Advocating for Patients With Inflammatory Bowel Disease: How to Navigate the Prior Authorization Process

Factors Associated with Delays in Initiating Biologic Therapy in Patients with Inflammatory Bowel Disease

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.

The IBD Clinic of Tomorrow: Holistic, Patient-Centric, and Value-based Care

There is increasing recognition of the associated bi-directional impact of inflammatory bowel disease (IBD) on patient well-being and the potential benefit of multidisciplinary teams to address these unique needs. At certain IBD centers, there has been an evolution towards patient-centric, holistic care to enhance well-being and improve health-related outcomes. Multiple models, incorporating various disciplines, care modalities, digital tools and care delivery, and resource support have arisen in IBD. Although most IBD centers of excellence are now incorporating such multidisciplinary care models, many practices still practice IBD-limited specialty care, limiting evaluations and interventions to the IBD itself and its direct consequences (eg, extraintestinal manifestations). In this piece, we seek to review the evolution of IBD care towards a patient-centric, holistic model (termed 360 IBD Care) including the role and impact of digital health tools, monitoring, and delivery in IBD, and a shift towards value-based care models with discussion of payor priorities in IBD. We also suggest potential opportunities for IBD practitioners to incorporate elements of holistic care on a local scale. Together, we hope such care models will enhance not only IBD-specific health outcomes, but also improve the general well-being of our patients with IBD today and tomorrow.

Advanced Therapies for Inflammatory Bowel Disease: Navigating Payor and Financial Challenges

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.

Discordance Between Inflammatory Bowel Disease Specialists and Insurance Authorization Denials-A Survey of Specific Inflammatory Bowel Disease Treatment Scenarios

Background

Prior authorizations are generally required by insurers for gastroenterologists to prescribe biologics and small-molecule drugs to treat inflammatory bowel disease (IBD). Authorization denials occur in a wide variety of clinical scenarios, including denials of standard and nonstandard medication dosing.

Methods

We performed a national cross-sectional survey on a broad variety of specific clinical scenarios to assess experience and opinions on whether or not insurance authorization denials are in accordance with clinical expertise.

Results

Eighty-four gastroenterologists completed the survey. Denial experience was common for infliximab dose modifications, vedolizumab dose modifications, ustekinumab first-time therapy, and maintenance dosing. The bulk of disagreement with authorization denials involved scenarios of dose escalation and re-induction guided by both loss of clinical response and/or therapeutic drug monitoring, denial of re-authorizations of stable dosing, and use of non-anti-TNFs in specific patient populations including the elderly and patients with multiple comorbidities. Respondents unanimously agreed that insurance companies do not play an adequate role in helping patients obtain PA. Furthermore, most of the respondents agree that to decrease the burden of the PA process, peer-peer processes should be between other IBD-trained providers who understand these complex treatment strategies.

Conclusions

Our cross-sectional survey highlights the degree of discordance in clinical decision-making between insurers and gastroenterologists. Further engagement between gastroenterologists and insurers is needed to foster common understanding on these discordant authorization denials in these real-world clinical IBD scenarios.

Representation and reporting of diverse groups in randomised controlled trials of pharmacological agents in inflammatory bowel disease: a systematic review

Inflammatory bowel disease (IBD) is now recognised as a global disease, with incidence rapidly increasing in newly industrialised countries in South America, Asia, and Africa. Trials in IBD, therefore, should adequately represent diverse groups with respect to gender, age, place of residence, race, and ethnicity to ensure the global applicability and generalisability of their findings. In this systematic review, we searched PubMed and Embase for randomised controlled trials (RCTs) published in English from Jan 1, 1995, to Jan 13, 2023, evaluating the efficacy of any pharmacological intervention in patients with IBD. Of 7543 records yielded in the search, we included 617 records reporting data from 627 RCTs and 108 986 participants. The results show a paucity of adequate representation of diverse groups in these RCTs. This finding was true for various groups, including racially and ethnically diverse populations, older (aged >65 years) and younger (aged <18 years) populations, those who identify outside of the gender binary, and people from South America and Africa. Also, some regions had an apparent scarcity of funding sources for trials. Pharmaceutical companies and clinical trial organisations should aim to ensure adequate representation of such under-represented groups in future IBD trials.

Insurance Approval Delay of Biologic Therapy Dose Escalation Associated with Disease Activity in Patients with Inflammatory Bowel Disease

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.

Delays in Therapy Associated With Current Prior Authorization Process for the Treatment of Inflammatory Bowel Disease

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.

Denials, Dilly-dallying, and Despair: Navigating the Insurance Labyrinth to Obtain Medically Necessary Medications for Pediatric Inflammatory Bowel Disease Patients

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.

Delays Related to Prior Authorization in Inflammatory Bowel Disease

BACKGROUND

Delays in advancing to biologic therapies are associated with adverse outcomes in inflammatory bowel disease (IBD). Insurer-mandated prior authorizations have been linked to prolonged medication initiation times. We hypothesized that prior authorizations are associated with prolonged biologic initiation time and increased IBD-related healthcare utilization among children with IBD.

