A recent study (A Yada et al. Inflamm Bowel Dis 2017; 23: 853-7) finds that insurance policies are not in compliance with expert guidelines. The authors reviewed 79 policies from the top insurance companies to examine their policies regarding anti-TNF agents, vedolizumab, and ustekinumab. These policies were compared with the American Gastroenterological Association (AGA) clinical pathway recommendations for ulcerative colitis (UC) and Crohn’s disease (CD).
- “90% of the policies required step-wise failure prior to starting anti-TNF for non-fistulizing CD.”
- “When choosing anti-TNF therapy, 26% of policies required the use of adalimumab as the first anti-TNF agent.”
- 98% of policies are inconsistent with AGA IBD guidelines
Discussion from authors:
- “The plans do not allow for treatment based on disease severity but rather dictate treatment based on the required failure of different drug classes.”
- “Only 2% of UC policies and 10% of CD policies allowed for early initiation of biologic therapy to reduce the risk of complications.”
- “The goal of medical management is to minimize the use of corticosteroids…However, the majority of the current policies…preclude this standard-of-care management.”
My take (from authors): “Most insurance companies do not comply with the current standard of care for treating IBD.” My expectation is that these problems will continue and/or worsen as the options for IBD treatment become more complex.