Shared insight on the process to gain access to fecal microbiota transplant for patients with clostridium difficile infection.
Transcript:
Neil Minkoff, MD: Let me ask a question to the whole group. I’m not trying to cause a rift between our panelists here, but Dr Allegretti or Dr Gerding, do you have difficulty getting procedures approved? Is your clinical judgment tracking along with the medical policies of the payers?
Jessica Allegretti, MD, MPH: I’m fortunate in that I’m well versed in this space. I have a lot of support in my clinic and I’ve worked with payers to get complex therapies for a long time, so I understand to an extent what needs to be documented and how that process needs to go to make it a bit easier on myself and my patients. Not everybody has those resources or that background knowledge.
That being said, there are circumstances where it certainly can be frustrating. You’re going through multiple layers of peer-to-peer [reviews] and multiple appeals and you still ultimately get denied, and it’s the patient who ends up suffering despite your best efforts and despite what guidelines say. There’s often that lag, as Dr Gerding pointed out. Sometimes what you think is the best science and the best thing that’s appropriate for the patient is not covered by their particular policy. That’s ultimately where there can be inconsistencies in terms of what you’re saying to the patient, what you believe is right, and ultimately what their plan covers.
I loop that into my informed consent discussion, too. “I may think that this is the best agent for you, but we may not have that option.” Unfortunately, that’s the state of medicine in health care in the United States. Unfortunately, the science doesn’t always lead some of the decision-making. And because there has to be such a long filter process, it often takes years for the most cutting-edge data to get incorporated into policy. That’s one of the frustrating aspects of practicing medicine today.
Neil Minkoff, MD: Let me ask the payers to weigh in on that based on how they define their medical policies and their efforts to be as up-to-date as possible.
Kevin U. Stephens, Sr. MD, JD: We look at the FDA guidelines as an approval process that’s important. If it’s investigational and experimental, we typically shy away from those. Albeit, as I mentioned previously, we also have to look at each case. If you have enough information, then those guidelines are only a guidance, and we have the latitude to do what’s in the best interest of the patient. Because as you look at the total cost of care, I can’t overemphasize that you can’t be penny-wise and dollar-foolish. You have to look at the total cost of care and the big picture. That’s where the peer-to-peer process is important, along with talking with the medical director who’s doing the reviewing to see if there’s some common ground.
Transcript edited for clarity.
5 Things Everyone Should Know for National Immunization Awareness Month
August 1st 2025National Immunization Awareness Month highlights the importance of lifelong vaccination to prevent diseases, a practice that has averted millions of deaths, proven to be a cost-effective public health strategy, and offers crucial protection even to individuals who are immunocompromised.
Read More
Politics vs Science: The Future of US Public Health
February 4th 2025On this episode of Managed Care Cast, we speak with Perry N. Halkitis, PhD, MS, MPH, dean of the Rutgers School of Public Health, on the public health implications of the US withdrawal from the World Health Organization and the role of public health leaders in advocating for science and health.
Listen
Updated mRNA Vaccines Against JN.1 Show Strong Safety Signal in Real-World Data
July 31st 2025A nationwide Danish cohort study demonstrated no increased risk of serious adverse events following vaccination with JN.1-updated mRNA COVID-19 vaccines, reinforcing their safety profile and supporting continued use in high-risk populations amid ongoing viral evolution.
Read More
Bird Flu Risks, Myths, and Prevention Strategies: A Conversation With the NFID's Dr Robert Hopkins
January 21st 2025Joining us for this episode of Managed Care Cast is Robert H. Hopkins Jr, MD, medical director at the National Foundation for Infectious Diseases (NFID), who will help separate fact from fiction about avian influenza and discuss what needs to be done to prevent a future escalation.
Listen
Breaking Down Barriers to Hepatitis Elimination on World Hepatitis Day 2025
July 25th 2025World Hepatitis Day 2025 and its theme, “Hepatitis: Let’s Break It Down,” emphasize the urgent need to remove barriers to prevention, testing, and treatment to reduce liver cancer and eliminate hepatitis by 2030.
Read More