Shah Eric D, Chang Lin, Salwen-Deremer Jessica K, Gibson Peter R, Keefer Laurie, Muir Jane G, Eswaran Shanti, Chey William D
1Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, New Hampshire, USA; 2Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA; 3Department of Psychiatry, Dartmouth-Hitchcock Health, Lebanon, New Hampshire, USA; 4Department of Gastroenterology, Central Clinical School, Monash University, Melbourne, Australia; 5Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA; 6Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA.
Am J Gastroenterol. 2021 Apr;116(4):748-757. doi: 10.14309/ajg.0000000000000989.
Insurance coverage is an important determinant of treatment choice in irritable bowel syndrome (IBS), often taking precedence over desired mechanisms of action or patient goals/values. We aimed to determine whether routine and algorithmic coverage restrictions are cost-effective from a commercial insurer perspective.
A multilevel microsimulation tracking costs and outcomes among 10 million hypothetical moderate-to-severe patients with IBS was developed to model all possible algorithms including common global IBS treatments (neuromodulators; low fermentable oligo-, di-, and mono-saccharides, and polyols; and cognitive behavioral therapy) and prescription drugs treating diarrhea-predominant IBS (IBS-D) or constipation-predominant IBS (IBS-C) over 1 year.
Routinely using global IBS treatments (central neuromodulator; low fermentable oligo-, di-, and mono-saccharides, and polyols; and cognitive behavioral therapy) before US Food and Drug Administration-approved drug therapies resulted in per-patient cost savings of $9,034.59 for IBS-D and $2,972.83 for IBS-C over 1 year to insurers, compared with patients starting with on-label drug therapy. Health outcomes were similar, regardless of treatment sequence. Costs varied less than $200 per year, regardless of the global IBS treatment order. The most cost-saving and cost-effective IBS-D algorithm was rifaximin, then eluxadoline, followed by alosetron. The most cost-saving and cost-effective IBS-C algorithm was linaclotide, followed by either plecanatide or lubiprostone. In no scenario were prescription drugs routinely more cost-effective than global IBS treatments, despite a stronger level of evidence with prescription drugs. These findings were driven by higher prescription drug prices as compared to lower costs with global IBS treatments.
From an insurer perspective, routine and algorithmic prescription drug coverage restrictions requiring failure of low-cost behavioral, dietary, and off-label treatments appear cost-effective. Efforts to address insurance coverage and drug pricing are needed so that healthcare providers can optimally care for patients with this common, heterogenous disorder.
保险覆盖范围是肠易激综合征（IBS）治疗选择的重要决定因素，通常优先于期望的作用机制或患者目标/价值观。我们旨在从商业保险公司的角度确定常规和算法覆盖限制是否具有成本效益。
开发了一种多层次微观模拟模型，跟踪1000万假设的中重度IBS患者的成本和结局，以模拟所有可能的算法，包括常见的IBS整体治疗方法（神经调节剂；低发酵寡糖、二糖、单糖和多元醇；以及认知行为疗法）以及治疗腹泻型IBS（IBS-D）或便秘型IBS（IBS-C）的处方药，为期1年。
与开始使用标签上的药物治疗的患者相比，在获得美国食品药品监督管理局批准的药物治疗之前常规使用IBS整体治疗方法（中枢神经调节剂；低发酵寡糖、二糖、单糖和多元醇；以及认知行为疗法），在1年内为IBS-D患者为保险公司节省了每位患者9,034.59美元的成本，为IBS-C患者节省了2,972.83美元。无论治疗顺序如何，健康结局相似。无论IBS整体治疗顺序如何，每年成本差异小于200美元。最具成本节约效益的IBS-D算法是利福昔明，其次是埃卢多啉，然后是阿洛司琼。最具成本节约效益的IBS-C算法是利那洛肽，其次是普卡那肽或鲁比前列酮。在任何情况下，尽管处方药的证据水平更强，但常规情况下处方药并不比IBS整体治疗方法更具成本效益。这些发现是由处方药价格较高与IBS整体治疗方法成本较低所致。
从保险公司的角度来看，要求低成本行为、饮食和非标签治疗无效的常规和算法处方药覆盖限制似乎具有成本效益。需要努力解决保险覆盖范围和药品定价问题，以便医疗保健提供者能够为患有这种常见的异质性疾病的患者提供最佳护理。
