About IBD Podcast Episode 113 - How to Be Happy & Healthy With IBD: Tips for Navigating Health Insurance

People who live with chronic illness don’t get training on how to deal with health insurance. Yet it is a major part of living with conditions such as Crohn’s disease or ulcerative colitis. Plus, it not only affects patients living with IBD, but our doctors and other healthcare providers are also frustrated and overburdened with dealing with red tape such as prior authorizations. Dr Shubha Bhat, a gastroenterology clinical pharmacist at the Cleveland Clinic and Jaime Holland, who is a healthcare activist and Crohn’s disease patient tell me how they handle health insurance complications and what we can do to change the system.

Concepts discussed on this episode include:

Find Shuba Bhat, PharmD on Twitter, LinkedIn, and Cleveland Clinic.

Find Jaime Holland at Pretty Rotten Guts, Twitter, and Instagram.

Find Amber J Tresca at AboutIBD.com, Verywell, Facebook, Twitter, Pinterest, and Instagram.

Credits: Mix and sound design is by Mac Cooney. Theme music, “IBD Dance Party,” is from ©Cooney Studio.

Transcript

[Music: IBD Dance Party]

Amber Tresca (00:04):

I’m Amber Tresca and this is About IBD. It’s my mission to educate people living with Crohn’s disease or ulcerative colitis about their disease and to bring awareness to the patient journey.

Welcome to Episode 113!

About IBD is excited to be partnering on this new limited podcast series, “How to be Happy & Healthy with IBD.”

Even as a long-term IBD patient, I still don’t understand how health insurance works. But to be fair, the rules are always changing, so it can be really difficult to keep up. As patients, we struggle with issues surrounding health insurance but what some might not realize is that our providers are also spending time and energy to deal with these problems.

To get both the patient and the clinician side of this issue, I asked Dr Shubha Bhat, who is a gastroenterology clinical pharmacist at the Cleveland Clinic and Jaime Holland, who is a healthcare activist and Crohn’s disease patient to tell me how they handle health insurance complications.

Jaime and Dr Bhat not only outline the major barriers with health insurance, but also provide some concrete solutions and tips to manage the approval and prior authorization processes.

Amber Tresca (00:50):

Jaime and Dr Bhat not only outline the major barriers with health insurance, but also provide some concrete solutions and tips to manage the approval and prior authorization processes.

Amber Tresca (01:24):

Our topic is tips and guidance for navigating health insurance. This is a topic that I don’t really understand very well myself, so I have asked two guests to come and share their knowledge and experience. First I have with me Dr. Shubha Bhat, who is a gastroenterology clinical pharmacist at the Cleveland clinic. Dr. Bhat, thank you so much for coming on About IBD, and I wonder if you would take a minute to introduce yourself?

Dr Shubha Bhat (01:52):

Yeah. Hi, everyone. I am very much and my name is Dr. Bhat, and I’m a clinical pharmacist embedded in the IBD Clinic at the Cleveland Clinic. I primarily focus on medication education, ASA, management, and monitoring and I interact frequently with patients in the capacity. My goals are really to make sure that patients initiated on medications are comfortable and knowledgeable about it, able to assess it in a timely and cost-effective manner, and so well on treatment without having any major side effects. I’m really excited to be here, so thank you, Amber and Jamie, for the opportunity.

Amber Tresca (02:24):

Your job is so critically important, truly, and yet I think so few patients have access to someone that’s in your role, so I’m really excited to get to hear more about what it is that you do and how that you can assist patients. I also have with me Jamie Holland, who is a healthcare journalist, advocate, and Crohn’s disease patient. She also moonlights as my Content Management Specialist. We last heard her all the way back on episode 17. I want to welcome you back, Jamie, to About IBD. Would you take a moment to introduce yourself as well?

Jaime Holland (02:58):

Hi, everyone. I am Jamie Holland, and as Amber mentioned, I am a health journalist, patient advocate. I’m also a patient. Not only am I a patient, I’m also a decision-maker for my nephew who has Crohn’s disease as well and a rare digestive disease.

Amber Tresca (03:18):

Right, which is another aspect of your knowledge and experience that really lends itself kind of sort of unfortunately to understanding all of these insurance issues, like I’m not happy that you’ve experienced some of the things and that your nephew has experienced some of the things that he has, but at the same time, we can totally mine that to help other patients, so I’m really glad to have you here today.

Jaime Holland (03:39):

Thank you.

