Insurance Companies Have Poor Adherence to Guidelines for UC, CD

Most insurance companies have yet to fully adopt current guidelines for managing patients with moderate to severe ulcerative colitis (UC) and Crohn disease (CD), according to study results presented at the American College of Gastroenterology (ACG) 2022 Annual Meeting, held from October 21 to 26, 2022, in Charlotte, North Carolina, and virtually.

Investigators aimed to determine whether current insurance company policies align with the latest guidelines from the ACG and American Gastroenterological Association (AGA) for management of patients with UC and CD.

The study authors searched the top 50 insurance companies for publicly available policy information regarding use of infliximab, adalimumab, vedolizumab, tofacitinib, and ustekinumab. They extracted data on authors, last revision date, citation of AGA/ACG guidelines, and policy requirements, as well as information regarding a requirement to fail conventional therapy, use of biosimilars, and use of first-line biologic agents. The data were compared with the 2018 ACG and 2020 AGA guidelines for UC and the 2019 ACG and 2021 AGA guidelines for CD.

Among the insurance companies, 48 provided health coverage, of which 33 (72.34%) had publicly accessible policies on biologics coverage. No authors of the policies were listed, and the ACG/AGA guidelines were directly quoted or cited in 70.6% of the policies. The policies were updated between January 1, 2016, and May 31, 2022.

Among the 34 policies analyzed, 58.8% were consistent with the ACG guidelines for CD vs 5.8% for the AGA guidelines for CD. Also, 8.8% were consistent with both the ACG and AGA guidelines for UC. In addition, 14.7% of the policies permitted any first-line biologic therapy in UC, and 17.7% allowed any first-line biologic therapy in CD.

“As of 2022, insurance companies that comprise nearly 80% of the market are yet to adopt the most current guidelines for inflammatory bowel disease management,” the researchers noted.

Most insurance companies require the failure of conventional therapies such as 5-aminosalicylic acid, immunomodulators, and corticosteroids, although the time required to determine therapeutic failure ranged from 7 days to 6 months.

The difference in adherence to the ACG guidelines vs the AGA guidelines for CD primarily results from the difference in recommendations for use of an immunomodulator compared with an anti-tumor necrosis factor agent as first-line agent and the length of treatment with corticosteroids before failure (short-term therapy vs 3-5 days). The inability to use immunomodulators concurrently with biologics was the second most common reason for nonadherence to the guidelines. First-line biologics were limited primarily to adalimumab or infliximab.

“Further work is needed to better understand the implications of these inconsistencies between insurance companies and formal medical guidelines on outcomes for patients with moderate-to-severe UC and CD,” the researchers noted.

Reference

Anand R, Anderson K, Feuerstein JD. Insurance companies’ poor adherence to ACG/AGA guidelines for moderate to severe ulcerative colitis and Crohn’s disease management. Abstract presented at: ACG 2022 Annual Meeting; October 21 to 26, 2022; Charlotte, NC. Abstract B0414.

This article originally appeared on Gastroenterology Advisor.