Healthcare provider (HCP) and payer viewpoints can be very different regarding the treatment and management of patients with chronic conditions. The HCP’s principal responsibility is to the individual, ensuring that every patient under his or her care receives the appropriate treatment necessary to optimize their patients’ health and quality of life. Although the well-being of individual patients remains the major focus, in recent years, HCPs have been forced to view healthcare delivery in a broader context, one that includes the financing side of the equation. The skyrocketing cost of healthcare in the United States is responsible for this change, and the burden is being felt by all stakeholders—patients, government, HCPs, payers, and employers. Payers, both private and government, are charged with managing healthcare utilization in the broader context, and, as a result, their perspective is increasingly guided by the value of healthcare services (ie, the value of services relative to cost). As healthcare costs continue to rise, so does the level of scrutiny placed on determining the value of services, be it a medical procedure, a prescription medication, a health management program, or any other healthcare service.
As in many chronic conditions, the cost of treating multiple sclerosis (MS) has escalated in recent years. This increase has been driven primarily by the cost of medications used to treat the condition.1 As a result, payers have begun to manage utilization in the category, and patients are being asked to shoulder a larger share of the treatment costs. In some cases, payer utilization management efforts have created friction between payers and HCPs.
The MS roundtable was convened to bring together a diverse group of stakeholders who either have treated patients with MS (ie, HCPs) or who were responsible for the reimbursement of treatment costs (ie, payers). Using an interactive approach to stimulate exchange of ideas between payers and HCPs, the roundtable sought to foster a better understanding of each group’s perspectives, roles, and responsibilities in the treatment or management of MS, seeking to find common ground within the broader value-driven paradigm that defines healthcare in the United States today.
Not surprising, program prework revealed that HCPs and payers had substantially different perspectives regarding the treatment and management of MS. For example, HCPs and payers differed in their perceptions of patient medication adherence (as measured by medication possession ratio [MPR]), with HCPs estimating that a greater percentage of patients were adherent to therapy. Payers possess the claims data allowing them to calculate MPR for defined populations and therefore quantitatively examine patient adherence.
Both payers and HCPs agreed that walking impairment was the most debilitating symptom associated with MS, and its impact was, in many cases, very substantial.
The roundtable program began with an overview of the MS disease state, including an interactive discussion with a review of MS subtypes, pathophysiology, disease course management, and symptom management. Subsequently, using a case-based format, the group was asked to focus on one area of symptom management—walking—and to discuss the impact of walking impairment, determine the need to treat, review the patient benefits of treatment, and work together to achieve consensus on an optimal approach to treatment and management from a value-based perspective.
- Express Scripts, Inc. Drug Trend Report. 2011. www.drugtrendreport.com/specialty/specialty-drugs. Accessed September 2, 2012.
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