Bhavesh Shah, RPh, BCOP

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: So great question about reevaluating formulary and how formulary decisions are made. Obviously, this all depends on or is driven by the type of plan you’re actually maintaining. So if you have a Medicaid plan, then you’re essentially at the mercy of how the Medicaid plan covers that product. You can’t go and create your own formulary pathway when Medicaid has a different pathway. That’s completely driven by a PDL [preferred drug list]. And we know that’s also tied to rebates and how the competitors have positioned their rebates to Medicaid. Then, in regards to commercial options and some of the other formularies are obviously a little bit different. With commercial options there is obviously more of a PDM [proportional disease magnitude] driven formulary guidance in terms of how a product is positioned more favorably from a PDM perspective. There’s a lot that is driven there. And then, of course, there are clinical studies that go into driving the formulary, too.I think reevaluation usually happens when let’s say, a new drug comes out and we haven’t reviewed it, and we’re receiving probably 20 or 30 requests a month. I think we need to establish guidance in terms of how this could be utilized, so we can actually guide our providers and maintain or preserve our formulary status. I think that kind of drives that. If a manufacturer approaches us and says, “Hey, we wanted to see if we can have a value-based contract,” or some type of contract where they have identified that they wanted to have a more favorable preference of their product on the formulary, then of course that will also trigger the need for reevaluation and how a product is positioned in the formulary. Then, as new agents come through the market, we have them reviewed because we’re going to be getting requests. But if we’re getting 1 or 2 requests a month, it’s not going to trigger an evaluation of the formulary. Then of course, if entities like Medicaid are determining or pushing out their formulary recommendations, that will also trigger us to reevaluate our formulary. At the same time, we’re looking at what are our needs while looking at our commercial options, and our Medicare options. I think not just doing a one-sided approach where we’re just looking at that Medicaid reevaluation, but we would do it, whole class, with all of the lines of businesses.

How do you actually create access for effective treatments? It’s really through innovative contracting or, I think, the bottom line to any payer is that they’re trying to have a more favorable cost profile so that they can sustain their PMPM [per member, per month], and also treat the number of patients that they have. So it’s thinking through what is the volume of patients that this payer is going to have to treat? And can they do that while preserving the PMPM? And what kind of partnership looks like with that payer to help them through that? I think we kind of saw this as a prime example in hepatitis D, where nobody anticipated the volume of patients that you would have, and then the cost that was built into the system, it was just not sustainable for payers. Even though the most effective treatments that we’ve ever had in that disease, curable treatment, an 8 to 12-week course, and there was significant access to it because of the way it was positioned from a cost perspective. I think really working with payers in understanding what that price-setting should look like, based on the volume, so you can actually have that access for those patients.

There are groups such as the National Eczema Association, of which I’m a proud board member and scientific advisory committee member, and they do try their best to advocate for patients. They have resources available to patients. As I said, I do work with a number of companies that have programs for patients. And I’m a big proponent of them. I wish we didn’t need them. It’s one of those crummy worlds that we have to fill out paperwork to have a company help a patient. The whole thing is so silly, but that’s the reality. These programs can be amazingly effective in getting patient assistance. Not only for getting a drug that they can’t get, but also helping with copay. Some of the medicines have high copay and the companies will reimburse the patient thousands and thousands of dollars of savings, which is real money for many families, for any family. I don’t know anybody who could pay for these things out-of-pocket. And if they could, then hopefully they’re doing charitable work because then you have a lot of capital, then you can use that money for good things. So those are some of the things we can do. We can try to work together to find specialty pharmacies, a huge part of my day, as dumb as it sounds, is shopping around; This pharmacy mail order can do it a little cheaper than that one. It seems like again, healthcare utilization, there’s a shortage of dermatologists. People get so frustrated that they have to wait so long to see us. What am I doing? That’s part of what I’m doing. I’m trying to find a cheaper pharmacy for people. So these are things that I wish we could alleviate. I wish there were better techniques. Again, the payers really are in the driver’s seat. They could make everybody’s life a lot better. I wouldn’t mind it being a little stricter; Here’s our criteria, but it’s clean, simple, and universal. That’s why I think you’ll hear some doctors, not all, I don’t want to put words in anybody’s mouth, but they’ll push and I’m in the group. I would totally consider a single-payer healthcare system. I stand to lose a lot, money-wise. Presumably, I’d get paid a lot less. Why? Because of the stress and the ridiculousness and the shenanigans, it’s worth something to me. I’d be willing to pay it from my salary to have simplicity. And that’s saying something.

