1
|
Abadir A, Troia A, Said H, Tarugu S, Billingsley BC, Sairam N, Minchenberg SB, Owings AH, Parker AM, Brousse B, Carlyle A, Owens BR, Hosseini-Carroll P, Galeas-Pena M, Frasca J, Glover SC, Papamichael K, Cheifetz AS. Factors Associated with Delays in Initiating Biologic Therapy in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2024:10.1007/s10620-024-08514-6. [PMID: 38963462 DOI: 10.1007/s10620-024-08514-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/29/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION Expeditious initiation of biologic therapy is important in patients with inflammatory bowel disease (IBD). However, initiation of biologics in the outpatient setting may be delayed by various clinical, social, and financial variables. AIM To evaluate the delay in initiation of an advanced therapy in IBD and to identify factors that contributed to this delay. METHODS This was a multi-center retrospective study. Outpatients who were initiated on a biologic therapy from 3/1/2019 to 9/30/20 were eligible for the study. Univariate and multivariate linear regression analyses were performed to identify variables associated with a delay in biologic treatment initiation. Delay was defined as the days from decision date (prescription placement) to first infusion or delivery of medication. RESULTS In total 411 patients (Crohn's disease, n = 276; ulcerative colitis, n = 129) were included in the analysis. The median [interquartile range-(IQR)] delay for all drugs was 20 [12-37] days (infliximab, 19 [13-33] days; adalimumab, 10 [5-26] days; vedolizumab, 21 [14-42] days; and ustekinumab, 21 [14-42] days). Multivariate linear regression analysis identified that the most important variables associated with delays in biologic treatment initiation was self-identification as Black, longer distance from treatment site, and lack of initial insurance coverage approval. CONCLUSION There may be a significant delay in biologic treatment initiation in patients with IBD. The most important variables associated with this delay included self-identification as Black, longer distance from site, and lack of initial insurance coverage approval.
Collapse
Affiliation(s)
- Alexander Abadir
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Angela Troia
- University of Vermont Medical Center, Burlington, VT, USA
| | - Hyder Said
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Spurthi Tarugu
- University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Nathan Sairam
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Scott B Minchenberg
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Anna H Owings
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Adam M Parker
- University of Mississippi Medical Center, Jackson, MS, USA
| | | | | | - Bobby R Owens
- University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Michelle Galeas-Pena
- Department of Medicine, Section of Gastroenterology and Hepatology, Tulane University, New Orleans, LA, USA
| | - Joseph Frasca
- University of Vermont Medical Center, Burlington, VT, USA
- Center for Crohn's and Colitis, Division of Digestive Diseases, Rush University Medical Center, Chicago, IL, USA
| | - Sarah C Glover
- University of Mississippi Medical Center, Jackson, MS, USA
- Department of Medicine, Section of Gastroenterology and Hepatology, Tulane University, New Orleans, LA, USA
| | - Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA, 02215, USA.
| | - Adam S Cheifetz
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA, 02215, USA
| |
Collapse
|
2
|
Allegretti JR, Bordeianou LG, Damas OM, Eisenstein S, Greywoode R, Minar P, Singh S, Harmon S, Lisansky E, Malone-King M, Litwin NS, Weaver A, Heller CA, Moss AC, Adler J. Challenges in IBD Research 2024: Pragmatic Clinical Research. Inflamm Bowel Dis 2024; 30:S55-S66. [PMID: 38778623 DOI: 10.1093/ibd/izae083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Indexed: 05/25/2024]
Abstract
Pragmatic clinical research is 1 of the 5 focus areas of the Challenges in IBD Research 2024, a multidisciplinary effort by scientists, clinicians, patients, and funders to identify priorities for patient-centric research. This summary provides a comprehensive overview of current gaps in inflammatory bowel disease (IBD) clinical research and actionable approaches to address them. This review is focused on identifying research that is needed to achieve the best outcomes for patients in clinical practice. Research gaps include understanding the needs of understudied patient groups and addressing barriers to care so all patients receive optimal care, validating and using biomarkers to enable early diagnosis and result in better outcomes for adults and children with IBD, and determining the optimal sequencing of treatments (medical, surgical, adjunct) in children and adults. Inclusive pragmatic research is needed to address these gaps and lead to improvements in patient care and outcomes for all populations of patients with IBD.
