This month’s news from across the specialty
What’s hot
December 1, 2024
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
More than 80% of prior authorization appeals are overturned. Insurance plans’ most common interventions to manage utilization of health care services include: requiring referrals to certain specialists, entering into risk-based contracts with physicians, care coordination programs based on specific conditions, and prior authorizations. The Kaiser Family Foundation recently published data on the use of prior authorization and its outcomes for multiple Medicare Advantage insurers.
In 2021, over 35 million prior authorization requests (or 1.5 requests per patient) were made for Medicare Advantage enrollees. After review, only 2 million of these requests were denied. If physicians subsequently appealed the denial, over 80% of the denials were fully or partially overturned. Interestingly, insurers with the highest prior authorization requests denied the lowest share of requests which means that the end result was very similar rates of denials (about 0.1 denials per enrollee) across insurers despite very different amounts of administrative work completed by physicians. With such a high frequency of favorable outcomes, the authors of the paper question the utility of prior authorization in managing utilization and worry that the extra steps created by the use of prior authorization delays care and negatively affects patients’ health.
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Checkpoint inhibitor treatment for metastatic melanoma is associated with durable survival at 10 years for the minority of patients that survive past three years of treatment. The final, 10-year outcomes reporting for the CheckMate 067 trial is notable for the lack of new adverse effects with cumulative dosing of nivolumab and/or ipilimumab. To recap prior reporting from this trial, 945 patients were randomly assigned to nivo-ipi, nivo, or ipi starting in 2013. Treatment was continued until disease progression, unacceptable toxic effects, or withdrawal of consent. Three- and seven-year outcomes highlighted the superior survival for the patients receiving the combination of nivo-ipi, but this cohort also suffered higher rates and severity of adverse events. This 10-year report suggests that both progression of disease and severe adverse events will most commonly occur in the first three years after diagnosis of metastatic disease. Biologically, this is very interesting because it suggests that the adverse events do not increase with increased exposure to checkpoint inhibition. When adverse events are associated with better cancer cures, it is reassuring that the risks of adverse events do not increase over time.
We strive to make timely diagnoses and alleviate patient suffering. One patient taught me this lesson when she presented with over three years of purpura and skin ulcerations before being diagnosed with amyloidosis that eventually involved her heart. I am grateful to have met and learned from her: monoclonal gammopathy of undetermined significance (MGUS) is not just MGUS when other organ systems become involved! A Mayo Clinic study (doi: 10.1016/s0190-9622(99)70434-2) showed that about a quarter of MGUS patients develop a plasma cell or hematologic malignancy. As dermatologists, we are often the first to recognize skin diseases associated with these conditions, enabling timely diagnosis and treatment. We are also advocates for more aggressive treatment when cutaneous involvement should not be ignored.
I was intrigued by a retrospective analysis out of Columbia University regarding the use of multiple myeloma drugs to treat cutaneous involvement of MGUS (doi: 10.1016/j.jaad.2024.02.050). The study identified 31 cases of “gammopathic dermopathy,” with an average patient age of 70 years. Over half were diagnosed with MGUS due to skin symptoms. Of the 31 patients, 12 (39%) received multiple myeloma treatments — primarily lenalidomide, daratumumab, and ixazomib. Remarkably, 11 of these 12 patients (92%) improved significantly whereas 16 of 19 (84%) patients who did not receive multiple myeloma treatments failed to improve despite trying other therapies such as steroids or hydroxychloroquine.
Effective treatment of gammopathic dermopathy can greatly enhance quality of life, underscoring the vital role of dermatologists in diagnosis and multidisciplinary care. Future research is essential to identify the safest and most effective treatments for various cutaneous manifestations. Meanwhile, we must remain vigilant!
More What’s Hot!
Check out more What’s Hot columns from the DermWorld Editorial Advisory Workgroup.
In the ever-evolving field of topical therapeutics and cosmeceuticals, it appears that the new cool kids on the block are topical exosomes. Exosomes are nano-sized extracellular vesicles that transport bioactive substances and can also act as signaling molecules. They have been postulated to hold great promise in terms of targeted therapies, reduction in inflammation and wound healing times, hair growth, and stimulation of collagen and elastin production. These molecules are derived from stem cells, with most current formulations sourcing from human-derived adipose cells and mesenchymal stem cells. While there are currently several exosome-containing products on the market, none are FDA-approved, and no consensus has been reached regarding their safety and efficacy. We can look forward to more robust clinical trials exploring the exciting prospect of adding exosome-containing products to our practice toolboxes.
