Seizure Management Across Health Care Settings: Roundtable Discussion

Winston Wong, PharmD, leads a roundtable discussion with Mohamad Koubeissi, MD, MA, FAAN, FANA, FAES; Edmund Pezalla, MD, MPH, PHD; Donald Vollmer, MD; and Steve Chung, MD, about seizure management across different health care settings and perspectives.

• Payer Perspective—Edmund Pezalla, MD, MPH, PhD, CEO of Enlightenment Bioconsult, Wethersfield, CT
• Long-term Care Perspective—Donald E. Vollmer, MD, Medical Director, Millennium Care & Rehab, Huntsville, TN
• Health Systems Perspective—Steven Chung, MD, Executive Director of the Neuroscience Institute, Director of the Epilepsy Residency Program at the Banner Medical Center, Phoenix, AZ
• Physician Perspective—Mohamad Koubeissi, MD, MA, Director or the Epilepsy Center at the GW Medical Faculty Associates, Professor of Neurology at George Washington University, Washington, DC
• Moderator—Winston Wong, PharmD, President of W-Squared Group, Longboat Key, FL

This video series is sponsored by Sunovion Pharmaceuticals, Inc and is part of a 4-part series on “Seizure Management Across Health Care Settings.” View the rest of the series here.

Read the full transcript:

Dr Wong: Welcome to an installment of PopHealth Perspectives, seizure management across healthcare settings. Joining us today are several speakers each providing a different perspective on this topic. On our panel, we have Dr Mohamed Koubeissi, who is representing the physicians’ perspective. Dr Koubeissi is the Director of the Epilepsy Center at the GW Medical Faculty Associates, and as a Professor of Neurology at George Washington University. Dr Ed Pezalla is representing the payer perspective. Dr Pezalla is the CEO of Enlightenment Bio Consultant. He works with various policy and industry groups on cutting edge coverage policy, innovations and value-based payments, and adaptive regulatory and market entry pathways. Dr Donald Vollmer is representing the long-term care perspective. Dr Vollmer is the Medical Director of Millennium Care and Rehab, as well as, the Medical Director of several other healthcare facilities, such as NHC, Murphysboro, and Geriatrics Consulting. And then finally, we have Dr Steven Chung representing the healthcare system perspective. Dr Chung is the Chairman of Neurology, Executive Director of the Neuroscience Institute, and Director of the Epilepsy Residency Program at Banner Medical Center in Phoenix, Arizona. Welcome.

Let's start with a question for Dr Koubeissi and Dr Vollmer. How would you identify a focal seizure patient?

Dr Koubeissi: Identification of focal seizures starts with the good history. If the patient describes that their habitual seizures start with symptoms that suggest focal onset, then the hypothesis would be that the epilepsy they have is focal. And then, the appropriate medications to be given would be ones that have been proven in clinical trials to be good for focal seizures. Further identification, or confirmation of the focality of seizures, may come from monitoring in the epilepsy monitoring unit where either the seizure semiology, that is the clinical manifestations, or the EEG, confirmed the focality of the seizure, or both often, as well.

Dr Wong: Dr Vollmer, in your setting, is there anything to add?

Dr Vollmer: Yeah. In longterm care, very frequently, the family or the patient can give a history of seizures or passing out, or just saying that they lose consciousness briefly, falls, irregular movements. Very often, it's subtle though, where it could just be an unnoticed loss of consciousness or incontinence, biting their tongue, staring very frequently. They won't have the mental capacity to describe it very well for you. So, sometimes we rely on the techs, or the nurses, or other staff. They'll frequently just say, "Dr Vollmer, this patient is just different. They were fine. They were participating in therapy, and they were alert. And now, they're just not themselves. They're just markedly different, just like that." So, that very frequently will give me a clue that there may be some underlying focal seizures.

Dr Wong: What do you consider in terms of a differential diagnosis?

Dr Vollmer: Definitely in the nursing home statute, you've got to rule out hypoxia; make sure that's not an issue. There can be infections. There can be cardiac issues. TIAs that could be a side effect of their medication. So, there are a lot of other things to consider. And so, it's important to get a good workup for other causes. But what stands out so often about these types of focal seizures that don't have a lot of visible manifestation, is just the sudden onset where they just say they were literally having a good conversation, and now they don't even seem to know their name or where they're at. And then, that typically will resolve over several minutes to several hours. And that's because they're postictal at that point. And that's something that's quite unique to focal seizures.