Amber Tresca (03:41):

Let’s get into this topic because it is super important in the management of IBD since so many of us rely on our medications to keep that pesky inflammation under control. Dr. Bhat, I’d really like to start with you because patients are pretty well versed on the ways that health insurance affects their care, but I think that they don’t truly understand how it affects our clinicians. What are some of the ways that insurance impacts your practice and those of the people that you’re on staff with?

Dr Shubha Bhat (04:11):

I really appreciate you asking this question. Similar to patients, the insurance effect on clinician and practices can be greater on some and exhausting, so specific barriers is the need for prior authorization, so this why I radically introduced to mitigate any youth expensive health services and treatments that are not medically necessary with the hope that we can actually contain care costs and promote evidence-based care. Essentially, what happens in the prior authorization process is that a patient’s clinician has to submit an application justifying the need for a service or a treatment, and the entrant would then assess if it’s actually necessary.

Dr Shubha Bhat (04:49):

Just a heads-up, the prior authorization process can apply to both medical-related procedures and medications, and from our perspective, from a clinician’s perspective at the office, it’s really frustrating when the prior authorization process is not utilized as it’s supposed to be. I can’t tell you how frustrating it is when I pass this order to various lab tests, imaging, or procedures that we know are necessary to help assess how well patients are doing and if any modifications are needed to keep their IBD under control, but then we find out afterward that it’s either not covered or it’s a major out-of-pocket expense for our patients. Then, we know this can lead patients to defer these tests in the future.

Dr Shubha Bhat (05:29):

From a medication perspective, some of the prior authorization requirements that have been put in place are completely unnecessary and they can actually leave the patient harmed due to treatment delays. This significantly affects their practice because now we’re spending additional time on unnecessary tests and we’re now limited in how we can actually pack this medicine. Moreover, during the prior authorization process, patients who are flaring continue to suffer, and those who may have been actually doing pretty well before the issue was brought on by the insurance may now start to have GI symptoms to flare, and we know this can increase the use of steroids, which is never an ideal for a long-time use, or it’s never really an ideal patient outcome.

Dr Shubha Bhat (06:13):

It’s interesting because the prior authorization burden has been studied before and actually one survey noticed that approximately 30 to 50% of patients may actually abandon the entire treatment just because of this whole complex, unnecessary process, so it’s really, really frustrating overall. Then, one last key point that I just would like to briefly talk about is that insurance processes are not designed to be helpful for clinicians.

Dr Shubha Bhat (06:38):

Here’s an example. In a process known as peer-to-peer, essentially what happens is that a gastroenterologist or a staff can verbally justify why a certain test or a treatment needs to be covered to the representing provider of the insurance company. However, this actually requires the insurance company or like the clinician’s staff to facilitate with the insurance company a block of time where both the gastroenterologists and the representatives are actually available to connect and talk. You need to give them like a three-hour block of when a gastroenterologist might be available.

Dr Shubha Bhat (07:13):

As you can imagine, no one has time for that. Then, sometimes essentially what’s more frustrating then is that the representative on the insurance side… Actually, that’s another call. It’s a really inefficient process. There’s additional barriers and time constraints that are placed on the practice that’s completely unnecessary and it’s just honestly time and resources that could be better spent elsewhere to just seeing or outreaching the more patients.

Amber Tresca (07:38):

Mm-hmm (affirmative). Do you have any thoughts about how much time is spent? I’m sure there have been studies on this as well.

Dr Shubha Bhat (07:46):

Yeah, so I know we haven’t specifically looked at the time spent on insurance issues in our practice, but I can easily see this end up as being 40-plus hours a week depending on the volume of a practice daily. In an ideal work situation, every practice should have one team or one person that is dedicated to handling all the insurance issues because honestly it is a full-time job. My perspective, I actually help a lot out with appeal letters and peer-to-peer-

Amber Tresca (08:11):

Mm-hmm (affirmative).

Dr Shubha Bhat (08:12):

… and I can tell you I easily spend maybe about 10 hours a week completing the activity. I think one study specifically found that two-thirds of practices have staff that is exclusively dedicated to the prior authorization process, and I think the reported time has been anywhere from like 10 to 20 hours a week or maybe even 21 to 40 hours a week depending on the volume of the patients that they’re saving.

Amber Tresca (08:35):

I feel like that also might be under reported or-

Dr Shubha Bhat (08:38):

Exactly.

Amber Tresca (08:38):

Yeah, because like you were saying, there’s probably also lots of other little pieces that don’t necessarily get…It’s very difficult to keep track of your time when you’re doing something, so like you can keep track of big chunks of time, but what if you’re spending 5, 10, 15 minutes here and there throughout your day working on something? Keeping track of all of that has to be really difficult, too.