Collapse
Affiliation(s)
- Jessica R Allegretti
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Liliana G Bordeianou
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Oriana M Damas
- Division of Gastroenterology, Department of Medicine, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
| | - Samuel Eisenstein
- Division of Colon and Rectal Surgery, Department of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Ruby Greywoode
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Phillip Minar
- Division of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Sabrina Harmon
- Division of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene Lisansky
- Patient representative for Crohn's & Colitis Foundation, New York, NY, USA
| | - Myisha Malone-King
- Division of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | - Alan C Moss
- Crohn's & Colitis Foundation, New York, NY, USA
| | - Jeremy Adler
- Susan B. Meister Child Health Evaluation and Research Center and Division of Pediatric Gastroenterology, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| |
Collapse
|
3
|
Constant BD, Long MD, Scott FI, Higgins PDR. Insurer-Mandated Medication Utilization Barriers are Associated With Decreased Insurance Satisfaction and Adverse Clinical Outcomes: An Inflammatory Bowel Disease Partners Survey. Am J Gastroenterol 2024:00000434-990000000-01152. [PMID: 38819004 DOI: 10.14309/ajg.0000000000002851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/04/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Insurer-mandated barriers to timely initiation of advanced therapies used to treat inflammatory bowel disease (IBD) have been shown to worsen clinical outcomes and increase healthcare utilization, yet rarely alter the medication ultimately prescribed. METHODS We conducted a survey within the IBD Partners longitudinal cohort to evaluate the frequency and patient-reported impacts of medication utilization barriers on insurance satisfaction and clinical outcomes. Barriers included medication denials, prior authorizations, and forced medication switches. Variables associated with insurance satisfaction, measured on a 1-7 Likert scale, were identified. The association between insurance-related barriers and downstream clinical outcomes (surgery, corticosteroid requirement, and disease activity) were evaluated. RESULTS Two thousand seventeen patients (age 45 [interquartile range 34-58] years, 73% female) were included. Seventy-two percent experienced an insurer-mandated barrier, most commonly prior authorizations (51%). Fifteen percent were denied an IBD medication by their insurer, 22% experienced an insurance-related gap in therapy, and 8% were forced by their insurer to switch from an effective medication. Insurance satisfaction was negatively associated with medication denials, prior authorization-related delays, gaps in therapy, and high-deductible health plan coverage. In the year following the initial survey, several insurance barriers were linked to negative downstream clinical outcomes, including prior authorizations associated with corticosteroid rescue (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.25-4.00), forced medication switches associated with continued disease activity (OR 3.28, 95% CI 1.56-6.89), and medication denials associated with IBD-related surgery (OR 8.92, 95% CI 1.97-40.39). DISCUSSION These data illustrate the frequency and negative impacts of insurer-mandated medication barriers on patients with IBD, including decreased insurance satisfaction and negative downstream clinical outcomes.
Collapse
Affiliation(s)
- Brad D Constant
- Department of Pediatrics, University of Colorado School of Medicine, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Millie D Long
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Frank I Scott
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Peter D R Higgins
- Department of Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
4
|
Sofia MA, Feuerstein JD, Narramore L, Chachu KA, Streett S. White Paper: American Gastroenterological Association Position Statement: The Future of IBD Care in the United States-Removing Barriers and Embracing Opportunities. Clin Gastroenterol Hepatol 2024; 22:944-955. [PMID: 38428707 DOI: 10.1016/j.cgh.2024.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/14/2023] [Accepted: 01/15/2024] [Indexed: 03/03/2024]
Abstract
Despite incredible growth in systems of care and rapidly expanding therapeutic options for people with inflammatory bowel disease, there are significant barriers that prevent patients from benefiting from these advances. These barriers include restrictions in the form of prior authorization, step therapy, and prescription drug coverage. Furthermore, inadequate use of multidisciplinary care and inflammatory bowel disease specialists limits patient access to high-quality care, particularly for medically vulnerable populations. However, there are opportunities to improve access to high-quality, patient-centered care. This position statement outlines the policy and advocacy goals that the American Gastroenterological Association will prioritize for collaborative efforts with patients, providers, and payors.
Collapse
Affiliation(s)
- M Anthony Sofia
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland Oregon.
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Leslie Narramore
- American Gastroenterological Association, Government Affairs Department, Bethesda, Maryland
| | - Karen A Chachu
- Division of Gastroenterology, Department of Medicine, Duke University, Durham, North Carolina
| | - Sarah Streett
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California
| |
Collapse
|
5
|
Imam N, Zaifman JM, Bassora R, Cherian C, Kohan EM, Alberta FG, Koerner JD. Nearly All Peer-to-Peer Reviews for CT and MRI Prior Authorization Denials for Orthopedic Specialists Are Approved. Orthopedics 2024; 47:141-146. [PMID: 37921528 DOI: 10.3928/01477447-20231027-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
In the event of prior authorization denial, physicians may request peer-to-peer review, which may delay treatment and increase administrative burden. The purpose of this study was to quantify the approval rate of peer-to-peer review and evaluate its efficiency in the context of advanced imaging use in an orthopedic practice. Patients at a single outpatient orthopedic clinic initially receiving an insurance denial for computed tomography or magnetic resonance imaging requiring peer-to-peer review from March to December 2022 were prospectively enrolled. Characteristics of the request, peer-to-peer review, and the reviewer and dates in the process were collected. If the study was approved after peer-to-peer review, the date of the imaging study and brief results were recorded. A total of 62 denials were included. One denial was approved prior to peer-to-peer review. Fifty-eight (of 61, 95.1%) reviews were approved, of which 51 (of 58, 87.9%) studies were completed by patients. Reviewers were always physicians (61 of 61, 100%), but of those whose specialty was known, none were orthopedic surgeons. Forty-four of 61 (72.1%) reviewers reported reviewing clinical notes in advance. The median number of days from visit to peer-to-peer review was 9.0 (interquartile range, 7.0-13.25). The median number of days from visit to imaging center appointment was 13.5 (interquartile range, 9.0-20.75) for approved studies. Of the 51 approved studies completed by patients, the results of 38 (74.5%) confirmed the suspected diagnosis. In an orthopedic specialty practice, almost all peer-to-peer reviews were approved, with the majority of the completed studies confirming the suspected diagnosis. Thus, patient care was delayed. Reform is crucial to improve the efficiency of the review process, especially in light of additional administrative and financial burden. [Orthopedics. 2024;47(3):141-146.].