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Current strategies used to evaluate the performance of therapies used to treat atopic dermatitis and guide formulary decisions, and recommendations to help patients receive access to effective therapies.

Increasing Access to Effective Therapies for Atopic Dermatitis

: In regards to the question about the difficulties in managing this disease, I think a lot of it stems from patients not having access to appropriate providers who actually have expertise in this. Then, the second aspect is that in some of the economic analyses that were done, we did see that patients of African-American or minority descent actually had poorer outcomes and lower satisfaction compared to the predominantly white patient population with atopic dermatitis. It shows that there is a disparity in access to care, education, and the connection with the right providers. I think that really drives some of the other indirect costs that we’re seeing. I think we talked about what happens to a patient with ineffective therapies, or not having the appropriate diagnosis. And I think being a managed care Medicaid health plan we do see a lot of those disparities in these patients. So I think there’s definitely more that we can do, and it’s definitely challenging when you don’t have resources poured toward creating that open forum for patients to be able to access despite having all of these disparities.

I think the landscape is definitely changing rapidly for atopic dermatitis. And you’re absolutely right in terms of not having the appropriate expertise. If you look at when I am part of the direct care of patient responsibilities, many providers are actually very used to how they manage a disease. So when a new drug comes out, there’s always some skepticism about adopting new therapies right away, even if they may be highly effective. And then, of course, not having a specialist who’s prescribing this, who may be well versed in the new agents that are coming into the market, and how they should be utilized. But where does it really fit into the treatment for many of their patients? There was a survey done by Bryan Chang and his team—he was a senior author—that was presented at the atopic dermatitis virtual symposium recently, I believe. Essentially, they identified thousands of patients who had atopic dermatitis and they did a 5-question patient satisfaction survey, using the CAHPS [Consumer Assessment of Healthcare Providers and Systems] methodology, which hospitals use HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems], so it’s actually measuring the providers. Did your provider explain to you the disease that you have in detail? Were you satisfied with the agent that they prescribed for you in your disease? Were they timely in providing you with information such as your labs and follow-ups and things like that? It was interesting because it was a 5-part, 5-question assessment, where many patients indicated they were not satisfied with their provider’s support. Essentially, there was also a finding that their disease wasn’t as controlled. So disease control was directly tied to patient satisfaction. So it’s really interesting when you can actually understand the dynamics of treatments and the treatment of the disease, where patients are probably not seeing the right providers and not getting the appropriate treatment in a timely fashion. There are a lot of barriers, I think, in optimizing these treatments, because maybe lack of provider expertise and not understanding the pipeline agents.