Amber Tresca (08:59):

I really wanted to make sure that patients hear your side of it because we know our side of it. I know Jamie is very well-acquainted with the amount of time that she spends on insurance issues. How much time do you think you spend Jamie? Like a year, a week? What do you think?

Jaime Holland (09:17):

You know, it honestly depends on the medication, how long I’ve been on that medication, the insurance cycle, and also if it is a move to a new doctor’s office.

Amber Tresca (09:28):

Right.

Jaime Holland (09:29):

Those are all different impacts. Or, if you’re at a university system every semester, you have fellows coming in and interns and all the like, and so some of them get tasked with that as part of their internship or-

Amber Tresca (09:43):

Oh.

Jaime Holland (09:43):

… their fellowship.

Amber Tresca (09:44):

Yeah.

Jaime Holland (09:44):

That cycle can also have things fall by the wayside, not intentionally, but because of the insurance lag that is created. If it is a new medication or something that just keeps getting denied, I could spend well over 40 hours in a week, let alone a month, with phone calls between provider staff members because you have to tell one staff member and then repeat the same thing over because it’s usually a gatekeeper or a message-taker. Then, they put you through to someone and then they’re like, “So I hear there’s a problem. What’s up?”

Jaime Holland (10:17):

So I give them the information and then eventually if you get to talk to your doctor as well, they’re going to want to know what happened. There’s just so much time wasted and I’m such a big believer in making things easy and smooth and just running things lean and it’s frustrating to see all of the stop-gaps, and especially when you see people say, “That it’s not worth it anymore, I’d rather not take the medication than have to worry about getting it approved.” That just guts me.

Dr Shubha Bhat (10:51):

Yeah, I’m sure of that, and to Jamie’s point, I mean, she brings up a lot of important things about at the end of the day, the patient actually doesn’t probably need to be involved in this. It’s just that there’s no seamless coordination between the insurance company and the office, right? They’re like, “Oh, we sent you a fax.” “Okay. Well, do you know how many fax we get? Oh, by the way, it’s also 2022. Why we still using fax machines?” For goodness [crosstalk 00:11:12] how many times I hear that comment, but [crosstalk 00:11:16] to the point again, but you know, there’s just a lot of inefficiencies in this process. Amber, to your-

Amber Tresca (11:21):

Yeah.

Dr Shubha Bhat (11:22):

… your point where you say that all of us, it’s underreported, it’s true because how much time do we spend documenting every little step? It’s at the end of the day, who has time to sit down and time that? You just got to keep leaving and because it is such an interrupted process, it’s not like you do it once, you get a determination and you’re done and move on. It’s just like there’s no point in kind of tracking. I mean, there’s utility in tracking it, but it’s just one other additional thing now that someone that’s already overburdened.

[MUSIC: About IBD Transition]

Amber Tresca (12:12):

Jamie, when you talk to your doctors, what do you tell them about this? Are they able to sort of intervene with you and help you get any of these problems solved?

Jaime Holland (12:21):

I’ve been lucky. Having established a relationship with the majority of my doctors and their like number one right-hand person or their second-hand person who does prior authorizations and prescription ordering, and especially mine in particular, at this point in time, all of my doctors, except for one, have been on my team for the last 10 years, if not a little bit longer. That relationship is established, but there was a gap where I lost my GI for two years when she was switching practices, and so I had to rely on another practice and thankfully they were a well-oiled machine. They were on it. They were used to treating IBD patients and I did not have to lift a finger. It’s funny that now that she’s at this other practice where they treat a lot of IBD patients, I still feel like I do a little bit more heavy lifting than I’ve had to.

Jaime Holland (13:17):

I still had to do heavy lifting with the university system at times. It’s just because there’s so many patients and there’s only so much time allotted per person. I’m type A personality. I need to know why and what is going on, so I’ve lost count of how many times my doctor’s team members have gotten back to me saying, “Well, I spoke to so-and-so on such date and I spoke to this person on this date,” and no, that is not what happened. I faxed this in on A, B, C, D, and E and the insurance company will come back and be like, “I never received a fax. We never received this document. We never received this phone call.”

Jaime Holland (13:57):

It becomes a bunch of finger-pointing and I have seen where I live in Central Florida patients get into a heated conversation with those team members from the doctor’s office and even their doctor having that conversation with them and it gets heated. People get offended being called liars because if the insurance company tells you that this person didn’t do it, who are you going to believe? The people who are fighting for you? Or the people who don’t want to provide you with anything because it doesn’t benefit them financially to help you?

