Provider advocacy

Physician helps change Utah Medicaid policies

New federal health care legislation means as many as 16 million more people will be eligible for Medicaid by 2019. Among them will be at least 400,000 people with psoriatic disease. Currently, it is estimated that more than 1.5 million people with psoriasis or psoriatic arthritis are covered by Medicaid, but multiple barriers keep them from getting appropriate health care for their disease.

Some doctors are laying the groundwork for access to care for these patients—and reducing the amount of paperwork it takes to prescribe effective treatments.

Information lowers BSA requirement

Until several years ago, Utah's Medicaid policies included a requirement that patients present with 10 percent Body Surface Area (BSA) coverage and fail multiple first-line therapies before receiving a prescription for a biologic drug. These policies have changed—thanks in part to physician activism.

Kristina Callis Duffin, M.D.The first policy change came a few years ago, when several doctors including Kristina Callis Duffin, M.D., an assistant professor in the University of Utah's dermatology department and a clinical practitioner, attended a meeting of the Utah Drug Utilization Review Board to explain the reality of living with 5 percent BSA.

Callis Duffin presented a slideshow demonstrating how severe and debilitating psoriasis can be—even with 5 percent BSA. Following the presentation, the Board adjusted its policy to allow biologics for patients with either 10 percent BSA or psoriasis in areas such as face, scalp, groin, hands or feet.

The burden of step therapy

The next year, Callis Duffin returned to the Drug Utilization Review Board to address another access-to-care issue: The Utah policy required that a patient fail treatment with ultraviolet light B, methotrexate and cyclosporine before being eligible for biologic therapies.

Again, Callis Duffin showed images of people with psoriasis to illustrate the severity of the disease, and explained the burden of requiring multiple first-line therapies.

"I told them I thought it was unreasonable, and not the standard of care. It would take someone two years (to try and fail all the therapies), and it wasn't productive."

The Board agreed to change the policy to require patients to fail just one of the first-line therapies before being prescribed a biologic drug.

"Now I do not have to write a long letter of explanation for each patient," Callis Duffin said. "All I have to do is check boxes on our form and fax documentation of TB screening. The process that used to require a letter and appeals, and take two or three months, is now down to two weeks."

Encouraging other providers

Utah's Medicaid policies mirror those of some other state Medicaid programs, as well as those of private insurers. Advocates such as Callis Duffin's can be effective at educating decision-making groups, which are often made up of general practitioners.

"They are not specialists. I don't think people really understand how much disease 5 and 10 percent is," she said.

A few years ago, Bert Tavelli, an Oregon dermatologist, advocated on behalf of psoriasis patients enrolled in that state's Medicaid program. He also achieved positive results.

Here are some tips for providers who wish to help change restrictive policies:

  • Write a letter to the state Medicaid director and Drug Utilization Review Board with the points you want to make about problematic medical policies.
  • Contact the Drug Utilization Review Board in your state to let them know you would like to make a presentation.
  • Bring visual materials to help people understand the disease and what it means to live with 5 percent, 10 percent or 25 percent BSA coverage. (For a copy of Dr. Kristina Callis Duffin's slideshow, e-mail the Psoriasis Foundation Health Policy Manager or call 503.546.5550).

For detailed steps, advocacy tips and tools for your presentation—including a copy of the slideshow to use—visit our Medicaid Advocacy Guide »