Jeffrey D. Dunn, PharmD, MBA: What’s the economic burden of this disease state? I want to ask all of you that because as physicians, you see patients and they ask about the cost. What are the economic drivers of this disease state from your perspective? Is it different from what Dr Epstein sees? Dr Epstein, how would you define the economic burden of vitiligo?

David Epstein, MD, MBA: I don’t think it was even being tracked. If you’re looking at the therapies that I already mentioned were covered, the generic steroids and PUVA [psoralen plus ultraviolet A] and all the others, we aren’t dealing with hugely expensive [therapies]. If you asked me how many members in our system have the disease, I doubt that information would even be available in our system.

Jeffrey D. Dunn, PharmD, MBA: That’s helpful. As we get medications and they become the driver of the direct total cost of care, that’s always the challenge. If you look at other disease states where the drugs are by far the majority of the cost drivers, such as hemophilia or multiple sclerosis, at least from a direct perspective, that becomes the challenge. There’s no medical offset or very little medical offset. I agree, we aren’t looking at this right now. But the reason we’re talking today is because this is going to change, so we need to have better conversations.

David Epstein, MD, MBA: To add to your thought process, which is absolutely perfect, you alluded to what has changed over the years. You’ve been in this business long enough too. For years, it used to be that in focusing on managing cost, it was the disease states that were looked at and then all of the different treatment regimens and all that. In the last few years, I’ve seen that change dramatically. It’s the drugs that are driving—not the diseases themselves. A perfect example is that if the JAK inhibitors are going to be approved for this, they have multiple indications, so it isn’t going to be focused on JAK use in vitiligo. It’s going to be looked at more broadly. They’ll look at the budget impact on JAK use, and then they may dig down through that to find where it’s being used and whether we’re seeing any trends that we need to get in front of.

Jeffrey D. Dunn, PharmD, MBA: It’s putting a lot of pressure on people who are purchasing insurance, whether that’s in the exchange or the employer. It’s causing a lot of challenges in terms of affordability, and that gets passed back to the patient through deductibles, coinsurance, and premiums. That’s the challenge. We need a better approach to this. Because at some point, patient affordability is going to be an issue. Dr Epstein, does your plan look at things like absenteeism or presenteeism when you’re evaluating drugs like this?

David Epstein, MD, MBA: Typically not. It comes up in the conversations. It’s nice to know, but it isn’t a decision driver.

Jeffrey D. Dunn, PharmD, MBA: There’s the disconnect. Dr King and Dr Rosmarin, I imagine that this is the stuff that matters to you. You’ve already talked about this. It’s the functionality of the patient and what they’re doing more so than trying to come up with some artificial objective measure, right?

David Rosmarin, MD: Absolutely. One of the challenges is measuring impact in vitiligo. I want to comment on the treatment of phototherapy. That certainly can affect work, because patients having to come into the office 2 or 3 times a week is challenging and can lead to missed work. There’s certainly an economic impact from that treatment, which should be taken into account. I also want to comment on something you mentioned earlier. Even though Dr King and I experience some challenges with getting topical calcineurin inhibitors covered, I imagine when we have an FDA-approved option for vitiligo, if it’s presumably more expensive, it may help encourage plans to cover the topical calcineurin inhibitors, because that will be a less expensive alternative to the approved treatments. I think that will happen.

Jeffrey D. Dunn, PharmD, MBA: Absolutely, spot on. It should change that. But then if these newer therapies are better, does it matter that they’re that much more expensive? Are they going to supplant those types of older therapies? Is it additive? These are all the questions we need to figure out.

David Epstein, MD, MBA: I don’t think they will unless the data are clearly there. It’ll be a step approach.

Jeffrey D. Dunn, PharmD, MBA: There’s still probably going to be a step approach to this. We’re all on the same page that the likely scenario is using a generic or two before you go to a more expensive biologic unless there’s clear rationale for why that approach is inappropriate.

David Rosmarin, MD: From my perspective, if a patient only has facial vitiligo, it’s reasonable for a payer to say, “Have you tried a calcineurin inhibitor first?” because there are good data that calcineurin inhibitors can help with facial vitiligo. However, we don’t have that same confidence when we’re using it for the rest of the body. If other areas are involved, such as the hands, which are notoriously challenging to help with, or genitals, extremities, or trunk, perhaps some of these newer options that have been proven to help in those areas make more sense as earlier first-line treatment. That may be one way this lays out in the end.

Transcript edited for clarity.