COMMENTARY
A unique psoriasis biologics clinic serving underprivileged patients in the United States Paolo Romanelli, MD, Lucas E. Cavallin, PhD, Jonathan Weiss, MD, Carlos Ricotti, MD, and Mariya Miteva, MD Miami, Florida Key words: biologics; costs; indigent; psoriasis; systemic treatment.
soriasis is the most prevalent autoimmune disease in the United States, affecting approximately 7.7 million people.1 As the economic impact of psoriasis correlates with the increased severity of the disease,2,3 it is of pivotal importance to provide patients who have psoriasis with comprehensive and continuous medical services. This is especially true for people with an underprivileged socioeconomic status as studies have suggested that these patients are more likely to have severe psoriasis and are less likely to be able to afford the most efficacious treatments, including costly biologic therapies.2,4 Although the implementation of the Affordable Care Act allows people who previously had no health insurance or lost their insurance to now have access to health coverage, the treatment options available for patients with psoriasis depend on their insurance plans and what they can afford to pay, making access to expensive biologics challenging. Although biologic therapies have significantly improved the lives of patients with psoriasis because of their efficacy, convenience, and tolerability, they are considerably more expensive than conventional systemic immunomodulating therapies such as methotrexate and cyclosporine.5 Thus, the high cost of biologics poses an almost insurmountable obstacle for low-income patients with no health insurance or with restrictive reimbursement plans. To overcome this financial hurdle and broaden the access to modern psoriasis care, the Monthly Biologics Center for Indigent Patients with Psoriasis was established at Jackson Memorial Hospital at the University of Miami Miller School of Medicine, which serves as the primary full-service provider of indigent
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health care for Miami-Dade County, Florida. To our knowledge, this is the only clinic in the United States specifically dedicated to offering biologic therapies at low cost to underprivileged patients. The clinic opened in October 2005 with 3 specific aims: (1) to facilitate access to biologics for patients with low economic status; (2) to centralize physicians and staff trained in acquiring biologics for the uninsured or indigent patients through pharmaceutical companies and Miami-Dade County assistance programs; and (3) to train dermatology residents to properly treat patients using biologics. The requests for direct assistance from the pharmaceutical companies that produce the biologics have generously and consistently been granted. The clinic is maintained by 1 attending dermatologist, 6 dermatology residents, 3 nurses, and medical student volunteers. Eligible patients include those with moderate to severe and severe psoriasis. A total of 356 patients (47.8% male and 52.2% female) with a mean age of 52.6 years (range 15.8-82.6, SD 12.2) have been seen during the 2078 total patient visits since the clinic’s inception. Each patient is systematically worked up with a patient history, physical examination, tuberculin skin test, interferon-gamma release assay, cell blood count, comprehensive metabolic panel, lipid fasting profile, and viral hepatitis panel. Enrolled patients are followed up at 1 month, and subsequently every 3 months. Among all 356 patients, 238 (66.9%) have been followed up continuously with a mean number of visits per patient of 8.2 (range 2-38, SD 7.2). The remaining patients (n = 118, 33.1%) were either not eligible to start biologics or were lost to follow-up after the initial visit. Among the 238 patients with
From the Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine. Funding sources: None. Conflicts of interest: None declared. Reprint requests: Paolo Romanelli, MD, University of Miami Miller School of Medicine, 1600 NW 10 Ave, RMSB, Room 2023-C, Miami, FL 33136. E-mail: [email protected].
