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Insurer Policies Misaligned with Ulcerative Colitis and Crohn’s Disease Treatment Guidelines, Study Finds

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Insurance policy adherence to clinical guidelines ranged from 6% to 59%, according to findings reported in American Journal of Gastroenterology.

Current clinical guidelines for the treatment of moderate to severe inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, have shifted from a step-up therapy approach to preferring the use of a biologic as a first-line option for remission induction. However, coverage from insurers in the United States does not always align with guideline recommendations.

In a study published March 15 in the American Journal of Gastroenterology, Kelsey L. Anderson, M.D., from the department of internal medicine at Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, and his colleagues searched the 50 top U.S. insurance companies for publicly available policies on four biologics and one small molecule drug used to treat Crohn’s disease or ulcerative colitis.

Kelsey L. Anderson, M.D.

Kelsey L. Anderson, M.D.

The biologics and the small molecule agent included Remicade (infliximab), Humira (adalimumab), Entyvio (vedolizumab), Stelara (ustekinumab), and Xeljanz (tofacitinib). Anderson and her colleagues compared insurance coverage requirements with current American Gastroenterological Association and American College of Gastroenterology treatment guidelines for Crohn’s disease and ulcerative colitis.

After looking at publicly available policies from 34 insurers, the researchers found that insurance policy adherence to clinical guidelines ranged from 6% to 59%. Most policies (91%) required failure of at least one conventional treatment, such as corticosteroids or immunomodulators, or another biologic before a specific biologic was covered. Only about 18% of policies allowed any biologic as a first-line treatment for ulcerative colitis.

The authors call for continued efforts to increase patient access to current standard-of-care treatment.

“Given most patients have employer-sponsored insurance with limited plan choice, our data elucidate a system-level issue requiring legislative change, not individual action. Comprehensive insurance policies in line with current guidelines are necessary to reduce costs, increase access, and increase compliance rates to help prevent poor outcomes in this high-risk patient population,” the researchers wrote.

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