- Email: [email protected]
The burden of prior authorizations in a large academic dermatology practice
4548
5498
The burden of moderate-to-severe genital psoriasis: Patients’ perspective on symptoms Caitriona Ryan, MD, Baylor Univeristy Medical Center; Kim Meeuwis, MD, Radboud University Medical Center; Alison Potts Bleakman, PhD, Eli Lilly and Company; April Naegeli, PhD, Eli Lilly and Company; Jiat Ling Poon, PhD, Evidera; Kristin Hollister, PhD, Eli Lilly and Company
The burden of prior authorizations in a large academic dermatology practice Zachary Eyre, MBA, University of Utah School of Medicine; Mark Eliason, MD, University of Utah Department of Dermatology; Kristina Callis Duffin, MD, University of Utah Department of Dermatology; Aaron Secrest, MD, University of Utah Department of Dermatology
Background: Genital involvement in psoriasis is common and can have profound physical and psychosocial implications, yet patients’ experiences of genital symptoms have only been sparsely described. Patient interviews were conducted to better understand symptoms associated with genital psoriasis (GP) and their impact.
Background: Most insurance companies now require a time-consuming prior authorization process for the approval of high-cost medications and procedures. Dermatology has been disproportionately impacted by this increased burden given the significant advances in biologic medications for psoriasis, chronic idiopathic urticaria (CIU), and other conditions, as well as recent dramatic increases the cost of previously inexpensive generic medications. We assessed the burden of prior authorizations in our large academic dermatology practice. Methods: All prior authorizations for dermatologic medications and procedures were documented over a 30-day period in July-August 2016 in the University of Utah Department of Dermatology. The department employs 26 general dermatologists, 2 pediatric dermatologists, 4 dermatopathologists, 2 immunodermatologists, 5 Mohs surgeons, 2 cosmetic dermatologists, 2 allergists, 1 nurse practitioner, and 6 physician assistants at 11 clinic locations across the Salt Lake valley and surrounding areas. Results: Over this 30-day period, there were approximately 9,000 patient visits. Nine staff members, two of whom are employed full-time for the purpose, handled 958 prior authorizations. The reasons for the prior authorizations were as follows: 267 (100% approved) for Mohs surgery, 196 (99% approved, 3 pending) for excisions, 235 (63% approved, 158 pending) for non-biologic medications (most commonly isotretinoin, other acne treatments, as well as various topical steroids and topical calcineurin inhibitors), 81 (80% approved, 21 pending) for biologic medications (for psoriasis or CIU), 99 (100% approved) for patch testing, 29 (96% approved, 2 pending) for blue light therapy, 25 (86% approved, 3 pending) for narrowband UVB therapy, and 26 for other procedures. Implications: The burden of prior authorizations in dermatology is tremendous and time-consuming, with approximately 1 prior authorization needed for every 10 patient visits. Procedural prior authorizations are almost universally approved in dermatology within 1-2 days, whereas medication prior authorizations often take much longer, with approval rates around 75%. Given the costly and cumbersome nature of prior authorizations, many dermatology clinics cannot commit the resources needed to complete prior authorizations, and patients are unable to receive their physician’s recommended care. Efforts are needed to standardize and simplify the prior authorization process.
Methods: One-on-one semi-structured phone interviews were conducted with patients from US clinics, aged $18 years, who had a physician diagnosis of chronic plaque psoriasis (duration $6 months) and self-reported current or recent (#3 months) moderate-to-severe GP (per Patient Global Assessment $4). Using information from a literature review and clinician interviews, patient interviews were designed to elicit information about GP symptoms and their impact on sexual function and health-related quality of life. Interviews were audio-recorded, transcribed, and de-identified. Transcripts were coded and analyzed to identify key themes and responses using ATLAS.ti 7.5.9. Data are presented on symptoms. Results: Patients (N ¼ 20) had a mean [standard deviation] age of 45 (14.2) years, most were white (90%), and half (55%) were female. The mean psoriasis and GP durations were 18 (14.0) and 7.5 (9.7) years, respectively; 90% reported current moderate-to-severe overall psoriasis and 95% current moderate-to-severe GP. Overall, the most common GP symptoms were itch (100%), discomfort (100%), redness/erythema (95%), stinging/burning (95%), pain (85%), and scaling (75%). Of these, patients spontaneously reported itch and redness/erythema most frequently (90% and 50%, respectively), and upon probing reported discomfort, stinging/burning, pain, and scaling (70%, 50%, 45%, 50%, respectively). In addition, cracking was spontaneously reported by 30% of patients. Patients considered the most bothersome symptoms to be itch (40%) and stinging/burning (40%). Patients reported that symptom severity often depended on their activities and/or the weather. Discussion: Patients reported multiple genital psoriasis symptoms. Itch and stinging/burning were the two most bothersome symptoms and itch and discomfort the two most common symptoms. Education of physicians and patients on the symptoms and burden of genital psoriasis may improve identification and treatment. Commercial support: 100% sponsored by Eli Lilly and Company.
