Guidelines of Care for the Management of Hidradenitis Suppurativa

What the guidelines say to payers

Two parts of the guidelines speak directly to coverage policy, and both sit inside the body text where they are easy to miss.

Step therapy

From the Recommendations section

“Step therapy, an insurance requirement that patients complete a sequence of insurer-designated treatments before coverage is approved for a physician-prescribed therapy, lacks evidence of clinical benefit and is associated with treatment delays, reduced access to guideline-concordant care, and worse clinical outcomes.”

Cost

From the Cost section

“We recognize that costs for some therapies may be prohibitive without adequate insurance coverage. Clinicians should be aware of cost differences among treatments, including lower-cost options within the recommended treatment landscape. Shared decision-making regarding treatment selection, initiation, and adherence should explicitly address affordability, insurance coverage, and out-of-pocket costs.”

From the Cost section

“Notably, effective treatments may reduce long-term economic burdens for payers and the healthcare system and direct costs of HS therapies should be weighed against indirect costs of uncontrolled disease, including wound care, lost productivity, and disability assistance. While payer and healthcare system tools to manage healthcare utilization and drug expenditures, including step therapy and prior authorization, are effective at reducing short-term therapeutic costs, they are also associated with treatment delays, reduced adherence, and worse clinical outcomes that can drive higher long-term costs. These effects compound existing barriers to HS care, including diagnostic delay averaging 7 to 10 years and limited access to specialty dermatology.”

The strong recommendations

Benefits clearly outweigh risks and burdens. These apply to most patients in most circumstances.

Recommendations for therapies that apply to most patients

These are conditional recommendations. Benefits are closely balanced with risks and burdens, so the recommendation applies to most patients, but the most appropriate action may differ depending on the clinical situation or on patient values. Grouped by category and listed alphabetically.