Detailing the ProblemThe safety and efficacy of phototherapy is widely accepted. Yet its usage in the United States is on the decline — mostly because of the logistics and costs involved in providing these treatments.Here, we describe how Kaiser Permanente reduced these impediments in order to more affordably and conveniently offer patients this well-established and trusted treatment for psoriasis, as well as a variety of other skin conditions.About Kaiser PermanenteKaiser Permanente (KP) is an integrated healthcare organization that was founded in 1945. It currently serves the needs of more than 8 million members in nine states and Washington, D.C. The organization encompasses Kaiser Foundation Health Plan and Kaiser Foundation Hospitals, which are nonprofit, public-benefit corporations. Kaiser Permanente also includes regional Permanente Medical Groups, which are partnerships or professional corporations of physicians responsible for providing and arranging necessary medical care. Dermatologic care is provided by KP at multiple medical facilities, with each department under the leadership of a dermatology chief.Historical Background of UV Phototherapy For centuries, ultraviolet (UV) light has played a role in the treatment of medical conditions, including skin disease. Beginning around 1400 B.C., Hindus used plant extracts containing psoralens followed by sun exposure (heliotherapy) to treat vitiligo.1 The first use of an artificial light source to treat skin disease (phototherapy) is believed to have occurred in 1894 in Germany when Lahmann employed a carbon arc lamp in the treatment of lupus vulgaris. In 1925, Goeckerman used black tar and UV radiation to treat psoriasis, and this approach remained the most utilized form of phototherapy in dermatology for several decades. Further developments in phototherapy during the 20th century included the use of 8-methoxypsoralen with UVA (PUVA, 320-400 nm) by Allyn in 1962 and the concept of broad-band UVB (BBUVB, 290-320 nm) therapy developed by Wiskemann in 1978. A major advance came in 1988 with the introduction of narrow-band UVB (NBUVB, 310-315 nm) in the treatment of psoriasis by van Weelden et al and Green et al. In addition, toward the end of the last century, UVA1 (340-400 nm) also came into use in the treatment of skin disease. Phototherapy Today: Advantages Efficacy for a wide range of skin conditions — Phototherapy continues to be utilized as treatment for multiple skin conditions. For example, it can be beneficial for vitiligo, pruritus, mycosis fungoides and dermatoses such as eczema, pityriasis lichenoides and pityriasis rosea. It is most commonly employed in the treatment of psoriasis and is appropriate for use in moderate to severe plaque disease, as well as guttate, pustular, and erythrodermic/generalized psoriasis.2 Ultraviolet light treatment is highly effective for psoriasis, whether used as monotherapy or in combination with topical treatments and/or oral medications such as retinoids or methotrexate. NBUVB has been reported to be more efficacious than BBUVB and almost as effective as PUVA for psoriasis, although the duration of remission is shorter than with PUVA.3 The length of remission of psoriasis with phototherapy is impressive: up to 5 months with office-based BBUVB, 6 months and longer with PUVA, and 8 to 12 months or more with Goeckerman therapy.4 Safety profile — In particular with UVB, phototherapy has an acceptable side effect profile. Treatment with UVB may cause redness, swelling and desquamation acutely and photoaging long term. Possible acute adverse effects of PUVA include nausea/vomiting and delayed erythema. Long term, PUVA poses an increased risk of cutaneous squamous cell carcinoma; its effect on the incidence of malignant melanoma remains unclear. PUVA can lead to hyperpigmented macules, actinic degeneration and psoralen photoproducts associated with cataracts.5Cost advantages — In addition to its clinical effectiveness, phototherapy offers cost advantages when compared with many systemic agents for psoriasis. At Kaiser Permanente in California, the cost per course of UVB treatment for psoriasis is estimated to be $1,600 to $2,000. In contrast, systemic retinoids, cyclosporine and biologic therapies are more costly. Biologics may cost $20,000/year or more. Phototherapy Treatment Obstacles for Patients and ProvidersDespite its clinical effectiveness, relative safety and reduced costs compared to many systemic treatments, the utilization of phototherapy as a treatment for psoriasis is declining in the United States.6 Obstacles to the delivery of phototherapy can be categorized as issues of either time or money:Logistics and time involved in numerous office visit scheduling and treatment — Patients’ schedules may not allow them to commit to coming for the two to five treatment visits required each week, at least until the maintenance phase of therapy is reached. In addition, therapy appointments may only be available at times that conflict with patients’ work or home schedules. At offices offering phototherapy, the amount of time needed for the staff to deliver phototherapy, for physician supervision, and for documentation related to phototherapy visits can prove cumbersome.Burdensome transportation and co-pay cost for patients; staffing and equipment costs for physicians. Patients may be unable to afford