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Managed Care Considerations in Wet AMD


Steven Peskin, MD, MBA, FACP, provides insight into managed care considerations of wet AMD including clinical evidence evaluation, formulary management, and value-based agreements.

Steven Peskin, MD, MBA, FACP: Looking at new therapies, certainly the FDA approval is the most important. Anything that’s approved will most likely find its way to our formulary. Its tier status and other considerations with regard to step edits, step throughs, quantity limits, or prescribing by subspecialists only are different considerations. The availability of the product is largely based on its status within FDA approval. Beyond that, if a product in an area that has established products has any safety signals or safety concerns, then that product may be disadvantaged or have to have a failure of other therapies. If the cost is considerably higher, then we may put in certain guardrails that prefer the less costly product with similar or the same efficacy in front of any new product.

Thinking about formulary, we certainly look at product classes at a minimum every year. If there’s a new product introduced, we’ll look at that product in a thoughtful way to measure comparative effectiveness. The contractual aspects are separate and distinct from what the pharmacy and therapeutics committee [P&T] and the formulary committee does.

In formulary, costs are mentioned, but that’s not the most salient issue. The safety effectiveness and tolerability—any longitudinal data that we can present—are typically the key drivers. Cost might be mentioned if something is 3 times the cost of the existing drugs with seemingly no improvement in effectiveness, and that might certainly get the clinicians on the P&T who are not totally isolated from costs. That’s something that everyone in health care considers broadly speaking.

With regard to challenges with value-based agreements, I don’t see any challenges there as it relates to adherence, persistence, and endurance. We’re looking at our clinicians to achieve the best outcomes, which she or he is certainly looking for. The payment for lower total cost of care per treatment episode is part of the construct for an episode of care—a bundle payment. The challenges always exist concerning whether you’re treating hypertension or diabetes or wet AMD [age-related macular degeneration] with regard to adherence, persistence, and endurance. There’s no particular challenge. We see these patients as being quite motivated because loss of visual acuity is something unlike, say, high blood pressure, because they’re very aware. The patient is very aware. They’re scared, and they don’t want to lose their vision, so they’re highly motivated patients for treatment.

Transcript edited for clarity.

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