: There are a lot of barriers to access, and this includes everything from misinformation to disinformation. Sometimes people come in and say, “I heard topical steroids are super dangerous. I don’t want to even touch them.” That’s an important thing. It’s difficult to convince somebody to change his or her mind in 15 minutes. Talk to anybody who’s discussing vaccination status or political things. We’re in a time now where people have very strong opinions and are very confident about them. Sometimes I find that it’s easier just to work with people at that moment rather than try to push back all the time. We have to sometimes take what we got and work overtime to establish a rapport and relationship. Education is part of the barrier but the other part, of course, is accessing them in terms of costs.There is a very confusing thing in American medicine. Sometimes the super expensive branded prescription will be much more accessible for the patient than what would appear to be the far cheaper generic. And it can have to do with things like a manufacturer’s coupon or a program where the company says, “You know what? We’ll take care of it for a year.” And that is confusing and difficult. There’s a lot of push back on us saying, “Hey, stewardship, we have to save the system money.” When you really pick that apart, yes, I’m trying not to bankrupt our healthcare system, but as we’ve already said, it is a for-profit healthcare system. And most of the people I’m dealing with are private insurance companies. On the other hand, I also have to take care of my patient. That’s my first concern. I can’t change that unwaveringly. The first real piece that I have to focus on is the patient. So if they can’t afford the medicine, well, what are we doing here? Then I’m completely powerless. I am more than happy to utilize programs from companies that are going to help make it more accessible. And sometimes it’s a better product to boot. It’s really hard. You’re making a sacrifice sometimes to pick a generic medicine, which you know less about. Sometimes it’s a different formulation. They are often the cheapest ingredients and I’m happy to do it. But when the price of the patient is $300, you’re saying, wait a minute, you can get the branded one that we know is nice. You can get that for $10. This is silly. These are some of the things that we face. Another issue is time. Patients have to do a lot in dermatology. If it’s just a pill, even that’s hard to get people sometimes to take, but when it’s a topical routine, it does take a lot of time and energy. So that could be another barrier to care. And we often just say, just put this cream on, but it’s not that easy. That is another aspect that we really have to consider for our patients and their families

: I think one of the biggest challenges that patients will face is going to be the cost-sharing involved with many of these agents. And as a payer, we have to basically use the dictated formulary that is chosen by the employer groups. Essentially, I think there’s going to be higher scrutiny for the oral agents, but less scrutiny for the topical JAK [Janus kinase] inhibitor. And I think Medicare patients will definitely be impacted more just because it is hitting part D for many of these patients.I think with oral agents there are always adherence issues. I think that’s one of the drug interactions and the system toxicities. And patients, in this specific disease, are not used to having drugs like a JAK inhibitor. I think just knowing some of the side effects, or listening to the side effects, patients may actually abandon therapy. I definitely think that there’s a lot that will need to be done in making sure patients stay on therapy. But in terms of formulary positioning, I think that’s going to be really driven by a lot of the cost factors, and even if there are opportunities for value-based contracting, or risk-based contracting, that may actually—can actually put these agents more frontline. I think there are definitely differences in how that will play out once they’re approved. Some are already being approved so I think we have some visibility on the cost. I think the cost will be one of the biggest factors where there will be a placed formulary in tiers in terms of the pathway and going from topical to oral.

Payer and clinician insight regarding access to effective therapies for atopic dermatitis and potential challenges adopting new therapies, including topical JAK inhibitors, into clinical practice.

Barriers to Treatment Access in Atopic Dermatitis

: There are still a ton of unmet needs for atopic dermatitis. I think one of the biggest areas right now and a big focus is a primary prevention. We would love to figure out how to prevent this disease and right behind that is what do we do for our littlest ones?The babies, as we've talked about, we don’t have many things approved down to this range. We’re excited to see crisaborole, get down to the 3-month range, but I even have 6-week-old babies. These are really tough so we would love for some more research and insight into how we can help these babies the best with best practices. And is there a chance that we could actually prevent or alter the course and modify the disease course of this by treating it appropriately early on? Maybe there’s some work going on in that? For other patients, I think we still need a lot more in the ICH [International Conference on Harmonization] domain. We still need to understand the microbiome. We need to be able to modulate that better. I’m very bullish that fixing the microbiome may be a real pathway, like an independent, powerful pathway to help this disease. I’ve seen some experiences already where it seems the microbiome was playing a very powerful role in all of this. I’d love to see more work done on sleep. I would love to see even more advanced things on skin barrier healing because right now if you notice everything we talked about pretty much focuses on inflammation. So it’s sort of every other area I think is still underserved relatively speaking, besides the inflammation/itch part.

