Dr Linda D. Bradley: How Payers Can Improve Care for Endometriosis

It's not normal to be in so much pain that you miss work several times a month and there are more things payers can do, said Linda D. Bradley, MD, professor of Obstetrics and Gynecology and Reproductive Medicine, Cleveland Clinic.Part 3 of this discussion with The American Journal of Managed Care^® (AJMC^®) continues here. Read part 1 here and part 2 here.

AJMC®: How can payers in the health care system overall better support appropriate treatment and management for endometriosis and uterine fibroids, particularly when it comes to health inequities?

Bradley: What I would say is I think we have to trust the physicians who are prescribing, or the health care providers. What frustrates me more is that we have to go through this multiple step of did they try this? Did they try that? When we sit with patients, we know what the patient's story is. We may not have proof because the patient, as we talked earlier, has seen 2 to 7 providers, if she's moved, if she has relocated, but if she tells me she's tried pills. She's tried NSAIDs. She's tried different things, then we need to move to the next options. There are also medications, again the classic one has been, put the patient on birth control pills. Women over 35 who smoke can't be on the pill. They are at risk for DVTs. They're immobile. They have hypertension. They have horrible headaches. They have severe—you name it, side effects, or co-morbidities, that I just write that off. It's not even an option.

If I could speak to the payors, let doctors and nurses that take care of the patient be the doctors and nurses and have the power of the pen. Approve 2 new drugs that are GnRH antagonists liberally for the treatment of fibroids and endometriosis. When we really look at FDA labeling, many of the drugs that we use for these conditions were never studied for endometriosis or fibroids. In particular, the 2 new GNRH antagonists, they are expensive, but they were studied in a population particularly with fibroids and with endometriosis.

The other drugs are used for symptom relief. It's really frustrating to get denials and to not be authorized. This is another thing for people that are underresourced, the ability to get newer drugs that are FDA approved, that have been published articles in the New England Journal of Medicine, that have been vetted.

Let the doctors and nurses be doctors and nurses. Let's keep the patient from suffering. We're not here to make money off these drugs. We're here to help the patient's symptoms and improve their quality of life. It's nothing more frustrating in patients who are poorly insured, or no insurance. They just rarely have access to the newer therapies, and it requires so much work from a doctor's office to call in and have our nurses try to advocate for these patients. Again, doctors see hundreds of patients a week. Our nurses just don't have the time for all of this micromanagement of the drugs.

That right now is very frustrating for me and the patients that I serve. Sadly, and I admit it, there are patients with certain insurance companies that will just- if I see insurance company x, I don't care if we spend 4 hours going to bat for that patient. I don't care what I write, a special letter, it is never approved.

When I see the next patient from that company, it's sad. I cannot spend, our office does not have the resource to do all of this back and forth, pre-certification, talk to the head of the peer review reviewer. I just think that is such a useless waste of time when we could be helping patients. I’m not working at my highest skill set.

AJMC®: What are the biggest challenges or barriers to managing patients in this space?

Bradley: It's having them see the provider that's with me and who's taking the steps to be thoughtful about different disease states. Basically, it's listening, examining, and imaging.

I would also say referrals to maybe another provider that may have more skill sets. I can just mention many things that I do extremely well, and things that I don't do well, and I make a referral. It's easy to do and have a list of when someone shows you their arm and it's a rash. Well, I don't know all the skin conditions, but I can certainly not just give you some kind of potion that may not work at all. So always have a referral and hope for a patient. You get them in with another provider, rather than just say, "I don't know."

AJMC®: What are you working on in endometriosis that you're excited to share?

Bradley: I think we know a lot about endometriosis, so when I get chance to talk to patients or women's groups, just letting women know that what am I working on is letting people know that they don't need to suffer, what is normal, what is not normal.

Some of these conditions run in families, genetically. They may hear that their mother or grandmothers or aunts suffered from fibroids, bleeding, pain, and they came to believe that it is just— and many older women feel—oh, it's just a part of being a woman. No, it is not a part of being a woman.

Let's stop normalizing pain, rather, but to investigate pain and improve the quality of our life. Menstrual cycles, they may be a nuisance, but it should not make women not do things: hobbies, activities, travel, being socially embarrassed, poor quality of life, living in bed for days, having to go home from work, taking extra clothing to places because of the fear for bleeding through and soiling clothing. It's just not normal.

I don't want to normalize pain. It’s different if you have metastatic cancer and you get pain everywhere, bone pain. We're talking about young women. I'll see patients, and they'll say, "Oh, my mother said this is just what to expect." I'm like, "No, it's not. Are you missing work?" and that's one of the questions I always ask. "How many days of work do you miss per month or in the last year?" And when COVID came, a lot of people who could work at home, it was interesting. Some patients said, "Thank God for COVID, because I could do my Zoom meetings, I could not show my face, I could be laying down with a heating pad," and many of them were lamenting that they would potentially have to go back to work and then miss activities. So, I phrase questions, because some women will work through pain and they'll just say, "I'm a single mother. I have to work, otherwise my paycheck gets 1 or 2 days less of my hourly wage," and they're just working through pain. So the question is, "No, I never miss work," and my next question is, "If you could without a penalty, financially, would you miss it?" and many of them say yes. It's very sad when we see young women literally crying in your office for a disease state that's not cancer, but they have such poor quality of life that it hurts just to see this. I think we would stop normalizing pain and figure out what the potential problem would be.