Managed Care - November 2008 - (Page RSV18)

ceived its first dose of palivizumab in the NICU, but is a borderline candidate for immunoprophylaxis, such as an infant born at a gestational age of 34 weeks who is relatively healthy but has only one risk factor for serious RSV infection. If we were to evaluate this case independently, we probably would deny coverage, yet the NICU has initiated treatment. At this point, it becomes difficult to deny further immunoprophylaxis because of the parents’ and the physician’s expectations. Establishing regional guidelines for RSV immunoprophylaxis prior to the onset of an RSV season and working collaboratively with NICUs to make them aware of reimbursement policies might help eliminate this kind of conflict. Among general practitioners, there seems to be some confusion about palivizumab. Some physicians equate it with a standard vaccine that requires only one or two injections. They seem unaware that palivizumab immunoprophylaxis usually involves a total of five or six injections, administered monthly starting prior to the onset of the RSV season and continuing for its duration. In terms of cost, the most expensive patient is the one who receives only one or two doses and, thus, fails to receive the long-term benefit of the drug. Sporadic administration of palivizumab is ineffective — an initial dose in November followed by a second one in January is suboptimal. Therefore, MCOs stress compliance. An MCO can put PA in place and provide access to the drug, and issue reminders and incentives to parents and physicians to get immunoprophylaxis, but in the end, successful immunoprophylaxis depends on a collaborative relationship between the parents or caregivers and their physician. ally marked up by some percentage that the MCO must then absorb. To counter this practice, it is very likely that MCOs will turn to home care more and more for palivizumab immunoprophylaxis, because it provides an opportunity for specialty pharmacy to contract for the drug at a volume discount and bypass the physician markup. This savings would more than offset the cost of a home care visit (often $70 or more). Another cost-reduction strategy is to have the pharmacy deliver the drug to the patient’s house, which the patient would then take to the physician’s office for administration. Summary RSV immunoprophylaxis presents a challenge for MCOs. Despite its demonstrated ability to protect highrisk infants against serious RSV infection and to reduce morbidity, immunoprophylaxis with palivizumab incurs high costs that MCOs must grapple with every year. If MCOs, physicians, and professional organizations can agree on common guidelines for RSV management, then MCOs will be able to provide affordable treatment for those children at high risk. References AAP (American Academy of Pediatrics). Respiratory syncytial virus. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Redbook: 2006. Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2006:560–566. CDC (Centers for Disease Control and Prevention). Brief report: respiratory syncytial virus activity – United States, July 2006–November 2007. MMWR Morb Mortal Wkly Rep. 2007;56:1263–1265. Cost-savings through home care Palivizumab presents a new challenge for specialty pharmacy, because sometimes it is provided through home care. When a physician administers the drug in the office, the price at which the physician acquired it is usuDisclosure: Douglas S. Burgoyne, PharmD, RPh, reports having received honoraria from Eli Lilly, GlaxoSmithKline, and Abbott. He has no real or apparent conflicts of interest with respect to proprietary products mentioned in this article. ROUNDTABLE DISCUSSION RSV Issues and Solutions RETURN ON INVESTMENT MICHAEL FROGEL, MD: The key message from Dr. ALBERT TZEEL, MD, MHSA: There are two ways to look Simões’s presentation is that you can’t just look at hospitalization as an endpoint. Managed care entities need to realize there is an association between RSV infections and recurrent wheezing later in life, so there may be more downstream costs if RSV immunoprophylaxis is not provided. That’s a key issue that has not been addressed well. STEVEN PESKIN, MD, MBA: For payers, what makes the kind of information Dr. Simões provided valuable? at it. I agree with what Eric [Simões] is saying in terms of the predictive value of a tool like the one he described. That is very helpful, because cost ultimately is where the rubber meets the road. Philosophically, I agree with the idea of looking further down the road in terms of the potential decrease in the risk of asthma. Given the amount of turnover in managed care, however, we are reduced to arguing in favor of paying for a treatment now rather than for one that will provide a return for some other MCO later. 18 MANAGED CARE / SUPPLEMENT

Table of Contents Feed for the Digital Edition of Managed Care - November 2008

Managed Care - November 2008 Editor’s Memo Contents News and Commentary Legislation & Regulation Letters Medication Management Compensation Monitor Do It Yourself for Less Biomarkers Promise, but Do They Deliver? Oncologists Complain About Drug Payment Consider Blood Pressure Self-Monitoring Q&A: Keep Industry in the Game Formulary Files Plan Watch Tomorrow’s Medicine Outlook Respiratory Syncytial Virus Managed Care Considerations Contents Continuing Education Objectives RSV Disease in the Pediatric Population In the Trenches RSV Infection in the Adult Population Health Plan Medical Director Health Plan Pharmacy Director RSV Issues and Solutions Assessment/Evaluation/Certificate Request Post-Test

Managed Care - November 2008

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.