Commercial support: None identified.
5427 The burden of pediatric psoriasis exhibited through quality of life impact Brenna Brady, PhD, Health Analytics, LLC; Nicole Gerlanc, PhD, Health Analytics, LLC; Derek Tang, PhD, Amgen; Bradley Stolshek, PharmD, Amgen Background: The burden of pediatric psoriasis on quality of life (QoL) in patients and caregivers is not well understood. Methods: The Medline and Embase databases were reviewed to identify articles reporting on QoL in pediatric psoriasis patients or their caregivers published in English from 2005-2015. Results: A total of 449 articles were identified; 35 articles met inclusion criteria, and 25 articles reported specifically on pediatric or caregiver populations. Focus was placed on the 25 pediatric articles. All studies found a negative association between pediatric psoriasis and QoL. Studies assessed QoL with multiple instruments; the Children’s Dermatology Life Quality Index (CDLQI) was used often (n ¼ 15). Mean CDLQI scores ranged from 4.7 to 9.6 in 6 articles that reported total scores. In studies exploring individual domains (n ¼ 16), physical (n ¼ 11) and psychosocial domains (n ¼ 15) were frequently worse in pediatric psoriasis patients. Increased disease severity or affected body surface area was associated with worse QoL in 6 studies. Itch accounted for the greatest symptom burden, and was ranked as the primary factor in 9 of 11 articles. Fatigue, partially due to itch related sleep disturbance, was also a major issue (n ¼ 5). Patients carried a notable psychosocial burden with increased rates of anxiety or depression (n ¼ 4) and decreased selfesteem, self-confidence, or negative body images reported (n ¼ 7). Caregivers reported increased stress and emotional burden (n ¼ 9), revealing the pervasive impact of pediatric psoriasis on the family unit. Reduced perceptions of acceptance, problems with personal relationships, and poor coping skills were observed in pediatric psoriasis patients leading to increased social isolation (n ¼ 7). The impact of age within pediatric psoriasis was assessed in 6 studies with 5 showing younger children to have reduced QoL compared to adolescents, particularly in the psychosocial domain. Adolescents more commonly reported reduced participation in sports (n ¼ 4), increased impact on clothing choice (n ¼ 2), and problems with sexual intimacy (n ¼ 4). Four studies identified a link between increased stress and disease exacerbation highlighting the importance of psychosocial factors on physical manifestations of psoriasis.
4748 The burden of prior authorizations in pediatric dermatology Duane Dilworth, MD, Saint Louis University; Elaine Siegfried, MD, Saint Louis University Background: Prior authorization refers to the pre-approval process required by payers for costly medications. Parameters vary by payer, but include medical necessity, expense, alternative medications, and FDA-labeled indication for the prescribed medication. They require the prescriber to submit pre-approval to insurance companies before the medication is approved under the patient’s insurance benefits. This system impacts patient care and results in treatment delay, denied access to medications, and utilization of office staff time. Objectives: We sought to analyze the time spent performing prior authorizations and the impact it has on providing quality care to patients. Methods: We reviewed prior authorization data from November 2014 to November 2015 from three academic pediatric dermatology clinics. The medical personnel collected information on the medication, quantity, personnel time, insurance type, and outcome.
Conclusion: Psoriasis in childhood and adolescence results in a substantial negative impact on QoL; improved management of physical and psychosocial aspects of disease could lead to improved QoL in pediatric psoriasis.
Results: 208 of the 259 total prior authorizations received were included in the study. Total time for all PA request equaled 6,675 minutes (avg 32.1 minutes per PA). 186 were approved (89%) and 22 were denied (11%). There was no statistical difference in the average time for approved versus denied medications (32.2 vs 31.4 minutes). The most common medications requiring a PA were topical calcineurin inhibitors, retinoids, and topical vitamin D analogues. The most common insurer requiring PA was Illinois Medicaid (40.4%) followed by Missouri Medicaid (36.1%) and private insurance (23.5%). Limitations: Limitations include data bias (;50% Medicaid-insured, pediatric population, and academic/tertiary care) and exclusion of medications changes or cancellations prior to PA submission. Conclusions: The practice of PAs should be reconsidered. The time required for processing PAs is high, the proportion of denials is low, and the therapeutic impact is negative.
Commercial support: Amgen - 100%.
Commercial support: None identified.
