PsA Treatment Challenges: Patient Education and Cost of Therapy


Reflections on the challenges inherent in managing psoriatic arthritis, particularly cost of care and educating patients on their disease.


Michele M. Cerra, MSN, FNP-C: Compliance is a big issue with our patients with autoimmune disease, because we tell them it’s lifelong. Our goal is to put you into remission with no active disease state, but how do you go about making sure your patients are educated about their disease state, and using a reputable website for getting their information? When do you start them on a new medication, and how do you set expectations? I have patients whom I’ll start on medication, and I tell them “Don’t stop your drug unless you’re having an allergic response, and don’t wait till your next visit to let me know you’re not doing well or having adverse effects.” The first part of that was disease state, education, and then expectations for new medications.

Nancy Eisenberger, MSN, FNP-C: That’s a good point. When a patient is diagnosed, the first thing I do is educate them that this is a chronic, progressive disease and that inflammation leads to lymphoma, heart disease, and stroke. I make that clear because if we’re not honest, they’re not going to feel immediate relief from our treatments. I let them know that some medications can take 3 months to kick in. I tell them, “If you have any adverse effects—nausea, rash—call me. If you have a full allergic reaction, hives all over, of course stop it. If you have any breathing issues, stop it. But always call me. Don’t wait till the 3- or 6-week visit.” That’s 1 reason why I do a 6-week follow-up too, to gauge patients’ adherence to medication and how seriously they’re taking their condition. Some people are in complete denial initially. They say, “I don’t need this medicine. I’ll be fine. I’ll exercise more and eat a low inflammatory diet.” Those are great things. They’re wonderful, but they’re not going to replace treatment for a disease like this. And I use education materials—the American College of Rheumatology’s handouts are fantastic. I’ll also use things from UpToDate. Things my patients can understand. It’s simple, and there’s no confusion. It’s still hard to get adherence with some people until they accept their disease, and sometimes they have damage at that point.

Michele M. Cerra, MSN, FNP-C: We know that cost is a big issue and how expensive these medications can be to treat psoriatic arthritis. How do you deal with patients getting assistance—getting them on drug and keeping them on drug—due to cost issues?

Nancy Eisenberger, MSN, FNP-C: Insurance dictates how we practice medicine these days. I’m very fortunate. I have a very large practice, and we have a whole department that will do that for me. I just send a request to look at the cost of this drug. Thank goodness almost every pharmaceutical company has, for insured patients or patients with no insurance whatsoever, programs. Our problem is when we get to our Medicare patients. That’s where it becomes a big challenge. In my state, if you have Medicare and a secondary, you can get an infusion medication vs a subcutaneous medication, or an oral medication, depending on most of their coverage. These are things we have to keep in mind because cost is everything. These medicines are thousands of dollars. And we must be sure that the patient is going to be able to obtain the medication before we can consider anything else.

Michele M. Cerra, MSN, FNP-C: What I’d like to do in my practice is touch base at each visit to see if they’re using the co-pay card. What are you paying for this? Is this a 30-day or 90-day supply? It’s important because sometimes they think that co-pay card will expire in a year. Sometimes their insurance has changed. Sometimes they go from commercially being insured to Medicare. It’s important because they come in and forget they have questions they need to ask us. It’s so important to keep them on drug, and that helps with compliance if we can help them get the drug. Insurance has many good patient assistance programs. [We have to] keep the patient and get them connected to that.

Nancy Eisenberger, MSN, FNP-C: Accessibility for our patients through foundations for patients who can’t afford it and don’t have insurance.

Michele M. Cerra, MSN, FNP-C: I teach the fellows, and even some of our rheumatologists don’t know about the HealthWell Foundation, which is for patients who have government insurance, especially with Medicare. Sometimes the funds run out of money each month, but they could keep checking back. That’s great way to keep patients who have Medicare on drug.

Transcript edited for clarity.

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