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Up Front | March 2018

Small Bottles…Big Issues

A constant theme throughout my time as a practicing ophthalmologist has been the consternation, frustration, irritation, struggle, and generally poor experience with the process of providing patient access to necessary prescription ophthalmic drops. The burdens and challenges surrounding this aspect of medicine has only worsened over the years, with ever-changing insurance formularies, so-called donut holes, deductibles, and meaningful use and electronic prescribing requirements.

The financial cost and personnel time associated with managing patient access to drops is staggering. We are constantly asked to change our preferred treatment choices and possibly compromise the quality of our patient care under this dysfunctional regime of government, big insurance, and pharma business. There is no question that a growing number of us are desperately looking for a solution to this daily disaster, as it negatively affects our ability to practice good medicine and achieve a healthy office environment for our patients and our staff.

Our allies in the ophthalmic industry have fortunately responded to the call with the recent trend toward innovation in the spaces of microinvasive glaucoma surgery and sustained release pharmacotherapy products and devices. A growing number of both established and startup companies are diligently working on solutions to reduce our patients’ financial and physical obligations to use eye drops in their medical and surgical care.

In cataract surgery, we all recognize the burden that prescribing three separate bottles of drops—all with different regimen timelines, costs, and compliance issues—is to our patients. We also know the cost of explaining drop use to patients, a cost that includes staffing the phones for callbacks, and the effect that such a drop regimen has on the patient’s overall cataract experience. It’s not uncommon for patients to call the office and scream at our staff that their eye drops cost $300 or more. Then we have to call the pharmacy, change the patient to another drop—often a generic—and then change the dosage regimen, provide them with a new schedule, and document the change in the patient’s electronic health record. In large practices, this process can overwhelm the phone room, possibly preventing a new patient from being able to call in and get an appointment. The trickle-down effect on a practice as pharmacy and insurance formulary modifications are made can be disastrous.

Some pharmaceutical companies are doing their best to provide support to our practices with incentives such as patient coupons, special drop access programs, patient hotlines, and product samples. However, these efforts continue to be only a Band-Aid on the globally worsening environment.

Companies such as Imprimis and Ocular Sciences, along with their supportive surgeon clients, are beginning to offer compounded drug formulations as a single-bottle solution for the »antibiotic/steroid/NSAID regimens needed in cataract surgery. Compounded glaucoma drops and cyclosporine are also being sold to practices and patients at significantly reduced costs compared with traditional branded and generic prescription drops. Perhaps this is a viable bridge, while companies such as Icon and Ocular Therapeutix continue their work on implantable sustained delivery devices.

With all this said, every one of us has experienced situations in which one set of problems is traded for another, and the situation we are experiencing now with eye drops and sustained drug delivery is no exception. Will these compounded therapies and implantable products be as safe and effective as our current branded topical products? What are the financial pathways to deliver these new therapies—patient pay or insurance coverage?

As this paradigm of care changes—which seems inevitable at this point—there stand to be big impacts in the pharmaceutical industry. Although there may big upsides for our practices and our patients, with a dwindling need for branded prescription eye drops, the negative impact on big and small pharmaceutical companies must also be considered. It’s well known that the company profits derived from branded pharmaceutical sales are often used to fund new R&D projects, both surgical and pharmaceutical, within those companies. If these profits begin to dry up, will this negatively impact our ophthalmic innovation cycle? In the big picture, will we see fewer novel devices and drugs to help our patients?

Only time will tell as we observe this continued trend toward fewer drops for our patients.

Robert J. Weinstock, MD | Chief Medical Editor

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