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Utilization Management in Psoriasis


Bhavesh Shah, PharmD, and Robert Groves, MD, discuss the priorities payers should be taking into account when managing psoriasis treatment.

Ryan Haumschild, PharmD, MS, MBA: Hello and welcome to this AJMC® Peer Exchange Program titled “A Personalized Approach to Disease Management in Psoriasis.” I'm Dr Ryan Haumschild, Director of Pharmacy Services at Emory Health Care at the Winship Cancer Institute. Joining me today in this virtual discussion are my esteemed colleagues. Starting off with Dr Mark Lebwohl, dean for Clinical Therapeutics, professor and chair emeritus of Dermatology at the Icahn School of Medicine at Mount Sinai Hospital; Dr Robert Groves, executive vice president and chief medical officer for Banner Health at Aetna; and Dr Bhavesh Shah, senior director of Specialty Pharmacy strategy at Boston Medical Center. Today, our panel of experts will explore the potential use of claims data and electronic medical record data to understand the cost and quality of health care for patients with psoriasis and comorbid conditions such as metabolic syndrome and discuss the execution of a personalized approach to psoriasis management through payer controls. We know that psoriasis is a crowded space in managed care. New therapies are getting added constantly and many of them are costly therapeutic options, especially as we're looking to manage the patients in the clinical outcomes, but also the spend. Thus, why is it such a priority for payers to create more utilization management around this space? Dr Shah, if you can kick us off with your thoughts.

Bhavesh Shah, PharmD: Absolutely, Ryan, thanks for the opportunity. I think the unique thing that we have knowledge of, from an IDN [integrated delivery networks] perspective, is the total cost of care that a patient with psoriasis actually incurs, right? It's not just about the biologic that they're on. We know that they're costly, but it's also what is the downstream total cost of care? Hospitalizations, ED [emergency department] visits, specialists, labs, medications that they're taking outside due to the co-morbidities that they have from psoriasis. Thus, I think looking at that overall total cost of care, we're challenged with actually managing a formulary with already costly agents. And then, we also have this total cost of care that we're trying to also contain. Also, there's been some economic studies that have been published around psoriasis that have shown that there is this direct cost from psoriasis that's probably 2 to 10 times higher compared to IBD [inflammatory bowel disease] and RA [rheumatoid arthritis]. And then you look at the indirect cost, which is actually even higher than IBD and RA again, in terms of the loss in productivity, a lot of the comorbidities that patients will develop because of the disease. Thus, I think we're trying to manage the disease and then you have this downstream total cost that you're also trying to manage and we kind of forget that. Unless you have a payer arm, you're not going to be really well informed and seeing those types of impacts for the disease.

Ryan Haumschild, PharmD, MS, MBA: Yes, you're correct. There are a lot of pain points there, from managing the cost to making sure that patients are staying adherent to the medication. That's so important to get those clinical outcomes. And then, especially if we look at cost of care, how do we manage kind of the patient continuum and not just dose by dose? And I think that's really something we struggle with as a payer arm in terms of managing this treatment population. Dr Groves, what are your thoughts? What are some additional key pain points or management considerations that you think about in that psoriasis treatment and care model?

Robert Groves, MD: Yes, well, this field has evolved a lot in the last decade and we now understand psoriasis as a clearly systemic problem that impacts patients in a variety of ways. You have to understand cardiovascular medicine, you have to understand psychology. I mean, this is a disease that has a very broad impact. And thus, the costs of not treating the disease are going to be relatively high. On the other hand, the treatment options that are available in biologics are very expensive. Hence, understanding which biologics should be applied to which individual patients becomes key. We don't want to spend time on drugs that aren't going to be effective and end up switching multiple times to find something that is effective. That’s the last-ditch effort, if you will, to find the appropriate therapy. But we're hoping that with advancements in our understanding, some of the research that Dr Lebwohl has done and is doing will help us zero in on the most effective therapies upfront in a very personalized way. We also know that there's an association between psoriasis and metabolic syndrome now. And in fact, I think the presence of psoriasis, according to the AAH and the ACC [American College of Cardiology], is an indication for starting statin therapy. Thus, that association is close, and the pathophysiology is interesting. We're starting to understand so much more intimately that many diseases have a chronic inflammatory component. That's what drives plaque formation in the arteries, and that's what drives plaque formation on the skin. Hence, it makes perfect sense that treating this disorder has systemic consequences that can be very positive. The cost is the one barrier that makes us hesitant to instantly look at a new drug, for example. All of us are still, as a critical care physician, we're still a little bit taken aback by the experience. With Xigris, for example. A decade or two ago, where everyone thought it was the next whiz-bang option for sepsis, and it turned out not to be so. Thus, you can expect the insurance companies to be cautious in moving forward with personalized, individualized therapy. There's also the legacy problem of this has always been prior authorization. We've always done step therapy. This is how we do it. But I think all of us on the insurance side are open to those strategies, which ultimately improve the patient experience and reduce total cost of care over time.

Ryan Haumschild, PharmD, MS, MBA: That was a great way to kind of build upon some of the discussions we've been having. I really appreciate you calling out the systemic disease. I think that plays such an important role in this space.

This transcript has been edited for clarity.

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