Payer Challenges in the Management of Wet AMD

Peter L. Salgo, MD: What are the implications, when we drill down on this, for primary care and millions and millions of folks on managed care? Who’s going to pay for this, and is this disease even on your radar? What’s the story on that?

Gary L. Johnson, MD, MS, MBA: It’s not really on the radar, if you will. It’s not one of the high…

Peter L. Salgo, MD: I’m just going to stop you, because you know where I’m going. These guys just told me this is the most common cause of blindness in this age group—all-comers—and it’s not on your radar. Why not?

Gary L. Johnson, MD, MS, MBA: Well, because we have the entire patient population to be concerned about and other disease states that occur at much greater frequency are much costlier. And in terms of being on the radar, I presume you meant if this is at the top of the list of things we need to take steps to address. You can ask Peter if there’s a different approach in his area, but I don’t think this is something that I hear talked about very often.

Peter Dehnel, MD: Just serendipity. We do have medical policy around the various treatment options to make sure that the right people are getting the right medications for treatment of wet AMD. The fact that we do have medical policy means that it has definitely gotten our attention, and we do want to make sure that the right people are getting the right medication. Likewise, people who don’t qualify for the medication do not get a treatment that is not needed for them.

Peter L. Salgo, MD: We’re going to move on to medication in a minute, but let’s take a look at the global problem because you alluded to it. There’s a whole patient population out there that you’ve got to effectively bankroll in terms of medical care. Yet, if you lose your sight, it affects everything, as we heard earlier.

Gary L. Johnson, MD, MS, MBA: Absolutely, and that’s why we do not put barriers in front of patients to have preventive care. You’re talking about the annual eye exam—totally covered, I would say, virtually by every health plan. And so, in terms of prevention and detection, I think we’ve removed any barriers to having that done. As for the cost implications you asked about, short-term, if somebody does have the diagnosis, there will be pharmacologic expenses. Long term, it’s not just the disease itself, but the other attendant issues: the falls and other things that come along with poor vision.

Peter L. Salgo, MD: That’s what I was getting it. If it’s not on your radar because you’ve got all these other plug-in systems to worry about, but somebody loses vision, then all the other organ systems are on the chopping block. They’re all at risk here. In the clinician’s view, are the payers shortsighted or are they about right?

Charles Wykoff, MD, PhD: I think the one very specific issue—it may not be relevant to either of your plans—that we’ve come across is that a few of the plans that we’re involved with only provide a few visits for a given provider. For example, if we have a new diagnosis of wet AMD, they’ll only cover 4 or 5 visits in the next year. There’s only a certain duration of follow-up that’s allowed before a new diagnosis is needed. We’ve run into that challenge. It’s a very specific issue, but it is a challenge, if you’re asking.

Peter L. Salgo, MD: But this is a lifelong issue.

Charles Wykoff, MD, PhD: It is. This is a chronic problem that these people need repeated visits for: often a dozen visits a year to treat, by a single practitioner.

Gary L. Johnson, MD, MS, MBA: And that will, of course, vary with plans. Many plans have no restrictions of that type. There may be some that do, though.

Peter Dehnel, MD: Just out of curiosity, is there an appeal process? Have you hit that barrier where you have 5 visits for a 12-month period of time? Are you successful or is there information that you can share with others about how to best overcome those barriers?

Charles Wykoff, MD, PhD: So, unfortunately, it takes multiple employees on our part—full-time employees—to deal with all the challenges that we need to undertake. But, yes, it is possible to overcome these challenges.

Peter L. Salgo, MD: This is a complaint I hear all the time, and that the disease state doesn’t matter, from clinicians over and over again: “We want to take care of patients, and I’ve got staff that’s doing nothing but sitting on the phone dealing with payers. What does that contribute to my practice?” What does that contribute to his practice?

Peter Dehnel, MD: I suspect not as much as what one would hope it would. From a payer standpoint, we’re trying to be fiduciary agents for the people who are paying for the premiums, and that may be a large employer—it may be Medicare, so government programs. So, we need to figure out a way to better deal with these issues of potential overuse or potential misuse of a product, which is, in this case, not inexpensive.