Division of Ophthalmology, Tel Aviv Sourasky Medical Center (Ichilov), 6 Weizmann Street, Tel Aviv, Israel.
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Isr J Health Policy Res. 2021 Jan 25;10(1):4. doi: 10.1186/s13584-021-00437-1.
High and increasing drug prices have prompted the establishment of a broad range of cost-containment treatment policies in health systems globally. In 2012, the supplemental insurance program of a large Israeli health maintenance organization (Clalit Health Services) introduced a prior authorization process for second-line use of ranibizumab in patients with retinal disease for whom treatment with bevacizumab proved to be ineffective. A Clalit steering committee established authorization criteria based on cost and periodically updated clinical considerations, while a team of ophthalmic specialists evaluated their colleagues' individual patient subsidization requests, based on the funding criteria. The objectives of this study were to detail this unique authorization process and study its effectiveness in limiting unwarranted spending, while allowing for a smooth transition to a second-line more expensive drug when needed.
A retrospective cohort study including all applications for a first or ongoing treatment with ranibizumab, for one or both eyes, received during March 1, 2012 - December 31, 2015. The key parameters examined were percentages of requests from patients treated by first line treatment bevacizumab, requests approved, reapplications, and results. Requests studied include reapplications and requests for treatment continuation.
During the study period, Clalit affiliated ophthalmologists' submitted 16,778 funding applications for intravitreal ranibizumab treatment on behalf of 5642 patients who applied for approximately three applications. An efficient sentinel effect was achieved, resulting in only 31% of patients treated with bevacizumab applying for treatment, while maintaining extremely high accessibility to second line treatment with almost 95% of requests being approved.
The data presented shows a low request rate for funding with a high approval rate, proving this peer reviewed report-based authorization process successfully achieved a sentinel effect while controlling cost. We suggest this innovative model be considered in similar decisions processes.
高企且不断上涨的药价促使全球各国医疗体系制定了广泛的控费治疗政策。2012 年，以色列大型医疗保险机构（Clalit 健康服务公司）的补充保险计划对视网膜疾病患者引入了雷珠单抗二线治疗的事先授权程序，这些患者在使用贝伐单抗治疗无效。Clalit 指导委员会根据成本制定了授权标准，并定期更新临床考虑因素，而一组眼科专家则根据资助标准评估他们同事的个别患者补贴申请。本研究的目的是详细介绍这一独特的授权程序，并研究其在限制不必要支出方面的有效性，同时在需要时为二线更昂贵的药物顺利过渡提供便利。
本研究采用回顾性队列研究，纳入 2012 年 3 月 1 日至 2015 年 12 月 31 日期间所有接受雷珠单抗一线或持续治疗（单眼或双眼）的申请。研究的关键参数包括：来自接受一线治疗贝伐单抗的患者的申请比例、批准的申请、再申请和结果。研究申请包括再申请和治疗延续的申请。
在研究期间，Clalit 附属眼科医生代表 5642 名患者提交了 16778 份雷珠单抗玻璃体内治疗的资金申请，每位患者申请了大约 3 次。实现了有效的警戒效应，仅有 31%接受贝伐单抗治疗的患者申请治疗，同时保持了极高的二线治疗可及性，几乎 95%的申请获得批准。
提交的申请资金请求率低而批准率高，证明这种基于同行评议报告的授权程序成功地实现了警戒效应，同时控制了成本。我们建议在类似的决策过程中考虑这种创新模式。
