Multiple Sclerosis for the Employee Benefits Professional

This video, presented by Dr. Eric Bricker of AHealthcareZ, provides a detailed explanation of Multiple Sclerosis (MS) specifically tailored for employee benefits professionals. Its primary purpose is to educate this audience on the nature of MS, its prevalence, the significant financial and personal impact it has on individuals and health plans, and the crucial role of comprehensive support systems. Dr. Bricker emphasizes that understanding MS goes beyond just its medical definition, delving into the complex biopsychosocial challenges faced by patients and their families.

The presentation begins by defining Multiple Sclerosis as an autoimmune disease where the body's immune system attacks the brain and spinal cord, specifically targeting the myelin sheath around neurons. This damage disrupts electrical impulses, leading to varied neurological symptoms such as weakness, numbness, muscle spasticity, bladder problems, visual disturbances, and even temporary blindness. The disease often manifests in a "relapsing and remitting" pattern, with periods of symptom flares followed by quiet phases. Dr. Bricker highlights the prevalence of MS, noting that approximately 914,000 Americans live with the condition, translating to about 1 in every 286 adults, with initial diagnoses typically occurring between ages 20 and 40. He illustrates this with a practical example: an employer-sponsored health plan with 1,000 adult members would statistically have about three individuals with MS.

A significant portion of the video is dedicated to the financial implications and treatment modalities for MS. Inpatient hospitalizations for severe flares, often involving IV steroids or plasmapheresis (a blood purification procedure), can range from $10,000 to over $100,000 per stay. For long-term management, various outpatient medications are available, including IV infusions, injections, and pills designed to minimize relapses. Dr. Bricker specifically mentions Gilenya and Tecfidera as common oral medications. He details the high cost of these specialty drugs, citing Gilenya at roughly $9,500 per month without insurance, and explains how manufacturer copay assistance programs (e.g., covering up to $18,000 in out-of-pocket costs) can reduce patient burden but still leave the health plan responsible for substantial costs (e.g., $48,000 annually for Gilenya after a typical 20% co-insurance). He also notes that Tecfidera now has a generic equivalent (dimethyl fumarate) at a significantly lower cost of about $640 per month.

Beyond the disease-modifying therapies, the video underscores that MS patients frequently require a host of additional medications and services to manage co-occurring conditions and symptoms. These include treatments for bladder issues, depression (which is highly prevalent among MS patients), pain, fatigue, and muscle spasticity. Physical therapy is also a common and often ongoing need, frequently exceeding typical plan limits of 16 visits per year. Dr. Bricker emphasizes the "biopsychosocial model of disease," explaining that MS profoundly impacts not only the individual's physical health but also their family, work, income, and mental well-being. He concludes by stressing the critical need for employee benefits professionals to utilize data analytics (e.g., ICD-10 codes) to identify plan members with MS and ensure they receive consistent, high-quality case management, nursing support, and healthcare navigation with frequent interactions, advocating for a "friend-like" level of support due to the complexity of the condition.

Key Takeaways:

