Balancing Cost and Physician Choice in HIV

Peter L. Salgo, MD: You mentioned that if we could eradicate this disease, that would be great. That 50 years or 100 years from now, this disease may cease to exist or exist only in the background. That’s cheaper for your successors. But that doesn’t answer your question today. Can you see a way to structure payments? Maybe it can’t be an individual company; maybe it has to be a consortium or the government who says, “Look, this is worth investing in.” How do you do that?

Jeffrey D. Dunn, PharmD, MBA: I don’t know how you do that. I will say, we all share the same goal. We want cure; we want eradication. The challenge is that you’ve got to look at the end user, whether it’s the patient, the employer, or the health plan. It’s still their money, and they still have a financial responsibility to manage the money so that medications are affordable for everybody. It’s not just HIV; it’s cancer. It’s all the orphan drugs, it’s inflammatory disease, and it’s multiple sclerosis. So, we all have the same goal. We’re all moving in the same direction. We don’t want to stand in the way of it. But at the same time, I can’t go back to an employer group and say, “Your premiums just doubled next year because of what we’re doing in this area.” There are some issues with it.

Peter L. Salgo, MD: You can’t go to the employer and say, “Your premiums are just doubled,” and yet it is the best thing for society. What do you do? You’ve got a tough job. I never thought I’d say this to him. You’ve got a really tough job.

Jeffrey D. Dunn, PharmD, MBA: The unfortunate reality is that an employer is probably going to say, “I’m going to go. I’m going to take my business and go to the payer down the street who has a lower premium that’s not doing this program.”

Peter L. Salgo, MD: If that’s the case, and if the treatment that an employer’s employees are getting is less effective not only for those employees but for their families and their associates, that employer is going to take an economic hit. Can you sell that?

Jeffrey D. Dunn, PharmD, MBA: It’s hard.

Michael G. Sension, MD: When I was a medical student in the ’80s, many years ago, I worked in an STD clinic in Baltimore. The treatment for chlamydia was tetracycline QID on an empty stomach, 4 times a day, for a week. It was 28 pills, 1 pill 4 times a day on an empty stomach. It was cheap; it was dirt cheap. But I think at some point, they had to realize that a more expensive treatment—doxycycline—was simpler and more people would take it and fewer people would fail their initial therapy. Even though it might be a little bit more cost-intensive on the front end, on the back end, you would have more success. Now, of course, we give a single dose of azithromycin to treat chlamydia because even though tetracycline would be still much, much cheaper, at the end of the day, you have more success with a better regimen. I think that’s where we are with HIV therapies. There may be cheaper ones that are out there, but in my mind, the cheaper ones that are out there today are not necessarily the ones that are going to be the most successful.

Jeffrey D. Dunn, PharmD, MBA: I think payers should be more involved; we want to be more involved. The challenge right now is whenever we get involved, we’re framed as an evil empire and as just doing things for cost, and that’s not the case. A lot of it is hands-off. Again, I would like to see it pivot. I would like to see more collaboration, having this conversation about these things. Are there ways that we can do a better job proactively of screening, of being more involved in care management and all these things, and of spending the money to do that? But at the same time, if I can’t do that without having a conversation with the providers or the pharmaceutical companies on how I can save money, it’s 1-sided.

Michael G. Sension, MD: But Jeff, I think if you followed the DHHS (US Department of Health & Human Services) guidelines, we would be in concert with each other. I think the DHHS guidelines are good in that respect.

Jeffrey D. Dunn, PharmD, MBA: There’s the question. We can dig into that. We have 4 preferred regimens. They’re all inhibitor based.

Michael G. Sension, MD: Recommended. That’s the word now.

Elly Fatehi, PharmD, MPH: Can we prefer one?

Jeffrey D. Dunn, PharmD, MBA: We have 4, right. We’ll say there are a couple of manufacturers. Now, 2 of them are single-tablet regimens, and the other 2 are 2-tablet combinations. If I go to you and say, “Manufacturer X is giving me a better price to pick this one,” are you going to allow me, within those 4, to say, “Initially start with that one, and after that, go wherever you want. But help me do that because then I can get a better price on that drug.” Is that something we can have a conversation about?

Michael G. Sension, MD: We could, but let’s also talk about that. Of the 4 recommended integrase inhibitors, 1 of them has a booster. It has a drug that inhibits the cytochrome P450 system and has a myriad of drug—drug interactions. One of them has a high genetic barrier to resistance. Two of them have a relatively low genetic barrier to resistance. All of a sudden, things get a little bit more interesting. What if you choose the one that’s cheaper but has a lower genetic barrier to resistance and more drug–drug interactions and more side effects?

Jeffrey D. Dunn, PharmD, MBA: There’s the crux.

Elly Fatehi, PharmD, MPH: But if you have a valid clinical rationale as to why your patient cannot be started on his preferred agent, then you have an exception to the process.

Jeffrey D. Dunn, PharmD, MBA: But for the 80% or 90% who fit, allow me to do that.

Elly Fatehi, PharmD, MPH: For the ones who you can prescribe with preferred medication…

Jeffrey D. Dunn, PharmD, MBA: See that’s the point; whenever we have these conversations, it’s “You can’t do that.” What I’m saying is what we get beat up on is “You can’t do that.”

Elly Fatehi, PharmD, MPH: I think we need to educate providers that there is an exception process. It’s not a 1-size-fits-all approach. I think that’s the myth.