Payer Coverage of Valley Fever Diagnostic Tests

Background The nonspecific symptoms of Valley fever, or coccidioidomycosis, hinders its proper diagnosis. This results in unnecessary health care costs and antibiotic usage. Thus, this study seeks to determine the coverage of the Valley fever diagnostic test as provided by Arizona insurance companies to increase early diagnosis rates. Methods Through scripted messaging and telephone communications, we contacted 40 health insurance companies in Arizona about their coverage of CPT 86635 (antibody diagnostic assay for Coccidioides) without prior authorization under all plan types provided in both primary and urgent care settings. If prior authorization was required, we discussed the coverage of ICD-10 codes J18.9 (pneumonia, unspecified organism), J18.1 (lobar pneumonia, unspecified organism), or L52 (erythema nodosum). Results Of the 40 health insurance companies contacted, 25 did not answer our inquiries, most requiring member-specific information to share coverage data. The remaining 15 companies covered Valley fever testing, of which 4 required prior authorization for the ICD-10 codes of interest. Of these 15 companies, 14 provided coverage in primary and urgent care settings, and 13 provided coverage for all available plans. Conclusion All payers that provided information covered Valley Fever testing. Most of the insurance companies that were unable to answer our inquiry likely cover Valley fever testing, but were unable to share information with third party inquiries. Obtaining general coverage information is difficult, which can potentially impact patient care.

Evaluating implementation outcomes (acceptability, adoption, and feasibility) of two initiatives to improve the medication prior authorization process

Background Processes such as prior authorization (PA) for medications, implemented by health insurance companies to ensure that safe, appropriate, cost-effective, and evidence-based care is provided to all members, have created inefficiencies within healthcare systems. Thus, healthcare systems have implemented supplemental processes to reduce burden and ensure efficiency, timeliness, and appropriate care. Objective Evaluate implementation outcomes of two initiatives related to PA for medications: a common record that records all PA-related information that was integrated into the health record and an auto-routing of specialty prescriptions to a hospital-owned specialty pharmacy. Methods We conducted semi-structured interviews with medical staff to understand their experience, acceptability, adoption, and feasibility of these initiatives guided by Proctor’s Framework for Implementation Outcomes. Transcripts were analyzed using consensus coding. Results Eleven medical staff participated in semi-structured interviews. The two initiatives were analyzed together because the findings were similar across both for our outcomes of acceptability, adoption, and feasibility. Participants found the implemented initiatives to be acceptable and beneficial but felt there were still challenges with the new workflow. The initiatives were fully adopted by only one clinic site within the healthcare system, but limitations arose when adopting to another site. Individuals felt the initiatives were feasible and improved workflow, communication, and transparency. However, participants described future adaptations that would help improve this process including improved standardization, automation, and transparency. Conclusion The acceptability, adoption, and feasibility of two initiatives to improve the PA process within the one clinical site were well received but issues of generalizability limited the initiatives adoption system wide.

908. Dismantling Barriers to Hepatitis Elimination: Automated Hepatitis C Screening with Care and Cure by a Primary Care Based Team

Background Liver cancer rates are rising in the US, viral hepatitis accounting for more than 65% of the cases. Yet more than half of viral hepatitis infections remain undiagnosed. In response to the rise in HCV due to the opioid epidemic, the Centers for Disease Control and Prevention began recommending a one-time HCV test for all adults in 2020. Screening, linkage to care (LTC) and access to HCV curative therapy must be scaled up to reach the WHO goal of eliminating hepatitis by 2030. Methods In 2018, automated HCV screening utilizing electronic medical record protocols began in the emergency department (ED) based on the date of birth. Drug testing and peer recovery consults were added as eligibility criteria. Screening became universal and expanded to the inpatient units in 2020. Patient navigators (PN) received alerts of positive results and worked with patients to arrange LTC, one site being a primary care-based practice (PCP) where internists provided HCV care and support from ambulatory care clinical pharmacists. Results From Mar 2018 to Mar 2021, 50,873 people were screened for HCV, with 977 (1.9%) testing HCV Ab+, and 259 (0.5%) had confirmed infection by reflex HCV RNA. LTC 86.6% of patients, and 128 (49.4%) were newly diagnosed. Universal screening led to 35,482 testings from Jan 2020-Mar 2021. People born out of the 1945-65 birth cohort made up 75.8% of the screened and 39.1% of the infected. The PCP evaluated 47 HCV patients, initiated therapy in 38; 36 required prior authorization and 15 needed financial assistance. Treatment breakdown was: 29 (76.3%) glecaprevir/pibrentasvir, 6 (15.8%) sofosbuvir/velpatasvir & 3 (7.9%) ledipasvir/sofosbuvir. Pharmacist intervention with prior authorizations and financial assistance significantly reduced the cost (table 1). Thus far, 35 achieved cure with undetectable HCV RNA at 12 weeks. Table 1. The Cost of Treatment before and after Pharmacist Assistance Conclusion Automated universal testing was an effective and seamless way to scale up HCV screening. Warm handoffs from a PN were important for engaging patients in care. A team approach assisted with removing barriers in therapy access, including prior authorization, specialist requirements, and financial assistance. Novel strategies utilizing ED and hospitals for testing with coordination to PCP are needed to find the missing millions and achieve hepatitis elimination. Disclosures Su Wang, MD MPH, Gilead Sciences (Grant/Research Support)Gilead Sciences (Grant/Research Support)

Trends in antipsychotic prescribing for approved and unapproved indications to Medicaid-enrolled youth in Philadelphia, Pennsylvania between 2014 and 2018

Background Antipsychotic prescribing to Medicaid-enrolled youth has been the target of numerous policy initiatives, including prior authorization and quality monitoring programs, which often target specific populations. Whether these efforts have changed the level or composition of antipsychotic prescribing is unclear. Methods Using 2014–2018 administrative claims data for Medicaid enrollees aged 21 years and under in Philadelphia, Pennsylvania, we measured antipsychotic prescription fills overall and for youth without an approved indication (autism, bipolar disorder, or psychosis). We then assessed whether trends differed for populations that have been targeted by policy initiatives, including younger children and foster care-enrolled youth. We also identified the most common approved and unapproved indications and examined whether the treatment duration of antipsychotic prescriptions differed based on whether the youth had an approved or unapproved indication. Results Overall, the number of Medicaid youth with an antipsychotic prescription fill halved between 2014 and 2018. Youth aged 17 years and under and foster care-enrolled youth, who were targeted by prior authorization and quality improvement efforts, experienced larger declines. Roughly half of prescriptions were for unapproved indications in both 2014 and 2018; the most common unapproved indication was ADHD, and the treatment duration was shorter for unapproved indications compared to approved indications. Conclusions Antipsychotic prescribing to Medicaid-enrolled youth is declining, particularly among populations that have been targeted by policy initiatives like prior authorization and quality monitoring programs. Despite the fact that these initiatives often assess diagnostic criteria, half of antipsychotic prescriptions were for unapproved indications in both 2014 and 2018. More research is needed to gauge whether this prescribing is appropriate.