Collapse
|
6
|
Harish KB, Chervonski E, Speranza G, Maldonado TS, Garg K, Sadek M, Rockman CB, Jacobowitz GR, Berland TL. Prior authorization requirements in the office-based laboratory setting are administratively inefficient and threaten timeliness of care. J Vasc Surg 2024; 79:1195-1203. [PMID: 38135169 DOI: 10.1016/j.jvs.2023.10.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/12/2023] [Accepted: 10/30/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the administrative and clinical impacts of prior authorization (PA) processes in the office-based laboratory (OBL) setting. METHODS This single-institution, retrospective analysis studied all OBL PAs pursued between January 2018 and March 2022. Case, PA, and coding information was obtained from the practice's scheduling database. RESULTS Over the study period, 1854 OBL cases were scheduled; 8% (n = 146) required PA. Of these, 75% (n = 110) were for lower extremity arterial interventions, 19% (n = 27) were for deep venous interventions, and 6% (n = 9) were for other interventions. Of 146 PAs, 19% (n = 27) were initially denied but 74.1% (n = 7) of these were overturned on appeal. Deep venous procedures were initially denied, at 43.8% (n = 14), more often than were arterial procedures, at 11.8% (n = 13). Of 146 requested procedures, 4% (n = 6) were delayed due to pending PA determination by a mean 14.2 ± 18.3 working days. An additional 6% (n = 8) of procedures were performed in the interest of time before final determination. Of the seven terminally denied procedures, 57% (n = 4) were performed at cost to the practice based on clinical judgment. CONCLUSIONS Using PA appeals mechanisms, while administratively onerous, resulted in the overturning of most initial denials.
Collapse
Affiliation(s)
| | | | | | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Caron B Rockman
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Todd L Berland
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY.
| |
Collapse
|
7
|
Gadepalli SK, Adler J. Perianal disease: Updates and controversies in closing the gaps. Semin Pediatr Surg 2024; 33:151402. [PMID: 38603820 DOI: 10.1016/j.sempedsurg.2024.151402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Perianal complications are common and morbid in children with Crohn's disease. In this review, we describe the epidemiology, the presentation and diagnosis, evaluation and management. We focus on updates such as the increasing frequency of biologic medications and MRI for evaluation. We also highlight controversies on the timing and approaches to surgical techniques. Finally, perianal disease requires the coordination of multidisciplinary care with nursing, radiology, gastroenterology, and surgery to optimize outcomes - both medical and patient-centered.
Collapse
Affiliation(s)
- Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States; Susan G. Meister CHEAR Center, University of Michigan, Ann Arbor, MI, United States.
| | - Jeremy Adler
- Susan G. Meister CHEAR Center, University of Michigan, Ann Arbor, MI, United States; Division of Pediatric Gastroenterology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, United States
| |
Collapse
|
8
|
Gupta R, Fein J, Newhouse JP, Schwartz AL. Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage. BMJ 2024; 384:e077797. [PMID: 38453187 PMCID: PMC10919211 DOI: 10.1136/bmj-2023-077797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To measure and compare the scope of US insurers' policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences in PA across insurers, physician specialties, and clinical service categories. DESIGN Cross sectional analysis. SETTING PA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B. PARTICIPANTS 30 540 086 beneficiaries in traditional Medicare Part B. MAIN OUTCOME MEASURES Proportions of government administered traditional Medicare Part B spending and utilization that would have required PA according to Medicare Advantage insurer rules. RESULTS The insurers required PA for 944 to 2971 of the 14 130 clinical services (median 1899; weighted mean 1429) constituting 17% to 33% of Part B spending (median 28%; weighted mean 23%) and 9% to 41% of Part B utilization (median 22%; weighted mean 18%). 40% of spending ($57bn; £45bn; €53bn) and 48% of service utilization would have required PA by at least one insurer; 12% of spending and 6% of utilization would have required PA by all insurers. 93% of Part B medication spending, or 74% of medication use, would have required PA by at least one Medicare Advantage insurer. For all Medicare Advantage insurers, hematology and oncology drugs represented the largest proportion of PA spending (range 27-34%; median 33%; weighted mean 30%). PA rates varied widely across specialties. CONCLUSION PA policies varied substantially across private insurers in the US. Despite limited consensus, all insurers required PA extensively, particularly for physician administered medications. These findings indicate substantial differences in coverage policies between government administered and privately administered Medicare. The results may inform ongoing efforts to focus PA more effectively on low value services and reduce administrative burdens for clinicians and patients.
Collapse
Affiliation(s)
- Ravi Gupta
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Jay Fein
- Medidata Solutions, New York, NY, USA
| | - Joseph P Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Kennedy School, Cambridge, MA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Aaron L Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
| |
Collapse
|
9
|
Whitmire N, Schlueter M, Kirkpatrick M. Advanced Therapies for Inflammatory Bowel Disease: Navigating Payor and Financial Challenges. Curr Gastroenterol Rep 2024; 26:68-76. [PMID: 38243152 PMCID: PMC10937800 DOI: 10.1007/s11894-024-00916-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2024] [Indexed: 01/21/2024]
Abstract
PURPOSE OF REVIEW In the United Sates the cost of managing Crohn's disease and ulcerative colitis, the two most common inflammatory bowel diseases, is a major factor that can alter the course of treatment. The increasing use of advanced therapies such as biologics and oral small molecules is a driver of these costs. Many IBD providers find navigating the payor and non-insurance cost assistance processes to be a significant challenge in care management. We aim to clarify these processes and provide an outline for success. RECENT FINDINGS Insurance companies use various processes to manage medication costs and while they may not ultimately be cost-effective, the processes have continued and are increasingly complex. This complexity has led to measurable delays in care and negative outcomes. With a deeper understanding of payor and non-insurance cost-assistance processes we have developed a workflow for navigating the use of advanced therapies in the treatment of IBD.
