Paradoxical effects of cost reduction measures in managed care systems for treatment of severe psoriasis.

BACKGROUND: Insurance companies vary widely in their coverage policies for severe psoriasis therapies. Unfortunately, coverage policies for psoriasis therapies do not necessarily follow current treatment paradigms, such that more expensive second or third line treatments may be more easily obtained than first line treatments. METHODS: We reviewed insurance policy bulletins, statements of coverage/medical necessity, and prior authorization forms for three large insurance carriers regarding psoriasis treatment with biologic agents and phototherapy. A cost comparison was performed to estimate total costs to patients and insurer under the current system as well as a hypothetical system in which co-pays and deductibles are eliminated. Additionally, we reviewed the total cost to an insurer for placing a patient on a trial of home phototherapy before approving use of expensive biologics. RESULTS: Requirements for coverage for phototherapy treatments are often the same, if not more stringent, than those for biologics. On an annual per patient basis, insurance companies pay an estimated $5, $76, and $23,408 for home phototherapy, office phototherapy, and biologics, respectively. The first year cost to patients, however, is estimated to be $2,590, $3,040, and $920 for home phototherapy, office phototherapy, and biologics, respectively. An initial 3-month trial of home phototherapy yields a graded annual cost savings to insurers of $21,610 to $2,110 per patient. DISCUSSION: The evolution of psoriasis treatment has resulted in a paradoxical situation in which the use of lower-cost psoriasis treatments, with longer safety track records, is discouraged relative to newer options. If co-pays, deductibles, and prior authorization requirements that discourage phototherapy were reduced or eliminated, more patients and physicians would likely choose phototherapy over biologics. This has the potential to reduce overall healthcare costs for psoriasis management.

Would elimination of copayments for phototherapy decrease the cost of treating psoriasis with systemic biologics? A cost analysis.

Phototherapy is a proven treatment method for the treatment of psoriasis, yet is typically underutilized because of the frequency of physician visits and copayments required for each session (typically 2-5 treatments/wk). Injectable biologic therapies are effective but costly. The objective of this study was to explore how changes in copayment strategies for phototherapy may affect biologic usage. Published estimates of the cost of phototherapy and biologic treatment were used to determine the costs of these treatments to patients and insurers. With an estimated patient copayment of $30 per office visit and a pharmacy copayment of $50 per month, the $1,800 annual patient expense for phototherapy far exceeds the estimated out-of-pocket expenses for etanercept, alefacept, and efalizumab ($840, $405, and $780, respectively). The estimated annual costs to MCOs ranged from $3,008 for phototherapy, to $20,300 for etanercept. Copayments for phototherapy may be shifting patients toward biologic treatment, which is more convenient but more costly to managed care plans.