Jaime Holland (14:32):

Unfortunately, I have seen people get kicked out of the practice because the conversations get too heated or too accusatory or it’s just not worth it for the practice to deal with that patient anymore. That’s another facet to this, so I try to be careful when I word my messages. I don’t point fingers. I just lay the facts out and hope for the best.

Dr Shubha Bhat (14:54):

Jamie, I really appreciate you sharing that perspective because I can tell that from our end, it’s the same thing on our end as well. At the end of the day, the patient’s the one that’s paying for it, but other than that, like this is time that we could be spending doing other things for patients. I will say that sometimes we do get a little bit of like angry comments and stuff and it doesn’t help us at the end of the day. We’re in the same boat as you in the sense that we can only do so much and the rest is in the insurance company’s hands.

Dr Shubha Bhat (15:21):

We’re here for you. That’s our main… We practice medicine because we want to make sure that we get people feeling better and we want to keep them healthy, but definitely appreciate you bringing up the fact that kind of weighs on every back and we’re already trying to do what we can at our end. At the end of the day, it just sometimes we just got to wait and have the insurance company hopefully get back to us and make the determination that we actually want.

Amber Tresca (15:46):

Dr. Bhat, this is a big question I’m going to ask you, but do you have any thoughts on how some of the stumbling blocks that we have with insurance could be minimized or lessened?

Dr Shubha Bhat (15:55):

Yeah, sure. There’s a lot that could be done. I think that the prior authorization process can be significantly refined. Not every insurance plan has a standardized process, so some will [inaudible 00:16:07] prior authorizations electronically, others will require to pass it through to be initiated by fax or phone. Then, even for the appeal process, like someone will say that you need to do two rounds of the PO letter and then you can do a peer-to-peer before they make a final decision, but then other insurance companies won’t even allow a peer-to-peer option. They say that the only way you can do this is to write a letter, but the insurance are not up to speed.

Dr Shubha Bhat (16:29):

Having them get up to speed, having them stand by the authorization process would eliminate so many unnecessary administrative burdens, and I would think that there’s no way to get away with the prior authorization process, then at least streamlining or improving the navigation process or insurance requirements and formulary. Keep in mind, formulary is often the foot services and medications that are covered or if there’s restrictions in place, so it can be a handy document to utilize if you know how to get to it and if you know how to interpret it.

Amber Tresca (16:58):

Hmm.

Dr Shubha Bhat (16:59):

There’s a lot of plans out there. Business standardized mechanism placed to look up individual enhanced requirements, but if this was actually standardized, then both the patients and providers could actually proactively see it ahead of time and maybe even come up with a plan that works for all parties. To highlight one of Jamie’s points, you mentioned something about medical basic pharmacy benefits, and I think this important for all IBD patients to know.

Dr Shubha Bhat (17:27):

In general, thought, just generally speaking, most infusions tend to get covered under medical benefits and most often injectables tend to be covered in the pharmacy benefits, but more recently we’re actually starting to see a blur of claims and this all has to go back to the cost perspective on the insurance side. Sometimes essentially a biologic or like an infusible medicine might actually be covered in the pharmacy, so then it gets even more confusing because, again, there’s no standardization of how to go about doing this. Again, I think if we can actually clean up the process, take out the most [inaudible 00:18:00] puzzle figuring out pieces, I think things could be so much better.

Amber Tresca (18:05):

Jamie, there’s been times when I know for myself that I’ve had a delay in care because of these things that have happened. Was there a time when you couldn’t access the care that you needed, did you ever get it resolved in some way?

Jaime Holland (18:17):

That’s basically how I became disabled because my health began to deteriorate so much because I was forced into step therapy as well as steroids, which my body just could not handle the long-term use of. Instead of it becoming helpful, it actually became detrimental to use them and expensive because insurance didn’t cover them either. I had to order them from Canada.

Amber Tresca (18:41):

Oh boy.

Jaime Holland (18:42):

A story for a different day, but-

Amber Tresca (18:43):

Yeah.

Jaime Holland (18:44):

… it took, I want to say, from the time where my flare started in 2012 to March of 2013 is when it was finally approved, and let me preface it with saying that knowing what I know now, I should not have had to wait and we probably should have gone through different avenues to just sidestep insurance altogether because I had a private plan, which at the time was called a catastrophic plan because I had preexisting conditions. The ACA had not fully blossomed and took over and made things easier. I was able to qualify for insurance on my own because I was working as a contractor. I didn’t have ERISA, which is an employer-based plan or a corporate plan.

