Moving target

By Jan Bowers, contributing writer

It probably comes as no surprise to dermatologists that actinic keratoses (AKs) are taking an increasing toll on an aging U.S. population. The AAD’s most recent Burden of Skin Disease Report, published in 2017, found that in 2013 more than 10 million Americans sought treatment for actinic damage — which includes solar dermatitis, sunburn, and chronic actinic dermatitis as well as AKs — with a total medical cost of nearly $1.68 billion, excluding the cost of prescription drugs. Among all age groups, 3.22% of the population and 14.38% of those 65 and older sought treatment for actinic damage in 2013, according to the report.

Over the years, the impact of AKs has been increasing. A study published in the Journal of Investigative Dermatology found that in the Medicare Part B fee-for-service population, more than 16.5 million AK lesions were treated in 1998. By 2016, that number had leaped to 37.1 million lesions (doi.org/10.1016/j.jid.2018.03.332).

Fortunately for patients, dermatologists are uniquely adept at treating AKs and there are a number of effective mainstream treatment options. Yet, given the prevalence of this diagnosis, are there cost implications waiting in the wings? Dermatology World talks with four dermatologists — three of whom served on the AAD’s Burden of Skin Disease Workgroup — about AK treatments in the context of cost to the patient, to insurers, and to the health care system in general.

Drug prices a wild card

Dermatologists are fortunate to have several effective AK therapies that allow them to shape a treatment plan according to the number and location of lesions, the age and fragility of the patient, the patient’s tolerance for discomfort, and their willingness to adhere to regimens for topical treatment at home. Cryotherapy, curettage, photodynamic therapy (PDT), chemical peels, and topical medications for field therapy all have their place in the treatment arsenal, dermatologists say.

But the most thoughtfully calculated treatment plan can be stopped in its tracks if the patient goes to the pharmacy and finds that they can’t afford the prescribed drug — a situation that more patients are encountering. “The cost of medications has just become the wild, wild West,” said Marta Van Beek, MD, MPH, clinical associate professor of dermatology and chief of staff at the University of Iowa Hospitals and Clinics and Burden workgroup member. “The prices of all topical drugs used in treating AKs are equally volatile. Even out-of-pocket prices for generics have gone up by 400 to 1,000%.” The price volatility is relatively new, Dr. Van Beek said, noting that “in the last couple of years, it’s been really out of control. This is for both the Medicare and non-Medicare populations.”

moving-target-quote Drug costs are “crazy,” and are becoming more of a consideration, along with efficacy and tolerability, as dermatologists plan treatment, said Scott Collins, MD, a partner at Dermatology Associates in Tigard, Oregon, and a prior member of the workgroup. “Drug costs vary day by day and region by region. One week 5-FU is $200 a tube, and we’re going to use that, and the next week it’s $1,700 a tube. It literally changes that fast and you’re thinking, we have to do something else.”

Dermatologists have no way to predict what the out-of-pocket cost of a drug will be until the patient fills the prescription, Dr. Van Beek said. If a drug is unaffordable, there needs to be another discussion with the patient to decide on an alternative treatment. “That is a very inefficient way to provide care,” she remarked. “Because now you need two or three conversations or visits for something that should only have taken one. This can lead to a significant delay in treatment for the patient and has substantial implications for patient access to care.”

The confluence of factors that go into planning AK treatment make it a highly complex process, Dr. Collins said. “First you have to look at the patient and ask, ‘are there just AKs or are there squamous cell carcinomas there?’ Then you have to decide if lesional or field therapy is indicated, and if you go down the field therapy path, what are the therapies that are tolerable, that are efficacious, that the patient can afford? Because of Medicare drug coverage, a Medicare patient might much more easily afford a PDT treatment or two versus a topical treatment.”

Getting a handle on the cost of AK treatments is also “a really complicated topic,” Dr. Collins maintained. “It has to do with whether reimbursement has changed, and/or has the utilization of technology changed, or with drugs, has the cost of the drug changed? Utilization for photodynamic therapy is going up, so the cost is going up, but the cost per treatment hasn’t changed except for the increasing cost of the photosensitizing agents.”

What AK treatment provides the highest value?

Yet, given that AKs are broadly recognized as a precursor to squamous cell carcinoma, the looming specter of a skin cancer epidemic has led several researchers to not only study preferred treatment options, but the cost of treating AKs to try to determine better ways of delivering high-value care to AK patients. Joslyn S. Kirby, MD, MS, associate professor of dermatology at Penn State Milton S. Hershey Medical Center, has published an investigation of geographic variation in AK spending (JAMA Dermatol. 2017;153(4):153-154) and a consideration of eight bundled payment models for AK management (JAMA Dermatol. 2016;152(7):789-797).