Dr Wong: Great. Thank you. Opening it to the entire panel; does the treatment setting impact the treatment selection for a seizure patient? Treatment setting being inpatient versus outpatient, a long-term care facility, or even a patient who may have, or not have, caregiver support.

Dr Chung: Generally speaking, I think a seizure treatment, especially the focal seizures, are quite standardized throughout the country. However, the main difference between the inpatient setting versus outpatient setting is a process of selecting a patient. For example, inpatient setting, they like to provide a medication acutely and quickly, often requires IV medications, and not so much considering the other patient factors such as the comorbid conditions, drug to drug interactions, potentially with potential medications they're taking, and examining the underlying cause. And other hand, outpatient setting, those are the more common and more important aspects that we consider. Not just which medication to use, but what kind of medication and, what kind of side effects they can tolerate better and more compared to others. One other aspect is what medication could be available in both outpatient setting and inpatient setting? Naturally, inpatient setting, there's more limited number of medications available. So, the choice of medication could be limited to whatever the hospital has approval in their facility.

Dr Pezalla: So, the differences in setting of care also reflect differences in who the payer is or, where the pharmacy benefit is being managed. So, as Dr Chung has said, inpatient things are really driven by the hospital formulary and not so much by the payers who tend not to be involved in most of the medications that are being used in inpatient setting. However, there is that transition of care, and this is an extremely important problem to manage, which is that when the patient is ready to leave, either going home, hopefully, or perhaps going to a SNF, or to long term care, or back to an institution where they may have come from, then there needs to be some preparation to make sure that their medications are available and, that there is not some payer control on a new medication, for example. So, it's going to depend on who the payer is for that patient when they leave the hospital, what drugs are available and, what the formulary looks like.

Impact of Treatment Settings/Access Challenges on Selecting Treatment for Seizures

Dr Wong: Moving on, Dr Pezalla, as the payer, I think you've touched upon this, but just directly asked the question, do you feel that there's any direct impacts to the access to treatment options in the various settings as a result of payer policies?

Dr Pezalla: There certainly are challenges, and it does vary considerably across health plans; not just by type of health plan, but also by specific plan. And this can sometimes be very difficult to tease out because you might have a plan that says, "The card says Cigna." But Cigna might have multiple formularies then. And the plan may not be an insured plan by Cigna. It might be Cigna is just managing a plan for an employer who is the ultimate payer, and they may have their own formularies and formulary rules. So, this gets really complicated in a hurry, sadly. And so, the biggest problem is more negotiating it than the fact that there might be some limitations. But everybody manages things differently. So, as I mentioned, everybody's covering the generic medication. So, that generally is not a problem. But as Dr Chung has pointed out, there are some medications for very specific syndromes, and you really need those medicines for those patients.

Dr Pezalla: In some instances, some of the generic medicines we use for other seizures may be contraindicated, or at least are not effective. So, they are usually available on most formularies because they're unique. However, they do require prior authorization. So, there has to be some planning and, there are certainly cost resources of the physician's office to deal with that and explain what the patient has. And the biggest problem with prior authorizations is that there can be incomplete information that is received by the health plan. And often time, that's because different health plans want different pieces of information. They want them in slightly different ways, which just drives everybody crazy. But, we do not have a specific one size fits all prior authorization process for the whole country, in part because health plans really aren't allowed to collaborate on certain things.

Dr Pezalla: So, prior authorization can get in the way, usually with the more expensive medicines and those with more specific individual indications. So, keeping that in mind, if you're seeing a patient who does have Dravet syndrome or, one of the other less common syndromes, that those medicines are going to be more expensive to the patient because they're more expensive to the health plan, and they're going to oftentimes have a prior authorization required. There are exclusion lists. Many times what's excluded are branded products where there's a generic available. And so, we then have to manage with the generics. Generics rarely have prior authorizations because their costs are low enough that it doesn't seem like it's worthwhile, and because the volume is much higher. Many patients are on generic medications. So, the big problems will be when you run it, when you need a brand product, either because the generics have been difficult to manage for a particular patient and get the right blood levels, or because it's a specialized medication and that's where it takes more time and resources for the physician's office or the hospital to organize that.

