Managed Care Perspectives on the Overall Cost of Glaucoma Treatment:
Does Focusing on Generic Treatments Increase Costs?
Gary M. Owens, MD*
*Gary Owens Associates, Past Vice President, Medical Management and Policy, Independence Blue Cross, Ocean View, Delaware.
Glaucoma is a common ophthalmic disease, putting a large portion of the population at risk for blindness.1 This is particularly true of the Medicare population, although the risk of glaucoma begins at approximately age 40 and increases with advancing age. Medicare coverage by managed care plans has grown slowly in the past, however, by 2014, 15.7 million seniors, or 30% of the Medicare population, were enrolled in Medicare Advantage plans.2 This number has increased by 4.6 million beneficiaries, or 41%, from 2011 to 2014 and is poised to increase as the population ages (Figure 1).2 As a result, it is important for managed care organizations, as purchasers of glaucoma care, to understand the consequences of glaucoma, available treatment options, and their related costs. As the population ages and the prevalence of glaucoma increases, costs related to this chronic disease will rise to unprecedented levels.1,3
Managed care organizations (MCOs) are facing a number of external challenges, including growing consumerism, with purchasers actively seeking increased healthcare choices and value. The “Baby Boomer” generation is different from previous generations of seniors and generally has higher levels of education, is more engaged in healthcare decisions, researching insurance plans, providers, and treatment options. Many members of this generation expect to retain excellent vision and have proven to be astute consumers of eye care. They demand superb outcomes from cataract surgery, purchase premium intraocular lenses, and accept nothing less than perfection from their surgical outcomes. It can be anticipated that their behavior toward glaucoma care will follow suit, and that they will reject insurance plans that do not offer coverage for the treatments they have carefully researched and vetted.
Another external challenge facing MCOs is difficulty in segmenting populations now that health exchanges are operating in the individual market. In addition, the Affordable Care Act’s Medical Loss Ratio requirement limits the portion of premiums spent on administration, marketing, and profits.4 All of these factors may negatively affect MCOs’ profitability. Consequently, MCOs will no longer be able to afford to be complacent about eye disease with relatively low costs and utilization like glaucoma, relying solely on generic medications for cost savings. Instead, they should focus on the overall value of glaucoma care, achieving the best outcomes at the most reasonable cost. In order to address the needs of insured populations as well as the need for profitability, the connection between pharmacy and medical departments of MCOs must be improved to ensure cost efficiency and excellent outcomes across treatment modalities.
This activity is designed to provide managed care leaders with the foundation they need to understand glaucoma against the background of current and future prevalence. It will detail current medical and surgical treatments and treatment advances that will be available in the near future for senior patients with glaucoma. Furthermore, we will consider the direct medical cost of glaucoma overall and the cost of disease progression, the role of adherence in disease management, and the costs associated with nonadherence. Pharmacoeconomic analysis of current and future glaucoma treatments will be considered, highlighting those that decrease or eliminate the need for adherence, and focusing on their potential for financial return on investment as they lead to improved clinical outcomes. Advantages and disadvantages of generic glaucoma medications will also be considered, providing valuable information to assist in the decision-making process regarding a patient’s course of treatment. The goal of this activity is to provide MCO leaders the tools to design analytical methods of determining coverage policies for glaucoma treatment for their healthcare plan’s specific populations, resulting in excellent visual outcomes for senior glaucoma patients in the most cost-efficient manner.
1. National Eye Institute. Glaucoma, Open-angle. National Eye Institute Web site. Available at: https://www.nei.nih.gov/eyedata/glaucoma. Accessed May 20, 2015.
2. Gold M, Jacobson G, Damico A, et al. Medicare Advantage 2014 Spotlight: Enrollment Market Update. The Henry J. Kaiser Family Foundation. Available at: http://kff.org/report-section/medicare-advantage-2014-spotlight-enrollment-market-update-overall-trends/. Published April 2014. Accessed May 2015.
3. Congdon N, O’Colmain B, Klaver CC, et al. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004;122:477-485.
4. The Center for Consumer Information and Insurance Oversight: Medical Loss Ratio. CMS.gov Web site. Avaible at: http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Medical-Loss-Ratio.html. Accessed May 2015.