Through a structured, interactive approach designed to facilitate collaborative discussion, the MS roundtable sought to identify areas of common ground between healthcare providers (HCPs) and payers in making clinically appropriate, value-based patient management decisions. HCPs and payers represented on the panel discussed their responsibilities, goals, and challenges in an open forum that encouraged the candid exchange of ideas.
At the onset of the program, each group identified their respective positions, acknowledging that their perspectives toward patient care and management were very different. HCPs focus on providing the best possible care to their individual patients. In this regard, they want payers to trust their professional judgment about clinical decisions, rather than impose restrictions that sometimes appear to be arbitrary and subjective. On the other hand, because they represent insured populations, payers take a value-based, fiscally sensitive approach to managing coverage decisions.
As the exchange of ideas continued, the two groups began moving closer to consensus. HCPs acknowledged that healthcare financing was a critical societal issue, noting that their patients frequently struggle with the burden of escalating healthcare costs. HCPs also recognized that they had a responsibility to be mindful of the cost of care, not only to the patient, but also to the insurer. As an example, they cited the prudence of discontinuing a therapy in the absence of clear patient benefit from both a safety and cost perspective. A neurologist at the roundtable commented, “We don’t want patients to continue to use [MS agents] indefinitely without clear benefit, just because there’s nothing else, and because it’s on the market and available….We don’t want to contribute to an unending cycle of unnecessary spend.”
Likewise, payers began to appreciate the HCP perspective, conceding that no one was more qualified to make clinical decisions than the direct providers of healthcare. Payers also acknowledged the importance of the subjective component of patient care, agreeing that the clinician’s expertise and judgment were critical. However, this subjective element is difficult to quantify, and therefore limits payers’ abilities to measure the quality of patient care. This is especially true in MS, because of the lack of consensus clinical guidelines and the fragmentation of the neurology community. As a pharmacy director at the roundtable explained, “It comes down to the well-selected patient. We’re just trying to make sure that we don’t waste money, as opposed to saving money but not covering something. Usually, the input of the physician is very important in making that decision.”
In the end, HCPs and payers were able to find sufficient common ground to work together on several real-world, case-based patient-management scenarios. In this consensus-building exercise, where patient benefit was not always clear cut, payers relied on the judgment of HCPs to help guide their management decisions. HCPs readily accepted the responsibility, appreciated the reliance on their professional judgment, and, acknowledging the cost issue, indicated their willingness to discontinue therapy in the absence of patient benefit. As a result of these discussions, HCPs and payers were able to achieve consensus regarding treatment decisions and subsequent management of the patient.
In our opinion, this interactive approach provided a constructive forum for stakeholders with differing points of view to candidly share their positions, ideas, and potential solutions. Through their interaction, each group achieved an enhanced understanding of the other group’s perspectives, and a better appreciation of their role in the care and management of patients with MS. It may be valuable to apply the concept at the regional level, bringing together community HCPs and payers to discuss the issues and challenges that may be specific to their respective geographical areas.
The author of this publication believes that this interactive consensus-building approach, which was tested on a micro scale, demonstrated proof of concept for the MS disease state, is potentially transferable to other disease states, and serves as an effective model to initiate multistakeholder interaction.
Overview
Multiple Sclerosis Disease State Review
Treating Multiple Sclerosis: The Healthcare Provider Perspective
Management of the Multiple Sclerosis Category: An Increasing Focus for Payers
Achieving Consensus between Healthcare Providers and Payers