And so, it's probably a good idea to figure out and print out some of those formularies in advance for the more common health plans that you see. And also, if a health plan has criteria that don't make sense to you, I mean, feel free to tell them that. And they may or may not change their minds about things, but it's good to let them know. If they're behind the times and their policies weren't updated for a couple of years, and the guidelines have changed or other things have changed, well then it's certainly appropriate to let them know. Whether they'll change, I can't tell you. It varies considerably how receptive they are to things like that, but they need to know.

Dr Wong: So, to the others, based upon what Dr Pezalla has just told us, which I totally agree with, does that have an impact upon your treatment selections?

Dr Vollmer: Well, I mean, there's no question you have to select something that is going to be covered that they're going to be able to actually get. So, that is one of the biggest determining factors is selecting a drug that the patient's going to be able to get.

Dr Chung: Well, as we discussed, choosing seizure medication could be quite complicated. So, I don't know, frankly, how they have been educated about which medication to approve and not to, not knowing specifics about the patient. So, making that as a policy to me is a limitation to begin with. And even though there is a channel that we can try to get medication approved pre-authorization, and then peer to peer later, it is time consuming. And oftentimes the people we talk to is not the influence of the company. Then, even though we complain and explain the situation, it's not necessarily the company's going to be hearing that rather than the specific person that we're speaking to. Same experience with the doctor's office as well as the patient's office. I am yet to have to hear from the patient that they called the insurance company, and then they magically resolved and went extra steps and tried to allocate them and fix the problem. It is always the term “fight.” They always use that term. They have to fight with the insurance company. So, that is telling how difficult the situation and the process could be.

Dr Koubeissi: I totally agree. I think all of us have been through similar situations. I am lucky to have an assistant who tends to look at all my prescriptions on a regular basis and figures out which ones need pre-authorization. And she does them in a finely fashion, but we always continue to have difficulties with insurance companies at times, necessitating switching the prescription.

Challenges of Transition of Care

Dr Wong: Thank you. Drs Chung and Vollmer, we talked a lot about the challenges that are faced with transitions of care. What would a best practice model look like in terms of managing a seizure patient going through a care setting transition?

Dr Vollmer: Well, in longterm care, we're mostly getting our patients from the hospital initially. And so, it's really important that we get a list of their medications before they arrive, screen what their medications are, and when the patient actually arrives, make sure we communicate with the family and look at what their home list of medication is, and what the medications that they came from the hospital. And frequently, we might have to make a few phone calls back to the hospital for clarification, because a lot of the times there's going to be discrepancies in their home medications, their hospital medications. Some things are just left off by mistake. So, it's really important to get to the bottom of what they're supposed to actually be getting.

Dr Chung: And also, system perspective, we're talking about the transition of the care from inpatient to maybe perhaps the outpatient setting. And frankly, there are a lot of system per se, do not operate outpatient clinics as much. They're more focusing on the inpatient hospital system, not the clinic system. So, there's a little bit of a disengagement between the hospital owned or ACO models versus a private owned practice in outpatient setting. I think ideally, the system has to own it, and the onus is on them to make the transition smooth. And that is more motivating factor if the hospital system operate both inpatient and outpatient. You can easily imagine that the system does not have outpatient operation. They may have a less incentives to make those transitions smoothly occur and for all patients. So, it is important to recognize the need and also, we call it nurse navigators who are overseeing, and connecting, and conversing with the patients and make sure things are going smoothly. But, no matter how we call it, navigator or coordinator, I think the hospital system has to invest a little bit more into that for the improve the healthcare overall.

Dr Wong: In terms of the nurse navigator, is there a multidisciplinary team behind that nurse?

Dr Chung: In our system, still in infancy, it is a single designated person for the couple of illness. Our nurse navigator deals with MS and the focal seizure disorder, and they're the ones who's going to be pulling the resources. It's not the team of people that she can work together, or he can, but our nurse navigator has the resources to tap into, but not necessarily fully dedicated to the cost.

Dr Wong: Dr. Koubeissi, is there a best practice model that you have seen?

