Challenges in Managing Patients With Plaque Psoriasis

Alexa Hetzel, MS, PA-C: Jayme, what are some of the challenges that you face when managing plaque psoriasis, especially when we’re talking about limitations that APPs [advanced practice providers] face when selecting a treatment option for managing plaque psoriasis?

Jayme M. Heim, MSN, FNP-BC: I think Doug did an excellent job discussing that. Talking about, you know, ruling out whether a patient has heart disease or other different physical attributes or whether medication would be appropriate for that particular patient. I see that the No. 1 challenge to face, even when we know which medication our patient needs to be on, is going through the step therapies and the different types of insurances. Whether it’s commercial insurance, whether it’s Medicaid, whether it’s VA [U.S. Department of Veterans Affairs] insurance, or patients who don’t have any insurance whatsoever, it’s very difficult. We know patients come to us; we know that they need help; we know that they need care. We have this arsenal of medications to use, but how do we get the medications to the patients to treat them?

For commercial patients, unfortunately, it has become a nightmare. It has become not only deductibles, but out-of-pocket costs on top of that. So many times, the copay assistance cards that are given to the patients, rightfully so, to help with the deductibles, are not able to be used for that purpose. They are also used up right away and they spend down all the money from the company itself, and then they’re hit with their out-of-pocket costs. That is just really difficult for patients to understand.

The other thing is, we have patients who are on Medicaid. If you have Medicaid with a spend down, a lot of times you have a lot of money up front to pay. However, if you have other certain Medicaid plans, you can get first-line access to medications, but it depends.

Then there are the formulary issues. All insurance companies have certain formularies, and that depends on their PBM [pharmacy benefit manager]. Because PBMs are pocketing up to 40% of the cost of these medications, they have to make a big profit, so a lot of times medications that don’t cost as much are not making the formulary. So there are several things that we have to do. It’s not just us providers saying “This what we feel is the best medication for our patients,” but it’s also the step therapies that we have to implement or the other things that we must go through daily to provide care for our patients.

Medicare patients are another group of patients where it’s just so unfortunate that a patient can have psoriasis or psoriatic arthritis in combination with their psoriasis. Let me tell you, when they hit Medicare, it’s a whole different game. They have access to certain medications one day, and the next day they don’t. We have a long way to go with that unfortunately. So I see that as one of the challenges for us as providers in allowing our patients to obtain the care they need and deserve.

Transcript edited for clarity