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Valdebran M, Amber KT. Coverage of Intravenous Immunoglobulin for Autoimmune Blistering Diseases Among US Insurers. JAMA Dermatol. 2017;153(11):1189–1190. doi:10.1001/jamadermatol.2017.2614
Treatment of autoimmune blistering diseases (AIBDs) has historically relied on systemic corticosteroids, but intravenous immunoglobulin (IVIG) has been shown in randomized clinical trials to be safe and highly effective in the treatment of pemphigus vulgaris and bullous pemphigoid.1,2 Despite its efficacy, the cost of IVIG remains a deterrent to its use. However, owing to the decrease in associated infections, complications, and hospitalizations, cost studies in the United States indicate that IVIG is an overall cost-saving therapy in the treatment of AIBD compared with traditional immunosuppressive treatment.3
Coverage for rituximab for AIBDs varies greatly, with Medicaid providing the most limited coverage.4 Given the growing body of high-quality evidence supporting IVIG’s efficacy and safety in the treatment of AIBDs, we sought to similarly evaluate coverage policies among selected private and public payers in the United States.
To determine coverage policies for IVIG, we used a modification of the protocol described by Wang et al.4,5 We identified coverage policies using the websites of each state’s Medicaid program and the Centers for Medicare and Medicaid Services. We identified the top 10 private health insurance providers by market share using the National Association of Insurance Commissioners 2015 market share report.6 Institutional review board approval was not required according to the Basic HHS Policy for Protection of Human Research Subjects (45 CFR 46). The search was performed in April 2017.
The US Department of Commerce, Economics and Statistics Administration report on health insurance coverage in the United States for 2015 was used to determine the number of Americans covered by private insurance, Medicaid, and Medicare.7 The report demonstrated 201 million privately insured individuals as well as 49 million individuals with Medicare and 54.9 million with Medicaid. Nine of the 10 private payers listed policies regarding the use of IVIG for AIBDs, accounting for 41.06% of the private market share or 82.5 million covered individuals. The Kaiser system was excluded, as it is a closed system. All Medicaid and Medicare databases were assessed. Thus, data apply to 186.4 million of 304.9 million total covered individuals (61.1%).
All 9 of the private payers assessed listed AIBD as a covered disease. Data from private insurance companies are shown in the Table. Of the 51 Medicaid state or district providers, 48 were assessed. Data for New Mexico, Oklahoma, and South Dakota were not readily available. Eleven state Medicaid websites listed AIBD as an acceptable indication for the use of IVIG. In October 2002, the Centers for Medicare and Medicaid Services issued a National Coverage Determination on IVIG for AIBD, directing all Medicare vendors to cover IVIG for AIBD.8
We herein demonstrate that although IVIG is, overall, accessible to patients with AIBD covered by private insurance or Medicare, patients with AIBD who are insured by Medicaid are often limited in their ability to receive coverage for IVIG. Because current data support IVIG as an overall cost-saving and efficacious therapy for the treatment of AIBD, Medicaid coverage of IVIG should match the policies of private payers and Medicare.
Corresponding Author: Kyle T. Amber, MD, Department of Dermatology, University of California Irvine Health, 118 Med Surg 1, Irvine, CA 92697 (firstname.lastname@example.org).
Accepted for Publication: June 3, 2017.
Author Contributions: Dr Amber had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important intellectual content: Both authors.
Statistical analysis: Amber.
Administrative, technical, or material support: Valdebran.
Study supervision: Amber.
Published Online: August 16, 2017. doi:10.1001/jamadermatol.2017.2614
Conflict of Interest Disclosures: None reported.