Video
Payer Perspectives on Risk Stratification for CDI Recurrence
Author(s):
Payer participants consider how they proactively risk stratify patients for clostridium difficile infection recurrence.
Transcript:
Neil Minkoff, MD: Let me ask a question to the payers on the panel. We talked a little about population health. Are you guys doing anything to try to risk stratify the populations proactively or is it just a matter of evaluating patients on a case-by-case basis as the requests come in for different types of medication?
Kevin U. Stephens, Sr. MD, JD: I can take a stab at it first. We do both. We do use risk stratification on a population basis. As I mentioned, there are generally 3 different categories: Medicaid, commercial, and Medicare. With each one, there are different stratifications for each population, including age range and so on. And then we also have to tailor each request because they can be fairly different. Many times, the biggest problem is lack of information. We don’t have enough information to make the decision. Many times, if that’s the case, it’s denied. So we use all of the above.
Karina Abdallah, PharmD: Yes, I agree with Dr Stephens. On the Medicare Advantage population, I’ve run some retrospective reviews or studies and benchmarked that against common data points. In the Medicare Advantage population, a third can end up with recurrence. Of those, half of them may end up with 2 or 3 reinfections or recurrences of CDI [Clostridioides difficile infection]. We’re making sure we’re looking at that and bucketing it by not only risk stratification but where the patient is. Where are they? Are they home? Are they in a long-term care facility? Where are they receiving treatments? We have to get down to benchmarking the different facilities to ensure that we’re doing everything that we can from the facility perspective.
Lastly, we mentioned employer groups as well. With the employer groups, if these costs are showing up on their radar, we sometimes pull in all-cause data to pair it so that the employer understands. Sometimes with bezlotoxumab [Zinplava], for example, you might be preventing something further down the line. That’s not in every patient, of course. Dr Allegretti went through and said there are certain high-risk patients in whom it’s appropriate to use in, so we use that and try to pair it with the clinical information that they would need to make those coverage decisions.
Transcript edited for clarity.