JUNE 2017
J AM ACAD DERMATOL
AB249
5498
The burden of moderate-to-severe genital psoriasis: Patients’ perspective on symptoms Caitriona Ryan, MD, Baylor Univeristy Medical Center; Kim Meeuwis, MD, Radboud University Medical Center; Alison Potts Bleakman, PhD, Eli Lilly and Company; April Naegeli, PhD, Eli Lilly and Company; Jiat Ling Poon, PhD, Evidera; Kristin Hollister, PhD, Eli Lilly and Company
The burden of prior authorizations in a large academic dermatology practice Zachary Eyre, MBA, University of Utah School of Medicine; Mark Eliason, MD, University of Utah Department of Dermatology; Kristina Callis Duffin, MD, University of Utah Department of Dermatology; Aaron Secrest, MD, University of Utah Department of Dermatology
Background: Genital involvement in psoriasis is common and can have profound physical and psychosocial implications, yet patients’ experiences of genital symptoms have only been sparsely described. Patient interviews were conducted to better understand symptoms associated with genital psoriasis (GP) and their impact.
Background: Most insurance companies now require a time-consuming prior authorization process for the approval of high-cost medications and procedures. Dermatology has been disproportionately impacted by this increased burden given the significant advances in biologic medications for psoriasis, chronic idiopathic urticaria (CIU), and other conditions, as well as recent dramatic increases the cost of previously inexpensive generic medications. We assessed the burden of prior authorizations in our large academic dermatology practice. Methods: All prior authorizations for dermatologic medications and procedures were documented over a 30-day period in July-August 2016 in the University of Utah Department of Dermatology. The department employs 26 general dermatologists, 2 pediatric dermatologists, 4 dermatopathologists, 2 immunodermatologists, 5 Mohs surgeons, 2 cosmetic dermatologists, 2 allergists, 1 nurse practitioner, and 6 physician assistants at 11 clinic locations across the Salt Lake valley and surrounding areas. Results: Over this 30-day period, there were approximately 9,000 patient visits. Nine staff members, two of whom are employed full-time for the purpose, handled 958 prior authorizations. The reasons for the prior authorizations were as follows: 267 (100% approved) for Mohs surgery, 196 (99% approved, 3 pending) for excisions, 235 (63% approved, 158 pending) for non-biologic medications (most commonly isotretinoin, other acne treatments, as well as various topical steroids and topical calcineurin inhibitors), 81 (80% approved, 21 pending) for biologic medications (for psoriasis or CIU), 99 (100% approved) for patch testing, 29 (96% approved, 2 pending) for blue light therapy, 25 (86% approved, 3 pending) for narrowband UVB therapy, and 26 for other procedures. Implications: The burden of prior authorizations in dermatology is tremendous and time-consuming, with approximately 1 prior authorization needed for every 10 patient visits. Procedural prior authorizations are almost universally approved in dermatology within 1-2 days, whereas medication prior authorizations often take much longer, with approval rates around 75%. Given the costly and cumbersome nature of prior authorizations, many dermatology clinics cannot commit the resources needed to complete prior authorizations, and patients are unable to receive their physician’s recommended care. Efforts are needed to standardize and simplify the prior authorization process.
Methods: One-on-one semi-structured phone interviews were conducted with patients from US clinics, aged $18 years, who had a physician diagnosis of chronic plaque psoriasis (duration $6 months) and self-reported current or recent (#3 months) moderate-to-severe GP (per Patient Global Assessment $4). Using information from a literature review and clinician interviews, patient interviews were designed to elicit information about GP symptoms and their impact on sexual function and health-related quality of life. Interviews were audio-recorded, transcribed, and de-identified. Transcripts were coded and analyzed to identify key themes and responses using ATLAS.ti 7.5.9. Data are presented on symptoms. Results: Patients (N ¼ 20) had a mean [standard deviation] age of 45 (14.2) years, most were white (90%), and half (55%) were female. The mean psoriasis and GP durations were 18 (14.0) and 7.5 (9.7) years, respectively; 90% reported current moderate-to-severe overall psoriasis and 95% current moderate-to-severe GP. Overall, the most common GP symptoms were itch (100%), discomfort (100%), redness/erythema (95%), stinging/burning (95%), pain (85%), and scaling (75%). Of these, patients spontaneously reported itch and redness/erythema most frequently (90% and 50%, respectively), and upon probing reported discomfort, stinging/burning, pain, and scaling (70%, 50%, 45%, 50%, respectively). In addition, cracking was spontaneously reported by 30% of patients. Patients considered the most bothersome symptoms to be itch (40%) and stinging/burning (40%). Patients reported that symptom severity often depended on their activities and/or the weather. Discussion: Patients reported multiple genital psoriasis symptoms. Itch and stinging/burning were the two most bothersome symptoms and itch and discomfort the two most common symptoms. Education of physicians and patients on the symptoms and burden of genital psoriasis may improve identification and treatment. Commercial support: 100% sponsored by Eli Lilly and Company.
