Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA.
Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA.
J Clin Lipidol. 2019 Mar-Apr;13(2):265-271. doi: 10.1016/j.jacl.2019.01.005. Epub 2019 Jan 16.
Despite patient and provider interest, the use of PCSK9i therapy remains limited in clinical practice. High annual listed prices have created intense payer scrutiny and frequent health plan denials, with national approval rates in the range of 30% to 40%.
Our goal was to validate the strategies for increasing PCSK9i approval rates and to present a framework for successful PCSK9i prescribing in clinical practice.
In Sept 2015, a systematic team-based approach was developed and implemented at our institution. The approach centered on a preventive team of 3 senior staff cardiologists, 1 nurse practitioner, 1 physician assistant, 1 care coordinator, 1 pharmacist, and 1 pharmacy technician. The team was responsible for gathering and compiling the required documents to support an approval, as well as collaborating with the in-house pharmacy to complete PA and appeals processes.
In the total study population, 141 (71.9%) were approved for PCSK9i therapy at first submission and 55 (28.1%) were rejected. Of those initially rejected, 48 (85.7%) appealed and all 48 who appealed (100.0%) were ultimately approved. The final coverage decision was 189 (96.4%) approved and 7 (3.6%) rejected.
Our study highlights the presence of modifiable barriers in the PCSK9i approval process. Given the crucial role of health care teams in overcoming these modifiable barriers, we developed a simple stepwise algorithm for navigating the PCSK9i approval process. Our algorithm can help relieve busy providers of heavy administrative burdens and facilitate greater accuracy, standardization, and efficiency in documentation.
尽管患者和医生都有兴趣，但在临床实践中，PCSK9i 疗法的应用仍然有限。高昂的年度标价导致了支付方的严格审查和频繁的健康计划拒绝，全国批准率在 30%到 40%之间。
我们的目标是验证提高 PCSK9i 批准率的策略，并为临床实践中成功开具 PCSK9i 处方提供一个框架。
2015 年 9 月，我们在机构内开发并实施了一种系统的团队方法。该方法以一个由 3 名资深心脏病专家、1 名护士从业者、1 名医师助理、1 名护理协调员、1 名药剂师和 1 名药剂技术员组成的预防团队为中心。该团队负责收集和整理支持批准所需的文件，并与内部药房合作完成 PA 和上诉流程。
在总研究人群中，141 人（71.9%）在首次提交时被批准接受 PCSK9i 治疗，55 人（28.1%）被拒绝。在最初被拒绝的人中，有 48 人（85.7%）提出上诉，所有 48 名上诉者（100.0%）最终都获得批准。最终的覆盖决策是 189 人（96.4%）被批准，7 人（3.6%）被拒绝。
我们的研究强调了 PCSK9i 批准过程中存在可改变的障碍。鉴于医疗保健团队在克服这些可改变的障碍方面起着至关重要的作用，我们开发了一个简单的逐步算法来指导 PCSK9i 批准过程。我们的算法可以帮助忙碌的提供者减轻繁重的行政负担，并促进文档的准确性、标准化和效率。
