Opinion
Video
The Cost of Waiting: Unlocking Treatment in a Timely Manner for MS Patients
Panelists discuss how providers and payers must collaborate to develop innovative coverage criteria for BTK inhibitors that prevent patients with subclinical progression from being forced to fail multiple inappropriate therapies before accessing optimal treatment.
Video content above is prompted by the following:
The introduction of Bruton tyrosine kinase (BTK) inhibitors presents an opportunity for innovative collaboration between payers and providers to develop evidence-based coverage criteria that move beyond traditional step therapy approaches. Kavita V. Nair, PhD, FAAN’s leadership role in the American Academy of Neurology’s committee working with payers exemplifies the potential for professional societies to facilitate these partnerships. Rather than forcing patients to fail multiple therapies, collaborative development of coverage criteria can ensure appropriate patient selection while maintaining cost-effectiveness.
Recent federal mandates to modify prior authorization requirements create a timely opportunity for multiple sclerosis (MS) stakeholders to develop innovative coverage approaches. The current system of 2- to 3-step therapy requirements benefits no one—not patients, providers, or payers. The challenge lies in creating appropriate utilization management that prevents inappropriate use while ensuring timely access to effective treatments. This balance requires clinical expertise, real-world evidence, and payer input to develop workable solutions.
The success of innovative coverage models depends on clinicians providing consistent, evidence-based recommendations and developing standardized assessment tools. The MS clinical community must take responsibility for creating the rubrics and evidence base that payers need to make informed coverage decisions. This includes developing clear criteria for identifying patients who would benefit from BTK inhibitors vs traditional therapies, creating practical monitoring protocols, and establishing outcomes measures that can be consistently applied across different practice settings.
Newsletter
Stay ahead of policy, cost, and value—subscribe to AJMC for expert insights at the intersection of clinical care and health economics.
