AI, Disparities, and Payer Readiness in CLL Care: Kirsten Axelsen, MS

Many patients with chronic lymphocytic leukemia (CLL) are not receiving guideline-recommended targeted therapies, and the gap is not shared equally: Minority patients are less likely than White patients to receive preferred treatments, according to a September 2026 report from Charles River Associates (CRA) commissioned by BeOne Medicines USA.¹ The report also calls on health plans to disclose when artificial intelligence (AI) is used in coverage decisions and to require qualified clinician oversight of care denials.

In part 2 of this interview with The American Journal of Managed Care^® (AJMC^®), lead author Kirsten Axelsen, MS, a consultant at CRA, discusses what drives disparities in CLL care, how AI is shaping patient information-seeking and prior authorization, whether payers are ready for Bruton tyrosine kinase (BTK) degraders and bispecific antibodies, what health plan leaders should take away, and what forthcoming state reports show. Read part 1 of the interview and AJMC’s previous coverage of the report’s key findings.²

This interview has been lightly edited for clarity and length.

AJMC: The report found racial disparities in who gets preferred therapies. How much of the access gap comes from insurance design, and how much from where and by whom patients are treated?

Axelsen: That’s a good point. I don’t know how much of the issues comes from the benefit design specifically. It’s consistent across nearly every therapy that racial minorities and people who are in rural areas do not get the same standard of care. I think we could probably attribute some of the rural differences to access to providers and specialists. As far as people of color getting prescribed chemotherapy more often than a targeted therapy, that’s probably a matter of education, insurance, and awareness by the provider of the coverage. I think more evidence is warranted to determine what the contributing factors are. It’s a persistent problem in this and other therapeutic areas that does deserve more focus, because those disparities, especially given that there is much greater survival with the targeted therapies, are leading to shorter lives for people who don’t get the targeted therapy. In addition, people who have more adverse effects often need other types of supportive care. It’s not only a drag on the person’s quality of life, but it can be a drag on their caregiver and on their ability to work, and it adds to their need to seek other types of care to treat the adverse effects.

AJMC: The report provides a full recommendation to AI, covering both patients using chatbots for treatment information and insurers using AI in prior authorization review. Why was that important to include, and what would meaningful clinician oversight of AI-assisted denials look like?

Axelsen: AI is becoming a bigger part of everything we do. Many of the patients and providers we spoke to said patients are going—as they always have—to internet searches, which are now largely AI assisted, and going to chatbots. When someone’s diagnosed with a potentially fatal or very disruptive disease, they’re going to search for information from every source, and with AI, there is a high likelihood that they will get misinformation. I think consumers are learning to be savvy about these tools, understanding that the information they get is not necessarily curated or validated and being able to come to their provider with questions—but recognizing that it is not the final answer. Of course, they also often get sent to treatments that have absolutely no merit. We even heard from oncologists about people coming in requesting ivermectin and wanting to take a break from their chemotherapy, things like that, which may come from unreliable sources of information.

As it relates to insurance denials, there still is a strong role for the provider in the insurance adjudication process. If a claim is being rejected purely because of data gathered by large language models and AI, there really needs to be a place for the provider to apply judgment, because the AI only has the data that’s entered into the patient record, and not everything is entered into a patient record, as we know, or collected across sites of care. There needs to be that ability for the provider to say, “Oh no, I know this person has had this issue with side effects,” or, “For whatever reason, I believe they should be able to get this genetic test or get this type of therapy.”

AJMC: With fixed-duration oral regimens, BTK degraders, and bispecifics on the way, are payers and policy ready, or will the same gaps repeat?

Axelsen: I don’t think anyone’s ready. Science has moved so much faster than law and regulation, and we have a health system that is set up to manage costs year over year, because that’s how our budgets work. Employers don’t plan for spikes in costs one year that then go down with innovation. Now that we can target so many more diseases at the genetic level, the medicines that are targeted therapeutics do tend to be more expensive. We’re going to have the opportunity to get better outcomes for patients—but at times, it’s going to cost more. More cost may mean more cost on a particular drug but less waste on untargeted chemotherapies that are not as effective.

But the fact is, living longer costs more money, and we don’t necessarily have a system set up, publicly or privately, that can really manage the cost of caring for an increasingly older and longer-lived population. With these new drugs being developed, not only are we not really set up to manage the cost, but biomarker testing is not routine and isn’t really part of general medical practice the way things like mammograms and maybe colonoscopies have become part of the standard that everyone knows they need to get. Again, I think some of this is awareness in the provider space, but people also need to know to ask for these things, because they do help you live longer if you have this disease and you do have a biomarker and can get one of these targeted therapies.

AJMC: If a health plan leader takes one thing from this report, what should it be?

Axelsen: I think it’s biomarker testing. Coverage is the right thing to do for patients, as is determining how to have biomarker testing in place so that decisions about which drugs are used are really based on clinical evidence. That both reduces waste from a therapy that is less effective than it should be and helps patients get the right information. Payers can have a big effect on what physicians do, and physicians need to be aware that these tests can save their patients’ lives and be encouraging their use, even if it is going to put the patient in the position of having to travel to a place where they can get the test done.

AJMC: The national report will be followed by state-level reports. What do those show?

Axelsen: In addition to the federal report, which really covered national policy and practice, we have 4 additional state reports coming out in the coming weeks and months, and those will focus on Florida, Texas, California, and New Jersey. What we find in those reports is that although states have made very positive efforts to encourage biomarker testing, either by requiring coverage in insurance without a co-pay or by limiting step edits, in some cases there is a gap between the policy that removes some of the barriers and the awareness in the physician and patient community that these really important lifesaving tools and treatments are available. We look forward to those coming out. They provide more insight into what state policy has been able to accomplish and what more might be needed to reach the full benefit of those enablers of better patient care.

References

1. Axelsen K, Jenkins L, Garvey L, Pan M. When Innovation Outpaces Access: Closing the Gap in CLL Care. Charles River Associates; September 2026. Accessed November 4, 2026. https://beonemedicines.com/patients/our-commitment-to-patients/

2. McNulty R. CLL treatment access lags behind innovation amid testing, step therapy gaps. AJMC. October 8, 2026. Accessed November 4, 2026. https://www.ajmc.com/view/cll-treatment-access-lags-behind-innovation-amid-testing-step-therapy-gaps