Collapse
Affiliation(s)
- Natalie Whitmire
- Division of Gastroenterology, UC San Diego Health, 9350 Campus Pt Dr Ste 2B, La Jolla, CA, 92037, USA.
| | - Michelle Schlueter
- Division of Gastroenterology, UC San Diego Health, 9350 Campus Pt Dr Ste 2B, La Jolla, CA, 92037, USA
| | - Melissa Kirkpatrick
- Division of Gastroenterology, UC San Diego Health, 9350 Campus Pt Dr Ste 2B, La Jolla, CA, 92037, USA
| |
Collapse
|
10
|
Constant BD, Albenberg L, Mitchel EB, De Zoeten EF, Clapp JT, Scott FI. Prior Authorizations Delay Therapy, Impact Decision-making, and Lead to Adverse Events in Inflammatory Bowel Disease: 2022 Provider Survey. Clin Gastroenterol Hepatol 2024; 22:423-426. [PMID: 37394025 DOI: 10.1016/j.cgh.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/12/2023] [Accepted: 06/21/2023] [Indexed: 07/04/2023]
Affiliation(s)
- Brad D Constant
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Lindsey Albenberg
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elana B Mitchel
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Edwin F De Zoeten
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Colorado Anschutz School of Medicine, Children's Hospital Colorado, Digestive Health Institute, Aurora, Colorado
| | - Justin T Clapp
- Department of Anesthesiology and Critical Care, Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Frank I Scott
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| |
Collapse
|
11
|
Marcus BS, Bansal N, Saef J, Fink C, Patel A, Shaffer KD, Mayer JE, Johnson JN, Shaffer K, Chowdhury D. Burden with No Benefit: Prior Authorization in Congenital Cardiology. Pediatr Cardiol 2024; 45:100-106. [PMID: 37750969 PMCID: PMC10776488 DOI: 10.1007/s00246-023-03255-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/25/2023] [Indexed: 09/27/2023]
Abstract
Prior authorization is a process that health insurance companies use to determine if a patient's health insurance will cover certain medical treatments, procedures, or medications. Prior authorization requests are common in adult congenital and pediatric cardiology (ACPC) due to need for advanced diagnostics, complex procedures, disease-specific medications, and the heterogeneity of the ACPC population. Prior authorizations in ACPC are rarely denied, but nonetheless, they are often accompanied by significant administrative burden on clinical care teams and delays in patient care. Prior authorizations have been implicated in worsening care inequities. The prior authorization process is insurer specific with differences between commercial and public insurers. Prior authorization rejections were previously found to be more common for women, racial minorities, those with low education, and in low-income groups. Prior authorization unduly burdens routine diagnostics, routine interventional and surgical procedures, and routine cardiac specific medication use in the ACPC population. This manuscript highlights the burdens of prior authorization and advocates for the elimination of prior authorization for ACPC patients.
Collapse
Affiliation(s)
- Brian S Marcus
- Pediatric Cardiology, Yale School of Medicine, 205 Church Street, New Haven, CT, USA.
- Pediatric Critical Care, The Medical College of Wisconsin, Milwaukee, United States.
| | - Neha Bansal
- Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, New York, NY, USA
| | - Joshua Saef
- Philadelphia Adult Congenital Heart Center, University of Pennsylvania, Philadelphia, PA, USA
- Heart Institute, Joe DiMaggio Childrens Hospital, Hollywood, Florida, USA
| | - Christina Fink
- Childrens Institute Department of Heart, Vascular & Thoracic, Division of Cardiology & Cardiovascular Medicine, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Angira Patel
- Ann & Robert H. Lurie Childrens Hospital, Chicago, IL, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katherine D Shaffer
- Texas Tech University Health Sciences Center, Jerry H. Hodge School of Pharmacy, Abilene, TX, USA
| | - John E Mayer
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kenneth Shaffer
- Dell Medical School, University of Texas, Austin, TX, USA
- Pediatric and Congenital Cardiology Associates / Pediatrix Cardiology, Austin, TX, USA
| | - Devyani Chowdhury
- Nemours Cardiac Center, Wilmington, DE, USA
- Cardiology Care for Children, Lancaster, PA, USA
| |
Collapse
|
12
|
Mizell R. The Impact of Insurance Restrictions in Newly Diagnosed Individuals With Multiple Sclerosis. Int J MS Care 2024; 26:17-21. [PMID: 38213675 PMCID: PMC10779716 DOI: 10.7224/1537-2073.2022-069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND The medical system in the United States has been riddled with insurance restrictions used by insurance companies to limit health care costs. The effects of insurance restrictions on patients receiving disease-modifying therapies for multiple sclerosis (MS) have not been specifically studied. METHODS A retrospective cross-sectional study of 52 individuals recently diagnosed with MS at a tertiary neurology clinic was conducted to measure the association between prior authorization (PA) duration and other variables of interest. The Cox proportional hazards model was used to determine likelihood of approval. Further analysis included multivariable logistic regression to assess the influence of variables of interest on the initial decision from the insurance company and the effect of the PA on disease activity. RESULTS Of 52 PAs, 50% were initially denied. An initial denial decreased the likelihood of approval by 98% (HR, 0.02; 95% CI, <0.01-0.09; P < .001). The odds of denial for oral medications (odds ratio [OR], 4.91; 95% CI, 1.33-21.52; P = .02) and infusions (OR, 8.35; 95% CI, 1.10-88.77; P = .05) were significantly higher than for injections. Medicaid had higher odds of denial compared with commercial insurance (OR, 4.51; 95% CI, 1.13-22.01; P = .04). An initial denial by insurance significantly increased the likelihood of disease activity (OR, 6.18; 95% CI, 1.33-44.86; P = .03). CONCLUSIONS Insurance restrictions delay necessary treatments, increase the likelihood of disease activity, and rarely change the approved disease-modifying therapy. Reducing PAs may lead to improved outcomes for patients with MS.
