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Supplements Easing the Economic and Clinical Burden of Psoriasis and Psoriatic Arthritis: The Role of Managed Ca

Managed Care Aspects of Psoriasis and Psoriatic Arthritis

Colby Evans, MD
The chronic and systemic nature of psoriasis has a significant impact on direct costs, indirect costs, and patient quality of life. Psoriasis is associated with comorbid conditions that add to the burden of the disease, especially in moderate to severe disease. The total estimated annual healthcare burden of psoriasis may be as high as $35.2 billion, with $12.2 billion in direct costs and $23 billion in indirect costs (attributed to reduced health-related quality of life and lost productivity). These costs vary based on the severity of the disease; pharmacy costs account for the majority of the burden, especially in severe disease. Biologic therapies are largely responsible for the pharmacy costs. Approval of biosimilar products in the near future may ease some of this burden for payers and patients, although new agents have also been recently approved, with more in the pipeline.

The healthcare costs of psoriasis management substantially increase with comorbid conditions, such as heart disease, hyperlipidemia, hypertension, diabetes, and lung disease. These comorbidities also include psychiatric conditions, such as social stigmatization, depression, and suicide. The overall costs associated with comorbidities are estimated to be an additional $22,713 per patient per year. Appropriate treatment selection and timing may curtail the progression of psoriasis, and, as a result, can decrease the economic burden. As treatment options vary based on comorbidities, long-term remission goals, and medication costs, conducting a comprehensive patient assessment is imperative. Drug utilization reviews steered by specialty pharmacists may help reduce costs and improve outcomes by providing treatment monitoring and patient education.
 
Am J Manag Care. 2016;22:S238-S243
    Psoriasis vulgaris, commonly called psoriasis, is a systemic and chronic immunemediated disorder that is characterized by scaly, erythematous patches, papules, and plaques that are often pruritic.1 Psoriasis is not solely a cosmetic problem. Patients with severe psoriasis die an average of 4 years earlier than controls, with a 50% greater risk of early death (likely due to comorbidities).2 The disfiguring and potentially painful patches resulting from psoriasis can significantly impact quality of life.1 Psoriasis is associated with various comorbidities, significantly adding to the disease burden, especially in moderate to severe disease.3 Available treatment modalities for psoriasis include traditional topical and systemic treatments, newer biologic and biosimilar agents, and phototherapy.

    Innovations in treatment options may help expand the armamentarium available for patients with psoriasis and provide greater efficacy with more tolerable adverse effects (AEs). However, the costs of new medications are typically high. One systematic review of 2013 costs reported that the estimated total cost burden of psoriasis was $35.2 billion, with $12.2 in direct costs and $23 billion in indirect costs (from reduced health-related quality of life and lost productivity).4 These costs may be even higher; another systematic review of 2013 costs reported direct costs of $51.7 billion to $63.2 billion and indirect costs of $23.9 billion to $35.4 billion.5

Understanding the Economic Impact of Psoriasis

    
New and emerging therapeutics, especially in the case of biologic therapeutics, have undoubtedly improved the treatment paradigm because of their increased clinical efficacy. However, these medications are also associated with increased healthcare resource utilization and immediate costs.3-6

Costs of Psoriasis

     A systematic review of selected peer-reviewed articles (N = 91), published between January 2003 and June 2013, examined the clinical, economic, and/or social burdens of psoriasis in the United States. The annual incremental per-patient healthcare cost to payers was estimated to be $1757.4 This did not include the estimated out-of-pocket costs of $527 per patient per year.

     Those with mild disease made up 83% of the population of patients with psoriasis. However, because the treatment modalities recommended are substantially different based on severity, it is important to differentiate between patients with limited disease and those with extensive disease.1,3 The cost amounts varied substantially based on disease severity; total healthcare costs ranged from an average of $1820 for mild disease to $9733 for moderate to severe disease. Accounting for 43% of the cost, outpatient costs were the largest source of expense for treatment of mild disease. Pharmacy costs, which were 10 times greater for moderate to severe versus mild disease, accounted for almost 64% of costs for patients in this population.4

     A more extensive study of treatment costs for moderate to severe psoriasis assessed the cost efficacy of currently approved systemic medications by standardizing each therapy based on stimated cost per number needed to treat to achieve a 75% reduction in the Psoriasis Area and Severity Index score (PASI 75). Methotrexate (MTX), cyclosporine, and acitretin required more frequent office visits than phototherapy, as well as more frequent office visits and laboratory costs than biologic medications.6 On a monthly basis, MTX was the least expensive treatment modality to achieve PASI 75, with adjusted monthly costs of $794 to $1503. Considerable variability was observed for the adjusted monthly costs across different studies of the same medications, especially for acitretin, for which the adjusted cost/PASI ranged from $4138 to $14,149, with 34% of patients achieving PASI 75. Infliximab and ustekinumab 90 mg were the most expensive, with adjusted monthly costs ranging
from $8705 to $15,236 and $12,505 to $14,257, respectively. The increased expense for infliximab was attributed to treatment infusion costs (an additional $1013). Cost estimates at 1 year assumed continuous use over the course of a year, although this may not always occur in clinical practice. Taking this into account, infliximab was more cost efficacious over a year (range of $1667 to $2138). Figure 16 shows the total medication costs per treatment period over 1 year.6 Although this analysis of costs was thorough in its inclusion of all available systemic therapies, it did not take into consideration the impact of potential AEs, comorbidity risk reduction, and combination treatments.

