196 - Insurance Delays in Initiation of TNF Inhibitors in Children with Juvenile Idiopathic Arthritis

Poster Number: 196

Jordan E. Roberts, Boston Children's Hospital, Boston, MA, United States; Mary Fan, Harvard Chan School of Public Health, BOston, MA, United States; Mary Beth F. Son, Boston Children's Hospital, Boston, MA, United States

Background: Prompt escalation to biologic tumor-necrosis-factor inhibitors (TNFi) is recommended for children with juvenile idiopathic arthritis (JIA) refractory to disease-modifying antirheumatic drugs (DMARDs). TNFi are also increasingly used as first-line treatment in severe JIA, and early treatment may be associated with better outcomes. It is unknown if prior authorization (PA) requirements delay initiation of TNFi among children with JIA.

Objective: We aimed to characterize causes and lengths of delays in TNFi initiation due to medical insurance, including PA requirements and denials, and to compare delays in initiation of TNFi among children enrolled in public versus private insurance.

Design/Methods: We searched the electronic medical record of a single large pediatric rheumatology center in Massachusetts to identify children with a new diagnosis of JIA from 2018-2019. PA requests, denials, prior/alternative therapies, and timing of first TNFi dose were extracted from medical notes. Wilcoxon rank-sum, t and Fisher’s exact tests were used to compare outcomes between public and private insurance. Clinic notes were searched to identify children for whom a TNFi was recommended, but not initiated.

Results: We identified 54 children and young adults with JIA prescribed TNFi. Most had received DMARDs (91%) and non-steroidal anti-inflammatory drugs (NSAIDs) (61%) by time of TNFi PA request (Table 1). 98% of children had plans which required PA for the first TNFi prescribed; 26% were denied and required written appeal and/or peer-to-peer. Reasons for denial are presented in Figure 1. Median time to approval was < 1 week in both public and private insurance groups, though 22% of children experienced delays in insurance approval of two weeks or more. TNFi initiation took > 30 days for over 25% (Table 2). Among the 4 children whose PA denials were not overturned on appeal, all were privately insured and required to use a different TNFi than recommended by their rheumatologist. Three children were recommended to start TNFi but not initiated by the end of the follow-up period; reasons for non-initiation included loss to follow-up (1), anxiety about injections (1), and parent safety concerns (1).Conclusion(s): Children with JIA and both public and private insurance experienced delays in TNFi initiation due to PA requirements and denials. However, nearly all were eventually approved for the TNFi originally requested, suggesting that utilization management strategies present barriers to care despite appropriateness of specialty medication use in children with JIA.
Jordan Roberts CVRoberts_Jordan_CV_Nov 2021.pdf

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