Peter L. Salgo, MD: There are 2 approved anti-VEGF therapies. There’s aflibercept and ranibizumab. Do you have a preferred one on the formulary?
Peter Dehnel, MD: We do not, and most of this is actually within medical policy, at least in our plan, because it’s something that’s injected. It’s not something that a patient can go to the pharmacy and purchase. So, it is under medical policy and, for this, we have all 3 available.
Peter L. Salgo, MD: Do you have a preferred one?
Gary L. Johnson, MD, MS, MBA: We do not.
Peter L. Salgo, MD: Now, when you said, “We do not,” I heard this groan to your right. At least to my ear, there was a disagreement.
Charles Wykoff, MD, PhD: No, but I think, in many markets around the country, there is a preference among payers for physicians to use cheaper agents. Maybe you guys don’t agree with that, but I think that’s pretty obvious around the country. Please, correct me if that’s wrong.
Peter Dehnel, MD: I would not disagree with you at all in that statement. I believe that’s very true.
Charles Wykoff, MD, PhD: We really do try to be good shepherds as retina specialists across the country. I often will start patients with bevacizumab because my local payers have asked me, either directly in writing or through a phone call, “Look, can you use more off-label please?” Because it’s expensive, and I respect that. I don’t want to bankrupt the country, if that’s where we’re going, so I often will start with bevacizumab. But I make sure the patients know the reason for that is not because I think it’s better and it’s not because I think it’s safer, but it’s purely a financial reason.
Peter L. Salgo, MD: Let me paraphrase that conversation in as dramatic and unfair a way as possible: “Hello, Mr. Jones, I’ve got a really good drug for you, but he won’t let me give it to you.” Is that it?
Jared Nielsen, MD: I find the exact opposite with patients. When I explain some of the financial dynamics associated with the selection of an agent, a lot of patients are willing to try an agent that’s less expensive.
Peter L. Salgo, MD: Really?
Jared Nielsen, MD: Sometimes, I feel like they’re adding to the greater good by saving money for whoever is helping them pay for their care.
Charles Wykoff, MD, PhD: It’s funny, I’ve had a couple patients who have come in with a Wall Street Journal article in hand saying, “These greedy doctors, they’re using the expensive drugs,” which I think is ridiculous. I’ve got a couple patients that wanted to start bevacizumab. In fact, in both of those patients, it didn’t work that well. And then, eventually, I ask, “Look, can we go on the expensive stuff?” and they got substantially better.
Gary L. Johnson, MD, MS, MBA: And we shouldn’t forget the coinsurance, because it can add up after a while.
Jared Nielsen, MD: I think that’s a huge challenge, and, ironically, with the way that some of the plans are structured and with some of the assistance programs that are offered for patients, the more expensive drugs are the ones that are less expensive for the patient out of pocket.
Charles Wykoff, MD, PhD: It’s funny that you bring that up. There are all these different plans now where it’s actually cheaper for me to use on-label drug for the patients’ out-of-pocket expenses than it is for them to use bevacizumab, because there are these co-pay plans that are from some type of nonprofit organization.
Peter L. Salgo, MD: I’m going to ask the same question to the payers and to the clinicians, which is, to whom do you have a responsibility: is it to the patient or is it to the entire healthcare budget of this country? That is, are you going to bankrupt the country for this guy sitting in front of you, or do you think that you need to think of the bigger picture?
Charles Wykoff, MD, PhD: As a physician, my absolute requirement is to the patient sitting right in front of me, and it will always be to that patient and that patient alone.
Peter L. Salgo, MD: And what about you?
Jared Nielsen, MD: I wholeheartedly agree. But you have to acknowledge that there are significant cost restraints that we all have to deal with on a daily basis. It would be nice if we were in a world where we didn’t have to deal with those, but, unfortunately, in reality we do.
Charles Wykoff, MD, PhD: I have one more thing to add. I find it frustrating that we are possibly the only country in the world that doesn’t bargain with pharmaceutical companies on prices of drugs before they’re accessible to the general public. I find that staggering. Why is it that we, as physicians, are the ones who are made to regulate price?
Peter L. Salgo, MD: Well, you’re actually not. He is, too. Carriers and physicians both, right? But let me pose the same question to you. Is it your responsibility to ensure that an individual patient gets the absolute best treatment, or are you there to protect the entire healthcare economy?
Peter Dehnel, MD: So, I’m going to take a middle road with that. From a payer standpoint, it’s often whoever is paying the premium that is actually our primary concern. It may be an employer that’s paying the premium; it may be the government that’s paying the premium. At the end of the day, it may not be the individual patient sitting in front of either Jared or Charlie in terms of who is actually paying the bill for that treatment.
Peter L. Salgo, MD: I know you took the middle of the road here, but, again, Mr. Jones’s sight is getting worse. He needs a drug. There’s an expensive drug and a cheap drug. If you give a lot of people the expensive drug, we run out of money. Is your allegiance to Mr. Jones, or is your allegiance to the pot of money that has to be protected for everybody?
Peter Dehnel, MD: And the answer is yes.
Peter L. Salgo, MD: But it’s tough, isn’t it?
Peter Dehnel, MD: Absolutely, absolutely.
Gary L. Johnson, MD, MS, MBA: It is tough, and my answer would be very similar: that we want the best for each individual patient, but in the context of the population. And our job is to be advocates for the population.
Peter L. Salgo, MD: But often the patient doesn’t care. The patient says, “But I want the best treatment for me. There’s a drug out there that’s going to be better than what I’m getting, please pay for it.”
Peter Dehnel, MD: In this particular case, though, we would have no barriers to that. So, it is the physician’s choice in the conversation with his or her individual patient. For this particular area, it’s not a conversation.