COPD: An Individualized Approach to Medication and Delivery - Episode 12

Issues with Reimbursement in COPD Care

Peter Salgo, MD: I want to circle back to something that Byron was talking about. The payers are changing the game, mid game. You start somebody on something that’s working. They get a letter in the mail. Everything changes. How do you start changing that? Can you change that? How do you enlist the payers to work with you, as a combined team of stakeholders, to get everybody better? Can I say something that may be controversial? Does anybody go into the insurance business to hurt patients?

James F. Donohue, MD: No.

Peter Salgo, MD: No, they want to help people. They all, at least on the surface, seem to have the same drive.

Barbara P. Yawn, MD, MSc, FAAFP: But they’re so removed from the patient that they think saving money is the primary thing to do to help patients. That just doesn’t compute, for many things. So, how do we work with this? I think that we really have to engage the patient community. Now, how many physicians and other healthcare professionals are there versus the 30 million people with chronic obstructive pulmonary disease? If we can engage those 30 million, or some group of them to help us, we have to have a consistent message.

Peter Salgo, MD: I’ll tell you, they’re going to come back and say, “You’ve got 30 million people. I’ve got 270 million Americans, and they’ve only got ‘this’ pot of money. So, I’ve got everybody at my table, not just the COPD people.”

James F. Donohue, MD: Like the rest of us, we’re forced to have many conversations with the physicians. They’re good people. Let me just say, they want to do the right thing by their patient. However, their world is that a contract has been reached between the insurer and pharma. Some pharma companies have really high prices and some have lower or discounted prices, or what have you. There’s only limits to what the people—the PharmDs, for example, and the MDs, the providers, and the business people in the insurance industry—can do, given those contracts. And, again, that takes place at another place. It’s a business. Again, some of the heat has to be exerted on the companies.

Peter Salgo, MD: I said before, wouldn’t it be nice if everybody got together?

James F. Donohue, MD: That’s right, absolutely.

Peter Salgo, MD: What needs to be done to do that? It’s really easy to sit here and yell at insurance companies and go to an insurance company conference and yell at providers. Somebody’s got to get them at the same table.

Antonio Anzueto, MD: Experience of conditions. And, as Barbara says, you have to get the patients involved.

James F. Donohue, MD: And that’s what Byron’s doing.

Antonio Anzueto, MD: If you get the patients involved, they can help to drive what is needed. This is the case with his COPD Foundation. You say, “Wait, with most of the initiatives for all of the respiratory and cardiovascular conditions, patients have to be the main driver.” What are their needs? The insurance companies have stakeholders who they have to respond to. “Why are you spending $10 instead of $2 for the same therapeutic?”

Byron Thomashow, MD: Ultimately, the providers can only do so much. People with this disease, and their caregivers—I want to stress Barbara’s point about that—need to stand up and they need to be heard. It’s not their fault. It’s part of the problem with this disease, from the beginning.

James F. Donohue, MD: It’s a stigma.

Byron Thomashow, MD: It’s the concept of blame. It’s a stigma. That’s ridiculous. Even in those people who smoke, only a small fraction develop severe COPD. There’s a combination of things. People need to stand up and say, “We have the right to breathe,” and that means having rehabilitation. That means having medicines and devices that I can use. But ultimately, it’s the people and their caregivers who are going to have to raise their voices.

Transcript edited for clarity.