An overview on how the cost of therapy for recurrent clostridium difficile infection may impact treatment planning.
Neil Minkoff, MD: You mentioned bezlotoxumab [Zinplava]. I want to come back to that. But before I do, I want to open it up to the 2 payers on our panel to discuss how they look at drug cost vs cost to the system vs recurrence and so on as you’re looking at the difference between fidaxomicin [Dificid] and vancomycin [Vancocin] and so on and how that affects coverage decisions.
Kevin U. Stephens, Sr, MD, JD: I could start off by saying that it’s very complex. When you get a complicated case, you have to go case by case. Typically, you use the guidelines as a guidance, and that’s when we count on the treating provider to chime in and, as Dr Allegretti said, make their case for the drug they want to use. It’s a competing theme. If you use Flagyl [metronidazole] and you have high readmission and high recurrence, then when you go to the emergency department and you get back and have repeat admissions, that doesn’t help anyone, and the costs are much greater. You have to weigh those types of things, and we have to individualize.
Many times, we have complicated cases and there are a plethora of things that can go on. Many times, the medical records might not completely reflect the dynamics that you’re seeing in the patients. We really like to have those peer-to-peer conversations. I like to pick up the phone and say, “OK, what’s going on? What are you doing? What are you thinking? Have you tried this? Have you thought about this? Let’s see if we can come up with something that makes sense for everyone.” Quite frequently, we do get to that middle ground. And then many times you don’t, as mentioned earlier, and you have the appeal and independent medical review and those things at your disposal, too.
Neil Minkoff, MD: Dr Abdallah, based on your title, I’m assuming you’re a quite active member of your organization’s P&T [pharmacy and therapeutics] committee. How do you weigh some of these things? That would be question 1. The follow-up question is, do you think there’s a difference between the way you as an integrated health plan look at this vs the way an independent PBM [pharmacy benefit manager] might look at it?
Karina Abdallah, PharmD: Thanks, Dr Minkoff. Yes, I’m very active on our formulary and our P&T committees. Broadly and generally speaking, the P&T decisions are made pretty broadly to be able to give each line of business some freedom to do what needs to be done. Dr Stephens mentioned this earlier. We’re a private insurer, Blue Cross Blue Shield of Michigan, and we have a lot of employer groups, so sometimes the decision to cover or not cover comes down to the employer group and cost. That’s what they’re looking at. It’s up to the partner health plans to come in with the data and information to look at total cost of care. That’s something that I strive to do.
I also oversee the Medicare Advantage population. [Clostridioides difficile] recurrence is really high in our space, so it’s really important to bring in the studies and show your total cost of care and bring it together for the folks who are making decisions solely based on cost alone. I’ll also mention that Dr Allegretti brought up some good points in terms of what she’s seeing on the other side of it. There’s also the burden of prior authorization, and it’s something that needs to be addressed. We’ve made a lot of great strides over the past few years. I’ve spent a lot of time looking at electronic prior authorization. What can we do to pull out the necessary information from the provider who might not be as familiar as Dr Allegretti is with what information each health plan is looking for in order to make sure they have everything they need to make that decision?
The most common reason for a denial is lack of information. Sometimes there are rules and regulations that are put in place that are meant to speed up the health plan’s process so that we can make a decision in a timely fashion, which is obviously better for our patients. But unfortunately, when the initial prior authorization is submitted and it’s missing critical information, such as recurrence or the studies that Dr Allegretti mentioned that can go well, those are sometimes done on appeal. But if that can be brought to the forefront on a case-by-case basis, that will show the most success overall and limit what we sometimes like to call administrative denials where we just don’t have the information that we need.
We have to recognize that the prescribing physician can’t be inundated every day with that paperwork for prior authorization. It comes down to staff training. With a large enough practice, sometimes they have a centralized department that does the prior authorizations. Maybe even the billers can do it. But it’s important to train the staff to recognize what information the health plan needs up front and ensure that comes in up front and then have the health plan make a decision. The problem there is if they don’t meet the health plan’s criteria, which is possible, Dr Stephens already mentioned the appeal and peer-to-peer options that can take place as well, either right after or prior to the decision. Lastly, I want to touch on the point Dr Allegretti mentioned regarding inpatient vs going home and outpatients.
Neil Minkoff, MD: Right.
Karina Abdallah, PharmD: We’ve done a lot of pilots in our...regional health systems where we can embed pharmacists within the hospital system who are employed by the health plan and help with the discharge orders. What can we do to work together to get the prior authorization piece complete? From our end, it’s important that one of our patients has been hospitalized and they’re going to go home, a lot of times with a caregiver, and we don’t want them to go home, send someone to the pharmacy, and get that standard denial from the pharmacy just because they needed prior authorization. It’s important to be proactive in this space in order to ensure that we’re controlling the actual infection and the symptoms that Dr Gerding mentioned earlier on and doing everything that we can to be proactive and prevent recurrences and readmissions to the hospital.
Dr Minkoff, you mentioned the PBM. A lot of times, the PBMs are delegated completely by some of the payers or health plans to do that prior authorization work. It’s the same here, where they might be just focusing on the prior authorization points. I’d probably encourage the health plan that has those types of items delegated to the PBM to make sure to focus on outcomes looking at those denials. How many were denied that ended up being approved? What can we do to get the missing information or lack of information from the provider up front to avoid that back and forth between the PBM and the provider?
Transcript edited for clarity.