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.

Adherence to acitretin and home narrowband ultraviolet B phototherapy in patients with psoriasis.

BACKGROUND: In the treatment of psoriasis, patient adherence to oral medications is poor and even worse for topical therapy. However, few data exist about adherence rates to home phototherapy, adding to concerns about the appropriateness of home phototherapy as a psoriasis treatment option. OBJECTIVE: We sought to assess adherence to both oral acitretin and home ultraviolet B phototherapy for the treatment of psoriasis. METHODS: In all, 27 patients with moderate to severe psoriasis were treated with 10 to 25 mg of acitretin daily, combined with narrowband ultraviolet B, 3 times weekly at home, for 12 weeks. Adherence to acitretin was monitored by an electronic monitoring medication bottle cap, and to phototherapy by a light-sensing data logger. RESULTS: Adherence data were collected on 22 patients for acitretin and 16 patients for adherence to ultraviolet B. Mean adherence to acitretin decreased steadily during the 12-week trial (slope -0.24), whereas mean adherence to home phototherapy remained steady at 2 to 3 d/wk. Adherence was similar between patients who reported side effects and those who did not. LIMITATIONS: Small sample size and lack of follow-up on some patients were limitations of this study. CONCLUSIONS: Adherence rates to home phototherapy were very good and higher than adherence rates for the oral medication. Side effects of treatment were well tolerated in this small group and did not affect use of the treatment. Home phototherapy with acitretin may be an appropriate option for some patients with extensive psoriasis.

The utility of a data-logging device for measuring adherence to home phototherapy.

BACKGROUND: Treatment adherence to home phototherapy is not well characterized. PURPOSE: To develop an accurate measure of home phototherapy unit usage. METHODS: We tested a commercially available data logger containing a photo-sensor on two home phototherapy units. RESULTS: The data logger accurately recorded actual usage and did not record stray light sources over the study period. CONCLUSION: A data logger can accurately capture usage patterns for a home phototherapy unit. These devices could potentially be used in clinical trials to measure adherence to home phototherapy treatment regimens.

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.

Home ultraviolet B phototherapy: a cost-effective option for severe psoriasis.

The cost of treating severe psoriasis has risen dramatically, and treatment options vary widely in terms of cost and efficacy. However, little information is available on the relative costs of home phototherapy and other long-term management options, specifically in the context of managed care. A payer-perspective cost model was developed to estimate and compare the direct expenditures associated with a 30-year course of various treatments for severe psoriasis. Within two years of treatment initiation, home-administered ultraviolet B phototherapy was less costly than any of the other treatments examined, including methotrexate, psoralen plus ultraviolet A, the retinoid acitretin, and new biologic agents. In addition, the efficacy and safety profile of home ultraviolet B phototherapy make it an excellent choice for extended management.

Do utilization management controls for phototherapy increase the prescription of biologics?

The use of phototherapy for psoriasis has declined because of inconvenience, managed care disincentives, and poor reimbursements. However, phototherapy is safer than other options, and the efficacy rates for different methods of phototherapy are among the highest of all available treatment options. Phototherapy is also one of the least costly treatments for moderate-to-severe psoriasis. We hypothesize that utilization management controls on phototherapy shift patients to more expensive and risky systemic treatments. Reducing disincentives on phototherapy will benefit both patients and payors, while increasing physicians' ability to manage this debilitating disease.