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.


CONCLUSIONS
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.
Yentzer
Brad A
BA
Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
Yelverton
Christopher B
CB
Simpson
Gregory L
GL
Simpson
Jason F
JF
Hwang
Wenke
W
Balkrishnan
Rajesh
R
Feldman
Steven R
SR
D000893:Anti-Inflammatory Agents / Q000191:economics / Q000627:therapeutic use; D015535:Arthritis, Psoriatic / Q000188:drug therapy / Q000191:economics; D017046:Cost Savings; D003669:Deductibles and Coinsurance / Q000191:economics; D000068800:Etanercept; D017048:Health Care Costs; D006701:Home Nursing / Q000191:economics; D006801:Humans; D007074:Immunoglobulin G / Q000191:economics / Q000627:therapeutic use; D007155:Immunologic Factors / Q000191:economics / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000191:economics / Q000627:therapeutic use; D007343:Insurance Carriers / Q000191:economics*; D019458:Insurance Coverage; D008329:Managed Care Programs / Q000191:economics*; D009819:Office Visits / Q000191:economics; D011701:PUVA Therapy / Q000191:economics; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011565:Psoriasis / Q000188:drug therapy / Q000191:economics* / Q000532:radiotherapy; D018124:Receptors, Tumor Necrosis Factor / Q000627:therapeutic use; D014467:Ultraviolet Therapy / Q000191:economics / Q000295:instrumentation; D014481:United States
D000893:Anti-Inflammatory Agents; D007074:Immunoglobulin G; D007155:Immunologic Factors; D007166:Immunosuppressive Agents; D018124:Receptors, Tumor Necrosis Factor; D000068800:Etanercept