CHARLOTTE, N.C.—Many major insurance companies do not adhere to the most recent recommendations on inflammatory bowel disease treatment from the American College of Gastroenterology and the American Gastroenterological Association, according to an analysis of insurance company policies.
The study, conducted by researchers at Beth Israel Deaconess Medical Center, in Boston, analyzed publicly available insurance policy data from the top 50 U.S. insurance companies, which represent 80% of the market. The investigators compared policy data for adalimumab (Humira, AbbVie), infliximab (Remicade, Janssen), tofacitinib (Xeljanz, Pfizer), ustekinumab (Stelara, Janssen), and vedolizumab (Entyvio, Takeda) with the latest ACG and AGA guidelines on ulcerative colitis (Am J Gastroenterol 2019;114[3]:384-413; Gastroenterology 2020;158[5]:1450-1461) and Crohn’s disease (Am J Gastroenterol 2018;113[4]:481-517; Gastroenterology 2021;160[7]:2496-2580).
Corey Siegel, MD, MS, the section chief of gastroenterology and hepatology at Dartmouth Hitchcock Medical Center, in Lebanon, N.H., and a professor of medicine at Dartmouth’s Geisel School of Medicine, in Hanover, N.H., who was not involved in the study, commented on the importance of the findings, stating that gastroenterologists have “felt for a number of years that it is better to treat IBD earlier.” And this study gets at, “Can you treat ealier and what are the barriers?”
Overall, 48 of the 50 companies provided some coverage for these medications, but only a subset had publicly available policies on the details of their coverage, the investigators reported at the 2022 annual meeting of the American College of Gastroenterology (abstract B0414). Among the 34 policies the researchers were able to analyze, adherence to guidelines was low. For UC, policies of only three companies adhered to the latest ACG and AGA guidelines (each 8.8%). For CD, 20 policies adhered to the latest ACG guidelines (58.8%), and two policies conformed to the latest AGA guidelines (5.8%).
Counter to the shift in the guidelines away from step-up therapy to use of biologics for induction of remission, 31 of the 34 insurance policies (91.2%) required failure of at least one conventional therapy (e.g., 5-aminosalicylates, immunomodulators, corticosteroids) before coverage of biologics for both UC and CD. The time required before “failure” could be established was inconsistent across insurers, ranging from one week to six months. Only five of the policies allowed any first-line use of biologics for UC (14.7%), and only six did so for CD (17.7%). Most policies also did not allow concurrent use of immunomodulators and biologics.
These findings “highlight the length of time it takes for practices to be updated,” investigator Rajsavi Anand, MD, a fellow at Beth Israel Deaconess, told Gastroenterology & Endoscopy News, emphasizing that insurance “policies need to be dynamic and evolve with evolving evidence to allow for better care of these patients.”
The results were in line with Dr. Siegel’s experience. He has found that despite guideline changes, “it’s gotten harder, not easier, with payors over the past couple of years. It’s become very difficult to get the medication that you would want. … It may take me months to argue for the exact right first drug.” That being said, with the right support from IBD-focused pharmacists and administrative staff, “you can almost always get your patient on a good medication early on in the course of their disease,” even if it’s not the first-choice agent.
This lack of adherence to ACG/AGA guidelines has consequences, according to Dr. Anand and his co-investigators, who noted that “lack of coverage limits access to appropriate care and can lead to poorer outcomes and increased medical costs to the patient.”
They stress that further research is warranted to foster understanding specific implications of nonadherence on patient outcomes. Dr. Anand also said it would be valuable to compare “public versus private insurances … as well as look at the cost this [lack of adherence to guidelines] adds to patient care.”
—Natasha Albaneze
This article is from the March 2023 print issue.