How much do AK treatment costs vary?

Read more from Dermatology World at staging.aad.org/dw/monthly/2017/august/how-much-do-ak-treatment-costs-vary.

“The high-value question is more and more on the minds of all practitioners, and in dermatology, not only in actinic keratosis patients but for all of our patients,” said Dr. Kirby. “As medications become more expensive and we have more choices, we have the opportunity to make decisions about treatment while considering the cost efficacy of those medications. The challenge with actinic keratosis is that a lot of that data comes from outside the U.S. health system. We really need to expand this research [in the U.S.] so that we have the data at our fingertips. A second step is to take it into our EMRs to use at the point of care, so that it’s very specific to that patient and their insurance situation.” Existing studies compare the efficacy of different treatments for AK, Dr. Kirby pointed out, “but the studies don’t have costs tied to them, so we know how well the therapies perform relative to one another, but we don’t know the costs relative to one another.”

moving-target-quote2 One study that does examine cost, published online in the Journal of the American Academy of Dermatology (doi.org/10.1016/j.jaad.2018.02.058), used data from the Veterans Affairs Keratinocyte Chemoprevention trial. An earlier publication using results from the same trial (JAMA Dermatol. 2018;154(2):167-174) had established that a two- to four-week course of 5% 5-FU cream, applied to the face and ears, was effective “not only in reducing multiplicity of actinic keratosis for a prolonged period of time — several years — but also in preventing squamous cell carcinoma for a year after treatment,” said senior author Martin A. Weinstock, MD, PhD, professor of dermatology and epidemiology at Brown University Medical School and member of the Burden Workgroup. The JAAD analysis found that the 5-FU arm of the trial had significantly lower costs per patient in the first year after randomization ($2,106) compared with patients in the control arm ($2,444), who received a vehicle cream. “So treatment with 5-FU is not just cost effective, it’s cost-reducing,” Dr. Weinstock remarked, adding that his results “need to be confirmed by others, as costs can vary.”

In addition to Dr. Kirby’s bundled payment models, Dr. Collins also developed an alternative payment model (APM) for AK as a member of the AAD’s Workgroup on Innovations in Payment and Delivery. The APM has not been implemented yet, as a major challenge, he noted, “is that there’s no ability to control drug costs, so if you look at the global cost of treatment, it’s a big problem. One of the goals for an APM for actinic keratosis would be to try to drive treatment more toward field therapy, and away from cryotherapy, with some of the modeling suggesting that would save money, but the science of that is not entirely clear.” He advises dermatologists to attain a comfort level with field therapy, because “it’s probably the direction that the shift from volume to value will drive things if that ever goes anywhere.”

In the meantime, while the cost of AK treatments to patients, insurers, and the health care system remain fuzzy at best, what is certain is dermatology’s role in stemming the tide of an increasingly prevalent health care concern, says Dr. Van Beek. “The treatment of actinic keratosis is an important responsibility that dermatologists have, because we have the ability to turn the tide on the skin cancer epidemic.”

AAD’s DataDerm™

DataDerm is a clinical data registry — created by dermatologists, for dermatologists — to transform your practice and elevate the specialty. To learn more about what DataDerm can do for you, visit staging.aad.org/dataderm.

CODING FOR PDT FOR AKS

While not much has changed with regard to reimbursement for most physician-provided AK treatments, there have been changes to coding. The photodynamic therapy (PDT) codes were also revised: Two new codes were introduced in 2018, so now there are three that apply to dermatology, said Scott Collins, MD, member of the AAD’s Burden of Skin Disease Workgroup.

“Whereas the 2017 CPT had one all-purpose PDT code, 96567, with no introductory language describing the procedure, the 2018 version expands the offering to three distinct codes,” said Alex Miller, MD, AAD representative on the on the AMA-CPT Advisory, in a recent DW Cracking the Code column.

The new and revised CPT PDT codes are:

96567 (revised): Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitive drug(s), per day. “This code has been revised from its previous years’ iterations. It is to be used only when a physician or other qualified health care professional (e.g., nurse practitioner, physician assistant) does not directly participate in the PDT treatment delivery,” said Dr. Miller.

96573 (new): Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day. “96573 describes PDT delivered by a physician or qualified health care professional (QHP). Specifically, the physician/QHP must be the one who applies the photosensitizer and initiates the light illumination.”

96574 (new): Debridement of premalignant hyperkeratotic lesion(s) (i.e., targeted curettage, abrasion) followed with photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day. “96574 stipulates that, in addition to personally applying the photosensitizer and initiating the illumination with light, the physician first curettes/abrades hyperkeratotic lesions within the treatment area,” said Dr. Miller.