Bio-Logistics: Steps for Improving Access to Biologic Therapy

Despite a growing pool of data indicating the efficacy and favorable safety profiles of biologic agents, patients with moderate to severe psoriasis remain an undertreated population. In the March 2015 edition of Practical Dermatology® magazine, Alan Menter, MD examined this phenomenon and emphasized the critical role biologics will play in the treatment of psoriasis and in the future of medical dermatology. Yet, access remains a major obstacle for many patients and physicians, due to a variety a factors, including insurance reimbursement.

Mary Wiatrowski, RN, DNC, Psoriasis Clinical Coordinator at Texas Dermatology Associates in Dallas, TX, has encountered many barriers associated with biologic therapy. Over the last decade-plus, she has performed many injections for biologic treatments and has lectured extensively on the topic. Ahead, Ms. Wiatrowski provides insight on dealing with insurance companies and how to relieve burdens and accelerate optimum treatment.

What are some of the common issues you’ve seen regarding insurance approvals for biologics?

While securing approval for biologic therapy has never been a simple task, Ms. Wiatrowski notes that in that last couple of years, insurance companies have “preferred” biologics. In other words, they can influence which drug the patient receives. That means that physicians may have a difficult time securing approval for a specific agent that’s not the preferred agent on the patient’s insurance plan.

The trend toward preferred agents can have a disruptive effect on patient care. “Consider a patient who has been on one agent for several years and had a recent change in insurance providers,” says Ms. Wiatrowski. “If the provider has a different preferred agent, they might send the practice a scary letter informing the physicians that the company will not approve the agent the patient has been receiving for years.” They will often encourage physicians to schedule a follow-up with the patient to make the switch, she continues. “A physician that’s not as familiar with the drugs or the process may go ahead and switch the patient,” says Ms. Wiatrowski. This may may not only be unnecessary, she notes, but also disruptive to a patient’s regimen.

When it comes to starting a new biologic, insurance companies typically require the use of a systemic agent first, such as methotrexate or cyclosporine. If these therapies fail, or if the patient has a contraindication (such as hypertension, woman of childbearing age, etc.), some insurance companies will even try to block certain biologics and cite similar contraindications, according to Ms. Wiatrowski. In these cases, or in the event of switching patients to a preferred agent, physicians have to go through a lengthy appeals process. “Whether the physician requests a patient to be grandfathered or files an appeal, the bottom line is that many physicians may opt to switch the patient and not deal with the constant fight with insurance,” says Ms. Wiatrowski. For those that do attempt to go through with an appeal, she points out that insurance companies often have 30 days to review and decide on a claim. “Unless your office has samples, your patient may run out of medicine and be off treatment for days or weeks,” she says.

What actions can practices take to ensure that patients receive the agent prescribed?

Often times, the difficulties insurance companies pose regarding the approval of certain biologics agents cause undue stress for patients and more work for offices. Ms. Wiatrowski has observed that this doesn’t have to be as arduous as it may sound, however. “Generally, taking a few minutes to write a letter to the company stating that changing therapies could destabilize the patient or lead to flares can be enough to sway some insurance providers,” she notes. Yet, despite not demanding a switch, insurance companies are banking on the fact that physicians and their staff do not have the wherewithal to endure the appeal process. But Ms. Wiatrowksi points out there are ways physicians can seek assistance in dealing with insurance companies, including help from specialty pharmacies and pharmaceutical manufacturers themselves.

For example, specialty pharmacies often help with insurance verification, Ms. Wiatrowski observes. “Being hooked up with a good specialty pharmacy can take the burden off of practices, as they will help with getting medications approved, as well as in the prior authorization period and in getting you the proper forms,” she says. “Specialty pharmacies can be a great advantage.”

Additionally, pharmaceutical manufacturers can also assist in insurance verification. Many companies can assist the office with finding out what the specialty pharmacy needs and what the benefits are. They may also be able to provide samples to assist during the appeals interval.

Do you have any other strategies to facilitating the process?

According to Ms. Wiatrowski, one of the most important elements in creating a smooth transition from prescription to treatment with biologics is ancillary staff training. “Often times physicians are taught that they’re the ones doing the prior authorization process and writing letters, but they often don’t have time for that,” she says. “Some nurses and medical assistants may be skittish about carrying these tasks out, but they should be empowered and trained on how to handle these steps.” Educational programs are often not oriented toward nurses and other staff members, but according to Ms. Wiatrowski, these people are the patient advocates and are in “the belly of the beast,” as she puts it.

Whether through specialty pharmacies, pharmaceutical companies, or empowering staff, Ms. Wiatrowski notes that there are several avenues of support that physicians may pursue to ensure easier access to biologic therapy for patients with moderate to severe psoriasis. “There is often fear of the unknown when you’re first starting out, but once you jump into the pool, you will likely find that you can swim well.” n

Mary Wiatrowski, RN, DNC is Psoriasis Clinical Coordinator at Texas Dermatology Associates in Dallas, TX.