Payer Engagement With the Retina Community

The panelists discuss how payers can best engage with the retinal disease community on a provider and patient level.

Jim Kenney, RPh, MBA: How do payers engage with the [retinal disease] community? What would you suggest? I’ll throw this out to all of you. How could we possibly engage with the retina community that would benefit both the provider and the patient? I know we’ve mentioned a lot of things already, but this is a general summary question as we get toward the end of our program today.

Joseph Coney, MD, FASRS, FACS: Jim, for me it always comes back to the patient, understanding the patient’s journey, how the disease impacts their life, and what does it mean for them to leave their job to go to a facility every single month? I think you have to understand how that impacts [their life]. When it comes to diabetes, a lot of these people have entry-level jobs, and if they are not at their job, they may not be able to keep their job. They may be the only breadwinner for their particular family. If we can decrease the amount of time they’re leaving, decrease the amount of time they’re traveling, decrease all those expenses, and also maximize their therapy, I think it’s a win-win situation. I think we have to find ways to move the needle in order to help certain populations take better care of themselves. Part of this has to do with how they look at the burden of therapy. All of us get burnout. They get injection burnout, and I understand. We find ourselves bargaining about when can we bring them back. But if we have drugs that are lasting 12, 14, or 16 weeks, it’s easy for people to plan those events versus every single month. I cannot afford to have my employees gone every single month. My patients can’t afford me to be gone every single month. I think we have to understand their journeys, and that once that happens, we can deliver better care for those patients without them having a burden in order to maximize their results.

Caesar Luo, MD, FASRS, FACS: I think that’s a great point. I’m going to add a bit to that too. I think communication from the payers to all associated members is extremely important. Like Veeral mentioned, the prior authorization process honestly is a broken process at this point. It needs attention, and it needs attention quickly because the amount of time and effort required to do something that was already authorized but not paid for, doesn’t make any sense to me at all. A lot of it is communication. I think the payers need to have a more effective method of communicating their formularies and their prior authorization process. They just don’t do that very well. We end up having to find it out after we’ve submitted a claim, we find out this is something they’ve changed recently. I think that also applies to patients. Like Dr Coney was saying, it’s really important that we understand the patient’s journey as well. The payers could also provide better communication to their constituents, to the people who are relying on them for their health care, saying, “It’s been 6 months. You need to go in for your diabetic eye exam. It’s been 3 months since your last injection. Why have you not gone back to see your ophthalmologist?” I think if there’s more communication, it does improve access to care across the board for the patients and for us as practitioners to be able to provide effective and timely care. Because again, at this point, we spend 80% of our time in the billing office chasing down 20% of our claims because there’s this black box, it just disappears, and we don’t know what’s going on.

It really is a broken system. That for me is extremely important, communication across the board, top down. We have to build up a layer of trust here that has been eroded through the years, and that would certainly be very helpful. Also there are these chronic disease funds, these funds that are put into by the pharmaceutical companies and the drug companies, and it’s been great with being able to provide access for those folks who have a larger co-pay. Being able to make sure that is solvent, I think is also very important. Whether the payers can help with that and being able to make sure patients are funneled into that and make sure they’re always having their benefits…run. That’s such an important piece of this. Again, we’re happy to help as long as everyone is pulling the boat in the same direction rather than kind of swimming around in a circle. Those are thoughts I’ve had through the years, and it’d be great if we were all on the same page.

Jim Kenney, RPh, MBA: Great insight. We think about this, in 2006 when these products launched, it scared the heck out of the payers because they were used to paying for topical ophthalmic products that were $150 a month, and now all of a sudden you’ve got these thousand dollars medications, and “Oh my God, what do we do? We’ve got to put some type of restrictions in place.” So they created the prior authorizations. In the early days, obviously with similar therapies, the prior authorizations probably weren’t as egregious because you pretty much had only a couple of choices. But now that we’ve expanded the class and the category and the options, and we have better options that although appear to be more expensive on the surface, you make a great point. We need to revisit this total process and educate the payers that there are differences and that we need to rely on the specialists to make the right choices for the patients, but not put in excessive burdens.

We’re also trying to control spending, to your point earlier, and you mentioned the G word, gene therapy scares the heck out of us. We had Luxturna [voretigene neparvovec-rzyl] as the first to come to market at $850,000 if you’re treating both eyes. That’s a shock to the system. We have to manage, we have to cover it for the appropriate patient. But I think working this concept of getting a better understanding of what’s necessary to assess more quickly whether a patient is responding and not saying, because I sit behind the desk, “Well, we think it should take 6 months to see whether a patient is responding.” When in fact, to the earlier comments, you might know as early as 4 weeks, and it’s time to move on to something else. I think that’s been a great piece of this conversation.

Transcript edited for clarity.

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