Providing Safe and Effective Intravitreal injections - Episode 7

Step Therapy and Impact of the COVID-19 Pandemic on Intravitreal Injection

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Nadia K. Waheed, MD, MPH; and David M. Brown, MD, discuss barriers to step therapy and the impact of the COVID-19 pandemic on intravitreal injections.

David M. Brown, MD: Nadia, we have a lot of issues in South Texas with step therapies and younger patients that have larger co-pays, etc. How do you handle that in the Northeast?

Nadia K. Waheed, MD, MPH: I think that is a little bit less of a concern in the Northeast. Many insurances do require that patients be preauthorized before you start them on one medication vs the other. But it is becoming an increasing concern, and of course, just overall the cost of care tends to be a concern. Realistically speaking, in many of our capitated care places within the Northeast, we do tend to start patients with something like Avastin just to start to keep down the cost of care and to see what the response is like. But what I do is, if I don’t see an optimal response, and especially in wet AMD [age-related macular degeneration] patients, but also increasingly in diabetic patients, you’re able to tell pretty fast if someone’s responding or not. And if they don’t look like they’re responding well, or if the injections continue to be too frequent, I tend to not hesitate in terms of switching them. Cost of care in terms of cost of medication is certainly concerning, but you alluded to this upfront—there’s also a cost that comes with having to have these patients come over more frequently, relatives having to take time off to transport them and having them be in the doctor’s office that frequently. Thus, I really do like to get my patients to a point where they’re needing injections once every 3 months or so, ideally and try to step them up to whatever medication takes them to that level. What about you—how do you approach it, David?

David M. Brown, MD: It’s really insurance dependent. What I see in the future that is going to be a big challenge is we’ve got biosimilar ranibizumab coming out July 1 from Biogen, Inc. We have another one shortly thereafter…and I can see where you’re going to have to have just fridges and fridges of various step therapy drugs. There’s already been step therapies proposed by Regence [health care insurance], where if you’re on ranibizumab, you have to switch to biosimilar. You have to fail Avastin with 3 doses before you can go to biosimilar ranibizumab before you can go to aflibercept before you can go to Vabysmo. Literally, you’re going to have 4 steps. It’s going to take whatever that is, 8 months to a year, for that recalcitrant patient. And I’m a little concerned you’re going to lose vision by wading through all these hoops. Certainly, we’re going to have to be better at inventory management and inventory management systems. Hopefully, we won’t have to keep multiple biosimilars. Hopefully, we’ll be able to stick with 1; it will be challenging. The other issue is the younger patients, the patients with diabetes and vein occlusion. With a lot of them, they may have a co-pay assistance card, but if they miss work, they’re going to get fired and then they won’t have health care insurance. Thus, they have a hard time. They want to come in and out of your clinic, you got all these octogenarians walking around in their walkers—just the logistics of running an efficient clinic. We try to design clinics where patients don’t have to walk as much, where you go from a screen immediately into an open area immediately into an injection room; sort of a lean Toyota manufacturing processes. I think as our injections get more and more, we’re going to have to more and more design our clinics to accommodate flow just to help us get the volume done.

Nadia K. Waheed, MD, MPH: It’s really interesting and one of the things that happened during the COVID-19 pandemic for us was we went from the moving patients around approach to moving services to patients. It would much more be the technician comes in and does a visual acuity then you set them up on the OCT [optical coherence tomography test] in the same room, and then the physician comes in and sees them, and then does the injection in the same room. And I think that certainly helps in some ways, but of course, the limiting factor over there is the number of rooms that even have availability. And you really do need a clinic with many rooms available as well as many imaging devices available for that kind of an approach to work well. I worry a little bit about step therapy and what that means in terms of—as you are alluding to patient visual acuity and the autonomy of a physician to decide what might be the best starting medication for patients—as opposed to having them run through cost-determination hoops. And increasingly, as we become obligated through that, it becomes more and more of a concern.

David M. Brown, MD: The things we learned in the pandemic that we’re sticking with though, is our exams were terrible in the pandemic with me wearing a mask, them wearing a mask, everything fogging up. We started doing a lot more wide-field imaging and you ended up finding a lot of pathology that I think I missed before. I thought my exam was pretty good until you get humbled by this experience. And I think we’re going to stick with wide-field imaging on every new patient. There are some patients that just don’t look up and left, no matter how many times. And that’s exactly where the horseshoe tear is. The other thing that does help the clinic, but I don’t know if we’ll maintain, is that it is helpful not having 15 family members pile in a room for…control of germs. And it’s good to have, certainly for patients with dementia, 1 caregiver there, but the ones that brought 5 or 6 in, it really is a more efficient clinic if you can limit the number of people in the rooms. I don’t know if we’ll be able to maintain that. I think a lot of the physicians liked it, but what we also found was that in the pandemic, you really were more cognizant of clearing the waiting room out. And we did more time studies to make sure that we weren’t packing our waiting rooms and being a COVID-19 petri dish. Hopefully, those time management things will continue post pandemic, although post pandemic is not something that I see immediately over the horizon.

Nadia K. Waheed, MD, MPH: Interesting.

Transcript Edited for Clarity