: There’s a lot of unmet need in atopic dermatitis. I think we don’t have a lot of data on the economic burden—on both patients and the healthcare system. So I think there needs to be more data, especially with new agents coming to market. I think that we definitely can provide more insight into the benefit that these agents are providing for the healthcare system and the patients. Because there’s a quality-of-life improvement that’s going to be directly tied to healthcare resource realization. These patients are not with a life-threatening disease, but there is an impact on disability claims. There’s an impact on healthcare resource realization due to symptoms and productivity loss. I think there needs to be more data that kind of provides even payers, in terms of knowledge of assurance that these agents are actually doing better than some of the previous agents that we have in the market. And then I think the other unmet need is that we need to have identification of biomarkers to really help manage the clinical management of atopic dermatitis in different stages of the disease. So I think it…really making it personalized. I think that’s another unmet need because when you have so many agents in the market, which one are you going to be using? There needs to be more of a targeted approach or more of a pathway-driven approach, in terms of indications, comorbidities, and severity. And then biomarkers would kind of incorporate it all to be this predictive model of which patients are going to do better.That would definitely change the perspective on how we manage patients with all the different stages of atopic dermatitis.

An overview of limitations faced by payers and clinicians who play a role in the management of atopic dermatitis.

Unmet Needs in the Treatment of Atopic Dermatitis

: Numerous JAK inhibitors are coming to the market. Three of them are oral and then one is topical, which is ruxolitinib, It’s really interesting because from a topical perspective, you avoid the systemic adverse effects that patients may have. Then based on the literature that I’ve seen with ruxolitinib topical, there is a significant reduction in itching very quickly, within 12 hours of using it, and then that’s sustained for over 4 weeks. Some may even say that there’s a benefit that’s equivalent to a biological. That reduction in itch that is within 12 hours from a topical perspective, which avoids the systemic adverse effects, I think, is very appealing.

I do think that the cost of a biologic is going to be way higher always compared to the cost of a topical. Especially seeing some of the preliminary results, and having those benefits, [use of the topical agent] would definitely move higher in the utilization criteria. Maybe even failing the topical before the patient goes to a biologic, or requiring them to fail the ruxolitinib topical before they go to a biologic. Of course, we know that ruxolitinib cream is not going to treat those patients with asthma, who require an agent like Dupixent, or allergic rhinitis, or nasal polyps.I think having some of those comorbidities may push a patient to get a biologic over ruxolitinib topical cream. But I think there’s definitely a bigger pool of patients who would qualify for the therapy. Talking about the adverse effect profile of oral JAK inhibitors, this is not the case with atopic dermatitis, but recently we’ve seen a communication from the FDA that agents such as baricitinib and upadacitinib and Xeljanz all carry this warning from the FDA for an increase in blood clots and other adverse effects, such as cardiovascular events. This was seen in other indications like rheumatoid arthritis [RA] but essentially carried over to indications like GI [gastrointestinal] as well.

I think there may be hesitation from providers to reach for a JAK inhibitor over a cream, especially because of the FDA warnings that have come out recently, which changed the label of these, specifically with Xeljanz and baricitinib, that patients should fail a biologic therapy such as an anti-TNF [tumor necrosis factor] before they should be considered for JAK inhibitors. Obviously, they haven’t said that it applies to other indications besides RA and IBD [inflammatory bowel disease], where Xeljanz is used. I think that having those types of warnings would definitely be a consideration.

But the other thing I should mention is that we also have identified that the JAK inhibitors provide benefit in patients with alopecia concurrently with atopic dermatitis. That’s a huge impact on patients across various comorbidities. I think patients would also prefer having multiple benefits even though the provider is going to be reaching for the cream first.

I should mention one other thing as COVID-19 is still around; it hasn’t gone away. But baricitinib is approved through an EUA [emergency use authorization] for patients with [COVID-19–related] ARDS [acute respiratory distress syndrome] pneumonia. There is this other aspect that providers may be thinking about. Say they have a patient who is highly immunosuppressed and if they’ve been vaccinated but are still not sure about the amount of antibody protection they may have, having a JAK inhibitor, which is approved through an EUA for COVID-19–related ARDS pneumonia, if this patient develops COVID-19 and ends up having that overactive cytokine release syndrome, there may be a benefit for these patients. There are so many ways to spin this, but I think we would definitely prefer the cream over the oral agents, based on the cost, too, primarily, and the efficacy.

