you’re counseling a patient or going through a new onboarding of treatment, you expand upon the benefits but also some of the adverse effects that might come up.
Amanda Hickman, PharmD, MPH, MSCS: Absolutely.
Ryan Haumschild, PharmD, MS, MBA: How do they mitigate those in creating shared expectations around the treatment journey so they’re not afraid to bring those up to you, so you can titrate medications appropriately? If you could, talk us through a bit when you go through an onboarding activity with a new patient. What are things you highlight, things you want to make them aware of, and then how do you reassess that patient as they have subsequent fills within your facility?
Amanda Hickman, PharmD, MPH, MSCS: Absolutely. It’s a combination of when they’re first referred to me, sometimes we have a little flexibility in having those medication discussions, so getting to know what’s their lifestyle. What are their goals? What are their values? What’s their family planning? This disease is often diagnosed in a patient’s 20s or 30s. That’s also prime family planning time, and a lot of these medications are not recommended during pregnancy or lactation. So, getting into what their plans are for that, so that we could still start those treatments but we have a plan for when they want to expand their families, and make sure it’s done safely for mother and baby. I also go over the adverse effects and let them know what the rates were and why they occur. A lot of times I go into this is what the medication is doing, and this is why we see this. But again, it’s not common. Then finally, every patient with MS [multiple sclerosis] is their own individual, and their experience is not going to be anyone else’s experience. So, we can have all these data, all of this population, but reinforce to them we’re a team. “Let me know what you’re feeling, and I will help you know if it is your MS, if it is something else, or if it is your drug.” Then keep that conversation going.
Ryan Haumschild, PharmD, MS, MBA: That patient-specific approach is huge. Because ultimately, if patients are better equipped and prepared for some of the adverse effects or part of the normal treatment journey that’s to come, I think they’re a lot more likely to stay adherent to their therapy. Reach out early instead of when rate-limiting toxicities occur, and ultimately if we can keep them on therapy longer, that’s going to give them their best chance.
Amanda Hickman, PharmD, MPH, MSCS: Absolutely.
Ryan Haumschild, PharmD, MS, MBA: I really appreciate the great feedback everyone provided there as we had that discussion. One of the things we need to do is create access, not only from a provider standpoint but also from a managed care and payer perspective. If we identify that a certain treatment might be important to initiate early, we want to make sure they can get access from a payer side as well. Dana, I know you have a lot of experience in this area, making sure we’re making patient-centered decisions and making sure that formulary placement and access reflect the best practice and guidelines. From your perspective, what can payers be doing to ensure access to therapies that could potentially delay the progression, even with primary MS, in terms of what is it that could reduce that and ultimately allow them better treatment earlier?
Dana McCormick, RPh: Sure. One of the struggles, and I think we see it in practice, not just in the physician practice as well as in the payer spaces, is the clinical inertia of new guidelines and new therapies and new approaches to how we think about disease treatment, as we have newer drugs that have better outcomes than previous therapies. I see this happening today and for the past several years as it relates to MS. One of the things is that there is a little time delay as the data are being generated and for managed care organizations to take that and build it into their policy decisions as they’re developing utilization management and prior authorization criteria. But clearly, there’s evidence to support early intensive therapy to delay disease progression and maintain quality of life. So it’s super important for payers to have that thought process in mind as they are developing different clinical programs.
A couple of things that are difficult though as a payer in looking at developing a population-based approach is building in that ability for patient-centered, shared decision-making to occur because it’s hard to do that in a policy. I think payers try to do that as best they can, but I think that, and also thinking about MS and developing policies, like the heterogeneity of the disease, makes it very complicated as well. The other thing is I do feel like, while everybody agrees early intensive therapy is the gold standard today vs escalation, I think there’s still a lack of consensus with the consensus algorithms that are coming out from AAN [American Academy of Neurology] and various other organizations. So from a payer’s perspective, trying to make sure we’re following and creating policies based on evidence-based guidelines when there is not a consensus among organizations makes it a bit more difficult.
It’s important for payers to, No. 1, especially in a complicated disease like MS, is to work with the physicians who are treating patients with MS. Talk about what is it, how are you defining it, because payers also tend to look toward clinical trials and how those clinical trials are developed, and what are those outcomes, and what are the tools and resources used to determine those outcomes. So if we think about those tools and resources that are used for clinical trials, they may or may not be used in everyday practice. It is important to make sure there’s communication between the payers and the physicians treating those patients living with MS.
For example, how are you, Dr Williams, measuring disease severity in your practice with your patients? How are you considering specific treatment for that patient? As Dr Hickman mentioned, is that patient concerned about the immune system? Are they concerned about their lifestyle, and how best can you provide a medication that the patient’s going to be adherent to? Some of those things. The other thing, again, it is important for payers to keep up with the data, make sure they are reviewing new literature as it comes out, and incorporating that information quickly into their policies and making changes to keep up. Because again, that’s one thing that could help with clinical inertia, if payers were creating policies that were keeping up to date, that could help inform some of the treatment going on with patients as well.
Amanda Montague, Ed.M.: To your last point though, I think that’s one of the challenges we face as an MS community because keeping up with the exploding landscape is insane probably for MS specialists, who all you treat is MS. But for the general neurologists who many MS patients see, it’s very challenging to keep up to date. I think that’s something from the patient advocacy community we see as a real gap in terms of how MS is being practiced. It’s hard. It’s really challenging with all of the innovations and all the new research to keep up with that if the majority of your patients are not those living with MS. I’m sure you all see the same dichotomy.
Dana McCormick, RPh: No, exactly.
Mitzi Joi Williams, MD FAAN: I think another important piece is the implementation of real-world evidence. When we talk about the efficacy of therapies, our clinical trial data, although they are great data, can be very limited. If we think about a monoclonal antibody’s efficacy versus another monoclonal antibody, nobody’s going to do that study. But there may be registries, global registries, where there is direct matching, where they do propensity score matching. Or there may be other data, for instance looking at underserved populations, which are often excluded from our clinical trials. I think certainly it also can be a challenge to make sure the correct entity is getting that data. So when I’m treating my population of patients who are often in underrepresented communities, and we see research focused on their outcomes, how do I then convey that when I’m trying to get a medication approved? There are multiple challenges there to keeping up with the real-world evidence as well.
Ryan Haumschild, PharmD, MS, MBA: A couple of key aspects I took away from this discussion for sure are, No. 1, we need to partner with our payer colleagues. We want better access earlier. How do we generate real-world evidence that gives them further confidence in terms of sequencing? And if we are going to offer more of a high-cost therapy early in the treatment journey, let’s make sure we can justify the benefits of that in making sure it would have offsets, too, in the total cost of care. Then forming what I call disease state working groups, or getting those key opinion leaders from the community and the academic side to come together and establish what might be best practice as a whole. We know there will always be patient-specific factors that have to be considered, but at least having the right approach that provides the best outcomes for all patients, I think could be a leading indicator for a health plan and also a practice.
Transcript edited for clarity.