Aetna creating new system for managing migraines

In the latest effort by a major insurer to use disease management to stem the costs of treating a chronic condition, Aetna is reaching out to migraine patients and their doctors.

The Hartford, Conn.-based insurer this summer launched a migraine management program that distributes written materials on the causes and treatment of headaches to both patients and physicians, asking them to work together to identify pain triggers. Aetna says it spends about $70 million a year to treat migraines.

Aetna is encouraging doctors to consider less costly medication alternatives, particularly preventive drugs, and to think twice about ordering brain imaging tests, which Aetna says usually provide little useful information about headache causes.

Aetna invited into the new program 2,500 patients who, based on claims data, appeared to be failing to get chronic headaches treated effectively, said Mark Rubino, chief pharmacy officer at the health plan. This represents a small portion of the 80,000 members that Aetna believes get migraines regularly.

"The idea is, let's try to prevent the episode," Rubino said. "Let's try to get them to use medications [for acute attacks] as infrequently as possible."

Patients opting into Aetna's program are sent a headache diary in which symptoms, medication use, therapy response and side effects are to be recorded for three months.

The program is the latest disease management initiative at Aetna, which also has programs for patients with asthma, coronary artery disease, congestive heart failure, diabetes, end-stage renal disease and lower back pain. Aetna and other major managed care firms have rolled out these programs to save money by pinpointing chronic users of health care services, supplying them with information on illnesses and in many cases offering regular contact with a specialized case manager by telephone. The migraine program does not now use case managers, Rubino said.

Aetna is hoping to save money over the long haul by paying for fewer brain scans and emergency visits and cutting the use of triptans -- drugs that treat acute migraine attacks and which can be relatively expensive.

Seymour Diamond, MD, director of the Diamond Headache Clinic in Chicago, said he likes elements of Aetna's programs, such as encouraging patients to keep a migraine diary. Tapping claims data to try to identify patients whose migraine treatment has apparently failed also is reasonable, he said. But Dr. Diamond said Aetna should go no further and not actually restrict the prescribing of triptans when needed.

"For most moderate and severe attacks, the triptans have been wonderful adjunctive drugs," he said. "They've been miracle drugs for these people."

Aetna might not find that doctors welcome efforts to teach them, or patients, about migraine drug options, said David Kudrow, MD, a neurologist with the California Medical Clinic for Headache in Santa Monica, Calif. "I'm a little bit put off that an insurance company might suggest I'm not making the right decisions for my patients," he said. "They're not doctors, and I don't like the idea that non-physicians are trying to make health care decisions. It's getting in between the doctor and the patient."

In addition to directly contacting patients, Aetna is sending their doctors utilization review reports that delineate patients' past care for headaches.

Some doctors are not prescribing preventive medicines for migraine patients, including beta blockers, antidepressants and anti-seizure drugs, when they might help, Rubino said. "They're not always effective, but it's something that should be considered," he said.

Aetna also is asking doctors to consider telling patients to try less costly, nonprescription drug alternatives such as aspirin, naproxen sodium, ibuprofen and combination products containing aspirin, acetaminophen and caffeine for treatment of acute migraine attacks.