Navigating Through the Sludge

July 8, 2025 | VOLUME 3, ISSUE 2

One of my roles at the University of Virginia is working in the Pulmonary Allergy Collaborative Clinic, or PACC. I work collaboratively in this clinic with a brilliant allergy/immunologist, Dr. Larry Borish, and a talented nursing team. Together, we care for patients with difficult-to-control diseases, including asthma, bronchiectasis, allergic bronchopulmonary aspergillosis, and eosinophilic granulomatosis with polyangiitis. As a subspecialized clinic at a university medical center, we typically care for patients who seek a second (or third or fourth) opinion and frequently drive hundreds of miles to see us.

Often, the physical distance from patients’ homes to our clinic serves as a barrier to care—which we can sometimes help mitigate through offering telemedicine appointments. (I’m licensed in three contiguous states for this reason!) But other barriers to care are more difficult to address. One such barrier is fresh in my mind after seeing a particular patient at PACC recently.

Our patient, who traveled more than 400 miles to see us, has asthma that is now largely in remission. But when we first met this patient in 2022, she was struggling with frequent exacerbations and near dependence on prednisone. Her local pulmonologists and allergists were unable to get her approved for biologic medications despite clear indications, hence her referral to see us.

I was shocked when our prescription for a biologic was similarly denied, but I was even more shocked when I learned that the only way to appeal the denial was by sending her insurance company a snail mail letter. There was literally no other way—no phone number to try, no email address to use, not even a fax number!

In my 17 years of doctoring, I had never had to purchase a stamp and lick an envelope to advocate for a patient’s needed medication, but this was apparently the only way forward… and nearly three months later, I received a letter back in the mail that the biologic medicine was finally approved.

This issue of CHEST Advocates is focused on access to care. In the feature article, read more about prior authorization, including the consequences of delays in care, burden on providers, and harm to patient outcomes. Hear from Anita McGlothlin, Senior Director of Economics and Health Policy of GO2 for Lung Cancer, a patient advocacy group, and Anthony Izzo, DO, FAAN, FAASM, Chief Medical Officer and Executive Vice President of Community Neuroscience Services & Community Specialty Services.

This issue also highlights some amazing advocacy work by CHEST members and partners who improve access to care. Read about CHEST’s work (in partnership with other organizations, like the COPD Foundation) to get a bill introduced into the US House of Representatives that will one day improve access and options for patients who depend on home oxygen. In addition, learn about recommendations from a CHEST technical expert panel that have been largely adopted by the US Centers for Medicare & Medicaid Services—work that will undoubtably improve access to noninvasive ventilation when it is needed for patients with COPD.

Other inspiring examples of access advocates featured in this issue include William Feldman, MD, MPH, Assistant Professor at Harvard Medical School, who recently testified at a US Senate Judiciary Committee to advocate for ways to tackle the complex issue of inhaler affordability; and Safia S. Khan, MD, Associate Professor at University of Texas Southwestern Medical Center, who is committed to educating others on the “often invisible” plight of underinsured patients.

Learn about how partnering organizations, the Patient Advocate Foundation and Pulmonary Hypertension Association, work together to help patients navigate through the complexities of health care and insurance to improve patient access to care. Finally, read about how CHEST has continually contributed to Mobile Care Chicago, a program that delivers free medical care for patients at high risk of asthma via a fleet of six mobile units.

I’m certain the themes in this issue—including the insurance authorization SLUDGE we all have to navigate through for our patients—will resonate with all of you.

And I hope no one else has to navigate through sludge as thick as we did—although I’m sure you will, until we enact change—to get our patient’s biologic approved.