In the US, eligibility for biologics is based on the clinical severity of the disease or impact on QOL. Severity parameters can be found in Table 1.

Gaps and Barriers

Despite favorable safety and efficacy data, biologic therapies continue to be underutilized, due to cost, insurance coverage, and physician reimbursement. Patients complain of difficulty filling prescriptions and negotiations with the insurance companies. Younger age (<55 years), lower income (<$1000,000/year) and lack of health insurance further contribute to difficulty accessing biologics. On a system level, hospitals and clinics are not always fully reimbursed for the cost of biologics, and physicians and staff are not adequately compensated for time involved in prescribing them.


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Recommendations for Improvement

  • Physician education and training
  • Reductions in the costs associated with these agents
  • Limiting economic disincentives
  • Streamlining the steps involved in prescription
  • As new agents are developed, first-generation agents might become more affordable
  • Adequate training of support staff
  • The involvement of “multiple entities,” including academic centers and pharmaceutical companies
  • Development of a prescribing and authorization service that “interfaces directly with the EMR”
  • Development of more consistent guidelines regarding approval of biologics by payers
  • Advocacy by interested patient and healthcare provider organizations

Resident Education

Standards

Residents should obtain “clinical experience in a high-volume psoriasis clinic that includes management of complex patients, under the supervision of a psoriasis specialist.” In particular, the authors emphasize that residents should “gain comfort with biologics, as utilization is correlated with experience and training.”1

Gaps and Barriers

Among US-trained residents, there is only “variable exposure” to the use of biologics, and only limited training in counseling patients. Residents are also not certain whether the dermatologist or PCP is responsible for screening and for counseling lifestyle modifications in psoriatic patients.

Recommendations for Improvement

  • “Well publicized” opportunities for residents to participate in elective and other learning sessions, live or recorded lectures
  • Short rotations at preapproved sites that focus on psoriatic care.
  • Training in counseling, motivational interviewing, and the processes required to prescribe biologic agents (eg, obtaining prior authorizations)

    Conclusion

    The authors conclude that collaborative efforts must be incorporated into addressing “the key deficiencies in psoriasis treatment, screening, and education.”

    References

    1.      Gottlieb AB, Greb JE, Goldminz AM. Psoriasis Trends and Practice Gaps. Dermatol Clin. 2016 Jul;34(3):235-42.

    2.      Gottlieb A, Korman NJ, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008 May;58(5):851-64

    3.      Menter A, Korman NJ, Elmets CA, et al. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol. 2009 Apr;60(4):643-59.

    4.      Kimball AB, Gladman D, Gelfand JM, et al. National Psoriasis Foundation Clinical Consensus on Psoriasis Co-morbidities and Recommendations for Screening. J Am Acad Dermatol. 2008;58(6):1031-1042.

    5.      Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H; CASPAR Study Group. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006;54:2665-73.

    Table 1 — Eligibility for Biologic Therapies in Patients with Psoriasis1

    QOL = quality of life
    Gottlieb AB, et al. Dermatol Clin. 2016 Jul;34(3):235-42.