J Am Acad Dermatol 2015;72:184-5. 0190-9622/$36.00 Ó 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.08.002
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continuous follow-up, 198 (83.1%) received at least 1 form of a biologic therapy at some point in their treatment. Among patients receiving biologics, 50.5% received etanercept, 28.0% adalimumab, 10.0% efalizumab, 8.2% infliximab, and 3.3% ustekinumab. Through this program, 61% of the patients had their medication expenses covered by Miami-Dade County and 39% by pharmaceutical companies. We believe our biologics clinic may serve as a medically responsible model to other county dermatology clinics around the country as it represents an invaluable humanitarian effort in advanced psoriasis care, evidenced by the increased number of enrolled patients. The unique characteristic of this clinic is the distribution of otherwise cost-prohibitive psoriasis treatments to underprivileged patients by a highly trained team of specialists knowledgeable in the administration and maintenance of biologics. Such clinics also create excellent opportunities to establish databases for large epidemiologic studies on psoriasis. As we are now experiencing a major health care reform by increasing health care coverage and affordability through the Affordable Care Act, we believe our biologics clinic serves a complementary role in the new realm of patient care, especially in the underprivileged patient population. The biologics
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clinic was created under the premise that all patients, regardless of socioeconomic status, have the right to access the highest quality of care. Moreover, our clinic is a fascinating example of the important role pharmaceutical companies have by providing health equality and protection to the less privileged and vulnerable groups in our society. We would like to thank the dermatology residents of the University of Miami Miller School of Medicine for the invaluable help they provide to the psoriasis biologics clinic. REFERENCES 1. Gelfand JM, Feldman SR, Stern RS, Thomas J, Rolstad T, Margolis DJ. Determinants of quality of life in patients with psoriasis: a study from the US population. J Am Acad Dermatol 2004;51:704-8. 2. Feldman S, Fleischer AB Jr, Reboussin DM, Rapp SR, Bradham DD, Exum ML, et al. The economic impact of psoriasis increases with psoriasis severity. J Am Acad Dermatol 1997; 37:564-9. 3. Prodanovich S, Kirsner RS, Kravetz JD, Ma F, Martinez L, Federman DG. Association of psoriasis with coronary artery, cerebrovascular, and peripheral vascular diseases and mortality. Arch Dermatol 2009;145:700-3. 4. Fowler JF, Duh MS, Rovba L, Buteau S, Pinheiro L, Lobo F, et al. The impact of psoriasis on health care costs and patient work loss. J Am Acad Dermatol 2008;59:772-80. 5. Beyer V, Wolverton SE. Recent trends in systemic psoriasis treatment costs. Arch Dermatol 2010;146:46-54.
A unique psoriasis biologics clinic serving underprivileged patients in the United States Paolo Romanelli, MD, Lucas E. Cavallin, PhD, Jonathan Weiss, MD, Carlos Ricotti, MD, and Mariya Miteva, MD Miami, Florida Key words: biologics; costs; indigent; psoriasis; systemic treatment.
soriasis is the most prevalent autoimmune disease in the United States, affecting approximately 7.7 million people.1 As the economic impact of psoriasis correlates with the increased severity of the disease,2,3 it is of pivotal importance to provide patients who have psoriasis with comprehensive and continuous medical services. This is especially true for people with an underprivileged socioeconomic status as studies have suggested that these patients are more likely to have severe psoriasis and are less likely to be able to afford the most efficacious treatments, including costly biologic therapies.2,4 Although the implementation of the Affordable Care Act allows people who previously had no health insurance or lost their insurance to now have access to health coverage, the treatment options available for patients with psoriasis depend on their insurance plans and what they can afford to pay, making access to expensive biologics challenging. Although biologic therapies have significantly improved the lives of patients with psoriasis because of their efficacy, convenience, and tolerability, they are considerably more expensive than conventional systemic immunomodulating therapies such as methotrexate and cyclosporine.5 Thus, the high cost of biologics poses an almost insurmountable obstacle for low-income patients with no health insurance or with restrictive reimbursement plans. To overcome this financial hurdle and broaden the access to modern psoriasis care, the Monthly Biologics Center for Indigent Patients with Psoriasis was established at Jackson Memorial Hospital at the University of Miami Miller School of Medicine, which serves as the primary full-service provider of indigent
P
