Payer, Provider Disagreements on PCSK9 Inhibitors for Cholesterol Management

Payers and providers agree that prior authorization forms and awareness of cost-effectiveness are barriers regarding the use of PCSK9 inhibitors and support more standardized eligibility criteria and documentation.

PCSK9 inhibitors are used for treatment in patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia. Researchers of a study published in Journal of Managed Care & Specialty Pharmacy. sought to understand discordance and facilitate face-to-face discussion between payers and providers.

Six focus group meetings were conducted in 2019 with local groups of 3 payers and 3 providers serving large US cities (population exceeding 500,000). Forums featured cardiologists or lipidologists and payer leaders from major health care management organizations. 

Meetings were aimed at identifying barriers to appropriate use of PCSK9 inhibitors and aligning understanding of clinical, cost, safety, and efficacy data. Participants responded to surveys before and after the meetings to indicate how payer and provider responses changed.

Premeeting survey results indicated that most providers and payers (67% to 78%) agreed that high copayments and inadequate prior authorization documentation were significant barriers to optimal use. However, 72% of providers but only 44% of payers believed that prior authorization presents excessive administrative burden. Additionally, 56% of payers, but only 6% of providers, believed that current evidence does not support PCSK9 inhibitors cost-effectiveness.

Post meeting surveys indicated that an increased number of providers (6% to 22%) believed that current authorization criteria accurately distinguish patients who benefit most from treatment, while payers decreased in this belief (72% to 50%).

More providers (22% to 50%) believed that properly documented prior authorization forms expedite access. Payers increasingly believed in standardized prior authorization requirements (50%-83%) and less stringent prior authorization requirements for patients with familial hypercholesterolemia (33% to 72%), considerations with which 89% of providers agreed.

Both providers and payers reported increased belief that PCSK9 inhibitors are cost-effective (44% to 61% and 28% to 50%, respectively) and were more willing to consider it as a treatment at the low-density lipoprotein threshold of >70 mg/dL for patients with ASCVD (78% to 83% and 44% to 67%) or familial hypercholesterolemia (22% to 39% and 22% to 33%).

Additionally, 83% of all participants supported educational programs for patient treatment adherence, and support for physician/staff prior authorization processes education increased from 83% to 94%.

“Provider and payer representatives… provided recommendations to improve quality of care in patients eligible for PCSK9 inhibitors,” researchers of the study noted. “Participants also provided tactical recommendations for streamlining prior authorization documentation processes and improving awareness of PCSK9 inhibitors cost-effectiveness and clinical efficacy.”

—Maria Asimopoulos

Reference:
McCormick D, Bhatt DL, Bays HE, et al. A regional analysis of payer and provider views on cholesterol management: PCSK9 inhibitors as an illustrative alignment model. J Manag Care Spec Pharm. 2020;26(12):1517-1528. doi:10.18553/jmcp.2020.26.12.1517