Preventive Therapy in Migraine: Payer Considerations

Peter L. Salgo, MD: Let’s talk about an economic issue for a moment. It occurs to me, and I don’t have the numbers, so I’m going to ask you, if you’re treating episodic migraines, those are punctate episodes, if you will. But if you’re now transitioning to preventive treatment, you’re getting put on a drug for a long time. That’s going to incur long-term, predictable, chronic costs. How do you determine the criteria to progress from acute therapy to chronic therapy? How do you qualify somebody?

Malaika Stoll, MD, MPA: Different plans would be different. For us, we say that 4 migraines a month would qualify you. That said, in Blue Shield of California, you can take any of these preventive medications if your doctor prescribes them. Maybe you only have 2 migraines a month and there may be an added benefit. For example, amitriptyline is also an antidepressant. So there would be other reasons to take these therapies even if you weren’t in that chronic category.

Peter L. Salgo, MD: Are doctors complaining that they want to go on chronic therapy but you, the dark side of the Force, won’t let them do it?

Malaika Stoll, MD, MPA: I’m happy that our plan has a liberal coverage policy. We really don’t want our members to be living with this horrible pain that we’ve talked about—this dysfunction. We want them to be productive members of the community.

Peter L. Salgo, MD: Yes, but you don’t want your plan to go broke either. Then nobody gets help.

Malaika Stoll, MD, MPA: Right. It’s fortunate that there are a lot of options. There are a lot of things that we need to solve in this complicated area, but there are a lot of options, and many of them are not high cost. We talked about lifestyle. We talked about some of the very low-cost drugs that can help. Unfortunately, there are some folks for whom these measures don’t work. We’re going to get to this a bit later, but I think there are some more expensive, new drugs that are going to help those folks who are refractory to the first methods.

Peter L. Salgo, MD: Do you insist on step therapy?

Malaika Stoll, MD, MPA: Our plan has very little step therapy, only in regard to the triptans. We do have some preferred triptans. If you have a particular one that only works for you, we may ask you to try a couple of others first. But other than that, we have no step therapy.

Peter L. Salgo, MD: Are patients getting adequate access to the appropriate medications? Let’s not talk about the new ones but the stuff that’s out there that’s been wrung out one way or another. Are they getting adequate access, or are the insurance companies blocking them, in your view?

Peter Goadsby, MD, PhD: Access is usually reasonable for these simple things. Propranolol and amitriptyline are not made out of gold dust, so they’re relatively straightforward discussions to have. Sometimes having a discussion for a drug like candesartan can be more complex because the evidence is a bit newer. But when you have a peer-to-peer discussion, most people aren’t unreasonable if you’re reasonable with them. If you start out with the idea that everyone’s difficult, then you’re going to get the result you expect. If you start out with a kind of reasonable discussion of why you want to do this…I really haven’t come across too many problems. I think having a stepwise approach, where you do the reasonable things first and then move forward to more expensive things, is a perfectly rational way to make sure that disabled people can get access when they need it.

Malaika Stoll, MD, MPA: Right.

Peter L. Salgo, MD: How do you go about making sure that the right people get the right drugs and that they’re not just getting prescriptions plastered for the wrong drugs? How do you work as a policeman on this?

Malaika Stoll, MD, MPA: For the newer, more expensive drugs, the more complicated drugs, we do have a prior authorization process. That means you can’t just go get a prescription filled. Your doctor has to do some paperwork with you. At Blue Shield of California, it’s only for Botox and some of the newer categories of drugs right now. For most of them, it’s between you and your physician—if it’s the right drug prescribed and we cover it.

Peter L. Salgo, MD: Let me interject here. Botox is cheap, isn’t it?

Malaika Stoll, MD, MPA: Botox is a relatively expensive treatment.

Peter L. Salgo, MD: Is it?

Malaika Stoll, MD, MPA: It’s several thousand dollars a year.

