John Barbieri, MD, MBA, FAAD, of the Department of Dermatology, puts patients at the center of both his clinical and research work. His research team conducts clinical trials, studying how to improve treatment for acne. The team also focuses on patient-reported outcomes — measures that facilitate capturing the patient’s perspective in both research and clinical care. Inspired by experiences he and his patients have encountered, Barbieri described inconsistencies in which dermatologic drugs are covered by insurance in a recently published Viewpoint in JAMA Dermatology. In this Q&A, he discusses these experiences, his research on patient-reported outcomes and the effect skin conditions can have on patients’ lives:
Q: Can you tell us more about the inconsistencies you document in your Viewpoint? Which examples stand out the most to you?
We discuss the tendency for skin conditions primarily impacting people’s psychosocial functioning through comorbidities like depression or anxiety, or through social isolation and stigmatization, to be less likely to be covered than skin conditions that have physical symptoms like pain or itch.
For instance, rosacea is a condition characterized by both pimple-like bumps as well as redness and flushing. Although treatments that predominantly help with those bumps are typically covered, treatments that address the flushing and redness are almost never covered. If we think rosacea is something that’s important to treat, why do we only cover treatments for bumps and not those for redness and flushing?
We describe similar issues with treatment coverage for acne, vitiligo and alopecia areata, among other skin conditions. For example, two of our main treatments for vitiligo — phototherapy and topical calcineurin inhibitors — are are often not covered, with the most common justification being that vitiligo is “cosmetic.”
Q: How did the Viewpoint come to be? Have you encountered payers who do not cover costs to treat a skin condition, and how do you respond?
I see these inconsistencies daily in clinical practice and often have to explain to patients why their treatment isn’t covered. The message they are hearing from payers is that they don’t think their condition matters.
Another challenge we frequently encounter is where there may be two or more roughly equivalent treatments, and between me and the patient, there’s no preference for which is prescribed. They both cost about the same. I prescribe treatment A and the insurance company responds they will only cover treatment B, which then creates delays in acquiring it. At the outset, it is not clear whether treatment A or B will be covered. It’s like flipping a coin.
One approach to combat this phenomenon is to become familiar with local payer policy to predict, as well as you can, what they will cover. Some of them, like Medicaid, are relatively consistent in posting their formularies online. However, other payers are more cryptic and ever-changing.
It’s also about finding creative solutions. Sometimes, when insurance won’t cover a medication that I think is important for a patient, I can have it compounded by a specialty pharmacy for a reasonable cost. For instance, the medicines for skin redness — also known as alpha agonists — are almost never covered by insurance, but I can often get them compounded by a specialty pharmacy that will mail it to the patient’s house for a small out-of-pocket cost, which many patients find acceptable.
Q: Who should be involved in conversations to develop a consensus about medical versus cosmetic treatments for skin disease?
It’s a conversation that requires an understanding of societal preferences. What things matter to us if we only have so many resources to spend on health care? We need community and patient stakeholders, health policy experts, health economists, payers, dermatologists and clinicians to participate in that dialogue.
It’s crucial for dermatologists to partake in these discussions, as they understand and can speak to the importance of recognizing skin diseases as more than “just cosmetic.” These skin conditions can have a huge effect on people’s lives.
Q: Can you tell us about your other areas of research?
Our primary focus is on patient-reported outcomes. These are especially important in dermatology because it doesn’t really matter how I think you’re doing; it matters how you feel you’re doing as the patient. For instance, I took care of a patient with some psoriasis on his hand. Many people might say it’s just a little bit, and not a big deal. But he was a chef and his peers thought he was contaminating the food with something infectious, even though it’s not. For this patient, treating his psoriasis was extra important for both his professional career and overall well-being. It’s so important to understand patients’ perspectives, and patient-reported outcomes are structured ways to invite and normalize such conversations. They help capture patients’ experiences in a structured manner, which is useful because you can track them over time to understand which treatments work best for improving patients’ lives.