the transportation costs and co-pays required for frequent visits. There are significant costs associated with purchasing and maintaining phototherapy equipment, space needs, staff salaries, etc. Physicians in fee-for-service practices may find reimbursement rates for phototherapy inadequate to cover their costs.First Steps Take by KP to Minimize These ObstaclesKaiser Permanente in California has taken a number of steps in order to minimize the obstacles to phototherapy and maintain the treatment as a part of the therapeutic armamentarium for psoriasis and other skin conditions. These include the following:PATIENT CONSIDERATIONS1. Multiple centers providing phototherapy have been established in order to provide short and affordable commutes for patients. There are 27 sites in Northern California and 17 centers in Southern California. The treatment sites provide BBUVB, NBUVB and/or PUVA phototherapy with full-body and hand/foot equipment. 2. Extended hours at some centers make appointments feasible in terms of most patients’ schedules (7:30 a.m. to 6:30 p.m. on weekdays and 8:00 a.m. to 4:00 p.m. on alternating Saturdays). PROVIDER CONSIDERATIONS1. The equipment and needed space are provided by Kaiser Foundation Health Plan (KFHP).2. Physician and staff time dedicated to providing phototherapy services is compensated by the regional Permanente Medical Groups.Next Steps Taken by KP1. Recognizing the biggest obstacle: the co-pay requirement. For the majority of patients insured by Kaiser Permanente in California, co-pays for phototherapy visits have never been collected by KFHP. With newer insurance options, which have started to be offered to patients in the last few years, approximately 25% of patients were going to have a co-pay for these visits ranging from $5 to $30. In contrast, co-pays for systemic medications were going to range from $0 to $40 per month. For most patients, monthly co-pays for phototherapy visits would significantly exceed their co-pays for treatment with systemic drugs. As patients began to be charged co-pays for phototherapy visits, it was found that the overwhelming majority refused to continue UV light treatments or consider starting the therapy. As an alternative, these patients typically required systemic medication, and they most commonly requested biologic therapy.2. Reviewing the co-pay policy.In 2005, the chiefs of dermatology from The Permanente Medical Group (TPMG) in Northern California met with the regional physician director in charge of benefits and policies. The chiefs discussed that co-pays for phototherapy visits were tending to drive patients from this safe and effective treatment toward more costly alternatives. They asked that consideration be given to eliminating co-pays for visits for UV light. The physician director reviewed the matter with the KFHP Benefit and Policy Development Team. It was decided that the issue would be further explored and taken to the Benefit, Contract and Policy Committee, California (BCPC). 3. Considering BCPC Recommendations. The BCPC California evaluates and recommends the benefits to be provided and policies to be established by Kaiser Permanente in the entire state. It is led by a triumvirate consisting of two physician directors from Northern and Southern California as well as a KFHP Vice President. Clinician expert opinion has a voice in the decision-making process. The financial impact of decisions is also weighed in order to ensure effective use of revenue. Put simply, the BCPC enables Kaiser Permanente to “do the right thing” for patients from a benefits and policies perspective.4. Implementing a Temporary Waiver of Co-pays.Pending final BCPC input, it was agreed that all co-pays for phototherapy visits in Northern California would be temporarily waived. Doing so led to the resumption of phototherapy by established patients who had refused to continue the treatment despite its having been effective. Also, new patients were willing to consider phototherapy along with systemic options and many opted for light treatment. Given the numbers of patients who chose phototherapy over systemic treatment, lost revenue from the waived co-pays was offset by savings on systemic medication costs.Ultimate Solution: Elimination of Phototherapy Treatment Co-PaysIn preparation for BCPC review, the chiefs of dermatology from the Southern California Permanente Medical Group (SCPMG) provided their experience with patients who had co-pays for phototherapy. They had found that the vast majority of these patients refused to continue or initiate light treatment and asked for biologic therapy as the alternative. The SCPMG chiefs concurred with the recommendation that co-pays for phototherapy visits should be eliminated.Ultimately, the BCPC concluded that co-pays for phototherapy treatments are counterproductive both therapeutically and financially. It therefore approved a co-pay of $0 for all phototherapy visits in Northern and Southern California, effective January 1, 2007. It is expected that this policy and other steps that have been taken by Kaiser Permanente to remove obstacles to phototherapy will ensure that it will remain accessible to patients who can benefit from the treatment. In addition, maintaining this relatively safe and highly effective therapy as a realistic option should have a positive financial impact on the organization.