Multidisciplinary Perspectives on the Management of Plaque Psoriasis - Episode 12
Mark Lebwohl, MD: Let me close with a couple of questions about a multidisciplinary approach by both rheumatologists and dermatologists. How can we help get that to optimized care? Do you do it at 1 visit? Do you do separate visits? How can gaps in care be addressed?
Philip J. Mease, MD: My response on all this is education, education, education. There is so much lack of awareness beyond the medical dermatology and rheumatology communities about psoriasis and psoriatic arthritis and the optimum management of the conditions, as well as diagnosing the conditions. Psoriasis may be a little easier, but you could have comments about that to diagnose, because it’s there on the skin surface.
Psoriatic arthritis gets interpreted as osteoarthritis or fibromyalgia. In 1 study we did, the PREPARE study, it was found that nearly half the patients who were ultimately considered to have psoriatic arthritis were never aware that they had the disease. As new generations of medical practitioners come along, they have very little in their schooling. It’s so important to get education to nonrheumatologists and nondermatologists about identifying the diseases and triaging them to get to dermatology and rheumatology care. Once there, if you’re with practitioners who are not hesitant to pick up the phone, call your colleague down the hall or down the street to the other discipline—dermatology or rheumatology—and kibitz about optimal management. They are sharing, either by serial visits to their own offices or in with what is present in many academic centers and combined clinics, so both rheumatologists and dermatologists see the patient at the same time. The quality of care that’s coming out of this shared decision-making approach is really fantastic.
Mark Lebwohl, MD: You raised a point about academic medical centers using a rheumatologist and a dermatologist together. We considered that, and in our polling patients we realized that there was going to be a problem in terms of a double bill—they were going to get billed by a rheumatologist and a dermatologist. Unfortunately, a lot of dermatologists don’t accept the Obamacare Affordable Care Act insurance plans that are out there. They have very high deductibles, they have significant co-pays, and their reimbursement rates are extremely low, so a lot of patients are paying out of pocket even if they think they have coverage. They come to an office and get to see a rheumatologist, and they get 1 bill that’s not well covered and then another bill that’s not well covered, and they object to having 2 bills. That’s why we did not do that at Mount Sinai.
We do have 2 people who are board certified in dermatology and rheumatology, but we opted not to have joint clinics in our clinic, which is largely a Medicaid population. We are actually working on having a board-certified rheumatologist and dermatologist as the person seeing them, but we’re doing it more for connective tissue diseases than we are for psoriasis. We’ll see how that evolves, and of course insurance will change if administrations change. If they stay the same, they may change insurance, and that may alter how reimbursements occur. Right now, it’s a drawback for us to have it together. As you know, there are organizations that encourage having dermatologists and rheumatologists work together. I can imagine it being a lot of fun; you learn from one another, you work together, and it is quite collegial. You’re together helping patients a lot, but the financial piece of it is problematic for us.
Transcript Edited for Clarity