Opinion
Video
Barriers Inhibiting Optimal Pediatric RSV Treatment
Medical experts discuss current obstacles facing ideal respiratory syncytial virus (RSV) treatment strategies in children.
Adam C. Welch, PharmD, MBA, FAPhA: I want to shift over now to [Kimberly C. Chin, [DO, MSHLM,] and talk a little bit about some social determinants. So, we have people who may be covered under Medicaid, some infants, or we may have infants who are covered under commercial health plans. Do you see the hospitalization rates differ with regards to RSV in these populations?
Kimberly C. Chen, DO, MSHLM: Definitely. What’s really interesting, is for hospitalization, your Medicaid, you have 91% more likelihood than commercial to be hospitalized for RSV treatment during their first year of life. And just like that kind of reference, even though preterm babies tend to have more comorbidity for hospitalization, full-term infants actually are the predominant source for RSV hospitalization, medical cost. And then what’s even more interesting: Guess who pays more for Medicaid vs commercial overall. You would think because there are more Medicaid patients in the hospital, you would think commercial will be paying less. But actually Medicaid pays 32% less per hospitalization compared with commercial. So overall, due to the Medicare reimbursement to the providers, lower. So in general, Medicaid pays about $790.6 million annually for infants for RSV prevention and treatment costs.
Adam C. Welch, PharmD, MBA, FAPhA: Well, those numbers are staggering. And when you think about it, you said 91% Medicaid population, 91% more likely to be hospitalized. Yet the reimbursement may be less for that. It seems that this issue that preventing RSV could be something could have a really powerful impact on the health care landscape with this. So, looking at some of our coverage policies and reimbursement mechanisms and the affordability of different payer types, when you think private insurance, Medicare vs Medicaid, what are some of these challenges, Dr Chan, about paying for RSV treatment and the affordability of RSV as a disease?
Kimberly C. Chen, DO, MSHLM: So RSV treatments are quite interesting. If we just talk about standard cost for hospitalization, supportive care, your care will cover that, and what that includes is nutrition and hospitalization, oxygen, hydration, those [types of] supportive care. But as we all know, there’s now the development of the monoclonal antibody. Now, those are prevention treatments. If you were to use that as an actual treatment for the disease—[in] somebody [who] already has RSV—it is determined to be investigational and experimental. So they will not reimburse for a treatment.
Adam C. Welch, PharmD, MBA, FAPhA:So that’s interesting. So, the monoclonal antibodies are a prevention tool, and it’s off-label. It’s experimental if we’re using that to treat RSV. So, when we think of this passive immunity that you’re giving through this monoclonal antibody, it’s really similar to what we would think of with the immunity that you build from a vaccine standpoint in trying to prepare you to not have those extreme complications that you would from the infection if you were to get exposed to it. So, thinking about some of the payer coverage, are we seeing any barriers to having people covered and having this be able to be afforded from a patient’s perspective? And how do we mitigate any barriers to care?
Kimberly C. Chen, DO, MSHLM: So with this prevention and treatment we consider the monoclonal antibody as a vaccine or as a treatment. ACIP [Advisory Committee on Immunization Practices] is still trying to decide that. Until then, we do know Medicare with the present approval of the RSV vaccine for adult Medicare, has agreed to reimburse the RSV vaccine as long as the provider and patient both agree that it is a treatment that they both need. Now, on the other hand, for commercial or Medicaid, a prior authorization is required, as mentioned earlier, they tend to be individuals who are premature infants. And that’s usually determined by any babies who are [aged] less than 29 weeks or young children [aged] less than 24 months at the start of the RSV season. Anybody who is immunocompromised. The babies with a heart congenital disease, lung disease, cystic fibrosis, on oxygen. Anybody with neuromuscular disease, they potentially could get prior [authorization] for this monthly series, up to 5 doses during the RSV season. And again, prior [authorization] is required. And on top of that, what makes it very challenging is the time required for that prior [authorization], which could take up to 40 business days. It takes about 1 to 3 days for a provider to write a [prescription], and they send it to the insurance company, and it takes about 10 to 14 days for the prior [authorization]. Now, if that gets denied, then there are 30 days for appeals, and then [assuming] it’s approved through prior [authorization] or appeal, it takes the pharmacy about 21 days through specialty pharmacy to get billed and then ship to the destination where they give an injection. So certainly, there is a lot of opportunity to improve that access to get the medications—the next vaccine or the preventing medication—to the patient much easier and quicker.
Debra Boyer, MD, MHPE: And I would just add on to that, Adam, that I just think from the provider perspective and my staff in our office here, it’s just all the things that Dr Chen just said. Think about the person-hours [it] takes to do all of that. Forget about the time from the patient, the family, to advocate for their child. But letter writing, phone calls, peer to peer it takes time away from being able to actually care for kids about other things when you’re spending a lot of time on this. So, it’s a tremendous amount of time and dedication that it takes to get these products approved.
Adam C. Welch, PharmD, MBA, FAPhA: That makes a lot of sense. From one end, the prior authorization for this treatment makes sense, right? Because some people really wouldn’t need this level of care with their RSV. But you mentioned some risk. So, the purpose of the prior authorization is to identify those who may have been born prematurely, who have the lung disease, the heart disease, the fibrosis, for example, immunocompromised. So on one hand, that’s a great way to help identify those people at higher risk. But the timing [is] burdensome, [and] the labor hours needed. We’re talking 4 to 8 days until things can get moving and then even longer with the pharmacy and getting the medication to the patient. That’s a long time when you’re thinking about an acute respiratory infection that someone has, so that can be very problematic from a public health perspective.
Debra Boyer, MD, MHPE: Usually all that time is, again, most of the time now, we’re still using that prophylactically when the kids are acutely ill but more in the prophylactic sense. But again, it is a tremendous amount of time that gets put into it to make sure that the kids get it in time for the respiratory viral season, starting in the later fall through winter.
Transcript edited for clarity.