Collapse
Affiliation(s)
- Ryan Mizell
- From AdventHealth Neurology, Orlando, FL, USA
| |
Collapse
|
13
|
Shah NB, Zuckerman AD, Hosteng KR, Fann J, DeClercq J, Choi L, Cherry L, Schwartz DA, Horst S. Insurance Approval Delay of Biologic Therapy Dose Escalation Associated with Disease Activity in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2023; 68:4331-4338. [PMID: 37725192 DOI: 10.1007/s10620-023-08098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 08/26/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Dose escalation of self-injectable biologic therapy for inflammatory bowel diseases may be required to counteract loss of response and/or low drug levels. Payors often require completion of a prior authorization (PA), which is a complex approval pathway before providing coverage. If the initial PA request is denied, clinic staff must complete a time and resource-intensive process to obtain medication approval. AIMS This study measured time from decision to dose escalate to insurance approval and evaluated impact of approval time on disease activity. METHODS This was a single-center retrospective analysis of adult patients with IBD prescribed an escalated dose of biologic therapy at an academic center with an integrated specialty pharmacy team from January to December 2018. Outcomes included time to insurance approval and the association between approval time and follow-up C-reactive protein (CRP) and Short Inflammatory Bowel Disease Questionnaire (SIBDQ) scores. Associations were tested using linear regression analyses. RESULTS 220 patients were included, median age 39, 53% female, and 96% white. Overall median time from decision to dose escalate to insurance approval was 7 days [interquartile range (IQR) 1, 14]. Approval time was delayed when an appeal was required [median of 29 days (IQR 17, 43)]. Patients with a longer time to insurance approval were less likely to have CRP improvement (p = 0.019). Time to insurance approval did not significantly impact follow-up SIBDQ scores. CONCLUSION Patients who had a longer time to insurance approval were less likely to have improvement in CRP, highlighting the negative clinical impact of a complex dose escalation process.
Collapse
Affiliation(s)
- Nisha B Shah
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - Autumn D Zuckerman
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA.
| | - Katie R Hosteng
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - Jessica Fann
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - Josh DeClercq
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - Leena Choi
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - Laura Cherry
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - David A Schwartz
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - Sara Horst
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| |
Collapse
|
14
|
Constant BD, Scott FI. The PA System: Is Prior Authorization for Dose Escalation of IBD Biologic Therapy a Tolerable Alternative or a Perpetual Annoyance? Dig Dis Sci 2023; 68:4279-4281. [PMID: 37792128 DOI: 10.1007/s10620-023-08100-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/26/2023] [Indexed: 10/05/2023]
Affiliation(s)
- Brad D Constant
- Department of Pediatrics, University of Colorado School of Medicine, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO, USA.
| | - Frank I Scott
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
15
|
Collen LV, Mitsialis V, Kim DY, Bresnahan M, Yang J, Tuthill M, Combs A, Barends J, Field M, Liu E, Bearup R, Okoroafor I, Klein C, Muise AM, Bousvaros A, Ouahed J, Snapper SB. Efficacy and Safety of Anti-Tumor Necrosis Factor Alpha in Very Early Onset Inflammatory Bowel Disease. Inflamm Bowel Dis 2023:izad196. [PMID: 37847820 DOI: 10.1093/ibd/izad196] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Very early onset inflammatory bowel disease (VEOIBD) is defined as disease onset in patients younger than 6 years. Challenges in treatment of VEOIBD include lack of approved therapies and increased incidence of monogenic immunodeficiencies. We report on patterns of anti-TNF use, efficacy, and safety in a large cohort of patients with VEOIBD. METHODS Very early onset inflammatory bowel disease patients receiving care at a single center were prospectively enrolled in a data registry and biorepository starting in 2012. Whole exome sequencing was available to all patients. Clinical data including IBD medication use and response were extracted from the medical record. We examined antitumor necrosis factor (anti-TNF) cumulative exposure and time to failure and evaluated the effect of covariates on anti-TNF failure using Cox proportional hazard regression. RESULTS In this cohort of 216 VEOIBD patients with median 5.8-year follow-up, 116 (53.7%) were TNF-exposed. Sixty-two TNF-exposed patients (53.4%) received their first dose at younger than 6 years. Cumulative exposure to anti-TNF was 23.6% at 1 year, 38.4% at 3 years, and 43.4% at 5 years after diagnosis. Cumulative exposure was greater in patients with Crohn's disease (P = .0004) and in those diagnosed in 2012 or later (P < .0001). Tumor necrosis factor failure occurred in 50.9% of those exposed. Features predictive of anti-TNF failure included ulcerative colitis/IBD-unclassified (hazard ratio, 1.94; P = .03), stricturing (hazard ratio, 2.20; P = .04), and younger age at diagnosis (hazard ratio, 1.25; P = .01). Adverse events occurred in 22.6% of infliximab-exposed and 14.3% of adalimumab-exposed. CONCLUSIONS Efficacy and safety of anti-TNFs in VEOIBD is comparable to what has previously been reported in older patients.
