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Optimizing PAH Treatment in Managed Care


Derek van Amerongen, MD, MS: One of the things that was very confusing to me as a physician, when I made the transition from clinical practice to being a medical director, was what I would call the very arbitrary distinction between medical benefit and pharmacy benefit. Because for many, many years to me, a drug was a drug. And, again, some drugs are PO, some drugs are IV. In the insurance world, we look at things in terms of benefits. There are different buckets from which the dollars come from, and for drugs that are self-administered, that’s usually coming from the pharmacy benefit, the pharmacy bucket. Drugs that are administered by a healthcare professional come from the medical benefit, the medical bucket.

But, at the end of the day, I think all of us need to step back and say, “What is the optimal therapy for a given patient based on his or her clinical profile? And whether that’s a self-administered agent, a medically administered agent, what difference does that really make?” So, I think that where health plans are going today and in the future is to get away from a lot of those arbitrary distinctions. Again, there’s a financial piece, there’s a reimbursement piece which reflects the different types of benefits. But, when we’re sitting in P&T, we’re not saying, “Well, let’s look at this drug, because it’s a pill, differently than this drug that’s an IV.” Because what we really want to do is say, “How do we create the best treatment options, or how do we support the best treatment options for that individual patient?”

If I was a patient with PAH, I would never say to my clinician, “Please don’t give me the IV because I’d rather take a pill, even though the pill works not as well as the IV.” I don’t think any rational person would say that. And so, one of the exciting things that I see in the managed care side of the world is this movement more and more towards looking at therapy from a holistic standpoint. We need to get away from those arbitrary divisions, which, again, still need to be considered when you’re talking about the nitty-gritties of claims processing and reimbursement, but saying, “How do we create an approach that really will support optimal outcomes?”

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