Jaime Holland (19:35):

In that year and some odd months that I had to wait, it got approved, but my deductible was $16,666. It is such a weird number to begin with and that has stuck with me for so many years. They said, “Sure, you can take this medication, but we’re not paying for it until you pay $16,666 out of pocket first.” I am now disabled and can no longer work and I lost my house and I lost my career, and where is that $16,666 going to come from?

Amber Tresca (20:11):

Mm-hmm (affirmative).

Jaime Holland (20:14):

At that point, thankfully, the medication’s manufacturer had a program for people who insurance plans either wouldn’t carry coverage for it, or it was just too unattainable, and so they had a foundation arm that sponsored my medication with a low co-pay of $50 a month at that point, which, I mean, in the grand scheme of things, $50 is amazing as opposed to $16,666, so-

Amber Tresca (20:44):

That was on top of your premium, right?

Jaime Holland (20:47):

My premium, which was more than my car payment. It was $425 a month.

Amber Tresca (20:52):

On the one hand, I’m a little bit in awe that you’re able to remember these numbers, but on the other hand, I completely understand why because-

Jaime Holland (21:00):

Yeah.

Amber Tresca (21:01):

… that’s obscene.

Jaime Holland (21:02):

It was, it absolutely was, and it was a lot easier to pay when I didn’t have a house payment anymore. Not as much when you don’t have a job [crosstalk 00:21:09].

Amber Tresca (21:12):

Oh my gosh.

[MUSIC: About IBD Transition]

Amber Tresca (21:19):

Dr. Bhat, has there been a time when you haven’t been able to get a problem with insurance resolved? What about a time or two when you have been able to resolve a problem?

Dr Shubha Bhat (21:27):

Yes, I definitely have discussed different barriers with the appeal process, but when a requested prescribed medication was not being covered. Again, the reason for why the insurance company refused to cover your medicine is it really varies. I can tell you at a time, and one example, a gastroenterologist had requested vedolizumab for a patient because she was in her 60s we know that the safety profile of the treatment is really unmatched and [inaudible 00:21:53] colonoscopy showed that there was some progression of disease that warranted biologic treatment.

Dr Shubha Bhat (21:59):

I can totally understand where she’s coming from, especially being in her 60s and having concerns about infection risks, side effects profile, et cetera. We had a whole clinical case built out. There’s justification for why this should be an appropriate medication for her. The insurance denied it saying that she has to either fail or have a contraindication, and so at that point we weren’t able to try to compromise, if you will-

Amber Tresca (22:19):

Mm-hmm (affirmative).

Dr Shubha Bhat (22:20):

… but I can tell you like in a successful case, so even for the successful cases where I’m actually able to get the coverage that we want for the treatment that we want or keep patients on the treatment that we’ve identified have been working for them, was the best treatment for them, they’re doing so clinically well, even in these situations, I can tell you that there’s often treatment delays or interruptions.

Dr Shubha Bhat (22:39):

We know that this is never ideal because in IBD, there’s a risk for flares and IBD symptom occurrence the longer they’re off medication. Even if we are successful, there’s still so many issues with the system and it’s so that it’s just not ideal for patient care.

Amber Tresca (22:56):

Absolutely, so dealing with insurance is not something that we know how to do. Nobody really teaches us how to do this. I can’t think of a class or anywhere to learn this at all, except by just the school of hard knocks, frankly. I’m going to ask you, Jamie, if you have any tips for patients on how to deal with insurance or any resources that you found that are helpful to you.

Jaime Holland (23:17):

Yes, so I think the first thing is first approach everyone with kindness. I used to work for a foundation and one of the first things that my former boss had tried to really instill in her team is lead with kindness. Nothing good ever comes of treating people with disdain or sheer meanness. You know, we get you can be frustrated over something, but kindness is going to get you a lot further in communicating with people than the opposite, so that is my first tip, number one. So important, no matter how frustrated you are, how sick you are feeling, remember that these people have heard a lot and maybe even more than you can imagine and taking it out on them is not going to get you anywhere. It’s okay to tell them you’re frustrated. It’s okay to tell them why you’re frustrated, but don’t take it out on them.

Jaime Holland (24:15):

Second, I don’t know, maybe some people think this is more important than leading with kindness, taking notes. Keep track of dates, who you’ve spoken to, what numbers you called when you’ve-

Amber Tresca (24:28):

Yes.

Jaime Holland (24:28):

… done that. It feels like a job and it feels so clerical and so stale, but do it because it will help you jog memories of those conversations when you see those notes. Oftentimes, when you’re speaking to someone from a call center or working in a call center environment for the insurance company, or even the doctor’s office if they’re part of the message-taking team, they’re not transcribing everything, so you need to really keep detailed notes for yourself so that if you do need to pass that on to your doctor or their right- or left-had person, you have that information there.

