S724 Insurance Companies’ Poor Adherence to ACG/AGA Guidelines for Moderate to Severe Ulcerative Colitis and Crohn’s Disease Management

Abstract

Introduction: Management of moderate-to-severe ulcerative colitis (UC) and Crohn’s disease (CD) has shifted from step-up therapy to induction of remission with a biologic agent based on disease severity. We sought to assess if current insurance company policies meet the latest guidelines from the ACG and AGA for UC and CD management. Methods: The top 50 insurance companies were searched for publicly available policy information for infliximab, adalimumab, vedolizumab, tofacitinib, and ustekinumab. Data extracted included authors, date of last revision, citation of AGA/ACG guidelines, and policy requirements. Additionally, data regarding need to fail conventional therapy, use of biosimilars, and use of 1st line biologic agents was obtained. The data was compared to the 2018 ACG and 2020 AGA guidelines for UC, and the 2019 ACG and 2021 AGA guidelines for CD. Results: Of the top 50 insurance companies, 48 provided health coverage. Of those, 33 (72.34%) had publicly accessible policies on the coverage of biologics. No authors of the policies were listed. ACG/AGA guidelines were directly quoted or cited in 70.6% of policies. Policies were updated from 1/1/2016 to 5/31/2022. Of the 34 policies that were analyzed, only 58.8% of policies were consistent with the ACG guidelines for CD vs 8.8% to AGA guidelines (Table). Additionally, only 14.7% and 17.7% of policies permitted any first-line biologic therapy in CD and in UC respectively. Conclusion: As of 2022, insurance companies that comprise nearly 80% of the market are yet to adopt the most current guidelines for IBD management. Nearly every insurance company requires the failure of “conventional” therapies such as 5-ASAs, immunomodulators, and corticosteroids. The time required to determine therapeutic failure was inconsistent – ranging from 7 days to 6 months. The large difference between adherence to ACG vs AGA guidance for CD is due to the difference in recommendations for use of an immunomodulator vs anti-TNF as first line agent, as well as length of treatment with corticosteroids before failure (short term therapy vs 3-5 days). The second most common reason for guideline non-adherence was the inability to use immunomodulators concurrently with biologics. Finally, first-line biologic medications 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. Table 1. - Adherence to Published Professional Society Guidelines Metric Ulcerative Colitis Crohn's disease ACG Guidelines (2018, 2019) 3/34 (8.8%) 20/34 (58.8%) AGA Guidelines (2020, 2021) 3/34 (8.8%) 2/34 (5.8%) Any first line biologic (infliximab, adalimumab, vedolizumab) 5/34 (14.7%) 6/34 (17.7%) Requirement to fail at least one conventional therapy 31/34 (91%)* 31/34 (91%)** *Certain policies have exceptions including hospitalization for UC.**Certain policies have exceptions including fistulizing disease for CD.