Optimizing Access to Endometriosis Treatment: Strategies for Timely, Effective Care

Announcer:
You’re listening to Advances in Women’s Health on ReachMD, and this episode is sponsored by Sumitomo Pharma. Here’s your host, Dr. Charles Turck.

Dr. Turck: 
This is Advances in Women’s Health on ReachMD, and I'm Dr. Charles Turck. Joining me to discuss how we can optimize treatment access and initiation for patients with endometriosis is Dr. Jacqueline Wong. She's a minimally invasive gynecologic surgeon and an Assistant Professor of Obstetrics and Gynecology in the School of Medicine at Oregon Health and Science University in Portland. Dr. Wong, welcome to the program.

Dr. Wong: 
Thank you so much for having me, Dr. Turck.

Dr. Turck: 
Well, to start us off, Dr. Wong, what are some of the biggest administrative hurdles that providers might face when trying to start patients on endometriosis treatment?

Dr. Wong: 
Endometriosis is a chronic and incurable condition that presents differently in each and every patient. And this means that it often takes many visits for patients to find their own ideal treatments that balance their benefit in terms of pain and bleeding relief while also limiting their risks of side effects.

In this busy world, I think one of the hardest administrative hurdles for patients and providers alike is having the visit time and frequency to be able to meet regularly enough together that they can keep an eye on progress and fine tune treatment plans until they hit that ideal balance of high benefit and low side effects together.

Insurance denials and prior authorizations also place enormous administrative burdens on provider offices and patients. And this can create this ever-changing patchwork that's complex, involving patient paperwork and back-and-forth with insurance companies that can delay treatments or place really unfair hurdles in ways of effective patient care at time.

Dr. Turck:
And what can providers do to proactively navigate prior authorization and other insurance requirements?

Dr. Wong:
An awareness of what the most common reasons for denial are can be extremely helpful in navigating this land of insurance authorizations. For me, this is relevant in two big areas, and that's note writing and diagnosis coding.

For note writing, I have a note template in my electronic medical record that I use for every initial endometriosis patient encounter. And this template includes a section that outlines prior treatments tried, including things like what the treatment was, like an oral birth control pill, how long it was used for, for instance, from 2020 to 2022, and why it was stopped. So maybe the patient had bleeding relief but began to have migraines with aura and therefore had intolerable side effects requiring cessation. An extremely common reason for denial of a medication will be a request to try an alternate approved agent first, and so I found that this note template style can successfully limit denials for this reason.

And then when we think about diagnosis coding, I would also advise physicians to understand their local Medicaid requirements for diagnosis coding, or to ask their high-volume endometriosis colleagues what codes that they have found success with using locally.

For instance, in our state, they accept pelvic floor dysfunction as a diagnosis code when we're seeking approval for pelvic floor physical therapy to treat high-tone pelvic floor dysfunction that can be associated with things like endometriosis and chronic pelvic pain. But Medicaid does not accept, for instance, either endometriosis or chronic pelvic pain as approved diagnosis codes.

And then finally, I almost always appeal a denial with very rare exception. Reading through denial paperwork, often these come because an improper note was attached, or information is missing that we know exists in the patient's history. So having a pre-drafted appeal letter for some common denials—for instance, in my world, this could be denial for something like onabotulinumtoxinA when we're thinking about treatment for vaginismus or treatment-refractory high-tone pelvic floor dysfunction. And these pre-drafted letters can be a huge time saver for myself and my administrative staff.

Dr. Turck:
For those just tuning in, you're listening to Advances in Women’s Health on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Dr. Jacqueline Wong about how we can address challenges in treatment access and initiation for patients with endometriosis.

Dr. Turck:
Let's now shift focus over to patient-centric challenges. On a human level, how can delays in care impact our patients?

Dr. Wong:
Delays in care can be very distressing to patient quality of life. And this can include delays in things like provider access or medication approval and pathways to surgery or other treatments. Particularly among patients whose pain may have already become constant and severe, it can be extremely hard to attend work or school, to exercise or to care for children or others.