health care for Miami-Dade County, Florida. To our knowledge, this is the only clinic in the United States specifically dedicated to offering biologic therapies at low cost to underprivileged patients. The clinic opened in October 2005 with 3 specific aims: (1) to facilitate access to biologics for patients with low economic status; (2) to centralize physicians and staff trained in acquiring biologics for the uninsured or indigent patients through pharmaceutical companies and Miami-Dade County assistance programs; and (3) to train dermatology residents to properly treat patients using biologics. The requests for direct assistance from the pharmaceutical companies that produce the biologics have generously and consistently been granted. The clinic is maintained by 1 attending dermatologist, 6 dermatology residents, 3 nurses, and medical student volunteers. Eligible patients include those with moderate to severe and severe psoriasis. A total of 356 patients (47.8% male and 52.2% female) with a mean age of 52.6 years (range 15.8-82.6, SD 12.2) have been seen during the 2078 total patient visits since the clinic’s inception. Each patient is systematically worked up with a patient history, physical examination, tuberculin skin test, interferon-gamma release assay, cell blood count, comprehensive metabolic panel, lipid fasting profile, and viral hepatitis panel. Enrolled patients are followed up at 1 month, and subsequently every 3 months. Among all 356 patients, 238 (66.9%) have been followed up continuously with a mean number of visits per patient of 8.2 (range 2-38, SD 7.2). The remaining patients (n = 118, 33.1%) were either not eligible to start biologics or were lost to follow-up after the initial visit. Among the 238 patients with
From the Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine. Funding sources: None. Conflicts of interest: None declared. Reprint requests: Paolo Romanelli, MD, University of Miami Miller School of Medicine, 1600 NW 10 Ave, RMSB, Room 2023-C, Miami, FL 33136. E-mail: [email protected].
J Am Acad Dermatol 2015;72:184-5. 0190-9622/$36.00 Ó 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.08.002
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continuous follow-up, 198 (83.1%) received at least 1 form of a biologic therapy at some point in their treatment. Among patients receiving biologics, 50.5% received etanercept, 28.0% adalimumab, 10.0% efalizumab, 8.2% infliximab, and 3.3% ustekinumab. Through this program, 61% of the patients had their medication expenses covered by Miami-Dade County and 39% by pharmaceutical companies. We believe our biologics clinic may serve as a medically responsible model to other county dermatology clinics around the country as it represents an invaluable humanitarian effort in advanced psoriasis care, evidenced by the increased number of enrolled patients. The unique characteristic of this clinic is the distribution of otherwise cost-prohibitive psoriasis treatments to underprivileged patients by a highly trained team of specialists knowledgeable in the administration and maintenance of biologics. Such clinics also create excellent opportunities to establish databases for large epidemiologic studies on psoriasis. As we are now experiencing a major health care reform by increasing health care coverage and affordability through the Affordable Care Act, we believe our biologics clinic serves a complementary role in the new realm of patient care, especially in the underprivileged patient population. The biologics
Romanelli et al 185
clinic was created under the premise that all patients, regardless of socioeconomic status, have the right to access the highest quality of care. Moreover, our clinic is a fascinating example of the important role pharmaceutical companies have by providing health equality and protection to the less privileged and vulnerable groups in our society. We would like to thank the dermatology residents of the University of Miami Miller School of Medicine for the invaluable help they provide to the psoriasis biologics clinic. REFERENCES 1. Gelfand JM, Feldman SR, Stern RS, Thomas J, Rolstad T, Margolis DJ. Determinants of quality of life in patients with psoriasis: a study from the US population. J Am Acad Dermatol 2004;51:704-8. 2. Feldman S, Fleischer AB Jr, Reboussin DM, Rapp SR, Bradham DD, Exum ML, et al. The economic impact of psoriasis increases with psoriasis severity. J Am Acad Dermatol 1997; 37:564-9. 3. Prodanovich S, Kirsner RS, Kravetz JD, Ma F, Martinez L, Federman DG. Association of psoriasis with coronary artery, cerebrovascular, and peripheral vascular diseases and mortality. Arch Dermatol 2009;145:700-3. 4. Fowler JF, Duh MS, Rovba L, Buteau S, Pinheiro L, Lobo F, et al. The impact of psoriasis on health care costs and patient work loss. J Am Acad Dermatol 2008;59:772-80. 5. Beyer V, Wolverton SE. Recent trends in systemic psoriasis treatment costs. Arch Dermatol 2010;146:46-54.