Dr Koubeissi: I agree with Dr Chung that I've worked actually in two different situations. One where the outpatient and the inpatient facilities are single, are a single entity, and another where the hospital and the outpatient practice are separate, with separate electronic medical records and separate administrations, and separate CEOs. The first example facilitates a smooth transition like Dr Chung mentioned, especially if there is a nurse navigator to work with the patients upon discharge and make sure that they follow up, and so forth. The second one requires an additional effort in order to guarantee that the medications are being provided, the pre-authorizations are being made, the follow ups are being made, and so forth.

Solving Challenges Associated with Treatment Setting and Access

Dr Wong: Let's move on our last topic. And I really want to try to focus in on possible solutions. And we've talked a lot about the challenges today. And each one of you representing different stakeholders, if you had a crystal ball or if you were able to go and make the world perfect, how would you work at towards contributing to improving patient care for at least the seizure patient?

Dr Chung: For the system perspective again, the best interest is to limit the readmission due to the same illness. And that is one of the quality metrics they need to be gauged in. And beyond that, it is actually good for the patient and patient care. And if they’re dealing with that, and as a primary goal, as oftentimes stated in their mission statement, I think we have to understand the need and have a more investment into it. We talked about the person or persons doing that transition and overseeing it, but we have a lot of technology advancement now, and people might be easily or engaged this providers easier. If there’s a certain way we can develop, maybe app based or internet based, web based, a system that patients can be followed through and check in through that system, it has to make it efficient.

Dr Chung: As I mentioned, one of the reasons that we are reluctant to make the whole team is the cost. So, we may be able to limit the cost if we utilized the investment into the early investment to the technology as well too. So, I do want to see little bit more investment into that technology section from specifically for the transition from the inpatient to outpatient setting.

Dr Vollmer: From a long-term care perspective, what I'd like to see, I think would be best practices just to make sure that the patient is on, first of all, the fewest amount of medications necessary and that, the medication has the fewest side effects; that their needs are getting taken care of. So, it needs to be a multidisciplinary team. The pharmacist, the nursing, the techs, just all working together to communicate about whether they're continuing to have seizures, continuing to have side effects from the medication, and then just balancing the medical needs of the patient with their quality of life.

Dr Wong: Dr Koubeissi?

Dr Koubeissi: Well, since you mentioned a genie of the lamp, or whatever we would like to see happen, it's to be able to provide the patient with the most appropriate medication for their condition. If they have issues with adherence, to provide them with long-acting medication. If they have issues with titration, or with complex regimens, to provide social work or somebody to make sure that they are receiving the appropriate medications. To provide close follow up for those who need it. But, very importantly, to be able to prescribe the medications that you think are most appropriate without having to deal with insurance approval hurdles and other difficulties.

Dr Wong: And Dr Pezalla, you get the last word.

Dr Pezalla: Payers can definitely do more to help out here. They recognize the transitions to care are difficult for patients. So, payers really need to focus on, "Can we support the patient and the physician both at the time that the patient is being discharged from one setting and moving to another setting?" And so, that might mean that they need to revise what their criteria are for case management programs, or something like that, so that someone can work with that patient, at least for a couple of weeks, until things get more settled. And as I said, Medicare advantage plans tend to do this a little bit better, but commercial plans really do need to focus on that. So, that's really something I think that everyone can work on here, but everyone who is a payer can really help to support patients in that. They can also bring to bear their medication therapy management programs, expanding those to include seizure disorders.

Dr Pezalla: Oftentimes they really are much more focused on cardiovascular disease, diabetes, and big things like that in terms of overall cost. But, these are patients who really do need somebody to review things for them. And then, in terms of how difficult it is to get the medication, payers really need to review their prior authorization criteria here. There is no particularly good reason why seizure disorder medicines should be that hard to get. And so, they can streamline those criteria. They can review their prior authorizations and say, "Do I really need this?" Many medications, especially the more specialized ones, are really only going to be written by those physicians who manage these patients on a regular basis. Patients who are neurologists, neuropsych, geriatricians, and others who are very familiar with the medications. They're not overusing them.

Dr Pezalla: And so, I think that a re-look at the clinical policies and the prior authorizations is really warranted for plans that are using a lot of step edits or a lot of prior authorization. We can certainly understand that they would like to see patients on generics, but beyond that, I think that there is definitely some places where there's excess controls, and they should review those policies.

Dr Wong: Thank you. This concludes this installment of PopHealth Perspectives. And thank you, Drs Koubeissi, Pezalla, Vollmer, and Chung, for your time and this informative discussion.