Collapse
Affiliation(s)
- Lauren V Collen
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Vanessa Mitsialis
- Division of Gastroenterology, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - David Y Kim
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Mairead Bresnahan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Jessica Yang
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Margaret Tuthill
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Abigail Combs
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Jared Barends
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Michael Field
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Enju Liu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Richelle Bearup
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Ibeawuchi Okoroafor
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Christoph Klein
- Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU Klinikum, and Gene Center, Ludwig Maximilians Universität München, Germany
| | - Aleixo M Muise
- SickKids Inflammatory Bowel Disease Center, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Jodie Ouahed
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Scott B Snapper
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| |
Collapse
|
16
|
Choi DK, Cohen NA, Choden T, Cohen RD, Rubin DT. Delays in Therapy Associated With Current Prior Authorization Process for the Treatment of Inflammatory Bowel Disease. Inflamm Bowel Dis 2023; 29:1658-1661. [PMID: 36715294 DOI: 10.1093/ibd/izad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Indexed: 01/31/2023]
Abstract
Lay Summary
Despite a high approval rate, there were unnecessary delays in therapy due to prior authorizations. This study identified the impact of type of IBD, FDA-labeled indication, and dose escalations on approvals.
Collapse
Affiliation(s)
- David K Choi
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Nathaniel A Cohen
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Tenzin Choden
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Russell D Cohen
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - David T Rubin
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| |
Collapse
|
17
|
Goss Sawhney T, Dobes A, O’Charoen S. Real-World Persistency for Inflammatory Bowel Disease Biologics Using Patient Registry Data. CROHN'S & COLITIS 360 2023; 5:otad051. [PMID: 37941597 PMCID: PMC10629214 DOI: 10.1093/crocol/otad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Indexed: 11/10/2023] Open
Abstract
Background Although it is a truism that drugs benefit patients only when taken, surprisingly little is known about real-world drug-use persistence and discontinuation, even for expensive biologic drugs. Methods We used longitudinal self-reported drug-use data from the inflammatory bowel disease (IBD) Partners registry of people with IBD to construct Kaplan-Meier drug-use persistency graphs for biologic drug-use spans that started between 2017 and 2022. Results We examined 2034 drug-use spans for 1594 survey participants. Most of the biologic drugs had a 75%+ persistency rate around the one-year mark and 60%+ persistency at the 3-year mark. The overall persistency and the differences in persistency between drugs were aligned with published literature. Conclusions This analysis demonstrates the feasibility of collecting IBD-specific patient-reported drug persistency data via a voluntary patient registry. Patient-reported persistency provides real-world drug persistency data and the patient's perspectives as to why they discontinued use of the drug-a combination of data and perspective that is not available from any other real-world medical record, claim, and pharmacy data source that are valuable to physician, patients, payers, healthcare policymakers, and health technology assessment organizations.
Collapse
Affiliation(s)
- Tia Goss Sawhney
- Teus Health, LLC, Newark, NJ, USA
- New York University, School of Global Public Health, New York, NY, USA
| | | | | |
Collapse
|
18
|
Nguyen N, Burger C, Skirka S, White S, Smith M, Menard-Katcher C, Furuta GT, Mehta P. One Year Into Dupilumab: Physician and Patient Experiences in Initiating Dupilumab for Pediatric Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2023; 77:536-539. [PMID: 37491718 DOI: 10.1097/mpg.0000000000003901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
In 2022, the US Food and Drug Administration approved dupilumab for treatment of eosinophilic esophagitis (EoE). The aims of this study were to report physician and patient perspectives on initiating dupilumab. A 2-pronged approach was used: (1) data on physician prescribing practices was gathered via retrospective chart review of EoE patients prescribed dupilumab and (2) pediatric patients on dupilumab were approached to complete a questionnaire regarding reasons for initiation. During this time, 42 patients were prescribed dupilumab. From the physician's perspective, the primary reasons for dupilumab included nonresponse to topical corticosteroids (TCS) (52%), nonadherence (28%), adverse effects (10%), or to treat multiple atopic diseases (5%). The median dupilumab initiation time, from day prescribed to first injection, was 37 days [interquartile range (IQR) 37]. Almost all required prior authorization (PA) (98%), while 17% required letter of appeal and 2% required peer-to-peer. Fifteen patients (36%) completed the questionnaire portion of the study. From the patient's perspective, the primary reasons for dupilumab initiation included nonresponse to TCS (27%), nonadherence to TCS (27%), concern about adverse effects of TCS (7%), and treatment of multiple atopic diseases (33%). In conclusion, physicians are prescribing dupilumab primarily for nonresponse to TCS and almost all required PA with a long delay to starting dupilumab.