Even with appropriate treatments, symptoms can also take weeks to months to de-escalate, and so this entire process can feel very prolonged and distressing, even once care is accessed. Chronic pain can also have enormous impacts on mental health, and this is another area that can also be extremely challenging to access care in in a timely way.

I've had a lot of patients express that it can feel like a full-time job having to continually navigate scheduling and insurance and follow-up visits, all while feeling the weight of their endometriosis symptoms.

Dr. Turck:
And once we prescribe treatment, what are some strategies we can use to optimize patient adherence?

Dr. Wong:
I think the very best treatments are ones that patients feel knowledgeable and confident about. I don't expect my patients to be adherent to something if they don't know how it works or why they're using it. And I don't want to prescribe my patient something if they think it's going to be hard or scary to use.

So in this way, I think that education is key. And I’ve found that by devoting time, especially in initial visits, to talking about how endometriosis functions as a disease, and how different treatments tackle different pathways of endometriosis and therefore also come with different benefit and side effect profiles, this can really allow patients to feel empowered to take all that knowledge together and make the very best choices for themselves that they feel they can be adherent to.

I also think that talking about differences in what "treatment failure” means can be really helpful. So this means, did my patient “fail” a treatment in the past because it didn't help with their symptoms? Or was it because it did help with their symptoms but caused intolerable side effects? Knowing this answer can help with adherence.

For instance, if a patient's treatment didn't help with symptoms, make sure your patient took the medication for long enough, like on the order of three months instead of three weeks, perhaps. And if a treatment did really help with symptoms but caused new side effects, think about finding a similar treatment in that same category that your patient may tolerate better—for instance, maybe a different progestin or oral birth control type.

Dr. Turck:
Now, in terms of collaborative care, how can a multidisciplinary approach help improve treatment outcomes in patients with endometriosis?

Dr. Wong: 
Endometriosis is a chronic pain condition that has a high potential for coexistence with other chronic overlapping pain conditions. That can be things like high-tone pelvic floor dysfunction, IBS, interstitial cystitis, major depressive disorder, and the list goes on and on.

So treatment of endometriosis itself can be a huge pain alleviator, but by the time pain has already become severe or constant, treatment of endometriosis alone is unlikely to alleviate pain stemming from all of these other pain generators as well.

So multidisciplinary partnership can mean that all these different painful conditions also have the time and focus that they need to be effectively treated. One by one, this can contribute to lowering of pain globally across the body, which is usually a patient's big goal.

Unfortunately, on the other hand, ignoring any one painful condition can make it hard to feel progress in this overall pain alleviation, and that's often why providers recommend tackling all of these conditions in unison, together with a multidisciplinary care team.

Dr. Turck:
And in our last moments here together, Dr. Wong, what can clinicians do to better advocate for patients who need long-term management solutions for endometriosis?

Dr. Wong:
This is a great question. Everything that I've talked about in endometriosis treatment takes time. I cannot stress enough the importance of having visit templates that allow clinicians this time to be able to do the absolutely necessary things, like what we've talked about in understanding prior treatments used, diagnosing all these chronic overlapping pain conditions, and devoting that crucial time to education. All of these parts are necessary for successful endometriosis patient care. And clinicians desperately need the support of their clinics and institutions to be able to treat this important and deserving population with the care and attention that they deserve.

Dr. Turck:
Well, with those final thoughts in mind, I want to thank my guest, Dr. Jacqueline Wong, for joining me to share these strategies for improving treatment access and initiation in patients with endometriosis. Dr. Wong, it was great having you on the program.

Dr. Wong:
Thank you so much for having me. I appreciate it.

Announcer:
This episode ofAdvances in Women’s Health was sponsored by Sumitomo Pharma. To access this and other episodes in our series, visit Advances in Women’s Health on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!