Jaime Holland (25:04):

The next part is kind of like an A/B type to number two because I usually keep one or two notebooks around. One or two notebooks at the end of the year has morphed into five or six notebooks-

Amber Tresca (25:17):

Oh boy.

Jaime Holland (25:17):

… and losing track of which notebooks you’re taking notes in, no bueno, so most cell phones and most computers and online software, there is a note or a document type of situation that you can do. Or, take a picture of those notes and make a file on your phone so that you always have access to it. You never know when you need to back up your own information to prove that you did do something on your end or to help your doctor’s office get that accomplished.

Jaime Holland (25:52):

Another one is depending on the medication, there may be patient assistance involved, and not just financial patient assistance, that there is a nurse and/or a business arm for that manufacturer’s patient assistance that will help you with questions such as, “I have a high deductible insurance plan through my spouse’s corporation, and that deductible is so expensive I don’t think I’m going to be able to afford any of my tests this year because my medicine used to cover that and I only had to [crosstalk 00:26:29] my 5, 10, 15, or $50 copay. Over the last two years, this has become a huge problem.

Amber Tresca (26:36):

Right.

Jaime Holland (26:36):

Those people and your manufacturer’s patient assistance program have tips that you can get from them. One of them is that if you can find a way to pay for the medication out of pocket, it’s going to hurt up front, but then you can apply to patient assistance to get remunerated, but I have to put a preface on this that some of the insurance companies have gotten wise to this and they put a lot of scary literature out there and they will send it to you and tell you that you technically have to tell them if you are doing that. I don’t think it’s legal. I don’t think it’s fair. I know that there are groups trying to fight this right now.

Amber Tresca (27:18):

Mm-hmm (affirmative).

Jaime Holland (27:19):

This literally could become a whole other subject unto itself because there are insurance companies that are being forced to share which patients could qualify for these programs, but aren’t utilizing them, so-

Amber Tresca (27:32):

Oh.

Jaime Holland (27:33):

… yeah. My recommendation is to speak to the people at the company for your manufacturer’s assistance and see what options you have in different ways. You might be able to get things accomplished in an affordable manner because one of the worst things that I think we can do as patients is, “Great, we’re taking our medication. We’re staying on schedule, but we’ve fallen off of the testing track.” Falling off of the testing track is… it’s detrimental to your overall treatment plan and also we know that we’re… Our groups, anyway, for IBD, we’re at higher risk for colorectal cancer and other cancers, so screening is so important and critical to our regular care.

Amber Tresca (28:17):

Right, exactly. We’re at risk of a host of things that seem related and make sense, and then other things that don’t seem related and don’t make any sense at all. I’m so glad every year that the pap smear and the mammographies are covered for me because it’s never something that I have to worry about. I’m so grateful for that every year because it is recommended that I get them every year. I’m wondering, Dr. Bhat, do you have anything to add? Any other tips for page on how they can manage this insurance process?

Dr Shubha Bhat (28:48):

Yeah, so Jamie brought up a lot of great points. I’m just going to add a few more things to supplement that. I think the most impactful step that a patient can take, if you have the option, it’s a fairly easy health insurance plan option, and pick the one that has the best coverage in regard to IBD management and treatment. This would ideally be the best case scenario. If you have the option, decide which insurance plan you can get and that actually like when you take a look at it, it’s going to be more comprehensive, most cost-effective for it managing your IBD. That would be the best thing you could do for yourself, but if you don’t have that option, then really the next best step is to know your insurance plan inside out, and so basically understanding what’s covered, what’s not covered, what’s the deductible? What’s the premium?

Dr Shubha Bhat (29:37):

There’s a lot of insurance concepts that are really hard to understand, but it’s critical to understand because the more you know about the terminology, the better you can kind of handle your expenses, handle your navigation of care, and et cetera. I would like to give a shout-out to The Crohn’s and Colitis Foundation. They have a great part of their website that actually highlights all the insurance navigation piece, so I would highly encourage patients to check it out.

Dr Shubha Bhat (30:02):

Then, once they’re conversing on the other side, once the patient is dealing with insurance issues, communicating with the gastroenterology practice is critical. I can’t tell you guys we’re not often aware of the issues until you contact us and let us know. If you are communicating with the insurance company directly and you get real-time information, so if you have that information already, relay that to us. That way we can make sure that we’re all on the same page and just know that once we do submit the prior authorization or once we submit whatever the insurance is acquiring, it’s honestly out of our hands until the insurer will be [inaudible 00:30:38] the determination.