Collapse
Affiliation(s)
- Nathalie Nguyen
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Cassandra Burger
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Stephanie Skirka
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Shannon White
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Department of Pharmacy, Children's Hospital Colorado, Aurora, CO
| | - Melanie Smith
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Department of Pharmacy, Children's Hospital Colorado, Aurora, CO
| | - Calies Menard-Katcher
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Glenn T Furuta
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Pooja Mehta
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| |
Collapse
|
19
|
Hyams JS, Russell RK. The State of Clinical Trials in Pediatric Inflammatory Bowel Disease. Gastroenterol Clin North Am 2023; 52:589-597. [PMID: 37543402 DOI: 10.1016/j.gtc.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
The gap between available biologic and small molecule therapy for inflammatory bowel disease for children and adults remains large. At present only 2 anti-TNF agents are licensed for pediatric use compared with multiple other agents with different mechanisms of action being used in adults. The reasons are many but largely revolve around the inadequate acceptance of adult efficacy data to children, and the reluctance of industry to commit to early pediatric drug development for fear of inadequate return on investment. We suggest common sense steps that need to be taken to improve this situation.
Collapse
Affiliation(s)
- Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA; University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children and Young People, Clinical Staff Offices, 2nd Floor, 50 Little France Crescent, Edinburgh EH16 4TJ
| |
Collapse
|
20
|
Pasternak B. Managing Inflammatory Bowel Disease in a Broken Health Care System. J Pediatr Gastroenterol Nutr 2023; 77:e49. [PMID: 37084336 DOI: 10.1097/mpg.0000000000003800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Affiliation(s)
- Brad Pasternak
- From Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ
| |
Collapse
|
21
|
Spencer EA, Abbasi S, Kayal M. Barriers to optimizing inflammatory bowel disease care in the United States. Therap Adv Gastroenterol 2023; 16:17562848231169652. [PMID: 37163167 PMCID: PMC10164253 DOI: 10.1177/17562848231169652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/17/2023] [Indexed: 05/11/2023] Open
Abstract
Significant progress in the management and modification of inflammatory bowel disease (IBD) has been made; however, significant barriers to the optimization of IBD care in the United States still exist. The majority of these barriers are constructed by insurance carriers and the integration of market pressures into healthcare decision-making. In this review, we highlight the barriers to IBD care optimization within the context of the US insurance system and review current and proposed solutions.
Collapse
Affiliation(s)
- Elizabeth A. Spencer
- Division of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sadeea Abbasi
- Division of Gastroenterology, Cedars-Sinai Santa Monica Gastroenterology, Santa Monica, CA, USA
| | - Maia Kayal
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1069, New York, NY 10029, USA
| |
Collapse
|
22
|
Ismail WW, Witry MJ, Urmie JM. The association between cost sharing, prior authorization, and specialty drug utilization: A systematic review. J Manag Care Spec Pharm 2023; 29:449-463. [PMID: 37121255 PMCID: PMC10388011 DOI: 10.18553/jmcp.2023.29.5.449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND: Specialty drugs are identified by high monthly costs and complexity of administration. Payers use utilization management strategies, including prior authorization and separate tiers with higher cost sharing, to control spending. These strategies can negatively impact patients' health outcomes through treatment initiation delays, medication abandonment, and nonadherence. OBJECTIVE: To examine the effect of patient cost sharing on specialty drug utilization and the effect of prior authorization on treatment delay and specialty drug utilization. METHODS: We conducted a literature search in the period between February 2021 and April 2022 using PubMed for articles published in English without restriction on date of publication. We included research papers with prior authorization and cost sharing for specialty drugs as exposure variables and specialty drug utilization as the outcome variable. Studies were reviewed by 2 independent reviewers and relevant information from eligible studies was extracted using a standardized form and approved by 2 reviewers. Review papers, opinion pieces, and projects without data were excluded. RESULTS: Forty-four studies were included in this review after screening and exclusions, 9 on prior authorization and 35 on cost sharing. Patients with lower cost sharing via patient support programs experienced higher adherence, fewer days to fill prescriptions, and lower discontinuation rates. Similar outcomes were noted for patients on low-income subsidy programs. Increasing cost sharing above $100 was associated with up to 75% abandonment rate for certain specialty drugs. This increased level of cost sharing was also associated with higher discontinuation rates and odds. At the same time, decreasing out-of-pocket costs increased initiation of specialty drugs. However, inconsistent results on impact of cost sharing on medication possession ratio (MPR) and proportion of days covered (PDC) were reported. Some studies reported a negative association between higher costs and MPR and PDC; however, MPR and PDC of cancer specialty drugs did not decrease with higher costs. Significant delays in prescription initiation were reported when prior authorization was needed. CONCLUSIONS: Higher levels of patient cost sharing reduce specialty drug use by increasing medication abandonment while generally decreasing initiation and persistence. Similarly, programs that reduce patient cost sharing increase initiation and persistence. In contrast, cost sharing had an inconsistent and bidirectional effect on MPR and PDC. Prior authorization caused treatment delays, but its effects on specialty drug use varied. More research is needed to examine the effect of cost sharing and prior authorization on long-term health outcomes.
