Abdelnabi Mai, Patel Aakash, Rengifo-Pardo Monica, Ehrlich Alison
Department of Dermatology, Medical Faculty Associates, George Washington University, 2150 Pennsylvania Ave, NW, Suite 2B-430, Washington, DC, 20037, USA.
Am J Clin Dermatol. 2016 Aug;17(4):421-4. doi: 10.1007/s40257-016-0194-4.
With the variability in health insurance coverage for psoriasis systemic therapies, recent changes in coverage for biologics have yet to be evaluated.
To determine changes in insurance coverage of biologics for moderate-to-severe psoriasis between 2009 and 2014, with a focus on insurance policies as stated in prior authorization (PA) forms, coverage denials, and time course of approval process.
A retrospective chart review was performed on patients with a diagnosis of psoriasis (International Classification of Diseases [ICD], Ninth Edition, code ICD 696.1) seen at the Department of Dermatology, Medical Faculty Associates, George Washington University between January 1, 2009 and December 31, 2014. Exclusion criteria included <9 % body surface area, loss to follow-up, lack of biologic treatment, biologic treatment via a clinical trial, and lack of health insurance. For all other patients, metrics collected included age, sex, body surface area, health insurance plan, prior therapies, prescribed biologic, PA necessity, time in days between PA submission and coverage decision, and denial justifications.
Eight hundred and sixty-four patients with a diagnosis of psoriasis within the time period were identified, 114 of who met the inclusion criteria. PA requirement increased from 16 % of patients prescribed a biologic in 2009 to 75 % of patients prescribed a biologic in 2014. The mean duration in days between PA submission and coverage decision from the insurance company increased from 3.7 days in 2009 to 6.7 days in 2014. PA denial rates increased from 0 % in 2009 to 19 % in 2014. The most common reason for coverage denial was failure to attempt alternative therapies prior to requesting biologics.
Insurance coverage of biologics for moderate-to-severe plaque psoriasis has become increasingly regulated between 2009 and 2014. Given both the cost burden and potential benefits of these therapies, further examination of healthcare coverage and treatment accessibility is warranted for optimal patient outcomes.
鉴于银屑病系统疗法的医疗保险覆盖范围存在差异，生物制剂覆盖范围的近期变化尚未得到评估。
确定2009年至2014年间中重度银屑病生物制剂的保险覆盖范围变化，重点关注事先授权（PA）表格中规定的保险政策、覆盖范围拒绝情况以及审批过程的时间进程。
对2009年1月1日至2014年12月31日期间在乔治华盛顿大学医学院皮肤科就诊的银屑病患者（国际疾病分类[ICD]，第九版，代码ICD 696.1）进行回顾性病历审查。排除标准包括体表面积小于9%、失访、缺乏生物治疗、通过临床试验进行生物治疗以及缺乏医疗保险。对于所有其他患者，收集的指标包括年龄、性别、体表面积、医疗保险计划、既往治疗、处方生物制剂、PA必要性、PA提交与覆盖范围决定之间的天数以及拒绝理由。
在此期间确定了864例诊断为银屑病的患者，其中114例符合纳入标准。PA要求从2009年开具生物制剂的患者的16%增加到2014年开具生物制剂的患者的75%。从PA提交到保险公司做出覆盖范围决定的平均天数从2009年的3.7天增加到2014年的6.7天。PA拒绝率从2009年的0%增加到2014年的19%。覆盖范围拒绝的最常见原因是在请求生物制剂之前未尝试替代疗法。
2009年至2014年间，中重度斑块状银屑病生物制剂的保险覆盖范围监管日益严格。鉴于这些疗法的成本负担和潜在益处，有必要进一步审查医疗保健覆盖范围和治疗可及性，以实现最佳患者结局。
