Anti-CGRP Therapy for Migraine: Cost Considerations

Peter L. Salgo, MD: Are there people sitting in a basement with a green eyeshade saying, “You only had 14 attacks. You can’t get this.”? Is there someone, in some company, somewhere, really doing this?

Malaika Stoll, MD, MPA: Not in my health plan. I think the prior authorization process gets a bad rap because its onerous and there is a bit of paperwork. But, in fact, what is good about it is you actually have an educated human, a specialist, who knows something about the topic. He or she is reading through the clinical notes, helping to make the right decision. So, there is a human at the end of it and that’s the good point.

Jill Dehlin, RN: I would like to add that there are some insurance plans, like Blue Cross Blue Shield subsidiaries in Florida, Pennsylvania, and Kansas, who are requiring that this drug be prescribed by a UCNS [United Council for Neurologic Subspecialties]—certified physician. There are only 520, I believe, UCNS headache specialists in the United States. There are, as you mentioned, millions of people with migraine. In Kansas, there are no UCNS-certified physicians. I think insurance companies run the risk of creating care deserts by doing this. I see a headache specialist and I can tell you that he’s on fluid restrictions during the day because he doesn’t have time to take a break. He is really, really busy. Most headache specialists are in the same predicament.

Peter L. Salgo, MD: Are you ascribing, to these folks, some nefarious motive? “We’re going to put a clamp on the pipeline by restricting the number of prescribers.”

Jill Dehlin, RN: Yes, I am.

Peter L. Salgo, MD: So, your plan may not do that?

Jill Dehlin, RN: No.

Malaika Stoll, MD, MPA: No.

Peter L. Salgo, MD: But other plans out there are doing it. What do you think of your colleagues?

Jill Dehlin, RN: From what it sounds like, it sounds like an unreasonable barrier to care, actually, given the access issues that you’ve described. Where I live, as well, there are access issues that are going to create barriers for patients—access to primary care and specialty care, for sure. Even though we have plenty of specialists in California, it’s not always easy to get in for an appointment. Many people have to wait. That is a real problem, I think, for all of us to help solve. It’s not something that one person can do. Certainly, those types of restrictions that say, “Only this person can prescribe it. We’re not bending on that,” seem a bit restrictive.

Peter L. Salgo, MD: Let me play devil’s advocate. I’ll put on my green eyeshade. You look through a paper and say, “Unless we do that, we’re going to bankrupt America.” Everybody’s got a new biologic they want for their disease.

Jill Dehlin, RN: I have a response to that.

Peter L. Salgo, MD: Oh, please, let me hear it.

Jill Dehlin, RN: Having migraine disease is expensive. It’s expensive for insurers, but it’s also expensive for the people who suffer from the disease. There are the direct costs that come with having migraine, but there are many, many indirect costs, such as having to work part time because you can’t work full time or having to quit your job and go on disability. Sometimes you don’t have the capacity to care for yourself at home and have to hire people to cook your meals and do your housework. And the expense of the medications.

Peter L. Salgo, MD: I’ll come back at you and say, “That’s not my silo.”

Jill Dehlin, RN: No, it’s not.

Peter L. Salgo, MD: My silo is, “This health care plan has this many dollars and I can allocate it this way. Society has other issues, but it’s not my silo. Nobody is paying me more because society is losing money on migraines.” How do you fix that, patient advocate?

Jill Dehlin, RN: You have the person spend a day with the person who is having a migraine.

Peter L. Salgo, MD: Good luck with that.

Jill Dehlin, RN: Because it’s disabling.

Peter L. Salgo, MD: I hear you. But, again, as long as it doesn’t impact my budget…

Malaika Stoll, MD, MPA: Well, I’ll jump in. I’ll help you out here.

Jill Dehlin, RN: Thank you.

Malaika Stoll, MD, MPA: As a plan, we partner with employers because patients who have migraines tend to be in the productive years of life, right?

Peter Goadsby, MD, PhD: Yes.

Malaika Stoll, MD, MPA: It’s a big issue for employers—missed days. We are selling our product to employers who need coverage for their employees. That’s exactly where we can come together and talk about this. “Hey, on the employer side, how can you help take care of your employees so they don’t have this? How can we work together? How can we make this easier?”

Peter Goadsby, MD, PhD: The dominant demographic of migraine is from the age of 20 to 60. They’re the people who are working and are paying your little man/woman with the green thing’s income. This is the dominant demographic. These are the people who are active in the play. And, of course, the other thing is, attending an emergency room with migraine is an appalling waste of resources.

Malaika Stoll, MD, MPA: Absolutely.

Peter Goadsby, MD, PhD: It’s bad for the patient. It’s bad for medicine, from my perspective. I see it happen to my patients, and it doesn’t help the bottom line, either, because tests get done. People come in with a horrible headache and they get all of the tests done again, and again, and again. This is a total waste of resources.

Peter L. Salgo, MD: They all get CT scans, don’t they?

Peter Goadsby, MD, PhD: Yes, exactly.

Jill Dehlin, RN: Or MRIs.

Peter L. Salgo, MD: Or MRIs. That’s right.