Collapse
|
23
|
Kahn SA, Bousvaros A. How to Write an Effective Letter of Medical Necessity. J Pediatr Gastroenterol Nutr 2023; 76:407-409. [PMID: 36735599 DOI: 10.1097/mpg.0000000000003724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Stacy A Kahn
- From Inflammatory Bowel Disease Center, Boston Children's Hospital, Boston, MA
| | | |
Collapse
|
24
|
Pereira DE, Kamara E, Krueger CA, Courtney PM, Austin MS, Rana A, Hannon CP. Prior Authorization in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership. J Arthroplasty 2023:S0883-5403(23)00042-6. [PMID: 36708936 DOI: 10.1016/j.arth.2023.01.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND This study surveyed the impact that prior authorization has on the practices of total joint arthroplasty (TJA) members of the American Association of Hip and Knee Surgeons (AAHKS). METHODS A 24-question survey was approved by the AAHKS Advocacy Committee and distributed to all 2,802 board-certified members of AAHKS. RESULTS There were 353 survey responses (13%). Ninety-five percent of surgeons noted a 5-year increase in prior authorization. A majority (71%) of practices employ at least 1 staff member to exclusively work on prior authorization. Average time spent on prior authorization was 15 h/wk (range, 1 to 125) and average number of claims peer week was 18 (range, 1 to 250). Surgeries (99%) were the most common denial. These were denied because nonoperative treatment had not been tried (71%) or had not been attempted for enough time (67%). Most (57%) prior authorization processes rarely/never changed the treatment provided. Most (56%) indicated that prior authorization rarely/never followed evidence-based guidelines. A majority (93%) expressed high administrative burden as well as negative clinical outcomes (87%) due to prior authorization including delays to access care (96%) at least sometimes. DISCUSSION Prior authorization has increased in the past 5 years resulting in high administrative burden. Prior authorizations were most common for TJA surgeries because certain nonoperative treatments were not attempted or not attempted for enough time. Surgeons indicated that prior authorization may be detrimental to high-value care and lead to potentially harmful delays in care without ultimately changing the management of the patient.
Collapse
Affiliation(s)
- Daniel E Pereira
- Department of Orthopaedic Surgery, Washington University, Saint Louis, Missouri
| | - Eli Kamara
- Orthopaedic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York
| | - Chad A Krueger
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew S Austin
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Adam Rana
- Maine Medical Partners Orthopedics and Sports Medicine, South Portland, Maine
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Washington University, Saint Louis, Missouri
| |
Collapse
|
25
|
Denials, Dilly-dallying, and Despair: Navigating the Insurance Labyrinth to Obtain Medically Necessary Medications for Pediatric Inflammatory Bowel Disease Patients. J Pediatr Gastroenterol Nutr 2022; 75:418-422. [PMID: 35836325 DOI: 10.1097/mpg.0000000000003564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Increasingly, in the United States, the prescribing of high-cost drugs has become a challenge for physicians and other practitioners. Such drugs are highly regulated by third-party payers (aka insurance), as well as pharmacy benefit managers. Not infrequently, a clinician prescribing a medication will have the payment for the prescription denied by the third-party payer, with the end result being a delay in getting a medically necessary medication to a patient. This article highlights the challenges involved in the prior authorization and denial process, with a focus on pediatric inflammatory bowel disease. The article reviews the role of pharmacy benefits managers in restricting access to drugs, and the reasons why denials of medically necessary medications may occur. The article also provides information on how to appeal denials, how to write a letters of medical necessity, and how to conduct a proper peer-to-peer review. Advocacy from patients and clinicians will be important, as we want to reform the process in the future.
Collapse
|
26
|
Sariahmed K, Kurian J, Singh AK, Leyton C, Minuti A, Jerschow E, Arora S, Jariwala SP. Social, political, and economic determinants of access to biologics: A scoping review of structural determinants in the clinical disparities literature. Res Social Adm Pharm 2022; 18:4038-4047. [DOI: 10.1016/j.sapharm.2022.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 05/05/2022] [Accepted: 07/28/2022] [Indexed: 02/07/2023]
|
27
|
Lepus CA, Hyams JS. Barriers From Third-Party Payers to Biologic Use in Pediatric Inflammatory Bowel Disease. JPGN REPORTS 2022; 3:e215. [PMID: 37168642 PMCID: PMC10158370 DOI: 10.1097/pg9.0000000000000215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/04/2022] [Indexed: 05/13/2023]
Abstract
Biologic agents are now standard of care in the treatment of inflammatory bowel disease (IBD). The ability to use biologics in clinical practice is in part dictated by insurance company policies. There is a long delay between adult and pediatric approval of biologic agents, and these therapies are often denied by third-party payers for use in pediatric IBD patients. This study prospectively identified pediatric patients with IBD who were started on a biologic medication at our institution, and third-party payer decisions were recorded. There were no denials in patients with Medicaid, but private payers frequently interfered with use of biologic agents. Reasons for denial are generally for use of a specific off-label agent or dosing of an approved agent. These denials lead to delayed treatment, nonmedically sound changes in therapy, and increased administrative burden on providers.
Collapse
Affiliation(s)
- Chelsea A. Lepus
- From the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Connecticut Children’s Medical Center, Hartford, CT
| | - Jeffrey S. Hyams
- From the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Connecticut Children’s Medical Center, Hartford, CT
| |
Collapse
|
28
|
Cook SC, Desmarais AG, Berry JG. Room to Improve Prior Authorization in Children With Complex Medical Needs. Pediatrics 2022; 149:184865. [PMID: 35190809 DOI: 10.1542/peds.2021-054843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Stacey C Cook
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Anna G Desmarais
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Jay G Berry
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|