Understanding the Opportunities in Dual Therapy and Emergency Department Utilization in Migraine Care.

Background and objectives: Value-based payment (VBP) models require organizations to understand conditions that are contributing to spending and utilization above negotiated targets. Headache was a top 10 reason for an emergency department (ED) visit in 2022. The high utilization continued with more than 2,000 ED visits for migraine in 2023. Nearly all these visits resulted in same-day discharge home, suggesting these may be avoidable. A Payvider council was used to affect medical policy change, and dual therapy for migraine treatment (concurrent use of anti-calcitonin gene-related peptide medications and onabotulinumtoxinA) was approved for coverage in May 2023. This study provides insight into the effect on cost and ED utilization of the medical policy change enabling dual therapy treatment of migraine by comparing cost for pharmacy and ED utilization across monotherapy or dual therapy patient groups.

Methods: Patients with a prescription for 1 (monotherapy) or both (dual therapy) medications of interest with an ED encounter for migraine were reviewed. Based on the medications prescribed, patients were classified as receiving monotherapy or dual therapy for the treatment of migraine. The rates of emergency department utilization, ED utilization costs, and pharmacy costs were compared between the groups. This analysis was extrapolated to the larger migraine population within the organization to understand the cost effect of changing migraine management to the organization.

Results: Three hundred fifty-seven health plan members used the ED posttreatment between January 1, 2023, and December 31, 2023. A significant difference (p = 0.02) in ED utilization was observed between monotherapy (31.9%, n = 93%) and dual therapy (16.7% n = 11%) patients during the study period. No difference was noted between groups in rate of ED use for patients using the ED. Cost savings associated with ED avoidance, approximately $782 per patient between monotherapy and dual therapy, were insufficient to balance the increased pharmacy cost, which was calculated as approximately $7,115.88 annually per patient based on average wholesale price.

Discussion: Dual therapy for migraine had a positive effect on ED visit utilization in our sample while also having cost implications. Health care systems and neurology providers may benefit from this assessment when establishing migraine care, developing data structures, and planning for VBP models.