Expense drivers for costliest psoriasis patients

Biologic medications are clearly a costly component of psoriasis care. However, new research from a retrospective study suggests that they may not be the major driver of cost in the subset of patients incurring the most expenditures.

Instead, investigators found that their costliest psoriasis patients had substantially higher comorbidities, inpatient stays, and emergency utilizations compared to psoriasis patients incurring less costs.

Based on these findings, published recently in the Journal of Drugs in Dermatology,¹ effectively managing comorbid conditions among psoriasis patients is likely critical for reducing overall costs, says investigator April W. Armstrong, M.D., M.P.H., director of the psoriasis program at the Keck School of Medicine, University of Southern California, Los Angeles, Calif.

“While biologics are costly, they are not the whole story,” Dr. Armstrong tells Dermatology Times.

“These findings challenge the misconception held by many outside of dermatology that psoriasis patients may be generally healthy and only occur expenses related to their medications or psoriasis,” she adds. “Instead, the findings show that, among the costliest psoriasis patients, much of the expenses were on medical expenditures and on comorbid conditions, rather than psoriasis itself.”  

Cost and psoriasis: Filling in the gaps

Cost accounting for psoriasis patients is an important issue because it impacts payer decisions, clinician prescribing behavior, and patient outcomes. However, not much is known about this topic; to address this, Dr. Armstrong and colleagues sought to examine costs among psoriasis patients in the United States whose healthcare service utilization were consistently the highest among their psoriasis peers over a three-year period.

In the retrospective study, investigators reviewed pharmacy, medical, and enrollment data for more than 12.6 million U.S. individuals enrolled in a commercial health plan. For analysis, they selected individuals who had two or more diagnoses of psoriasis and who were continually enrolled in the plan from Jan. 1, 2011 through Dec. 31, 2013 (N = 18,653). These individuals were stratified into four cost groups: top, high, medium, and low.

The top group included individuals who were in the top 10% of spending for all three years of enrollment. Despite being a very small portion of the overall study population (just 3% of enrollees), they accounted for 13% of the overall spending on health care utilization.

The top group’s total psoriasis-related expenditure was two times higher than the bottom group ($8,716 vs $4,541; P < 0.001), but more notably, their total all-cause costs (combined medical and pharmacy costs) were eight times higher than the bottom group ($68,913 vs $8,815; P < 0.001).

Much of what was responsible for the costs in the costliest psoriasis group was the medical expenditure to treat comorbid conditions.

“They had substantially higher comorbidities, inpatient stays, and emergency utilizations compared to psoriasis patients incurring less costs,” Dr. Armstrong explains. “The implication of this finding is that comorbidities incur disproportionately large amount of cost in psoriasis patients, so screening and managing comorbidities at the outset may reduce long-term clinical sequelae and costs.”

NEXT: How do biologics relate to psoriasis cost?

How biologics relate to psoriasis cost?

Some previous studies have found, in contrast, that biologic medications are a substantial component of medical costs, or responsible for increased costs, in patients with psoriasis.^2-3 The differences in the findings are mainly attributable to differences in methodology. The earlier studies focused on the biologic costs alone, or did not separate out pharmacy versus medical costs. In this study, Dr. Armstrong and colleagues stratified pharmacy and medical expenditures to determine the contribution of drug-related versus non-drug-related healthcare expenditure to the overall costs.

Investigators acknowledged several caveats to the findings of this observational study. Notably, the administrative claims data the analysis was based upon is for purposes of payment, rather than research, and so may not contain all the information required for a confirmed diagnosis, medication adherence, or other factors.

The group recently published another related study showing that use and cost of biologics did not differ significantly between patients incurring the highest 10% of total costs and the bottom 90%.⁴

Lessons for providers

Next, the group plans to examining the cost and health impact when patients are not placed on the most appropriate biologic first; i.e., the financial and clinical consequences when patients are cycling through multiple biologics.

For dermatology providers, Dr. Armstrong says, it is important to note that psoriasis patients incur significant costs in managing sequelae of their comorbidities, such as arthritis, cardiometabolic diseases, neuropsychiatric diseases, and other immune-mediated conditions.

“Being vigilant for these comorbidities, and ensuring that patients are screened and intervened early for their comorbid conditions, can not only improve patient outcomes but can also be cost effective in the long run,” she adds.

Disclosures:

The study was supported by Novartis Pharmaceuticals Corporation.

Dr. Armstrong reports serving as investigator, advisor and/or consultant to AbbVie, Janssen, Novartis, Lilly, Regeneron, Sanofi, Modernizing Medicine, and Valeant.

References

1 Armstrong AW, Zhao Y, Herrera V, et al. Drivers of Healthcare Costs Among the Costliest Patients With Psoriasis Over Three Years in a United States Health Plan. J Drugs Dermatol. 2017 Jul 1;16(7):651-658.

2 Gleason PP, Alexander GC, Starner CI, et al. Health plan utilization and costs of specialty drugs within 4 chronic conditions. J Manag Care Pharm. 2013 Sep;19(7):542-8.

3 Norlin JM, Steen Carlsson K, Persson U, Schmitt-Egenolf M. Resource use in patients with psoriasis after the introduction of biologics in Sweden. Acta Derm Venereol. 2015 Feb;95(2):156-61. doi: 10.2340/00015555-1895.

4 Armstrong AW, Zhao Y, Herrera V, et al. Rethinking costs of psoriasis: 10% of patients account for nearly 40% of healthcare expenditures among enrollees with psoriasis in a U.S. health plan. Journal of Dermatological Treatment 2017 March 20, DOI: 10.1080/09546634.2017.1303566. Epub ahead of print.