Developing a treatment plan for AMD

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Yeah, I think it's wonderful that we have so many new treatment options, but I think there are challenges that come with it. And I think that that's really important to address and be aware of as you start to utilize these treatments. So some of the new challenges are the prospect of combination therapies, and I think that there are two challenges that come with that in my mind. One is the technical challenge of how to administer them. For instance, can you administer two medications on the same day? Do they interact? How are those followed? So more to come on that as we certainly develop these treatments. And then second, I think there's the logistical challenge because you really have to figure out the coding and reimbursement issues that come with it. There are unique challenges that have come up by virtue of multiple diseases being treated potentially at the same time in some of these patients.

And then I would really say that the kind of backbone of a lot of this to make it work is the reimbursement process. And so insurance and payer policies, while not hot topics, they are relevant to how this care is delivered. And it really has become harder and harder to navigate that. So for instance, we have issues of step therapy and prior authorizations, but we're seeing this even more evolved as you have multiple treatment options because now it's no longer step therapy, it's steps therapy where you have to go through multiple medications in the list of the insurer or payer policy, maybe not necessarily in the order that you would like to, but based on that order. So those are things that have to be navigated.

When we think about new treatments, at least the way that I like to think about it, the first and most important thing is first to determine if it's appropriate for your patient. So does this meet a need that your patients have? Will it offer better care to your patients to treat certain diseases that they're dealing with? So I think that's first and foremost. But then the second question is equally relevant and that is, can your practice deliver this care? And so whether that means understanding the coding and reimbursement logistics, whether that involves retraining or retooling. So for instance, for some of the surgical procedures, developing those techniques or kind of learning how to implement those approaches, those are the things that you want to consider in terms of whether you're gonna jump into the new therapy. These can be challenging. I think there's several steps that I like to keep in mind.

First is you want to have an overall practice implementation strategy. And so that includes things like updating your EHR and consents so that you have the new medications with the correct dosages. It sounds simple, but audits have failed because EHRs have hard coded the correct dosage for new medicines. So certainly want to have that in place. Once you decide that you have patients where it's appropriate to use the medication, then you want to start with I think the most straightforward cases first. And now I'll use a geographic atrophy as kind of a case study in some ways because that's been perhaps the newest addition. You want to first make sure certain ICD-10s apply, and so knowing which dry AMD codes allow that to be effectively reimbursed. And then you may start with these most straightforward cases. So you might start with a patient with dry macular degeneration who has geographic atrophy and nothing else going on. And so that's kind of your most straightforward case. You may then move on to patients who have wet macular degeneration in one eye and dry in the other eye and then see and make sure that there's no conflict of those reimbursements going through. I'd move it forward to patients who have wet and dry in the same eye. And then those patients that are being treated, for instance, less often than 28 days, which was often a common rule that many payer policies implemented a frequency edit of 28 days for using injections. And then finally go to cases where potentially you'd be using this treatments in the same eye at the same time. And so with each step, there's an additional hurdle that we're kind of going through, but you're not going for all four hurdles at once. You kind of start with the first and kind of build up.

I think you need to be prepared to appeal subsequently. And so you need to follow claims and be prepared to go through an appeal process. I think having your team ready and looking for these claims is gonna be important. And I think this is especially true when we're talking about permanent J codes and Q codes not being present. So this is in typically the first six months before therapies when therapies get implemented. Once the J codes and the Q codes get implemented, it becomes a little bit more straightforward. But again, for those that are earlier adopters, I think that's something you need to keep in mind. Then you want to utilize patient assistance programs and these really help to mitigate the reimbursement risk that can happen for your practice. But it's also helpful to reducing the financial burden and patient risk for your patients in terms of their financial burden. So I think it's a really nice way to kind of smooth out that process, especially early on. And finally, as always, I think unfortunately you gotta monitor payer policies and keep in mind that initial payment does not guarantee continued payment. So that's a common error. And so you really want to be aware of what their payer policies are, monitor the frequency edits that come with it. And then there may be additional requirements.

So going back to the case study of dry macular degeneration, some of the payers may go back and say, well, was the GA subfoveal or not in terms of whether they approved it or not. And initially they may have approved it for all cases of geographic atrophy or they may go back and say, well, did you do an autofluorescence photo or not? And many of us can see the geographic atrophy clinically. We might not have an order of photo, but being aware of those policies is gonna be important to ensuring that those reimbursements continue to come in. So keeping that in mind. I would say beyond the strategies we just discussed, I think it's really important that you utilize the presence of some of the national organizations. I think that's very helpful. I think in ophthalmology, we have a very strong presence. And so specifically I can speak to the retina space where I would say the AAO, the Academy, and the ASRS, American Society of Retina Specialists, are truly two shining examples of organizations that really help to put out guidelines, regular updates and things like that. And I think there are really three areas where they are very helpful in terms of how we implement it. So one is providing some clinical guidelines from a lot of experts in the field that have kind of looked at the data in a very thorough manner. And you can kind of piggyback off of some of that knowledge.

The second is looking at the coding logistics, so you know, whether it's developing which codes to use, which unlisted codes to use before the J codes and Q codes come out, things like that. And then finally, I think perhaps the most important, and we've seen this in the retina space certainly, is the follow-up that happens after the FDA approves it. So if there are any adverse events, what's happening with those adverse events? These might be issues that pop up that were not seen in the clinical trials but subsequently show. And it also offers an ability to engage other physicians in terms of their approaches to handling some of these complex situations that can happen because again, in some ways we're still learning together, despite the fact that the FDA approvals are in place. When we treat millions of patients, as we do with some of our injections, there are other issues that do come up and it's important to be aware of all of those.

And then finally, I would just kind of highlight the fact that I think we all want to do better for our patients. I think that's the ultimate mantra and it goes back to the Hippocratic oath of do no harm. And so that's where the adverse event follow-up is really critical to make sure that not only are we developing and implementing top-notch care, but making sure that there is no adverse events or at least those are discussed with patients so that these are informed decisions that patients are making when they're choosing their therapy. And I'll end by saying this is a super exciting time in the retina space. I mean, there are more drugs, targets, delivery mechanisms available now, more diseases that we can treat than ever before, and the pipeline looks incredible. And I really kind of highlight the fact that I think ultimately this means patients are the real winners. I think we're gonna have more options for them now than ever before.