Integrated specialty pharmacy improves access to IBD drugs
ORLANDO, Fla. — Patients with inflammatory bowel disease and their providers face significant barriers to therapy access due to insurance coverage decisions and costs, but integrating a specialty pharmacy at University of Chicago’s IBD clinic helped overcome these obstacles, according to presenters at AIBD 2017.
“The collaboration is very successful ... in not allowing payers and cost hurdles to interfere with our patients and what they need,” Shivani Patel, PharmD, of University of Chicago, said during her presentation.
In describing these obstacles, David Rubin, MD, also of University of Chicago, said quality and access are two critically important components of IBD care, and they are inextricably linked.
“You can’t provide patients the quality of care that they need without being able to get them that care,” he said during the presentation. “So as we talk to our patients and make our recommendations, it’s always couched in the final statement which is, ‘Let’s see if we can get that for you,’ or, ‘How will you pay for this?’ or, ‘What will your payer allow us to do?’ It is the reality that we all know well, that although we’ve made great progress in the way therapies work for our patients, [they] are very expensive.”
This challenge stems from conflicting forces in insurance coverage decisions — namely, advancing standards of care vs. the payer’s obligation to provide care in a cost-effective way, Rubin noted.
“We’ve seen some stark contrasts between the grading of available evidence vs. what we think is the advancing standard of care, and these don’t often align in real time,” he said. “This is a challenge to us as well, especially now that payers look to those guidelines and the level of evidence as ways to determine their policies and their approvals or denials of therapies.”
However, he cautioned against the assumption that every denial of coverage is wrong on the part of the payer.
“It’s not necessarily ‘wrong’ that payers deny coverage of certain therapies — that’s their policy and that’s what goes along with having a private insurance company,” he said. “What’s wrong is when it’s counter to what is safe, and when it is counter ... to their own policies, if they’re inconsistent, and what I think is consistently wrong is when the communication techniques and availability of making decisions and having real time communication for a sick patient is delayed and inefficient.”
To illustrate this problem, Rubin shared survey results showing that among 158 gastroenterologists, some reported their practice communicated with payers to obtain preauthorizations and reauthorizations more than 30 times per day, and 63% reported a full-time employee in their practice spent 25% of their time dealing with these issues. Further, a national survey of IBD patients showed 13% had insurance that would not cover the therapy their physician recommended, and many went without therapy, or rationed therapy, in response.
Rubin noted that this patient survey took place before the Affordable Care Act was implemented, and he and colleagues are currently performing a new survey to determine whether these trends have since changed.
Because the pathway to obtain access to the appropriate therapies for patients is complicated, Patel outlines a number of ways to help.
First, she noted that denials for coverage of biologics are often inaccurate, and thus “it’s imperative that we fight them and get patients the care that they need. I recommend doing whatever it takes to get these patients on the therapy that they require.”
To do so, she recommended first speaking to the medical reviewer, then submitting a letter of appeal, and a second if that fails, after which she said to request to have case reviewed by an independent third-party organization, and as a last resort, reach out to the state department of insurance.
“This is to secure access to care,” she said. “Once you secure access, affordability is still a concern for our patients.”
Cost barriers and their solutions vary depending on the type of insurance patients have, she said.
For commercial patients, she recommended obtaining manufacturer co-pay cards that can help offset their out-of-pocket costs.
“This literally is one of the easiest things you can do as a provider is sign them up online,” she said. “I do this on my own, and I print out the co-pay card and send it to our patients. It takes less than 5 minutes to do so online,” and, as a result, some patients pay less than $5 a month for their biologic therapy, she said.
In contrast, Medicare patients are not eligible for co-pay cards, so they face a different set of challenges, she said.
“Patients that are on Medicare Part D plans ... have this ‘donut hole’ that we all know about, and things are supposed to get better when they hit their catastrophic phase, because they’re only responsible for 5% of their co-pays, but when you’re talking about biologics that 5% is still hundreds of dollars, so patients often cannot meet their co-pay for their biologic medication and then they’re stuck without medications,” she said.
Therefore, she recommended that for patients with Medicare part D plans, which is their prescription coverage, providers should check to see if they have a Medicare part B plan, which is their medical coverage.
“If they have a Medicare part B plan, and they have supplemental insurance to cover costs for their inpatient visits, you can route some of these patients to have their medications administered in clinic,” she said.
For those who are completely uninsured, she recommended reaching out to various IBD foundations, which may be able to help.
“Often funding is not available, though, so the last resort are manufacturer patient assistance programs,” she said. “These are good options if your patients cannot get access.”
Aiming to mitigate these barriers of cost and access, University of Chicago integrated a specialty pharmacy into its IBD clinic, which Patel said has been a great success, as it is dedicated to the process of communicating with payers and ensuring IBD patients have access to their required therapy.
“Not only is this heavily beneficial to our providers, because it’s freeing up all the time that they spend doing prior authorizations and appeals and coordinating all these phone calls with payers, but it’s tremendously beneficial for our patients, because now they have a direct, single point of contact that they can reach out to,” she said.
Involved patients have reported increased satisfaction since this program was implemented, and only two out of 691 that were denied therapy, a more than a 99% approval rate, Patel said.
“My take away point is to get a dedicated team that can take over this process and really own it,” she concluded. – by Adam Leitenberger
Reference: Rubin D, Patel S. Clinical Session IIA. Presented at: Advances in IBD; Nov. 9-11, 2017; Orlando, Fla.
Disclosures: Rubin reports he has financial relationships with AbbVie, ACG, Celgene, Cornerstones Health, Forward Parma, Genentech, GoDuRn, Janssen, Lockwood Group, Miraca Life Sciences, Pfizer, Prometheus Laboratories, Roche, Samsung Bioepis, Sandoz Pharmaceuticals, Shire, Takeda and UCB Pharma. Patel reports no relevant financial disclosures.