Dr Shubha Bhat (30:39):

Again, I wish that patient didn’t necessarily have to be in the middle of this and I wish that clinician had the resources to directly handle this themselves, but the reality is that, again, that it’s just another thing that’s imposed by the insurance company, so having that dynamic partnership and making sure that as much as we can reconcile the differences and making sure that we’re on the same page about what’s expected and what should he happening going forward.

Amber Tresca (31:03):

Mm-hmm (affirmative). Yeah, and we love our healthcare providers. Like we would love to make this all easier on you as much as we can, so I’m sure patients are willing to do whatever they are able to do in order to move the process forward and also take some of the burden as well. That makes me think about activism, so Jamie, what do you think? How can patients get involved in healthcare reform?

Jaime Holland (31:29):

There’s a few ways that patients can get involved in healthcare reform. The first thing is you can just simply write a letter to your members of Congress, state representatives and senators, and it can be at the state level as well as the federal level. Sometimes people do actually get back to you. A lot of the senators and legislators are available on Twitter and on Facebook, and it’s not necessarily them manning the page, but they have staff who are manning their boxes and their tweets and looking for things that they might be able to help with.

Jaime Holland (32:10):

Another thing that you can look for is if you think that you’re being affected by step therapy, you can check to see if your state has created a law around it. Recently, I live in Florida, State of Florida has made some headway on step therapy reform, but what I found out was it’s like two steps forward and one step back.

Amber Tresca (32:33):

Mm-hmm (affirmative).

Jaime Holland (32:34):

The step therapy legislation that they came out with really only covers private plans because ERISA, would would be corporate provided insurance, plans can be based out of multiple states. Then, there’s these rules that kind of fall in a gray area where some of Florida’s laws may count for that plan, but also if the plan is based out of another state, some of the laws from that state may help the plan make decisions and rules that may not be in your favor. As much as states are making reform right now, federal legislation versus step therapy, for example, needs to be said in place so that everybody can fall under one umbrella for this per particular reform.

Jaime Holland (33:21):

The Crohn’s and Colitis Foundation is a great way to start. You can reach out to them and ask them how you can get involved. You can look online for other advocates who are involved in this particular reform, especially when there is days on The Hill like The Crohn’s and Colitis Day on the Hill. There is also The Digestive Disease National Coalition. We just had their day on The Hill. That was great. Also, there’s going to be other foundations that are involved with inflammatory bowel disease that my also have some of their own reform points of contact figure out what it is you like to do and also some training sessions on how to communicate better with members of Congress.

Jaime Holland (34:09):

Another thing that I think people can do is look and see if… Look for key words if there is any type of legislation around something that’s been bothering with either your insurance plan, your medication, or the way that things are being handled by your insurance plan because you’d be surprised to see that there’s a lot of legislation out there that’s just kind of sitting, and the only way that we can get it to move is attention is brought to it and it’s brought to a vote and it comes out of committee. You find something that becomes a passion point, makes contact with your state legislator, your federal legislator also, to see if there is something that can be done. If it hasn’t been done yet, what can we do about that It starts with an ask basically.

Dr Shubha Bhat (35:02):

Definitely, so I know The American Gastroenterological Association, or the AGA, actually has an advocacy group and they’ve identified their advocacy priority for 2022 to include both developer reducing prior authorization burden, but delay patient access to care. The second bullet point, if reducing or eliminating step therapy and insurance initiated switches, and then insurance-indicated switches patient access to care. The second bullet point, if reducing or eliminating step therapy and insurance initiated switches in patient of treatment for non [inaudible 00:35:22] that are typically referring the biosimilar that are typically referring the biosimilars in this capacity.

Dr Shubha Bhat (35:26):

Then, there’s also a few bills in Congress that healthcare providers can utilize an online system to essentially bring their representative attention to and ask their co-sponsorship. I know that The Crohn’s and Colitis Foundation, again, they’re also committed to advocacy, so they’re bringing attention to bills that are currently drafted or being considered. They’re encouraging members to reach out to their representative as well to emphasize the importance of these bills and IBD care. There’s definitely an advocacy. I’m a component generally so that healthcare providers can look more into to kind of help advance some of this on a legislation level.

[MUSIC: About IBD Transition]

Amber Tresca (36:27):

Dr. Bhat, I was on your Twitter the other day and I saw a couple photos of your dog. Would you tell me some more about your dog?

