Biologics in Plaque Psoriasis: Cost Versus Efficacy

Melodie Young, MSN, RN, ANP-C: I’m going to ask you, Douglas, about the conversation of cost. We all know that insurance is always the third and most troublesome part of determining what therapy you’re going to treat a patient with. When people say, “Oh, these drugs are expensive,” and all drugs are expensive, how do you address that with patients, as far as their expectations? Because we’ve talked about setting expectations on their clearance rates, and how these drugs should help with their signs and symptoms, and how they’re going to be administered. When you talk about the timeline of, “I see what you have. I want to order this medication,” literally, within a couple of weeks patients should be able to be on a drug, except they’re all worried about something that’s going to be expensive. So how do you talk about that?

Douglas DiRuggiero, PA-C: I give them a warning up front that these medications are impressive in what they do, and in order to develop that impressive portfolio of help that they bring it comes with a cost. It came with a cost in development, and it comes with a cost to get it. Fortunately, the companies, the insurance companies, are beginning to realize that because psoriasis is associated with so many comorbidities—because it’s pro-inflammatory, autoimmune, lifetime, chronic—it’s a very expensive disease to manage. I think we’re going to find out that even though these products are very expensive on an annual basis, of course the prices are discounted and negotiated too. I don’t really know what the real price is, even though the say they’re $40,000 a year, $50,000 a year, even some $60,000 a year if you had to buy out of pocket. I don’t really think that’s what the insurance companies are paying. But the fact is that it’s going to end up being less expensive to put someone on these products and manage their disease well than it is to leave them poorly treated.

I have good success in my area, but it’s regional and differs by state. We’re able to fill out a form to use specialty pharmacies to get these things approved. Most of these products have $5, $10, or even $20 co-pays to the patient, because they severely decrease it. They all have patient-assistance programs. I see Medicaid in my office. I am 1 of the few offices that does. I have lots of patients who get qualified based on their income. So I think there are a lot of options out there for patients. That should not be a hinderance to the provider prescribing it nor to the patient, to say cost is an issue, because if you have no insurance there are ones I can get you on. Some are easier than others, and you know which ones those are in your area. If you do have insurance and you have a high co-pay or a doughnut hole, we can figure out a way to work around that as well.

Melodie Young, MSN, RN, ANP-C: I agree. I think the team approach within most practices, where if you have access to a biologic coordinator, or otherwise, as an NP [nurse practitioner] or a PA [physician assistant], you will very well be the 1 who has to work toward access. But after you’ve done it a couple of times, you start to get the hang of it. You realize what data you need to have in the chart to get it approved—not just the body surface area and their psychosocial impact and the out-of-pocket costs to the patients. They’re surprised to find how most of the time it’s much less costly than any other disease they’re trying to treat, compared with going through tons of topicals and having large co-payments for those. When you’ve got a drug that can be used as monotherapy, and these drugs are FDA approved as monotherapy, you’re only having to buy 1 thing. Your out-of-pocket cost is going to be minimal, and your time impact is going to be minimal.

The conversation usually goes quickly, and then I’ll always say, “But you’re worth it. It’s really great to be clear, and you’re worth it.” You would never ask, if you needed a stent before they put it in, “How much is that going to cost?”

Melissa Davis, PA-C: That’s a great example.

Melodie Young, MSN, RN, ANP-C: Yeah, because you have to have what you have to have. You live in a time right now where if you have to have psoriasis, this is the best time in history. We do have therapies. Let’s use them. We need them. “You deserve it.”

Douglas DiRuggiero, PA-C: That’s right. It’s the same with transitioning. “You’re worth being better.” If we start them on a product and they just don’t respond to it, then I’m going to switch. I don’t give up immediately, because I know there is some benefit to being on it for a longer period of time. But if there is an adverse effect or you just don’t get the response rate, then we’ll make a transition to another 1.

Melodie Young, MSN, RN, ANP-C: That is our last topic of discussion. Really quickly, do you have any concern about going from 1 IL-23 to another IL-23? Or do you feel as though you have to move outside the class? In the studies, we talked about IL-12/23s. With Stelara [ustekinumab], they then used guselkumab. They were able to show that it works differently. Do you use 2 drugs within 1 class without any problem in the same patient?

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: It doesn’t bother me 1 way or another. There are many variables. I might stay, or I might go to another.

Transcript edited for clarity.