Clearance of Psoriasis: The Impact of Private Versus Public Insurance
February 2015 | Volume 14 | Issue 2 | Original Article | 119 | Copyright © 2015
Catherine D. Buzney MA,a Caitlin Peterman BS,a Ami Saraiya MD,b Shiu-chung Au MD,b
Nicole Dumont,b Ryan Mansfield AS,b and Alice B. Gottlieb MD PhDa,b
aTufts University School of Medicine, Boston, MA
bDepartment of Dermatology, Tufts Medical Center, Boston, MA
BACKGROUND: Psoriasis treatments and therapeutic response as they relate to private versus public patient insurance in the United
States have not yet been reviewed. Improved understanding could clarify factors challenging optimal psoriasis management and offer
insight for dermatologists treating psoriasis within our healthcare system.
METHODS: 258 subjects were included from a database of psoriasis patients seen at Tufts Medical Center (Boston, MA) during 2008-2014. Insurance was classified as primarily private or public (Medicare or MassHealth/Medicaid). Patients required a minimum of two consecutive visits per treatment and at least 8 weeks within one of four treatment categories: biologics, oral systemics/ phototherapy, combined biologics and oral systemics/phototherapy, or topicals only. Primary endpoint was the Simple-Measure for Assessing Psoriasis Activity (S-MAPA) calculated by multiplying Physician Global Assessment by Body Surface Area. S-MAPA<3 constituted absolute clearance. Insurance type was evaluated as a predictor of prescribed treatment categories, maximum S-MAPA
improvement from baseline, and total drugs used per treatment course (“drug-switching”).
RESULTS: 80.2% (n=207) and 19.8% (n=51) had primarily private and public insurance, respectively. 69.6% with private insurance were prescribed biologics versus 66.7% (public insurance) (P=0.689). 54% (private) versus 49% (public) achieved clearance (P=0.514). However, S-MAPA decreased 78.35% from baseline in those with private insurance compared to 61.48% (public) (P=0.036). On average, privately insured patients used at least twice as many same-category treatments, most commonly biologics, than publicly insured individuals (P=0.003). Drug-switching was significantly associated with clearance (P=0.024). Multivariate analysis demonstrated no significant differences in prescribed treatment categories, drug efficacy, clearance, S-MAPA, or drugswitching with respect to patient age.
CONCLUSIONS: Treatment categories were comparably prescribed between insurance subgroups. However, privately insured patients achieved significantly greater degrees of clearance and switched between more medications within biologic and systemic categories, potentially explaining their overall improved therapeutic response. Further studies including cost-analysis could clarify any difference in the effectiveness of prescribed therapy for these two patient populations.
J Drugs Dermatol. 2015;14(2):119-125.
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Psoriasis is a chronic inflammatory disease which affects approximately 3% of the population and profoundly influences the quality of lives of those afflicted.1,2 While topical corticosteroids are the first-line drug of choice for 85% of physicians treating mild psoriasis, more intractable forms of the disease have led to an armamentarium of powerful treatment options3; these agents include phototherapy/photochemotherapy, less expensive oral traditional systemic agents, and injected or infused biologic agents which may cost up to 10 times the price of their systemic counterparts. As a result, annual treatment amounts to several thousands of dollars per patient and billions nationally.3,4
Affordability of health care services and medications as affected by insurance policy has been shown to shape health status and mortality across numerous diseases with studies demonstrating worsening disease with rising medication costs.5-7 Implications of insurance type for health outcomes in the United States over the past six years (before the Affordable Care Act) is especially relevant as, during this time, approximately 65% of the American population possessed private insurance, 15% possessed public insurance, and 20% lacked insurance altogether.8
For patients with psoriasis, the role of insurance in limiting treatment options is an ongoing struggle.1-4,9 Although 91% of patients surveyed in 2013 possessed insurance, 50% reported that finances restricted their treatment choices, and nearly 25% sought care from a primary care physician to avoid seeing a more costly specialist.10 Newer biologics may cost up to $70,000 annually with insured patients paying as much as 30% depending on deductibles. Even less expensive treatments like oral systemic drugs or phototherapy require co-pays with each office visit or safety monitoring laboratory tests given extensive toxicity profiles, rendering these regimens non-sustainable for many