Right now, because the topical JAK inhibitor is so expensive, it is orders of magnitude more expensive than the things we have on the market right now. I’m reserving it for those patients really who have in earnest tried and failed at least topical steroids, probably one of the calcineurin inhibitors, and potentially, it’s not always appropriate, but crisaborole. The thing is crisaborole, as we said, it has its own niche, and for many, especially a severe patient, it’s not an appropriate thing to try. But for those patients who still need it, I’m really excited about it. There’s no doubt that for some of the patients, this could potentially mean the difference between having to go on a systemic agent and not, if we can get them under better control. So that’s exciting.

For the oral ones, I think for my personal practice right now, they’re going to generally be reserved for severe patients. They’re not something I think I will dabble in unless they really need it. Ideally, they will have failed something like a biologic first for my practice, because I feel that the biologics, in general, seem to have a more favorable safety and efficacy balance, at least the way it’s written. Again, that’s the hard part because the black box warning is so severe sounding, even if the truth is not quite to that level, it does make our life a little bit harder with talking to a patient.

They are probably going to be initially for patients who’ve had failures, who’ve done these other things, but if they prove themselves and as we get some experience, maybe we’ll start to say, you know what, they’re easier to use. It’s a pill; it’s not a shot. And maybe as I alluded to, we will be able to use them in smaller bursts for patients sometimes to be a true steroid-sparing agent. I’m excited about all of these options because we just have so many unmet needs.

Drs Shah and Lio explore where topical ruxolitinib fits into therapeutic sequencing in atopic dermatitis, compared with oral JAK inhibitors.

JAK Inhibitor Treatment Selection for Atopic Dermatitis

 We’re looking at the effectiveness and safety of therapies. The cost is the most important driver of how that product is going to be positioned to the formulary. We know that mild to moderate patients may be controlled by creams, topical emollients, and topical corticosteroids. There are higher strength topical corticosteroids. There are topical calcineurin inhibitors. Then there are PDE4 topical agents. All those agents have some efficacy in these patients. If you can control someone’s disease with a low-cost therapy, then that would definitely be the choice. If you look at most of the payers, they have this pyramid that starts with the topical emollients, topical corticosteroids, and topical calcineurin inhibitors. Then you move toward the PDE4 inhibitors and to systemic therapy. For some payers, systemic therapy is cyclosporin, thiopurine, or methotrexate—some of the drugs that could be required for a patient to go on to biologic therapy. We know that there’s a significant cost for biological therapies, so if we can control the disease with some lower-cost options, then that’s how a formulary is positioned.

Sometimes even if we prefer a more aggressive treatment approach, we’re limited depending on the type of service line you have. If you have a primarily Medicaid service line, you’re going to be tied to a PDL [prescription drug list], which is going to dictate what you can prefer and what you can’t. A lot of that is driven by contracts, formularies, and rebates, unfortunately. Of course, we know that there are patients who will eventually fail these therapies and will require these more effective therapies.

Managing utilization for a class like this, there’s a significant amount of patients who are going to qualify for a drug that’s approved for moderate to severe atopic dermatitis. Cost plays a huge factor in deciding how that utilization gets to that biologic. We’re looking at the baseline characteristics required for a patient to receive treatment in the first place, which is pretty straightforward. You have a differentiating factor of low, moderate, and severe disease that these patients will have. We know that topical treatments often have limited efficacy in moderate to severe disease. Of course, they don’t always address the systemic inflammation or allergic comorbidities that patients have, like allergic rhinitis. If you have some of those factors already on board, like if a patient has allergic rhinitis and atopic dermatitis, or atopic dermatitis and asthma, then they require a biologic. That also changes the utilization management of the patient. Comorbidities are factored into utilization management. But we also have to have a hierarchy of starting with the basic agents, where there’s some efficacy, and then move to the more costly agents or more of the systemic therapies for patients who require more aggressive treatment or dual-indication management.