• Prevalence and Demographics of MS: Multiple Sclerosis affects approximately 914,000 adults in the U.S., or 1 in every 286 adults, with initial diagnosis most common between the ages of 20 and 40. This means most large employer health plans will have members living with MS.
• Nature of MS and Symptoms: MS is an autoimmune disease attacking the brain and spinal cord's myelin sheath, leading to a wide range of neurological symptoms including weakness, numbness, visual problems, muscle spasticity, and bladder issues, often in a relapsing-remitting pattern.
• High Costs of Inpatient Care: Hospitalizations for MS flares, involving treatments like IV steroids or plasmapheresis, can incur significant costs ranging from $10,000 to over $100,000, depending on the severity and duration of the stay.
• Expensive Outpatient Medications: Disease-modifying therapies (DMTs) for MS, particularly specialty pharmaceuticals like Gilenya (brand-only), are extremely costly, with Gilenya priced around $9,500 per month without PBM negotiation.
• Impact of Copay Assistance Programs: While manufacturer copay assistance programs can significantly reduce patients' out-of-pocket expenses (e.g., up to $18,000), they shift the majority of the drug cost burden directly onto the health plan, which can still pay tens of thousands annually per patient.
• Generic Options and Cost Savings: The availability of generic equivalents, such as dimethyl fumarate for Tecfidera, offers substantial cost savings, being approximately one-eighth the cost of brand-name alternatives.
• Multifaceted Treatment Needs: MS patients often require a comprehensive treatment approach beyond DMTs, including medications for co-morbidities like depression, pain, bladder dysfunction, and muscle spasticity, as well as ongoing physical therapy that may exceed standard plan limits.
• Biopsychosocial Impact: MS is a complex condition with profound biopsychosocial implications, affecting not only the patient's physical health but also their mental well-being, family dynamics, ability to work, and financial stability.
• Importance of Case Management and Navigation: Due to the complexity of MS and its treatment, robust and frequent case management, nursing support, and healthcare navigation are crucial for patients and their families to ensure adherence, manage symptoms, and coordinate care.
• Data-Driven Patient Identification: Employee benefits professionals (and by extension, pharmaceutical companies) should leverage data analytics, specifically ICD-10 codes, to identify plan members with MS and proactively offer tailored support and resources.
• Managing Medication Side Effects: The numerous medications taken by MS patients often come with their own side effects, requiring careful management in addition to treating the underlying disease.
• Need for Continuous Support: The chronic and relapsing nature of MS necessitates ongoing, personalized support and advocacy, rather than episodic interventions, to help patients navigate their complex medical journey.

Tools/Resources Mentioned:

• LinkedIn (for video requests)
• Mayo Clinic (mayoclinic.org) - Source for MS symptoms/causes
• HealthWarehouse.com - Source for Tecfidera pricing
• PharmacyChecker.com - Source for Gilenya pricing
• National MS Society (nationalmssociety.org) - Sources for MS medications and prevalence data
• "16 Lessons in the Business of Healing" by Dr. Bricker (book)

Key Concepts:

• Autoimmune Disease: A condition in which the body's immune system mistakenly attacks its own healthy tissues.
• Myelin Sheath: The insulating layer around nerves, including those in the brain and spinal cord, that allows electrical impulses to transmit quickly and efficiently. Damage to this is central to MS.
• Relapsing-Remitting MS: The most common form of MS, characterized by clearly defined attacks (relapses) of new or increasing neurological symptoms, followed by periods of partial or complete recovery (remissions).
• Plasmapheresis: A medical procedure that involves removing blood plasma, separating it from blood cells, and replacing it with a substitute fluid (like albumin) before returning the blood cells to the body. Used to remove antibodies in autoimmune diseases.
• Corticosteroids: A class of steroid hormones used to reduce inflammation and suppress the immune system.
• Specialty Pharmacy: A pharmacy that dispenses high-cost, high-touch, and often complex medications for chronic or rare conditions.
• Copay Assistance Program: Programs offered by pharmaceutical manufacturers to help patients afford their medications by covering a portion of their out-of-pocket costs (e.g., co-pays, co-insurance).
• PBM (Pharmacy Benefit Manager): A third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, and other government-sponsored programs. They negotiate drug prices.
• Biopsychosocial Model of Disease: A framework that recognizes the interconnectedness of biological, psychological, and social factors in understanding health, illness, and healthcare delivery.
• ICD-10 Codes: International Classification of Diseases, 10th Revision, a standardized system used to classify diseases and health problems for clinical and administrative purposes, including identifying patient populations.
• Case Management/Healthcare Navigation: Services that help patients coordinate their care, understand their treatment plans, access resources, and navigate the complex healthcare system.

Examples/Case Studies:

• Prevalence Example: A statistically average employer-sponsored health plan with 1,000 adults would have approximately 3 members with MS.
• Patient Case: A 19-year-old gentleman presenting with sudden weakness in one hand, illustrating a classic initial presentation of MS.
• Drug Cost Examples: Gilenya (brand-only) costing ~$9,500/month; Tecfidera (with generic dimethyl fumarate) costing ~$640/month.
• Copay Assistance Scenario: A patient with 20% co-insurance on a $5,000 PBM-negotiated drug price would owe $1,000/month, totaling $12,000/year, which could be covered by an $18,000 copay assistance program, leaving the plan to pay $48,000/year.