Treatment of Diabetic Macular Edema: Physician Choice Versus Cost Management

Peter Salgo, MD: Does everybody know about this research? Is everybody doing it this way?

Rishi P. Singh, MD: It’s all brand new. Many different studies have come out, and probably the most notable one was a comparison of laser versus anti-vascular endothelial growth factor therapy for proliferative disease, the worst of the worst.

That study showed that patients gained more visual acuity in those patients who got anti-vascular endothelial growth factor therapy, had a longer chance of keeping that visual acuity above the mark that they were at when they started, and they avoided the need for additional surgery as a result of that.

Those patients who got those therapies had less laser over time and developed some benefit. So, I think at this point, anti-vascular endothelial growth factor therapy is probably the primary goal and primary way we treat most of the patients with both proliferative and diabetic macular edema. We have a lot of great outcomes in those patients.

Peter Salgo, MD: Are our paying partners aware of this data? Have you modified, compared to 10 years ago, what you’re willing to pay for?

Steven Peskin, MD, MBA, FACP: We certainly do pay for these therapies. Where the rubber meets the road sometimes is the amount of the treatment or the treatment options, as you were talking about in terms of some differences in these anti-vascular endothelial growth factors. But, absolutely, they are recognized as part of the standard of care.

Our medical policy people have acknowledged that, and certainly do not discourage. Whether we encourage is another question. But certainly, we do encourage that these persons get seen and treated by appropriate subspecialists who are qualified to make the best treatment decisions.

John W. Kitchens, MD: Where the rubber meets the road though, is to get these outcomes.

Number one is you need to do the same types of treatments that they did in the studies. On average, that’s eight or nine injections the first year. If you fall short of that, you’re really not going to achieve those same sort of outcomes and you’re going to leave vision on the table.

The other controversial area for us, as retina specialists, is that the Diabetic Retinopathy Clinical Research Network did a study called the Protocol T study where they actually compared all three of our commonly used anti-vascular endothelial growth factor therapies, one of which is an off-label therapy. It’s bevacizumab, which is an oncology product that we’ve been using for 10 years now off-label. We had a compound. There’s an extra step in that, but it’s the number one used anti-vascular endothelial growth factor in the eye. And it showed that for those patients with better seeing vision, 20/40 or better, that they did equally well with all the medicines.

But, if you take those patients that are 20/50 or worse, they actually did better with one of the other anti-vascular endothelial growth factor medicines. Not by a little bit, but by a lot. By about a line-and-a-half.

So, that’s where we run into trouble with our payers is when they go, “You can only use the bevacizumab,” which is about $50 an injection for the cost of the medication. You can’t use anything else unless this patient fails. And it’s that definition of failure that paints us into a corner.

Peter Salgo, MD: Okay. So how do you respond to that?

Steven Peskin, MD, MBA, FACP: We absolutely encourage the lower cost drug, initially. The point is how the clinicians influence us, and we certainly are available to that kind of clinical and evidence-based medicine. The folks that are involved with medical policy at my organization do pay very serious attention to those kinds of data and then make, or change, our medical policy to reflect that.

Peter Salgo, MD: This all, of course, impinges on physician choice.

Rishi P. Singh, MD: Sure.

Peter Salgo, MD: You may get a physician who’s been using it.

“I’m going to try this now. You’ve had 10 years to work on it, bevacizumab, how’d I do?”

And is seeing some good results with it but doesn’t know that there may be better results with something else, and so, doesn’t press the payers as hard. Is physician choice really critical to treating diabetic macular edema?

Rishi P. Singh, MD: I think it’s the preservation of physician choice at the end of the day. That’s what, I think across medicine, is really the benefit there.

I understand the policy makers and the healthcare organizations that want to mandate a certain cookbook way of taking care of something, but the problem is that takes away some of the art of medicine. Sometimes we’re kind of hog tied to not do what we think is in the best interest of the patient. We do what we think is right for the insurance company.

Peter Salgo, MD: With all due respect, what I’ve heard over the years and I know you’ve heard too is, “Don’t tell me how to practice medicine.” It’s an art, which is occasionally an artful dodge, which is “I like to do what I like to do. Don’t confuse me with the latest research. Don’t confuse me with the all-comers data that you’ve got. I want to do what I want.”

Rishi P. Singh, MD: If that was true, we wouldn’t have some of these therapies available to us because some of these things came out of the art of trying.

Peter Salgo, MD: Okay.

Rishi P. Singh, MD: If we had no way of doing those sort of things, if we didn’t have a way of getting that off-label medication or to see what happened when we switched patients on the better drug versus the cheaper drug and we saw better outcomes, we wouldn’t be able to really determine what those outcomes are. I think that that’s a key feature where the art really helps the process.

Steven Peskin, MD, MBA, FACP: Yeah. We’re looking at choice based on evidence, so that becomes a really a sine qua non: is there evidence?

Interestingly, on this art of medicine which I really enjoy talking about, it’s also bringing back the joy to the practice of medicine. One of my physician colleagues who is a primary care physician says, “I’m increasingly, as I get into my 60s, moreso influencing the behaviors of my patients. And I really feel like that’s where I can have even more influence than all of the magnetic resonance imaging and positron emission tomography—computed tomography scans and things like that.”

Again, not to be a nihilist toward technology. Goodness knows there’s some amazing advances, anti-vascular endothelial growth factors among those. But, it’s great insight from him in terms of the trajectory of patients, diseases, their problems, their overall health, and well-being.

Peter Salgo, MD: He’s treating patients, not numbers. Patients, not statistics.

Steven Peskin, MD, MBA, FACP: Yeah, the humanism, the art.

John W. Kitchens, MD: Yeah. He’s got a great point. I think that one of the nice things about this revolutionary treatment that we have is it gives us an opportunity to message our patients with hope.

Diabetic patients always hear bad news. They’re never going to get better. They’re always going to get worse. Their kidneys are going to fail, and if they don’t do a really good job, it’s going to happen quicker.

We can actually take those patients in, now, and show them their pictures, show them their scans, explain to them what’s going on, and say, “Guess what, I’m going to make this better.”

Peter Salgo, MD: It occurs to me that this is what we used to say to people with ischemic heart disease. “There’s nothing we can do, the calcium is going to grow, soft plaque is going to kill you.”

And then, along came statins. And what do you know? Their risks went down not just below where we started, but below baseline. Am I interpreting this right? Is that what we’re talking about here?

John W. Kitchens, MD: I think it’s an order of magnitude even higher.

Peter Salgo, MD: Wow. That’s very, very impressive.