Barriers and facilitators to quality HS biologic care and outcomes for the Medicaid population across US states

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Steven Daveluy
Brindley Brooks
Brent Hazelett
Iltefat Hamzavi
Ginette A. Okoye
Laura Bush
Jasmine I. Espy
Danuta Marchi
Matthew Rudberg
Tae Oh
Stephanie Goldberg

Keywords

Medicaid, hidradenitis suppurativa, HS Coalition

Abstract

Introduction: Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease characterized by painful skin lesions and dermal abscesses.1 US-based patients with HS are often covered by Medicaid (21.6–31.0%)2–5 with substantial state-by-state variations in coverage. Barriers to accessing biologics for HS may delay treatment and worsen patient outcomes. Here, we report differences in Medicaid criteria to access biologic care for HS across all 50 US states.


Procedure/study: A qualitative review of the Medicaid Utilization Management (UM) policies for biologic use in HS was conducted. Data were collected from the Medicaid UM policies, Medicaid websites, and Managed Medicaid UM policies of each state in February 2024. All 50 states were analyzed; barriers to access and discrepancies across state Medicaid UM policies were identified, and opportunities to address these discrepancies in the form of an HS coalition were recognized. The analysis stratified the Medicaid UM criteria for each state for treatment with a biologic (adalimumab/secukinumab) into no or low, medium, and high barrier levels. For high barrier level states, comparison with UM criteria for psoriasis was made.


Results: Overall, the UM policies varied widely, and burdensome barriers to biologic care were identified in some states. In total, 40 states had no or low barrier criteria; states with low barrier criteria required an HS diagnosis and a prescription, or inadequate responses to ≥1 therapy (steroids/antibiotics). Alabama, Kentucky, Minnesota, Missouri, Ohio, Oregon, Pennsylvania, and Washington had medium barrier criteria and generally required an HS diagnosis and failure with ≥2 therapies. Here, criteria may be reduced to align with low barrier states. Iowa and Oklahoma had high barrier criteria. Both required ≥3 abscesses or inflammatory nodules, an HS diagnosis with Hurley Stage II/III, and failure with ≥2 therapies. In Iowa, eligible requests received three months treatment, with additional authorizations conditional upon ≥50% reduction in abscess and nodule count. The approval criteria of biologics for psoriasis were less stringent than HS in Iowa and Oklahoma, including fewer criteria items and therapy failures: Iowa ≥2 vs ≥3; Oklahoma ≥1 vs ≥2.


Conclusion: Substantial state-by-state variations in Medicaid criteria were observed, with ten out of 50 states having medium to high barriers to accessing biologics. Large disparities in criteria for access to biologic care between psoriasis and HS were observed in two states. These barriers and discrepancies represent opportunities for an HS coalition at the state level, to improve access to care and patient outcomes.6

References

1. Zouboulis CC et al. J Eur Acad Dermatol Venereol 2015;29:619–44;

2. Marvel J et al. BMJ Open 2019;9:e030579;

3. Wang et al, JAMA Dermatol 2022;158:1378–86;

4. Garg A et al. Dermatology 2017;233:396–8;

5. Garg et al. Dermatol Ther (Heidelb) 2023;13:581–94;

6. Hidradenitis Suppurativa Coalition, https://hscoalition.org/ [accessed September 2024].

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