Treatment for PH and PAH: Factors That Inform Coverage

Expert perspective on factors that determine the coverage of agents used to treat PH or PAH.


Derek van Amerongen, MD, MS, FACOG: When payers look at subpopulations in various diseases like PH [pulmonary hypertension] and PAH [pulmonary arterial hypertension]—but certainly across the board when we’re talking about these complex conditions—we are not focused on the total cost of care as much as the cost for individual members, mainly because the prevalence of these subpopulations is typically so low. From a plan-wide perspective, we’re talking about fractions of a penny per member, per month, which is the metric that health plans use to look at cost: per member, per month costs. Certainly, the individuals may be very expensive and probably will be very expensive.

For many years, one of my roles has been to sit with employers and review their high-cost claims list, or people who are using a lot of services and spending a lot of money. When patients show up on those lists and have conditions like PH and PAH, and certainly if they’re in a subpopulation that is at even higher risk of requiring more resources, a lot of questions come about such as, “What is going on? Explain this condition.” That’s one of our roles. However, from a plan perspective, the cost in total for subpopulations, and even for a condition as a whole with something like PAH, pales beside the costs we see for oncology, heart disease, diabetes, orthopedic implants, or many of those other areas that have very high utilization. There is not as high a cost per member necessarily but cost in terms of the volume and prevalence.

When there are multiple agents available for treating a general population, or even a subpopulation, ultimately our goal is to make sure that our medical policies reflect the current standard of care; the FDA label, obviously; and anything that is really salient and pertinent from the evidence-based literature. We want to incorporate recommendations from national professional society guidelines if they are available. It may well be that for a certain population, you use drug A and then drug C, or you use drug C plus drug B at a certain point. That’s ultimately going to be a decision for the clinician. Our goal is to make sure that the requests that we receive from the clinicians are in line with the best evidence-based literature, the standard of care, and the FDA label, so that we can target these agents as appropriately as possible to make sure that we’re getting optimal clinical outcomes.

When we think about fragile patients, patients who receive many drugs, which we call polypharmacy, they certainly represent a very important focus, both for the clinician but also for the health plan. Now, the ultimate decisions on treatment are going to fall to the clinician based on that particular clinical scenario. But as a health plan, we have long recognized that polypharmacy is a huge issue for patients with these complex, chronic conditions.

We have always used our tremendous data sources to identify members with polypharmacy. Anyone at Humana who is on one of these specialty drugs receives contact from a pharmacist on a monthly basis. The purpose of that contact is severalfold. We want to find out how the patient is doing. Do they have any questions about their treatment? When was their last visit with a clinician? When is their next visit? Do they have any issues regarding testing, or are there other ongoing needs that they might have? Very importantly, when are we going to ship the next dose of the drug to make sure that it gets to them safely and in a timely fashion?

One of the things that we also seek to do is make sure that we understand if the members, if the patients, have any problems accessing care or if they have questions about some of their benefit issues. One of the challenges for anyone who has a condition like PAH or PH is seeing multiple providers, going to multiple sites, and receiving many claims. One of the things that our care managers and pharmacists do is help wade through that and make sure that they’re addressing a patient’s concerns and issues.

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