Wide Gaps Found in Insurance Coverage of Common Skin Conditions

People with melasma and postinflammatory hyperpigmentation (PIH) do not receive the same treatment coverage from insurance companies as people with other disorders that manifest on the skin, such as rosacea and acne, according to a new report.

These findings, published in Journal of the American Academy of Dermatology, also highlight racial disparities in insurance coverage, since melasma disproportionately affects people of color.

The study authors said lack of insurance coverage of such skin disorders is often tied to their classification as “cosmetic” conditions, rather than medical concerns. This classification results in denials by insurers, leaving patients to either skip treatment or pay for it out of pocket. However, not all skin conditions are treated the same way. The authors noted that a previous study found that patients with rosacea, an inflammatory skin condition characterized by red patches on the face, were 26 times more likely to obtain prescription treatment than patients with melasma, a skin disorder characterized by blotches of skin discoloration, even though both share similar clinical features.

“Given that melasma disproportionately affects people of color, this suggests that these patients are less likely to access appropriate health care,” the study authors wrote wrote.

To better understand the extent of disparities in coverage for skin disorders, the investigators conducted a literature review to identify the best first-line treatments for melasma, PIH, vitiligo, rosacea, and acne, and then reviewed the formularies of California’s largest insurance companies to see whether those treatments were covered. The insurers included in the study were Medicare, Medicaid, and 4 private insurers.

None of the insurers analyzed covered the first-line therapies for melasma or PIH. In contrast, all of the first-line treatments examined for acne were covered (although some had restrictions, such as prior authorization or age limits), and all of the insurers covered multiple treatments for rosacea, the authors said.

“Like rosacea and most forms of acne, melasma, vitiligo, and PIH manifest cutaneously, and their first-line treatments are aimed at addressing skin-limited disease,” they wrote. “Despite these similarities, treatments for these conditions have different coverage patterns.”

The burden of coverage denials can be significant, the authors added, in part because of the psychological stress of living with a condition that manifests on the skin.

“In one study, almost half of non-White adult women with PIH were severely troubled by their condition, which often caused more distress than the inciting acne,” they wrote. “Patients with melasma report feelings of frustration, embarrassment, and depression due to their condition.”

Yet, for many patients, paying out of pocket for costly treatment is not an option, and the investigators said even if a patient can pay for coverage, treatment delays associated with the cost burden can result in worsened or unresolved clinical symptoms.

They said their research demonstrates the limitations of the existing insurance paradigm when it comes to treatment of dermatological conditions and how the contours of coverage result in demographic disparities.

“Dermatologists are needed to bring awareness to this issue and advocate for meaningful policy changes to improve insurance coverage,” they said.

Reference

Tilahun M, Lester J. lack of coverage for first-line treatments of pigmentary disorders in contrast to treatments of acne and rosacea: a survey of public and private insurers in California. J Am Acad Dermatol. Published online April 15, 2023. doi:10.1016/j.jaad.2023.04.010