Jill Dehlin, RN: With a very high co-pay.

Peter L. Salgo, MD: Is that right?

Malaika Stoll, MD, MPA: Yes.

Peter L. Salgo, MD: I thought it was being prescribed like water, no?

Jill Dehlin, RN: No.

Peter L. Salgo, MD: Not where you come from. I live in New York City. What do I know?

Malaika Stoll, MD, MPA: They’re paying for it.

Peter L. Salgo, MD: Do you hear a lot of screaming from people with migraine? “My doctor wants me to get this, but the insurance company is not letting me do it.” Do you have to interface here?

Jill Dehlin, RN: In advocacy, you have to teach people how to advocate for themselves.

Peter L. Salgo, MD: Is that a yes?

Jill Dehlin, RN: Yes. If I need to help somebody write a letter to their insurance company, I will do that. Sometimes looking at the process that patients have to go through, there are a lot of brick walls. You have to get through to the right person, to have them understand exactly what it is that you’re trying to do and the consequences if you don’t get that drug.

Malaika Stoll, MD, MPA: That’s the huge opportunity. Yes, we’re doing a great job with our formularies. But when we look at making it easier for patients, health plans can be difficult. I think we’re causing migraines, right?

Peter L. Salgo, MD: Health plans can be difficult. Really?

Malaika Stoll, MD, MPA: We’re causing migraines.

Peter L. Salgo, MD: There are 3 moving pieces here, right? There’s the person with migraine, the prescriber, and then there are the folks who have to pay for the whole thing and have to maintain some fiscal responsibility here. They don’t always match up. It’s wonderful to sit here and say that we’re going to join hands and sing “Kumbaya,” but my expectation and experience is that’s not what happens. In the real world, there are the barriers. There are brick walls. Why do we have to fight this? Is it simply for fiscal responsibility, or is there something else?

Malaika Stoll, MD, MPA: That’s why this forum is so great. I think it’s getting everybody aligned to the well-being of the patients and our members. We have to do more of this. We do have an aligned vision. We want to help the society. We want these people to be healthy.

Peter Goadsby, MD, PhD: Exactly.

Malaika Stoll, MD, MPA: But it’s what we’re up against in our little worlds. So I think more communication is helpful.

Peter L. Salgo, MD: How much of your practice is spent doing paperwork?

Peter Goadsby, MD, PhD: Oh, very little. I delegate it.

Peter L. Salgo, MD: You delegate it. Let me do this differently, then. He’s ducking this one.

Peter Goadsby, MD, PhD: I delegate everything that I can possibly delegate.

Peter L. Salgo, MD: How big of a stack is this, that you’ve delegated? I hear that it’s enormous.

Jill Dehlin, RN: It is.

Peter L. Salgo, MD: I’ve got 2 people on staff. All day long, all they do is get prior authorizations, right? Is that rational? Is that a good thing?

Malaika Stoll, MD, MPA: I think minimizing prior authorizations is the right policy. At the same time, when we’re talking about these novel agents, if they don’t work for everybody, or if we want to use them sparingly, and if we want to use them after other things are tried, it is a reasonable approach. That said, I think you can make the prior authorization process much easier than it is.

Peter L. Salgo, MD: She’s talking about really expensive, brand-new drugs. Is that what you’re seeing, or are you having trouble just getting the basic stuff?

Jill Dehlin, RN: The problem with the brand-new drugs—is that what you’re talking about?

Peter L. Salgo, MD: Let’s put those aside for the moment. The biologics—we’re going to get to them. But everything else.

Jill Dehlin, RN: No, I don’t think that there’s a huge issue.

Malaika Stoll, MD, MPA: But access to care is an issue.

Peter L. Salgo, MD: That’s one thing. But once you have prescribed, you still have to get this thing authorized and paid for.

Jill Dehlin, RN: Right. Then the patient has to continue taking it. If the adverse effects are onerous, you’re not going to get very good adherence.