What can dermatologists do to get appropriate coverage for serious skin conditions deemed cosmetic by payers?
Dr. Schwarzenberger is the physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, FAAD, August 1, 2023
In this month’s Clinical Applications column, Physician Editor Kathryn Schwarzenberger, MD, FAAD, talks with John Barbieri, MD, MBA, FAAD, and Avery LaChance, MD, MPH, FAAD, about their JAMA Dermatology paper, ‘Double standards and inconsistencies in access to care — What constitutes a cosmetic treatment?’
DermWorld: We don’t often cover opinion pieces in our Clinical Applications column, but I thought your recent article offered a strong message that was worth sharing with our colleagues. For those who might have not had a chance to read your piece, can you summarize your recent JAMA Derm Viewpoint article?
Dr. Barbieri: Our Viewpoint discusses the issue of inconsistencies in classifying cosmetic versus medical care in dermatology. We highlight examples from skin conditions such as vitiligo, rosacea, acne, and alopecia areata, where medical coverage is denied due to the skin disease being categorized as cosmetic despite the significant psychosocial effects experienced by patients with these skin diseases. There is an opportunity for dermatologists to establish clear definitions and guidelines to differentiate between cosmetic and medical treatments, as well as to engage in advocacy efforts and clinical research to improve appropriate access to care.
DermWorld: What prompted you to write this article? Why now?
Dr. Barbieri: In our clinical practice, we routinely encounter patients who are denied access to care due to their skin condition being viewed as cosmetic, despite meaningful effects on their quality of life. For instance, why are treatments for bumps of rosacea often covered but treatments for redness rarely covered? This issue of defining what constitutes medically necessary care versus cosmetic treatment has been a longstanding challenge, and we felt the need to bring attention to this issue and advocate for better access to appropriate treatment for patients with skin diseases.
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DermWorld: Are there any nondermatologic diseases that you are aware of that are similarly not covered, or do you believe that this “cosmetic” or “nonmedical” discrimination primarily affects dermatologic diseases? Are skin diseases easier to discount?
Dr. Lachance: Similar challenges have been observed in plastic surgery, and working with their national organizations, they have crafted their own definitions and guidelines of cosmetic versus medical treatments within their field to help address these issues. I think skin diseases can often be easier to discount because without widespread use of patient-reported outcome measures it can be more difficult to rigorously document the significance of treating skin disease to payers (unlike reporting a blood pressure, cholesterol level, mortality, etc.). This may be especially relevant for skin diseases that are asymptomatic such as vitiligo. In addition, since some skin diseases have few or no FDA-approved therapies, this is also sometimes used as a justification for not providing coverage.
DermWorld: You suggested many potential ways that dermatologists can engage to help advocate for coverage for skin disorders that have psychosocial impact. Is there a risk that dermatologists could be perceived as self-serving in this pursuit, and can you suggest ways to minimize this risk?
Dr. Lachance: There is a potential risk that dermatologists advocating for coverage for skin disorders may be perceived as self-serving. To minimize this risk, dermatologists can and should focus on the overall well-being of their patients and the effects that these conditions have on their quality of life. They can emphasize the physical and psychological burden of skin diseases — issues we face and hear first-hand from our patients daily. In addition, they can, and should, collaborate with other stakeholders (i.e., patients, patient advocacy groups, family members, mental health providers) to raise awareness about these issues and to develop collaborative solutions. By taking a rigorous, evidence-based approach and engaging in a broader discussion about the importance of treating skin conditions, dermatologists can demonstrate their commitment to patient care and raise awareness about the critical need for insurance coverage to provide our patients with the best outcomes possible.
DermWorld: Have there been successes in getting coverage for disorders that might have once been deemed cosmetic, such as vitiligo?
Dr. Lachance: In just the past few years, we have seen increased insurance coverage for specific medications that now have FDA approval for treatment of vitiligo and alopecia areata — two disease states that have historically been viewed as “cosmetic” by insurers. The efforts to get these medications approved and now on formulary for certain insurance plans have taken significant work and coordinated efforts in research, advocacy, and innovation from multiple stakeholders. Across the board, advocacy efforts play a critical role in improving coverage. For example, ongoing legislative efforts in Massachusetts to mandate insurance coverage for scalp hair protheses in the setting of medical alopecias are making progress currently. Dermatologist engagement in these advocacy initiatives is crucial to enable improved access to care for our patients.
DermWorld: I'm sure many of us agree with your opinions, but don’t know what we can do to help. What can the average dermatologist do to get appropriate coverage for skin conditions we all know have an impact on our patients’ well-being?
Dr. Barbieri: There are several actions that average dermatologists can take to help in the effort to get appropriate coverage for skin conditions. They can actively participate in professional organizations and with other key stakeholders such as patients, payers, and health policy groups to establish standards clearly defining medical versus cosmetic treatments; one approach could be to define cosmetic treatments as enhancement of appearance compared to an average individual (e.g., treatment of rhytids, treatment of androgenetic alopecia, removal of asymptomatic benign skin lesions) and medical treatments as alleviation of symptoms (e.g., itch, pain) or restoration of appearance to improve psychosocial functioning (e.g., flushing, dyspigmentation, scarring, non-androgenetic alopecia).
In addition, they can contribute to research evaluating the psychosocial impact of skin diseases and the importance of appropriate coverage. Dermatologists can also engage with patient advocacy groups, collaborate with other health care professionals, and participate in discussions and awareness campaigns to educate payers, policymakers, and the public about the significance of treating skin conditions. By raising awareness, sharing their expertise, and working collectively, dermatologists can contribute to the broader effort of improving coverage for skin diseases.
John Barbieri, MD, MBA, FAAD, is the director of the Advanced Acne Therapeutics Clinic at Brigham and Women's Hospital, and instructor in dermatology at Harvard Medical School. Dr. Barbieri has received personal consulting fees from Dexcel pharma for work unrelated to the described study.
Avery LaChance, MD, MPH, FAAD, is the director of the Connective Tissue Diseases Clinic and the Health Policy and Advocacy at Brigham and Women’s Hospital Department of Dermatology. She is also assistant professor of dermatology at Harvard Medical School.
Their paper appeared in JAMA Dermatology.
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DermWorld.
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