Direct Costs of Psoriasis Comorbidities
     Psoriasis is not limited to the skin; immune dysregulation and resulting inflammation of psoriasis affects many body systems, and the disease is associated with multiple comorbid conditions, including psoriatic arthritis (PsA), heart disease, stroke, and diabetes.1,7 Psoriasis and its comorbidities impose considerable economic burden. Although the exact cost burden is defined differently
by various sources, the numbers are staggering. In a systematic review of the annual national burden of psoriasis, including related comorbidities, the cost was estimated at $112 billion in 2013 US dollars.5 Estimates were derived by identifying studies that assessed direct, indirect, intangible, and comorbidity costs of US adults with psoriasis: medical comorbidities contributed $36.4 billion annually, and over a lifetime, a patient with psoriasis would pay $11,498 out of pocket for relief of physical symptoms and emotional health.5   
     To understand the full impact of psoriasis and its comorbidities on cost, records over a 5-year period from the OptumHealth Reporting and Insights claims databases were reviewed. A total of 5492 matched pairs of patients with moderate to severe psoriasis and controls were compared for the prevalence of comorbidities, healthcare resource utilization, and costs. Patients with psoriasis were significantly more likely to have comorbidities than the control patients. The 4 most common comorbidities were hyperlipidemia (33.3% vs 27.3%, respectively), hypertension (32.8% vs 23.5%), iabetes
(15.8% vs 9.7%), and lung disease (9.2% vs 6.2%). Patients with psoriasis were more likely to have any medication filled (98.8% vs 76.6%, psoriasis vs control, respectively; odds ratio [OR], 27.5), including antidiabetic drugs (11.3% vs 6.8%; OR, 1.7). They also incurred significantly greater all-cause medical service utilization, as well as greater corresponding costs (Figure 23). Patients with
psoriasis had higher annual total healthcare costs per patient ($22,713 vs $4993; adjusted cost difference [ACD], $18,960; P <.001) than the control group. This was led by significantly higher all-cause medication costs ($14,698 vs $1101; ACD, $13,990; P <.001), the majority of which were attributed to treatment costs for systemic psoriasis therapies ($12,958) that included biologics, nonbiologic agents, and phototherapies (Figure 33).3

     
A similar study was conducted comparing patients with psoriasis and PsA (N = 1230) to psoriasis- and PsAfree matched controls (N =1230), and the results were similar. Patients with moderate to severe psoriasis and PsA had a higher prevalence of comorbidities, healthcare utilization, and costs than matched controls. Patients with psoriasis plus PsA had significantly more related comorbidities than controls, with the 3 most common being hypertension (35.8% vs 23.5%, respectively; OR, 1.9), hyperlipidemia (34.6% vs 28.5%; OR, 1.3), and diabetes (15.9% vs 10.0%; OR, 1.6) (P <.0001 for all comparisons). Compared with controls, patients with psoriasis plus PsA were also more likely to have inpatient admissions (OR, 1.6), emergency department visits (OR, 1.3), and outpatient visits (OR, 62.7) (all P <.05). The adjusted annual cost differences per patient were $23,160 higher for total costs; $17,696 higher for pharmacy costs; and $5077 higher for medical costs for patients with psoriasis plus PsA than for controls (all P <.01).8

Indirect Medical Costs
     In terms of loss of productivity and decreased quality of life, psoriasis imparts a profound economic impact on patients, payers, and employers.4,5,9-11 A National Psoriasis Foundation survey from 2003 to 2005 of adults older than 30 years found that an adult with psoriasis lost an average of 26 days of work a year due to their illness.9 Those with severe psoriasis were less likely to work full time, and were significantly more likely to report psoriasis as the reason for not working than patients with mild psoriasis (P = .01). Those with severe disease were also significantly more likely to have an income lower than $30,000 compared with patients with mild disease (P = .0002).
     The social burden of psoriasis in the United States, in terms of productivity loss related to presenteeism (working while sick), was estimated at $4.4 billion annually in a systematic analysis of peer-reviewed articles published between January 2003 and June 2013. In addition, an estimated 16.7% of patients with psoriasis are unemployed because of their disease; this results in estimated lost productivity due to unemployment of $700 per patient and a total of $4 billion annually. The aggregated productivity losses caused by psoriasis (including presenteeism, absenteeism, and unemployment) were $11.2 billion.4

     As with direct costs, these numbers go up substantially when the cost of comorbidities are considered. Another systemic review of studies published between 2008 and 2013 found the estimated indirect costs of psoriasis (absenteeism and lost productivity on the job due to psoriasis and/or its comorbidities) to be upwards of $4000 per person annually (2013 dollars).5 

Impact on Quality of Life
     Psychiatric comorbidities are important among dermatology patients because dermatologic ailments have a substantial impact on body image, a major contributor to depression and suicide. Of the major dermatologic disorders that can be cosmetically disfiguring, patients with psoriasis with extensive disease and residing in an institution had the highest rate of depression—8.9% of outpatients and 10.3% inpatients answered yes to the question, “I often wish I were dead.”10

 
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