Contrasting Clinician and Insurer Perspectives to Managing Irritable Bowel Syndrome: Multilevel Modeling Analysis

Am J Gastroenterol. 2021 Apr;116(4):748-757. doi: 10.14309/ajg.0000000000000989.

Eric D Shah 1, Lin Chang, Jessica K Salwen-Deremer, Peter R Gibson, Laurie Keefer, Jane G Muir, Shanti Eswaran, William D Chey


Author information

  • 11Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, New Hampshire, USA; 2Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA; 3Department of Psychiatry, Dartmouth-Hitchcock Health, Lebanon, New Hampshire, USA; 4Department of Gastroenterology, Central Clinical School, Monash University, Melbourne, Australia; 5Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA; 6Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA.


Introduction: Insurance coverage is an important determinant of treatment choice in irritable bowel syndrome (IBS), often taking precedence over desired mechanisms of action or patient goals/values. We aimed to determine whether routine and algorithmic coverage restrictions are cost-effective from a commercial insurer perspective.

Methods: A multilevel microsimulation tracking costs and outcomes among 10 million hypothetical moderate-to-severe patients with IBS was developed to model all possible algorithms including common global IBS treatments (neuromodulators; low fermentable oligo-, di-, and mono-saccharides, and polyols; and cognitive behavioral therapy) and prescription drugs treating diarrhea-predominant IBS (IBS-D) or constipation-predominant IBS (IBS-C) over 1 year.

Results: Routinely using global IBS treatments (central neuromodulator; low fermentable oligo-, di-, and mono-saccharides, and polyols; and cognitive behavioral therapy) before US Food and Drug Administration-approved drug therapies resulted in per-patient cost savings of $9,034.59 for IBS-D and $2,972.83 for IBS-C over 1 year to insurers, compared with patients starting with on-label drug therapy. Health outcomes were similar, regardless of treatment sequence. Costs varied less than $200 per year, regardless of the global IBS treatment order. The most cost-saving and cost-effective IBS-D algorithm was rifaximin, then eluxadoline, followed by alosetron. The most cost-saving and cost-effective IBS-C algorithm was linaclotide, followed by either plecanatide or lubiprostone. In no scenario were prescription drugs routinely more cost-effective than global IBS treatments, despite a stronger level of evidence with prescription drugs. These findings were driven by higher prescription drug prices as compared to lower costs with global IBS treatments.

Discussion: From an insurer perspective, routine and algorithmic prescription drug coverage restrictions requiring failure of low-cost behavioral, dietary, and off-label treatments appear cost-effective. Efforts to address insurance coverage and drug pricing are needed so that healthcare providers can optimally care for patients with this common, heterogenous disorder.



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