Dr Shubha Bhat (36:36):

Yes. I have a… He’s now three years, a Dalmatian. His name is Jackson. I got him from the shelter, so I think he might have been up here. Brad said he’s definitely deaf, so he has no hearing capabilities. Interestingly, if you’re a purebred dog, you can’t have like any genetic feedback or any issues like that. I think what might have-

Amber Tresca (37:00):

Wow.

Dr Shubha Bhat (37:00):

… essentially happened was that he probably would bred to be like a purebred Dalmatian, and then when they did the testing, they found out that he’s like deaf or hard of hearing, and so they basically put him in the shelter. The shelter [crosstalk 00:37:15]-

Amber Tresca (37:15):

Oh my gosh.

Dr Shubha Bhat (37:15):

… that they said that they basically they found him on the street, but I think that the prior owners probably dropped him off at the shelter because legally they’re supposed to euthanize them otherwise so that they don’t necessarily pass down those genes. Needless to say, he’s not compounded by his hearing or lack of hearing, I should say, at all. A very robust, hyper boy [crosstalk 00:37:38] very energetic love [inaudible 00:37:41] and nature. It’s a lot to handle, but I wouldn’t trade him for anything in the world.

Amber Tresca (37:46):

He’s really cute. He looks… Like his face, there’s such intelligence in his face. Jamie, you have a dog, but I’m not going to ask you about your dog. I’m instead going to ask about your most recent addition to your family because you are a new mom. You know, babies change all the time, so just tell me, what’s your daughter up to like this week? Or maybe even just today? What’s she doing today?

Jaime Holland (38:17):

Well, man, you missed the perfect pun intro for IBD moms. Yeah. What isn’t she up to? It’s weird. Like in a matter of days, she went from kind of like rolling around like a little potato to crawling, not fully crawling, but just army crawls and attempting to crawl to… I had her on the changing table where she does alligator barrel rolls, which if you are from Florida, you kind of understand about the alligator barrel roll thing. While trying to catch her mid-roll, she tried to stand up and I don’t know where this is coming from, and she’s not even eight months for another 12 hours or so, so I’m not ready for this. I’m just sitting here going, “oh God, oh God.”

Amber Tresca (39:03):

You know, it’s hilarious because you spend the first year of their life trying to get them to walk and talk, and then you’re going to spend the next several years getting them to sit down and shut up.

Jaime Holland (39:15):

This is very true, and I feel like I wasn’t even in a rush. I wasn’t trying to encourage her to crawl. Everybody-

Amber Tresca (39:19):

Yeah.

Jaime Holland (39:19):

… else was. I was like-

Amber Tresca (39:20):

Yes.

Jaime Holland (39:20):

… “No, just be my baby a little bit longer,” and nope.

Amber Tresca (39:26):

Well, I enjoy the pictures that you share. Thank you so much for letting us in on a little bit of what it’s like to be a new mom in your house and your daughter, what she’s up to this week. Dr. Bhat, Jamie, thank you both so much for coming on About IBD and talking with me about insurance issues. You’ve given me a lot to think about and the show notes are going to be so very long, so thank you so much for all of the tips and information that will help patients on their journey. Thank you both.

Jaime Holland (39:55):

Thanks Amber.

Dr Shubha Bhat (39:56):

Thank you, Amber.

[MUSIC: IBD Dance Party]

Amber Tresca (40:02):

Hey super listener! Thanks to Dr Shuba Bhat for sharing her knowledge and experience surrounding health insurance. She is clearly passionate about patient care and her work benefits not only her patients, but also everyone who lives with an IBD. You can follow Dr Bhat on Twitter as @GI_PharmD.

Thank you also to Jaime Holland, who not only helps me on a daily basis as my unofficial content management specialist, but she also works behind the scenes to help many other patients understand insurance issues. You can find her all over the interwebs as Pretty Rotten Guts.

Amber Tresca (40:38):

Links to a written transcript, everyone’s social media handles, and more information on the topics we discussed is in the show notes and on my Episode 113 page on AboutIBD.com.

You can follow me, Amber Tresca, across all social media as About IBD.

Thanks for listening, and remember, until next time, I want you to know more about IBD.

Amber Tresca (41:01):

The American Gastroenterological Association and About IBD “How to be Happy & Healthy With IBD” podcast series is supported by Arena Pharmaceuticals.

About IBD is a production of Mal and Tal Enterprises.

It is written, produced, and directed by me, Amber Tresca.

Mix and sound design is by Mac Cooney.

Theme music is from Cooney Studio.

About IBD

Articles and podcasts about inflammatory bowel disease (Crohn's disease and ulcerative colitis).

About IBD Podcast Episode 113 – How to Be Happy & Healthy With IBD: Tips for Navigating Health Insurance

Transcript

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