Jeffrey D. Dunn, PharmD, MBA: Could you summarize the biggest patient cost drivers in the management of COPD [chronic obstructive pulmonary disease]?

Courtney Crim, MD: The biggest cost drivers are exacerbations, because they require a health care visit, whether it’s to the doctor’s office or the emergency department [ED], and they put patients in the hospital and in the ICU [intensive care unit]. Prescription drug costs over the course of a year pale in comparison with the cost of hospitalization. That’s why it’s important that we do things to keep patients out of the hospital, because that will definitely drive the cost. Those exacerbations clearly do that.

Jeffrey D. Dunn, PharmD, MBA: I agree. Sometimes we chase our tail worrying about a few hundred dollars between cost of inhalers, when the goal is to avoid hospitalizations, ED visits, and exacerbations. Unfortunately, the pharmacy costs are what people see, and the medical cost isn’t as clear.

What advice would you give to a payer? I’m a payer, I represent that. We’re trying to do the right thing by the patient, but we have financial issues that we have to worry about with people who use us for insurance. We have a fiduciary responsibility. Having said that, what advice would you give a payer [about] utilization or formulary management that could better drive optimal treatment of patients with COPD? Rey, do you mind starting with that?

Reynold Panettieri Jr, MD: I’m trying to open my playbook for managed care here. You have a tough job because you’re the custodian for all the costs, and we want to do the best we can with the resources we have. In my experience, there’s been a lot of switching of compounds based on [rebates], which is incredibly frustrating for providers because an inhaler that was approved now needs a preauthorization, even though the patient has been on it, because you got a different cost for different groups of medications, and now this is preferred. We’d love the ability to show that on this medicine, the patient has been stable. The patient should continue on that medicine regardless of how you’ve [provided rebates for] other disease-state medications related to that sponsor or vendor. Every time an approved drug becomes a preauthorization, you put the burden on the provider and the nurses who have to go through the preauthorization.

Second, we need to embrace new therapy quickly, as long as it’s better. For example, we don’t want to delay the opportunity to use a biologic in a space where there’s never been a biologic that has clearly showed improved outcome. That’s a big pill to swallow—no pun intended—cost-wise, but if it’s really an [impressive] drug, then let’s not wait a year to be able to approve it. Let’s move swiftly through it. Jeff, the question you raised is unbelievably difficult, and I don’t want your job.

Jeffrey D. Dunn, PharmD, MBA: It gives us opportunities to better coordinate, but it’s challenging. Not to go down a rabbit hole, but when we’re talking with employers or other people who are purchasing insurance, we hear “Help me manage the cost of my medications.” That’s the question we get because we’ve seen such an explosion of drug costs in this country. That’s a whole other conversation, and I don’t want to go down that rabbit hole, but there’s definitely an opportunity here for better collaboration.

Reynold Panettieri Jr, MD: The point that you made and Courtney highlighted is really important. Health care utilization is the big-ticket item. PBMs [pharmacy benefits managers] are often separate and distinct from the other side of the equation. In managed care, in my experience, they’re siloed. They look at this cost, but they don’t look at the other side: the benefit. I suggest that the companies come together so that there’s a liaison to make the difficult choice between the 2 silos. It would make our job a lot easier.

Jeffrey D. Dunn, PharmD, MBA: I love that, Rey. But even in an IDN [integrated delivery network], I don’t think those things are de-siloed, generally speaking, which is frustrating. But it’s a great point. It’s data, it’s big picture. We should spend more on 1 side if it decreases overall expense and improves outcomes, but it isn’t always done. Courtney, any parting comments?

Courtney Crim, MD: Rey alluded to the rabbit hole. We all recognize that the social structure of health care in the United States has major issues in terms of how we address health care in the United States. That’s a rabbit hole. When we have patients in the ICU, it’s truly a team approach from the standpoint of nursing, physicians, pharmacists, and respiratory therapists on down the line, with the goal of making the patient better. With COPD, particularly when patients are leaving the hospital or coming out of the hospital, a siloed approach where payers and practitioners can address it as a team, as opposed to everyone being concerned about their piece of the pie, would work like it does in the ICU. That doesn’t mean the cost in the ICU isn’t there, but at least everyone is working as a team for a common goal, with the patient at the center of that. We lose that in this outpatient setting, as Rey alluded to.

Jeffrey D. Dunn, PharmD, MBA: Perfect. Mike, any advice or comments to other stakeholders, ie, payers?

Mike Hess, MPH, RRT, RPFT: It comes down to communication. We touched on this toward the beginning: it’s easy to forget that inhaled therapy isn’t like other therapy. There’s this stereotype that if you can swallow a capsule, you can swallow a tablet. It doesn’t really matter if those things change. Inhalers, nebulizers, inhaled medications aren’t the same as that. Both sides can do a little better with communication on the office side. If we take the time to teach the technique or evaluate whether they can generate things like inspiratory flow, we can get a pretty good idea of whether they’re going to be able to use a particular device.

The clinician side needs to do a better job of teaching and assessing there. The payer side needs to do a better job of listening to the clinician side when they say, “I know this person isn’t going to be able to use this medication. Can we skip ahead to something that might work?” Once we get that kind of communication going, then we get that whole team approach together.

Transcript edited for clarity.

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