Insurance delays in juvenile arthritis not impacted by private, public coverage
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Children with juvenile idiopathic arthritis who require TNF inhibitors often experience insurance-led delays to therapy initiation, according to a research letter published in JAMA Network Open.
“Although insurance is associated with treatment delays in adults with rheumatoid arthritis, it is unknown if prior authorization (PA) requirements delay [TNF inhibitor (TNFi)] initiation among children with JIA,” Jordan E. Roberts, MD, of Boston Children’s Hospital, and colleagues wrote. “We aimed to characterize delays in TNFi initiation because of insurance among children enrolled in public plans vs private plans.”
To examine care delays among patients with JIA on private vs. public health insurance plans, Roberts and colleagues compared TNF-inhibitor initiation among newly diagnosed patients between 2018 and 2019 at Boston Children's Hospital. Researchers used automatic extraction to collect patient demographic and insurance information from the hospital’s electronic medical record system.
The researchers compared outcomes from patients enrolled in private and public insurance plans using Wilcoxon tests, t tests and Fisher exact tests.
In total, the researchers identified 54 children and young adults who were prescribed TNF inhibitors for JIA. The average age was 9.9 years and 81% had private insurance. When prior authorizations for TNF inhibitors were first requested, 91% of patients had already received disease-modifying antirheumatic drugs and 61% already received NSAIDs. Prior authorizations for TNF-inhibitor treatment were needed in 98% of cases.
There were 14 cases — or 26% of the total — where prior authorization was denied. Overall, the median time to approval was 3 days in publicly and privately insured patients, though 22% of cases experienced delays longer than 2 weeks. Median approval time in the cases requiring appeals was 15.5 days, compared with 4.8 for therapy approved on the first attempt.
“Children with public and private insurance commonly experienced delays in TNFi initiation because of PA requirements and denials,” Roberts and colleagues wrote. “Although denials were common, all were eventually approved for a TNFi, suggesting that utilization management strategies present barriers to care despite appropriate specialty medication requests, which is consistent with work in adults.
“Our findings highlight barriers to specialty medications for children,” they added. “Currently, no TNFi is FDA-approved for JIA in children under 2, although onset in toddlers is common. Requirements to use specific TNFis may differentially impact children.”
Perspective
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One of the main frustrations for rheumatologists is the abuse by the insurance industry causing harm to our patients by delaying necessary care. This results in physician burnout and drives up costs for physician offices due to unnecessary prior authorization. In this study by Jordan Roberts, et al., the authors examined the delays to initiation of therapy in children caused by insurance company procedures.
When no denial was made, the time to initiation of medication was quite good at 16 days. However, with prior authorization, a required letter, a required review of records or a peer-to-peer requirement, the delay stretched to more than 30 days, which is still good compared with adults, which can sometimes take up to 3 months. Still, 30 days is far too long when there is active disease.
What I find striking is that, of the 54 children in the study, all eventually received therapy. This makes the insurance mandates useless and in fact costly to both the physician, who has to pay staff and do prior authorization, and to the insurance company, who also has to pay staff for the review, not to mention the potential lifelong cost to the patient if joint damage occurs during this delay.
In an article by James Robinson, the authors state physicians should study the cost effectiveness of using biopharmaceuticals. Well, I would challenge the insurance industry to prove that their delay tactics save money and do not cause harm to patients — in this case our children. I applaud the authors on studying this population and urge them to show this data to legislators to change the law and make it more difficult for the insurance industry to abuse us and our patients.
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