Commercial support: None identified.
5427 The burden of pediatric psoriasis exhibited through quality of life impact Brenna Brady, PhD, Health Analytics, LLC; Nicole Gerlanc, PhD, Health Analytics, LLC; Derek Tang, PhD, Amgen; Bradley Stolshek, PharmD, Amgen Background: The burden of pediatric psoriasis on quality of life (QoL) in patients and caregivers is not well understood. Methods: The Medline and Embase databases were reviewed to identify articles reporting on QoL in pediatric psoriasis patients or their caregivers published in English from 2005-2015. Results: A total of 449 articles were identified; 35 articles met inclusion criteria, and 25 articles reported specifically on pediatric or caregiver populations. Focus was placed on the 25 pediatric articles. All studies found a negative association between pediatric psoriasis and QoL. Studies assessed QoL with multiple instruments; the Children’s Dermatology Life Quality Index (CDLQI) was used often (n ¼ 15). Mean CDLQI scores ranged from 4.7 to 9.6 in 6 articles that reported total scores. In studies exploring individual domains (n ¼ 16), physical (n ¼ 11) and psychosocial domains (n ¼ 15) were frequently worse in pediatric psoriasis patients. Increased disease severity or affected body surface area was associated with worse QoL in 6 studies. Itch accounted for the greatest symptom burden, and was ranked as the primary factor in 9 of 11 articles. Fatigue, partially due to itch related sleep disturbance, was also a major issue (n ¼ 5). Patients carried a notable psychosocial burden with increased rates of anxiety or depression (n ¼ 4) and decreased selfesteem, self-confidence, or negative body images reported (n ¼ 7). Caregivers reported increased stress and emotional burden (n ¼ 9), revealing the pervasive impact of pediatric psoriasis on the family unit. Reduced perceptions of acceptance, problems with personal relationships, and poor coping skills were observed in pediatric psoriasis patients leading to increased social isolation (n ¼ 7). The impact of age within pediatric psoriasis was assessed in 6 studies with 5 showing younger children to have reduced QoL compared to adolescents, particularly in the psychosocial domain. Adolescents more commonly reported reduced participation in sports (n ¼ 4), increased impact on clothing choice (n ¼ 2), and problems with sexual intimacy (n ¼ 4). Four studies identified a link between increased stress and disease exacerbation highlighting the importance of psychosocial factors on physical manifestations of psoriasis.
4748 The burden of prior authorizations in pediatric dermatology Duane Dilworth, MD, Saint Louis University; Elaine Siegfried, MD, Saint Louis University Background: Prior authorization refers to the pre-approval process required by payers for costly medications. Parameters vary by payer, but include medical necessity, expense, alternative medications, and FDA-labeled indication for the prescribed medication. They require the prescriber to submit pre-approval to insurance companies before the medication is approved under the patient’s insurance benefits. This system impacts patient care and results in treatment delay, denied access to medications, and utilization of office staff time. Objectives: We sought to analyze the time spent performing prior authorizations and the impact it has on providing quality care to patients. Methods: We reviewed prior authorization data from November 2014 to November 2015 from three academic pediatric dermatology clinics. The medical personnel collected information on the medication, quantity, personnel time, insurance type, and outcome.
Conclusion: Psoriasis in childhood and adolescence results in a substantial negative impact on QoL; improved management of physical and psychosocial aspects of disease could lead to improved QoL in pediatric psoriasis.
Results: 208 of the 259 total prior authorizations received were included in the study. Total time for all PA request equaled 6,675 minutes (avg 32.1 minutes per PA). 186 were approved (89%) and 22 were denied (11%). There was no statistical difference in the average time for approved versus denied medications (32.2 vs 31.4 minutes). The most common medications requiring a PA were topical calcineurin inhibitors, retinoids, and topical vitamin D analogues. The most common insurer requiring PA was Illinois Medicaid (40.4%) followed by Missouri Medicaid (36.1%) and private insurance (23.5%). Limitations: Limitations include data bias (;50% Medicaid-insured, pediatric population, and academic/tertiary care) and exclusion of medications changes or cancellations prior to PA submission. Conclusions: The practice of PAs should be reconsidered. The time required for processing PAs is high, the proportion of denials is low, and the therapeutic impact is negative.
Commercial support: Amgen - 100%.
Commercial support: None identified.
JUNE 2017
J AM ACAD DERMATOL
AB249