METHODS

We performed a retrospective cohort study of 190 pediatric patients with IBD initiating biologics at a tertiary care hospital to measure the association between prior authorization, biologic initiation time (physician recommendation to first dose), and healthcare utilization (hospitalization, surgery, or emergency department visit). Demographic, insurance, and disease severity-related covariables were collected. Multivariable linear regression was used to measure the association between prior authorization and biologic initiation time. Propensity score methods were used to measure the associations between prior authorization and IBD-related healthcare utilization within 180 days and corticosteroid dependence at 90 days, with adjustment for insurance type, demographics, and disease severity-related characteristics.

RESULTS

Median biologic initiation time was 21 days. Prior authorization and complicated prior authorizations (requiring appeal, step therapy, or peer-to-peer review) were associated with 10.2-day (95% confidence interval [CI] 8.2 to 12.3) and 24.6-day (95% CI 16.4 to 32.8) increases in biologic initiation time, respectively. Prior authorizations increased the likelihood of IBD-related healthcare utilization within 180 days by 12.9% (95% CI 2.5 to 23.4) and corticosteroid dependence at 90 days by 14.1% (95% CI 3.3 to 24.8).

CONCLUSIONS

Prior authorizations are associated with prolonged biologic initiation time and increased IBD-related healthcare utilization. Minimizing prior authorization-related delays may expedite biologic delivery and reduce the risk of IBD-related healthcare utilization.

Analyzing the costs of developing and operating an integrated health-system specialty pharmacy: The case of a centralized insurance navigation process for specialty clinic patients

Purpose

Direct and indirect costs related to the growth of specialty pharmacy services and the insurance navigation process for specialty clinic patients are discussed, and development and implementation of a pharmacy-driven and system-wide prior authorization (PA) processing center within a health system are described.

Summary

Expensive specialty drugs require PA. Due to the concentration of specialists, health systems with multiple specialties experience higher PA burden and resulting care delays. Although clinic staff typically handle PA requests, health-system specialty pharmacies are well positioned to support patients, clinic staff, and physicians by assuming responsibility for the PA process entirely. University of Utah Health established its Pharmacy Ambulatory Clinical Care Center (PAC3) to centralize PA processing for selected specialty and primary care clinics within the health system. In fiscal year 2019, the PAC3 team (10 pharmacy technician and 1.5 pharmacist full-time equivalents) completed over 13,000 PAs. The pharmacy labor cost increase was significant; however, the benefits gained from increased services, quality, and financial strength surpassed all costs associated with the implementation and maintenance of the pharmacy operation. Other tangible benefits included decreased delays in therapy initiation, increased patient satisfaction, increased clinic visits, and increased staff and provider satisfaction and engagement.

Conclusion

Increased PA requests associated with specialty drugs have placed considerable stress and staff burden on specialty clinics within health systems. However, development and implementation of an efficient PA processing infrastructure within a health-system specialty pharmacy may reduce the burden, increase financial strength, and improve the patient experience.

Evolving Role and Future Directions of Natural Language Processing in Gastroenterology

In line with the current trajectory of healthcare reform, significant emphasis has been placed on improving the utilization of data collected during a clinical encounter. Although the structured fields of electronic health records have provided a convenient foundation on which to begin such efforts, it was well understood that a substantial portion of relevant information is confined in the free-text narratives documenting care. Unfortunately, extracting meaningful information from such narratives is a non-trivial task, traditionally requiring significant manual effort. Today, computational approaches from a field known as Natural Language Processing (NLP) are poised to make a transformational impact in the analysis and utilization of these documents across healthcare practice and research, particularly in procedure-heavy sub-disciplines such as gastroenterology (GI). As such, this manuscript provides a clinically focused review of NLP systems in GI practice. It begins with a detailed synopsis around the state of NLP techniques, presenting state-of-the-art methods and typical use cases in both clinical settings and across other domains. Next, it will present a robust literature review around current applications of NLP within four prominent areas of gastroenterology including endoscopy, inflammatory bowel disease, pancreaticobiliary, and liver diseases. Finally, it concludes with a discussion of open problems and future opportunities of this technology in the field of gastroenterology and health care as a whole.

Impact of Clinical Pharmacists in Inflammatory Bowel Disease Centers During the COVID-19 Pandemic

INTRODUCTION

To characterize the clinical pharmacists' impact on caring for patients with inflammatory bowel disease during COVID-19.

METHODS

A clinical pharmacist's encounters between March 17 and April 14, 2020, were audited to determine encounter frequency and indication.

RESULTS

The clinical pharmacist addressed COVID-19 and inflammatory bowel disease treatment concerns with 140 patients, conducted 34 medication education and monitoring visits, reviewed 141 patients' charts and helped rescheduled 18 patients who missed their biologic infusion, transitioned 12 patients to home infusions, and assisted 5 patients with medication access.

DISCUSSION

Clinical pharmacists embedded in gastroenterology practices permit for continued optimal patient care during a pandemic.