Addressing Gaps in Treatment Access

In this exclusive interview as part of the National Eczema Association’s Atopic Dermatitis (AD) Expert Series, Lisa Swanson, MD, met with The Dermatologist to discuss gaps in treatment access for patients with AD, including connecting the right patient to the right therapy at the right time.

The Dermatologist: Can you explain what we mean when we talk about treatment access?

Dr Swanson: Treatment access basically means I prescribe a medication for a patient and the patient gets the medication, and that has become increasingly complicated over the years. Often, we have to step through what is called prior authorization to get approval for the medication. Sometimes we have to try other things to get approval for the medications that we prescribe. Most dermatology practices employ biologic coordinators to help us navigate this world of access to get patients on certain biologic medications, such as dupilumab and the Janus kinase inhibitors. We have had to expand our staff to accommodate all the paperwork and process that goes into prescribing these therapies.

The access issue has become increasingly problematic and will likely continue because we are going to continue getting new medications. I think we get better with time. Our offices get better at managing this, the pharmaceutical companies get better at providing us with tools to improve the process, and I learn as time goes on what certain insurance companies prefer so I can most effectively navigate their process. Getting patients the medications they need is the number one priority for me, but it takes a lot of time and energy, and sometimes denials. Hopefully, with some time and effort, we can make the access issue better. In the meantime, we are developing tools to help us get our patients what they need.

The Dermatologist: What are some of the challenges you face in accessing both topical and systemic therapies for your patients?

Dr Swanson: Topical therapies are a little bit easier; pretty much all insurance companies cover a good assortment of topical steroids. Probably the biggest access issue in the topical AD treatment world right now is topical ruxolitinib. There are always growing pains with a new medication as the company figures out how the copay card is going to work and what the relationship with the dermatology pharmacies is going to be. I am sure we are just in the midst of this now and it will get better.

In the systemic AD treatment world, we have a lot of tools to help us navigate access issues. The US Food and Drug Aministration approved biologic and systemic therapies for AD have good support programs and copay cards. All the companies do a good job of trying to increase access and help patients with their copays so they can get the therapy for a reasonable amount. Probably the biggest issue nationally with coverage for some of the systemic therapies is copay accumulators. There are some insurance companies that have instituted a copay accumulator where the drug company’s copay card is run for the full amount of the medication but instead of counting toward the patient’s copay and deductible, it goes to the insurance company. This means that the patient gets the medication for free for the first 2 or 3 months, but then the copay card runs out. The patient is left with their deductible because that money went to the insurance company, not to the patient, which is a big burden. Legislatively there are moves being made to try to stop this. There are states that have outlawed copay accumulator policies. Hopefully, this issue gets better because often the patient does not even know they have one of these policies until they get to the third or fourth month of their biologic and, suddenly, they have a huge bill.

The Dermatologist: What do you consider the major barriers to treatment access that make it challenging to get the right treatment to the right patient at the right time?

Dr Swanson: One crucial thing that helps us in the world of prescribing biologic and systemic therapies for our patients with AD is having samples of those medications in our office because then we can start the patient with severe AD on a medication that day. We do not have to wait to navigate through the process to get the patient feeling better. We can give them something to start with, depending on which therapeutic modality we are using, and they can at least start getting better while we do the background work to get the therapy officially approved. Also, this way I do not feel as much pressure working my way through the insurance process because I know the patient is on their therapy and they are starting to get better. I have time to focus on the logistics.

I mentioned before that most practices, especially larger practices, have a biologic coordinator. That is an important and essential aspect of a practice to provide the best care for our patients and minimize the work providers are doing on the logistical end. There is even an organization called the Biologic Coordinators of Dermatology that is creating a strong network of people who are working hard to get the right medications for our patients.

The Dermatologist: With so many new and exciting AD therapies now available and more to come, how do you address access for your patients in the real world?

Dr Swanson: I did my residency at the Mayo Clinic where the motto is “the best interest of the patient is the only interest to be considered,” and I try to follow that in my daily practice. When I give my patients the list of treatment options I have proposed for them, I tell them there are several plans on the list that are easy, which I know will get covered no problem. If I feel a biologic or systemic medication is the best for the patient and that is what they choose, then I can usually predict which ones are going to be problematic and which ones are not. Once we have selected our plan, I basically tell my patients and their families that I do not take no for an answer, so I will continue to push until we get the medication. And again, it is nice to have samples, so I know that my patient’s needs are being met while I work with my biologic coordinators.

The approach I take is that I am going to get the patient the medication they feel is the best for them or the best for their child. One of the ways I do that is by requesting a peer-to-peer review. This is an important part of the process, and it is often during this step that I can get the medication approved for the patient. As a provider, do not get discouraged if you get a denial or if your appeal gets denied; request a peer-to peer-review. If you are struggling to get approval for your patients’ medications, speak to another provider and explain your point of view.