A discussion on the patient preference for specific medications based on administration and dosing schedule, and the payer approval process.
Peter L. Salgo, MD: Well, with that, what role does patient preference play in these various biologic treatments?
Joel Gelfand, MD, MSCE, FAAD: I think in a perfect world it would be central to what we’re doing. The patient and the physician would make a decision together about what makes most sense for them. We recognize that there are payer issues as well, of course. I think what’s most challenging is that most dermatologists really care a lot about this issue—the cost of some of our therapies. But we don’t have a way of knowing what the cost will be when we prescribe a drug. And things change so rapidly in terms of what insurance companies will cover or not cover, that it’s very hard for us to know which is the preferred first-line agent from an insurance company at that particular moment.
Peter L. Salgo, MD: But do you actually think about that, or do you think about what’s best for my patient, then go to war with this guy?
Joel Gelfand, MD, MSCE, FAAD: I usually think about what’s best for my patient, but I do explain to them we’ll make a recommendation for a prescription. But if the insurance company comes back and wants to try something different, we may have to switch course if there’s no medical reason not to try something different.
Peter Dehnel, MD: Thank you, I do appreciate that. A couple of observations. One is that the patients, if they have insurance, which most people do, there will likely be some sequence of therapies that they need to get to in order to get the latest and greatest, if you will. There are, on the other hand, so many patient payment support options out there. Some people may have a really high co-pay, for example, for their new biologic. But with the help of the pharmaceutical company, it may be a lot less than what it would be otherwise.
Joel Gelfand, MD, MSCE, FAAD: At the University of Pennsylvania, we’re lucky, we have a full-time pharmacist who helps us navigate all this stuff. For most dermatologists, they don’t have that type of resource available to them to deal with all the prior authorizations, to help the patient navigate what way they could reduce their co-pays, things of that nature. And it changes so rapidly that even if you sort of know all these things, that now becomes obsolete quite quickly. I wonder if, Steve, you feel the same way, or if your experience is different. What do you think?
Steven Feldman, MD, PhD: My experience mirrors everything you said, but as a Libertarian, as somebody who believes that economics affects decisions, which is good, insulating both the patient and the physician completely from the cost, doesn’t make sense to me. And so, in this ideal world, yes, cost wouldn’t matter, but there is no ideal world, and cost does matter. And the drugs are all so good that if an insurer says, “Well, you’ve got to try this one first. If it doesn’t work, OK, then we’ll consider the next one,” that doesn’t upset me as much as it does other dermatologists. That doesn’t make me feel like the insurer is practicing medicine. As Pete said, they’re just telling me what they pay for, but they’re not telling me what to do.
Peter L. Salgo, MD: But the complaint isn’t so much that I’m going to pay for this good drug or that good drug. The complaint is that we have far better drug than what we had, let’s say, 15 years ago, and the insurance companies want step therapy. They want us to start with the least efficacious in our armamentarium first because they’re the cheapest, and then move up.
Joel Gelfand, MD, MSCE, FAAD: The experience is really variable depending on who your payer is. I’ve had experiences where patients have severe disease, they’ve failed 2 TNF [tumor necrosis factor] inhibitors already, and I get a payer response back saying, “Well, you have to fail calcipotriene and tar.” OK, that obviously doesn’t make any medical sense, right?
Peter Dehnel, MD: No.
Joel Gelfand, MD, MSCE, FAAD: And also in situations where, maybe we would want to use a drug, there is a comorbidity where maybe the person has a history of optic neuritis, and I don’t want to use a TNF inhibitor. And so then we’re told we have to use a TNF inhibitor, and then we have to go back for medical exceptions—things of that nature. Or we know the patient’s failed a class of drugs already. They already failed maybe a very good Il-17 [interleukin-17]. Why would I try a second IL-17; it makes more medical sense to switch to a different mechanism of action.
Peter L. Salgo, MD: For which patients, if there are any, would you simply jump right in to biologics and skip all the preliminaries?
Joel Gelfand, MD, MSCE, FAAD: Well, we never think about preliminaries. We think about what the patients need at this stage of their disease. If someone comes in with extensive disease, that’s not something that could get better with topical medication. So again, it’s patient preference. Do they want to try phototherapy? Is a pill what they want to do? Is an injectable appropriate for them? We make the decision together and move forward together.
Peter Dehnel, MD: Joel, in your population, are you more likely in your clinic to see them at a more advanced stage of their disease? They’ve been through primary care, they’ve been through community dermatology, and then they get to you, is that it?
Joel Gelfand, MD, MSCE, FAAD: Well, it’s interesting. The average patient with psoriasis in the population has had disease for about 2 decades, so they’re pretty experienced with their disease, and the delay in getting effective therapy is substantial. But I see all spectrums of disease, from people with more recent onset disease where they’re early in their journey, to people who are more experienced, and now they’re on their last drug in their journey, and still not responding. I see the whole spectrum out there. And each case is unique.
Steven Feldman, MD, PhD: You could take somebody who has brand new onset guttate psoriasis, little tiny plaques that just appear all over their body, just exploded with psoriasis. And you could try topicals, but that’s not going to be practical. You could do light therapy, they could come to the office 3 times a week for 6 weeks or so, it would be very inconvenient for them. Or you could do methotrexate for a little while, ramp them up on the dose. It would take a while for it to take effect because you have to start low and work your way up. Or you could give people 1 shot of the latest and greatest biologic, and that would probably clear them up, and they might stay clear for possibly forever.
Peter L. Salgo, MD: Sign me up.
Steven Feldman, MD, PhD: Clearly, it would be ideal to take that shot, but that’s also probably the costliest way of treating them. So it’s a balancing act.
Peter L. Salgo, MD: Can you put this into a bucket? Do the insurance companies do this where it’s expensive, it’s 1 shot, but he’s going back to work, he’s going to make more money, he’s going to be more productive, he’ll be able to do other things in his life? And then when you add it all up, maybe it’s not that expensive.
Steven Feldman, MD, PhD: Yes, but as you were saying earlier, Peter Dehnel, you’re going to take that money from somebody who has heart disease or needs a transplant. The bucket is only so big.
Peter L. Salgo, MD: But in the early days of the statins, I used to hear this a lot, which is the statins are expensive and they work, so we’re going to maybe not put them on the formulary. And I asked, “Well, supposing I told you that these patients now wouldn’t get MIs [myocardial infarctions], they wouldn’t be hospitalized, they wouldn’t have chronic heart failure, they wouldn’t need transplants. Aren’t you saving money in the long run?” And the answer was yes, but I’ve got to make my third quarter. That’s an issue.
Peter Dehnel, MD: Well again, in general, in the insurance world many people don’t stay with an insurer for 10 years, they’ll stay with them for 24 months. And so if a therapy has a significant impact on their cost of care over that 24 months, insurance companies are going to be much more likely to embrace that. If you’re looking at 10, 15 years out, that’s not going to be as attractive.
Peter L. Salgo, MD: Got it. So the time course of this thing is important. Continuity.
Steven Feldman, MD, PhD: That’s a game theory question because if all insurers acted well and treated people with things that would be cost-effective, it would help all insurers.
Peter L. Salgo, MD: Right.
Peter Dehnel, MD: Yes.
Peter L. Salgo, MD: You’re right, game theory is where I was going with the train track problem. It’s another classic game theory issue. But we always talk about medical continuity of care. Why don’t we talk about insurance continuity of care? And maybe you can compare data and you can all say, “Look, this is a good idea for us as an industry.”
Peter Dehnel, MD: That would be an interesting conversation to have.