For the first time, managed care organizations are attempting to understand ophthalmologic diseases, particularly glaucoma. Their interest is driven by the appearance in recent years of several new pharmaceutical products to treat glaucoma. These new pharmacotherapeutic classes, including the prostaglandins and alpha2 agonists, are improving quality of life for people with glaucoma — preserving vision and halting progression of the disease more effectively than older products. Their efficacy has created demand for them and, in turn, a need for appropriate criteria for their utilization.
It wasn’t always this way. For years, glaucoma floated beneath the radar screens of most MCOs. The reason? Until recently, glaucoma was not a cost center. Medical directors’ agendas tend to be shaped by cost and utilization drivers that affect the bottom line: pharmacy, injectables, office visits, hospitalization, and emergency care. Most pharmacy directors will acknowledge that they actively monitor utilization of only the top 10 classes of drugs, including antihistamines, antidepressants, and antihypertensives. Traditionally, ophthalmologic agents rarely made the top 20, meaning that pharmacy directors weren’t overly concerned about them being significant contributors to expenses.
All the while, glaucoma continued its insidious assault on more than 2 million people, particularly the elderly, black, and Hispanic populations (NEI 2002). The second-leading cause of blindness in the United States, glaucoma is primarily associated with elevated intraocular pressure (IOP).Over time, IOP damages the optic nerve — destroying, at first, peripheral and then central vision — often silently, going unnoticed until its late stages. IOP can be controlled with medication, and, as the Ocular Hypertension Treatment Study demonstrates, early detection and treatment can prevent or delay onset of primary open-angle glaucoma, the most common form of the disease (Kass 2002).Argon laser trabeculoplasty , which aids fluid drainage from the eye and thus reduces IOP, is generally indicated after medications have been tried. End-stage glaucoma is often treated with conventional surgery after medication and laser-treatment failures.
The turning point in treatment — and what gained the attention of health plans and their pharmacy and therapeutics committees — was the development of powerful new medication therapies. Specifically, two things occurred. First, the introduction of popular new prostaglandin and alpha2 agonist products abruptly brought about higher utilization, while their expense relative to older therapies produced a new cost driver in managed care organizations. Second, the recent appearance of competitive products within these drug classes offered patients, health plans, and physicians new treatment options. Suddenly, there were choices to be made. Health plans will need assistance in dealing with these formulary options.
