Therapies and Preventive Strategies for Recurrent Clostridium Difficile Infections - Episode 14
Shared insight on the process to gain access to fecal microbiota transplant for patients with clostridium difficile infection.
Neil Minkoff, MD: Let me ask a question to the whole group. I’m not trying to cause a rift between our panelists here, but Dr Allegretti or Dr Gerding, do you have difficulty getting procedures approved? Is your clinical judgment tracking along with the medical policies of the payers?
Jessica Allegretti, MD, MPH: I’m fortunate in that I’m well versed in this space. I have a lot of support in my clinic and I’ve worked with payers to get complex therapies for a long time, so I understand to an extent what needs to be documented and how that process needs to go to make it a bit easier on myself and my patients. Not everybody has those resources or that background knowledge.
That being said, there are circumstances where it certainly can be frustrating. You’re going through multiple layers of peer-to-peer [reviews] and multiple appeals and you still ultimately get denied, and it’s the patient who ends up suffering despite your best efforts and despite what guidelines say. There’s often that lag, as Dr Gerding pointed out. Sometimes what you think is the best science and the best thing that’s appropriate for the patient is not covered by their particular policy. That’s ultimately where there can be inconsistencies in terms of what you’re saying to the patient, what you believe is right, and ultimately what their plan covers.
I loop that into my informed consent discussion, too. “I may think that this is the best agent for you, but we may not have that option.” Unfortunately, that’s the state of medicine in health care in the United States. Unfortunately, the science doesn’t always lead some of the decision-making. And because there has to be such a long filter process, it often takes years for the most cutting-edge data to get incorporated into policy. That’s one of the frustrating aspects of practicing medicine today.
Neil Minkoff, MD: Let me ask the payers to weigh in on that based on how they define their medical policies and their efforts to be as up-to-date as possible.
Kevin U. Stephens, Sr. MD, JD: We look at the FDA guidelines as an approval process that’s important. If it’s investigational and experimental, we typically shy away from those. Albeit, as I mentioned previously, we also have to look at each case. If you have enough information, then those guidelines are only a guidance, and we have the latitude to do what’s in the best interest of the patient. Because as you look at the total cost of care, I can’t overemphasize that you can’t be penny-wise and dollar-foolish. You have to look at the total cost of care and the big picture. That’s where the peer-to-peer process is important, along with talking with the medical director who’s doing the reviewing to see if there’s some common ground.
Transcript edited for clarity.