Variables considered when developing and referring to treatment formularies for atopic dermatitis.

Building Out Treatment Formularies for Atopic Dermatitis

The main goals of therapy for every patient are three hurdles. The first hurdle is can I get you clear? We have to get the skin cleared up significantly. Honest to goodness, there are some patients where I’m having trouble. No matter what I throw, they’re so severe that I can’t even shut off the primary inflammation. That’s step one. Hurdle No. 2, can I keep you clear safely? That’s important because if somebody can stay clear but is using tons of steroids or taking oral immunosuppressants for long periods, this isn’t safe. Even though the disease has a lot of risks, the treatments start to outweigh the risks of the disease. We have to constantly balance this.

The third hurdle is more vague and a little harder to conceptualize: can the patient keep it up? This is a complex, multifaceted idea that includes everything from access to medications to lifestyle choices. Sometimes if the answer is phototherapy and coming to an office three times a week is safe and effective for them, they can’t keep it up because life is too busy. There are kids in the house or they have other meetings. There are many reasons why people are not able to keep it up, including things like they’re just exhausted from putting on all these creams all day and having a schedule. In each hurdle, we need to think, what can we do better for this given patient? Those are the goals of the treatment.

 There are four major goals. You have your biologic therapy, which a patient with moderate to severe atopic dermatitis is going to eventually be on. We know that it has to be related to this inflammatory path process that drives the disease itself, but we forget that there are other components, such as avoiding triggers, daily skin care, anti-inflammatory agents, and complementary modalities. These patients have a very cumbersome lifestyle where there are daily skin-care emollients they have to apply. There are recommendations to have baths with bleach to avoid Staphylococcus aureus colonization, so that needs to happen. There’s a specific temperature and humidity level they have to keep their house at. Even clothing that they have to wear to prevent exacerbation of irritation. It’s a multimodality approach: there are therapeutic drugs, complementary modalities, and supportive care that patients need to have. There are daily skin-care and some anti-inflammatory agents that are always going to be needed by these patients.

 There are many considerations for payers to think about. No doubt, there are organizations like ICER [Institute for Clinical and Economic Review] that look at individual medicines and talk about their cost-benefit analysis, but it’s more complex than that. As a clinician, that’s what I do, and I work directly with patients and families. I implore payers to think about the clinician’s desires and goals and the patient’s well-being, and understand that not everybody reads the textbook, so to speak.

Another frustrating thing is when we have step therapies that make us do things that are inappropriate or irrational or that are not going to be reasonable for this patient. You’re trying to push back against a very large machine. Clearly, the purpose of these tools is to create steps, create barriers, and save costs. It’s OK—we can say that. You’re allowed to say that. It’s a business, and the way we’ve decided to do it—at this time, in this place—is to make medicine, for better or worse, a capitalistic endeavor to some degree. The companies have to make money. These payers are paying, and they have to watch their own budgets. That being said, it would be nice if there were more escape valves. If we could save time and energy for certain situations that arise and have an easier mechanism—a lot of times, the resources that go into getting even a relatively inexpensive medicine approved for a patient are staggering. We’re using my time and my staff’s time, going back and forth.

Meanwhile, the patient is suffering. They’re caught in the middle. Sometimes they’re mad at me and I’m saying, “I’m doing everything I can. I’ve written my letter. I’ve written the prescription. I’ve sent my chart notes. I don’t know what more to do.” From a doctor’s standpoint, I’ve already told the insurance company what we need, and now we’re playing the game. If they could just be more open to this, there are many ways to solve the problem from different tools. For example, there’s something called the Atopic Dermatitis Control Tool [ADCT]. It’s a free survey you can download. I use this with my patients sometimes. It’s a teaching exercise and an opportunity to ask good questions. There are six questions. It takes about a minute to go through. It’s no time at all, and you realize how many patients are not well controlled.

