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Payer Management of MS


Maria Lopes, MD, MS discusses payer considerations and challenges in MS treatment management with the ongoing paradigm shift toward early high-efficacy treatment.

Neil Minkoff, MD: In my experience, there’s been a significant divergence between what we’re often asked to cover as payers and what an MS [multiple sclerosis] center or MS specialist would be asking for as opposed to a community neurologist. On some level, that’s been an important part of our payer interest and clinician interest talking past each other. Dr Lopes, I know you’ve looked at this. What have you seen in the level of requests for more aggressive treatment, in terms of sticking with traditional therapy and the self-injected therapies? What are the requests you’re getting?

Maria Lopes, MD, MS: We’ve evolved in our understanding of the disease and the different types of disease—primary progressive, secondary progressive—and recognize that MS is maybe more than just 1 disease, but there’s no coding that reflects some of these other forms of MS. There’s so much we don’t know. Fundamentally, we’re still struggling to know a consistent approach to management. We need a guideline that helps ensure the way we think about that initial approach, depending on where the lesions are and the level of severity. As a payer, that’s my wish list. As we have more treatment options, how can that approach evolve? As we think about what excellence in MS care looks like, whether you’re seeing a neurologist or an MS specialist, how can we elevate that standard? In the Medicaid world, many patients never get to a neurologist. It’s not just my wish list as a payer. Regardless of where patients are seen or whom they’re seen by, a standard approach would be helpful. Within that standard, there’s choice that is helpful to the payer, patient, and even the provider.

We’ve seen the recommendations that with the availability of more infused options as well as orals, especially of the S1PRs, you don’t have to take it every day. It’s still about how much choice is appropriate, especially in categories. I love Dr [Thomas] Leist’s analogy because, as a payer, that’s exactly how we think about things: MOA [mechanism of action], class, and do we need to cover everything or can we cover 1 or 2 agents? Can that suffice in terms of choice within that MOA? As we now have more generic options, particularly in the S1PR and dimethyl fumarate spaces, how can we ensure choice yet not have endless choice? Will that satisfy both patient and provider needs in the initial first line or possibly even second line?

If there’s a reason to consider based on patient characteristics, aggressive disease, what else has been tried, or adverse effects you’re concerned about, that’s usually reserved for a 1-on-1, in which a physician gets on the phone and helps us understand why that exception has to occur. We don’t want this to happen for every single case, where you have to appeal. We recognize both the payers’ and the providers’ time. But do we need endless choice? Is there some level of agreement as to the options in the front or second line that should be able to assist in the management of 85% of patients with MS?

Transcript edited for clarity.

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