Collaborative Approach in Managing HIV Treatment Costs

Peter L. Salgo, MD: Some of the new drugs are much better, but some are only marginally better. Is he in a good position to at least look at that financially and say, “Look at the difference in outcomes; look at the difference in price,” since price may be important? What do you think?

Michael G. Sension, MD: I am concerned that newer drugs don’t price themselves out of the market. I don’t work for a pharmaceutical company, and I would hope that as new drugs come out that offer benefits to our patients, those decisions will be made wisely.

Elly Fatehi, PharmD, MPH: Shall we talk about hepatitis C?

Peter L. Salgo, MD: Yes, tell me about hepatitis C, since you brought it up. Clearly, what you’re talking about is the fact that the hepatitis C drug is very expensive and yet it’s curative.

Elly Fatehi, PharmD, MPH: Yes.

Peter L. Salgo, MD: So, that’s a cost-benefit discussion the insurance companies have had with the physicians. What did you mean by bringing this in?

Elly Fatehi, PharmD, MPH: When the hepatitis C drugs first came out, they were extremely expensive, and we ended up managing them. We chose preferred products, we put in prior authorization criteria, and doctors were kicking and screaming. They did not like that, because they said, “My patient has hepatitis C; I need to treat them.” But because of the exorbitant prices, it was just unbearable. So, we started to manage it and slowly, competition started and the prices went down. As we think about HIV, I think that we’ve seen it work with hepatitis C. I think we can make it work with HIV, but we need cooperation.

Michael G. Sension, MD: But that’s a good example though. I’ll say that I’ve had very frustrating experiences with payer sources in the hepatitis C arena in that one hepatitis C product in particular was 7 pills broken up in a BID fashion, so a lot of pills. An alternative was 1 pill a day. We were told in many situations that we needed to give the 7 pills at twice-a-day dosing with much more drug-drug interaction and tolerability issues because of price.

Peter L. Salgo, MD: What was the difference in price?

Michael G. Sension, MD: I don’t know. I don’t think we are talking about going back to a 6 or 7 BID or TID type of thing. I’m looking at the 4 “preferred regimens.” You’ve got a couple StRs (single-table regimens), you’ve got a couple other non-StRs, and you’ve got a couple manufacturers here. But you’ve got 2 drugs versus 1 and 2 different manufacturers. I think it’s different to maybe have a conversation about if I can leverage one of these manufacturers versus another to set up the first-line strategy, and that’s all I want to do. Again, I don’t think we’re talking about going back to the 7- or 8-drug type of dosing.

What I would encourage you to do is get HIV expert treaters or clinicians or pharmacists to incorporate more than just price, to say, “Yes, but can we pick something that has the high genetic barrier to resistance or has the least drug—drug interactions?” Is there one of these that we might zero in on? If all things were on a level playing field, if it was the same cost, which one out of the 4 might rise to the top, as darunavir has risen to the top in the protease inhibitor class?

Peter L. Salgo, MD: Let me see if I heard you right. You want to talk to him about this. If he wants a conversation with you, what am I missing? Aren’t you both saying the same thing? He thinks so.

Michael G. Sension, MD: I think we are.

Peter L. Salgo, MD: Then why did you react with such alarm? “No, he can’t control my practice.”

Michael G. Sension, MD: Suspicion, suspicion.

Jeffrey D. Dunn, PharmD, MBA: But rightfully so. I get it. There are some misalignments in this new system. But I also think that there’s a misperception that everything we do is about cost, and that’s not true. We don’t have to spend time on that soapbox, but I think there’s a misperception of what we do. We do want to do the right thing. We are still looking at efficacy and safety, it’s not just cost. But at the same time, I want to have a conversation about valuing the nuanced difference in efficacy. Is it really worth twice as much money? We should have those types of conversations, because a physician is going to look it and say, “I don’t care if this is $50,000 and this one’s $20; this one’s much better. I’m going to go with the one that’s much better.”

Peter L. Salgo, MD: My responsibility is to my patient.

Jeffrey D. Dunn, PharmD, MBA: Right.

Peter L. Salgo, MD: And you also have a responsibility to the patient. You also have a responsibility to society. You’re sitting in the middle smiling because you don’t want to get involved in this argument. Where do you fall on all of this, since I’m going to moderate?

Elly Fatehi, PharmD, MPH: I totally understand the managed care perspective because it is a societal issue. One thing about HIV that does make it different from other disease states or conditions is that diabetes is an isolation. It’s owned by the individual. Even cancer is with an individual. But HIV is something that’s a societal issue. As I mentioned before, if we get individuals to the undetectable level, we can prevent transmission. So, all of us own it. As we think about it from the payer perspective, all of us are paying for it. So, that collaboration really is important.