Blue Cross Blue Shield company Health Care Service Corporation is limiting access for in-office administration of asthma infusion treatment, drawing concerns from providers.
The insurer posted notices of the policy change in October for Illinois and Texas (PDF), set to take effect in March. On the same day Fierce Healthcare sent a list of questions about the policy to HCSC, which has not yet been responded to, the company appeared to delay the policy until mid-April in all impacted states. The policy will apply to its plans in Montana, New Mexico and Oklahoma as well.
HCSC said the medical necessity of administering four drugs—Fasenra, Tezspire, Nucala and Xolair—at facilities will be reviewed, requiring members to instead self-administer at home. Medicare, Medicaid and HMO members will not be impacted.
These drugs, also useful for other respiratory issues, are commonly used for moderate to severe symptoms of asthma, affecting up to 2.7 million Americans, according to the American Lung Association. In Illinois, there are about 800,000 people with asthma and 40,000 to 80,000 classified with severe asthma, said Priya Bansal, M.D., a private practice allergist and immunologist in Illinois. The drugs listed by HCSC are also used for nasal polyps and food allergies.
Providers worry the new standards will increase the likelihood of unsafe outcomes, including anaphylactic shock in rare cases.
“If you go into shock in an office, it’s easily treated,” said Brad Traverse, executive director of the Infusion Providers Alliance representing its members in 43 states. “But if you’re at home, you can’t. You’d have to have the wherewithal if you’re alone to call an emergency ambulance and be rushed to the hospital.”
The treatment is applied through a tube or subcutaneously. Some individuals won’t mind this policy change and will be fine with self-administering the drug. Others could have a fear of needles, be too young or too old, have shaky hands or a disability, or simply apply the drug incorrectly.
Docs suspect HCSC’s new policy is a financially driven decision to be able to route drugs through its specialty, mail-order pharmacy owned by Prime Therapeutics. Blue Cross plans jointly own Prime Therapeutics, a pharmacy benefit manager.
Studies show medication adherence drops when administered at home versus in a facility. Adherence dropped from 79% in an office to 64% at home, one analysis found in The American Journal of Gastroenterology.
Patients are also less likely to continue their treatment and visit specialists for follow-up appointments, and researchers noted increased odds of hospitalization and emergency room admissions after administering the treatments at home, a study of more than 57,000 patients in JAMA Network Open showed.
Language barriers could spell trouble for patients affected by this policy. Asthma infusion treatment drugs require specific handling and refrigeration requirements that could get lost in translation. Patients that don’t have a language barrier may still be unaware a package will be delivered or unclear how to best store the drug, said Traverse.
Exceptions can be granted to individuals that can prove they, as well as no caregiver, are able to administer the drug at home.
“It’s putting the onus on us to prove those conditions are there and creating another barrier to access,” said Bansal.
In a letter sent by the Infusion Providers Alliance to members of Congress and HCSC, the group said the decision drives a “wedge in the patient/physician relationship.”
“For my clinic, I see a lot of chronically sick or severely sick patients,” Bansal explained. “If I have 100 patients with biologics, if at least 25 of them want to come to the office, we have to file more prior auth to prove it.”
Administrative burden is already a significant issue for providers in the allergy space. Bansal noted she handles around 100 prior auth requests daily, so adding to that strain will inhibit her ability to connect with patients.