, which may disproportionately affect patients of color.
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Those are the conclusions from an analysis of vitiligo treatment coverage policies across major health insurers in the United States.
“Vitiligo can be less noticeable in patients with lighter skin types, becoming apparent only when affected patches fail to tan,” first authors Andrew Blundell, MD, MSc, and Moniyka Sachar, MD, wrote in a study published online on July 16 in Pediatric Dermatology. However, they pointed out that, in patients with darker skin types, “vitiligo can be far more evident due to the stark contrast of involved versus uninvolved skin, and as such can lead to a significant impact on quality of life, as well as heightened stigmatization.”
Nevertheless, they noted many health care insurers consider vitiligo as a cosmetic condition, and do not cover treatments, and for the 1%-2% of the general population with vitiligo, “this lack of recognition from health care insurers makes treatments both less accessible and affordable, and only further marginalizes patients with this condition.”
Dr. Blundell, of San Juan Bautista School of Medicine, Caguas, P.R., and Dr. Sachar, of the department of dermatology at Brown University, Providence, R.I., and colleagues surveyed 15 commercial health care insurers, 50 BlueCross BlueShield plans, Medicare, Medicaid, and Veterans Affairs to determine the level of treatment coverage for vitiligo. They looked at office visits, medications (the topical calcineurin inhibitors [TCIs] pimecrolimus, and tacrolimus), excimer laser therapy, and phototherapy (psoralen with UVA [PUVA] and narrow-band UVB [nbUVB]). They collected information from medical policies available online or by direct contact with the plans in 2018.
The researchers reported data from 17 organizations with regional or national coverage policies for vitiligo treatment and two others – BlueCross BlueShield and Medicaid – which had policies that differed by state and plan. Of the 17 organizations, only 12% did not cover TCIs, 56% did not cover nbUVB phototherapy, 53% did not cover PUVA phototherapy, and 41% did not cover laser therapy.
As for BlueCross BlueShield, the health plan did not cover pimecrolimus and tacrolimus in 39% and 35% of states, respectively. At the same time, NbUVB and PUVA therapy were not covered in 20% and 10% of states, respectively, while excimer laser therapy was not covered in 82% of states.
Of accessible Medicaid information from 32 states, 11 did not cover topicals, 5 did not cover nbUVB, 4 did not cover PUVA, and 7 did not cover laser therapy. “The two most commonly cited reasons for denial of coverage were (a) vitiligo is considered a cosmetic condition and (b) certain therapies are not FDA-approved for vitiligo, though they may be approved for other skin conditions,” the study authors wrote.
While the analysis revealed that topical TCI therapy is more widely covered by insurance companies, compared with phototherapy, “multiple studies have shown that a combination of both topical and phototherapy is more effective in treating vitiligo than either alone,” they noted. “Vitiligo treatments can delay the progression of the disease and result in better outcomes when started early, furthering the need for insurance coverage of these treatments. If all proven and accepted vitiligo treatments were covered by their health insurers, patients would have better access, as well as timely and affordable ways by which to limit depigmentation and to repigment affected areas.”
In addition, lack of access to treatments “may increase health disparities among already-marginalized groups, such as children and adults of darker skin phototypes,” they wrote.
Dr. Desai
Seemal R. Desai, MD, who was asked to comment on the study, said that the findings resonate with him based on his clinical experience as a dermatologist at the University of Texas Southwestern Medical Center in Dallas and in clinical practice. “Vitiligo has a high psychological impact, continues to increase in its prevalence, and has been shown to be an autoimmune, chronic, inflammatory skin disease, yet we’re still having challenges with treatment,” said Dr. Desai, who is also a member of the board of directors for the American Academy of Dermatology and the Global Vitiligo Foundation (GVF).
He said that he is working with the AAD, the GVF, and other stakeholders to improve treatment coverage. For example, in Massachusetts, the Tufts Health Plan had stopped covering treatment for vitiligo. “Through a series of advocacy efforts, that was reversed a couple of years ago,” said Dr. Desai, who is also a past president of the Skin of Color Society. “We also have seen isolated reports of Medicaid and Medicare coverage where local contractors aren’t following national Centers for Medicare and Medicaid Service directive guidance. The challenge becomes, how do you get consistency in treatment coverage, and how do you make sure patients continue to get access to treatment?”
Turning the tide will require “a concerted effort” by dermatologists to engage with the payers, he added. “I’ve had to get on the phone with countless insurance companies on behalf of my patients and make them understand the comorbidities associated with vitiligo, sending them copies of studies that show it’s an autoimmune disease linked to thyroid issues,” Dr. Desai continued. “We talk a lot about the psychological burden and quality of life. There’s still a lot of work to be done in this sphere, but I think we’re making progress.”
With hopes that Janus kinase (JAK) inhibitors and other new products being investigated will soon be approved as a treatment option for vitiligo, Dr. Desai said that now is the time to standardize coverage for patients. “It’s important that we start talking about insurance coverage and denial issues now and get ahead of it, so that when we get those JAK inhibitors available, we don’t fight coverage decisions then.”
The researchers acknowledged certain limitations of the study, including the fact that it was based on insurance coverage from 2017 to 2018 and the lack of easily available state Medicaid policies.
The study coauthors were Colleen K. Gabel, MD, of the University of Massachusetts, Worcester, and Lionel G. Bercovitch, MD, of Brown University. None of the study authors reported financial disclosures.
Dr. Desai disclosed that he has conducted vitiligo research trials and has done consulting work for several pharmaceutical companies.