It’s been validated to help us get a sense of disease control. If we could show that if you just ask these questions, then maybe it wouldn’t take the doctor’s time. Wouldn’t it be neat if the insurance company had a question? They could work with their client, the person paying them. I don’t pay the insurance company. The patient pays the insurance company. If they could say, “Mr. so and so, your doctor says you need this medicine. I hear you. Can you just answer these six questions for me?” If it’s appropriate, “Holy cow—you’re right. Done.” Whatever it would take.

There’s clarity and some degree of universality, because we take a number of insurers, and every time it’s a new game. They have their own setup and their own thing. There are only so many hours in a day. There’s only so much bandwidth, especially for people who are taking care of a lot of patients. How can I know what’s going to happen with each medicine I write or each patient or each patient visit? It’s very complex. It would be nice to see some consortiums where people work together to say, “Here’s what we’re going to agree on. We’re going to make it relatively simple.” It can be strict but simple. We’d all trade strictness for simplicity because right now it’s a mess.

I think tools like the POEM score, the Patient-Oriented Eczema Measure, and its close cousin, the ADCT, are great places to start. Tremendously smart people have worked on these for years and studied them and validated them. Something like that would be great. Many insurance companies will mandate that we have to give some kind of a severity score, so that’s why I’ve gotten into the habit of putting my IGA [Investigator Global Assessment] score. It’s inappropriate and not right to ask for something like an EASI [Eczema Area and Severity Index] score, which paradoxically isn’t very easy. It’s difficult to do. If you’re not trained to do it, you’re going to get garbage in, garbage out. If you’re having somebody try to follow the thing and do it, then you’re supposed to be trained to do it. I can do it, but it takes time and energy, and I don’t think it’s appropriate for this sort of thing. Something like that would be fantastic.

For many of these medicines, I don’t think people are abusing them. This isn’t like a pain medicine, where people are trying to get eczema treatment. People are trying to get relief from their disease. I don’t understand ultimately why there are so many barriers to this because 99% of the time, I get through. It takes energy and time. We waste everybody’s time, and we get what we want. Can’t we just cut to the chase? Can we not just say, “You see my track record”? Maybe people don’t want this. There are probably some unintended consequences as I say this, but maybe there could be regional centers where it’s from this center. You’re a doctor that doesn’t see a lot of eczema cases. We’re not sure. We don’t feel comfortable with you approving this medicine. Can you send them to one of five centers around where this other person can approve it? Something like that. There’s probably a ton of bad things on that, but I’d trade simplicity and knowing what we need to do for the current labyrinth.

Ten years ago, I would’ve looked like an absolute superstar. The outcomes I would’ve picked are quality of life and happiness. I was doing great. Now I get tough cases from all over. I started focusing on it because I like it. I’m interested in it, and unfortunately my outcomes aren’t so great because I get difficult cases, and we do the best we can with them. I’m using everything I’ve got and sometimes bringing other people in—up to a seventh opinion—so I’d feel sad if they looked at me and said, “Dr. Lio stinks. He doesn’t get anybody better.” Wait a minute—we got the worst of the worst. Especially if there are capitation pipe setups or bonuses for people who spend less money, then it just makes you say, “Nope, I’m not seeing the hard cases.”

We already see this to some degree because for a patient with eczema, a new intake is at least 30 minutes face-to-face. There are hours that go unpaid—I’m in the background doing stuff or following up. Many offices will say, “Send it out. I don’t want to deal with it, because I can see a new patient with acne with a couple of pimples in five or 10 minutes. We can do the thing and keep moving.” The problem is, you then start to discriminate against the severity of the disease, and that’s not fair either. Everybody there loses eventually. Then you have a bunch of people who are turning and burning. People who are trying to do the right thing are getting penalized. To some degree, this already happens. The system already works this way, but it would really stink to make it even worse, to push it further in that direction.

Considerations for quality measures established for atopic dermatitis when assessing how well patients are responding to treatment.