Drs Groves and Lebwohl discuss payer considerations for ensuring treatment with the appropriate agent for patients with psoriasis and metabolic syndrome.
Ryan Haumschild, PharmD, MS, MBA: A question for the group, but we’ll start with Dr Groves. We’ve heard a lot, and Dr Lebwohl described really well some of the data around metabolic syndrome and patients who respond better to certain therapies and have better disease response, even when they have metabolic syndrome, compared to other agents. You as a payer, and most of us as payers, how do we take these key considerations when we’re treating patients and there are different therapeutic options in this space? How do we start to think of some of these unique patients who may have comorbidities with certain disease states, and how do we consider their unique needs when we’re looking at a whole patient population in terms of the therapeutic landscape?
Robert Groves, MD: As I mentioned earlier the insurance industry tends to be highly conservative in terms of adding new therapies, particularly when those therapies are more expensive. There is a rationale for that, we’ve been burned before on things that we thought were going to be OK, that weren’t OK. I mentioned one earlier, an activated protein C. Thus, there’s a little bit of caution around this. The other problem I think is, again, one of knowledge management. This is a narrowly focused area, particularly with psoriasis. When you look at all of the things that an insurance company has to look at in terms of managing costs, based on the evidence; now, I’d love to call it evidence-based, except that the notion of what constitutes evidence and how strong it is will vary across insurance plans. Thus, it’s not purely fact-based, there is some judgment involved, but typically we tend to be very cautious. I can’t wait for the data on the interleukin blockers to come out with regard to the ability to reduce the incidence of major adverse cardiac events because I think that would go a long way toward streamlining our approach and really being able to target specific therapies for specific patients.
In the absence of clear data that have been reproduced by other authors, it tends to be a one-size-fits-all approach, a step-therapy kind of approach, if you will. I’m not suggesting that’s the best way to manage it, but under our current incentive structure and under our literature structure and the absence of a lot of good knowledge management in that space, it is where we are. I think it is true of most physicians who will take peer-to-peer objections to a denial, that most of us will listen carefully to the physician who is making the case. We’ll do our very best to accommodate that physician when we can, when it makes sense and when we feel like, “Yes, the data are there, it just hasn’t reached the level that a committee of folks have signed off on it yet.” Thus, it’s a challenge, and it’s a challenge for the entire industry. Nobody loves prior authorization. Doctors don’t like it, insurance companies don’t like it; we all hate it. We’re looking for strategies that will help us get past that. Part of that is the work that Dr Lebwohl and others are doing to help us understand exactly where specific agents belong in our armamentarium for specific patients. We’re getting more and more toward personalized medicine, and this is part of that journey.
Mark Lebwohl, MD: I have to say something because I know a lot of my colleagues who are dermatologists will be angry at me if I don’t.
Ryan Haumschild, PharmD, MS, MBA: Go ahead.
Mark Lebwohl, MD: When I was president of the American Academy of Dermatology [AAD], we surveyed our members, and burnout among dermatologists, which was unheard of before, had increased dramatically. The leading cause was the inability to give the drug that you knew was best for your patients because of step therapy and hurdles. I was responsible for the AAD leading the effort on step therapy legislation, which is now approved in 28 states, and hopefully we’ll have it federally as well. I will tell you the reason for that. I published an article 2 years ago; the lead author was Shivani Kaushik [MD]. It was the lead article in January 2019 in the Journal of the American Academy of Dermatology. It was 2 articles, and it was called “Which Drug for Which Patient,” because we have so many choices to go by. And it turns out that under certain very common scenarios, there are drugs that should not be considered and drugs that absolutely should be first-line therapy. There is not one drug that you’re going to have to fail this drug first and then go to the next drug.
I’ll give you some perfect examples. For example, TNF [tumor necrosis factor] blockers increase the frequency of squamous cell carcinomas of the skin. If someone has a history of getting multiple squamous cells, to treat them with a TNF blocker is almost malpractice. Yet, we were being asked to have our patients fail a TNF blocker as the first line. Of course, it was appealable, but as it was stated, prior authorizations are not only unpleasant, they sometimes don’t work, and we have to fight it out with an insurer. Often what was happening is patients were being treated and allowed to fail those drugs, which led to squamous cells, in order to get the drug they needed to get. I will tell you right off the bat, no dermatologist went to medical school to write appeal letters.
To emphasize that, I was asked to speak to a group of 107 patients with psoriasis. The title of my lecture to them was, “Which Drug for Which Patient?” They were all in one room. I asked them to stand up when I started the lecture. I said, “I’m going to read off a list of conditions and at the end of my reading it off,” because I didn’t want to embarrass anyone, “if I mentioned a condition you have, I’d like you to sit down.” We started with obesity, joint pain, lupus, hepatitis B, hepatitis C, HIV, cardiovascular risk factors like diabetes, hypertension, obesity. I kept going with a longer list than that. At the end of my reading from that list, I said, “If I mentioned a condition you have, I want you to sit down.” At the end of that out of 107 patients, 106 sat down. There was 1 patient standing who did not have any of those conditions, including, for example, multiple sclerosis or demyelinating disease. We know TNF blockers make those worse. Crohn disease; you probably are not going to give an IL-17 [interleukin-17] blocker because of the uncommon exacerbation of inflammatory bowel disease that occurs with IL-17 blockers.
Thus, the bottom line is that there is not a best drug for a particular patient. If you think about it now, we’re going to get a biosimilar for adalimumab. Adalimumab has boxed warnings. The IL-17 blockers and IL-23 blockers don’t, and they work better. Why would we start with a drug that has a boxed warning? The only answer is cost. I understand that. Cost should be a factor. We should try to save the system money. But when we’re dealing with patients who almost for sure are going to have some comorbidity that defines what’s good or not for them, why are we forcing them to go through a particular drug first?
This transcript has been edited for clarity.