Understanding Biologics: Current Barriers in Health Care Equity, and Why it Matters

Over the past two decades, treatments for chronic immunomodulatory conditions such as atopic dermatitis (eczema) and psoriasis have significantly advanced. Initially, mild cases were managed with topical steroids and emollients, while more severe cases required systemic immunosuppressants including methotrexate, which often fell short of achieving sustained remission. The introduction of biologics, such as alefacept and efalizumab for psoriasis in 2003 and dupilumab for atopic dermatitis in 2017, has revolutionized treatment by offering improved efficacy and safety profiles.¹

However, as the availability of biologics expands, health care professionals face the challenge of navigating the complexities associated with these therapies to optimize patient care and alleviate disease burden. Physicians must be particularly mindful of existing health care inequities, as these disparities can influence individualized care and treatment outcomes.

Retrospective studies reveal that minority populations often endure prolonged suboptimal therapy for treatment-resistant immunomodulatory skin conditions. For example, one registry found that Black patients with psoriasis were 57% less likely to be switched to biologic therapies within 6 months compared to White patients, indicating disparities in treatment management.² This trend likely extends to other chronic skin conditions, as research suggests that although dupilumab prescription rates for atopic dermatitis were twice as high among Black patients, this increase may reflect a prolonged disease course and suboptimal management, leading to more severe disease presentations rather than improved accessibility.³

Financial barriers further complicate long-term disease maintenance. The high wholesale prices of biologic medications, often costing several thousand dollars per injection, quickly compound as treatment regimens often require weekly or biweekly administrations. This financial strain disproportionately affects lower-income individuals, intensifying existing health care disparities. Limitations in current insurance practices, such as copay accumulator programs used by private insurers and the 5% cost-sharing requirement under Medicare Part D, exacerbate this issue. These practices prevent manufacturer assistance from contributing toward deductibles, resulting in ongoing out-of-pocket expenses even after reaching the maximum limit, which further complicates access to necessary treatments.⁴

Moreover, treatment delays present another significant barrier, with the time from prior authorization submission to the first dose often exceeding a month.⁵ While these barriers independently reduce the likelihood of long-term patient compliance, many patients face multiple barriers simultaneously. These obstacles are not limited to issues within the health care system itself; external factors can be equally, if not more, impactful. For example, limited health care accessibility is closely linked to medical noncompliance, particularly for patients in rural areas who may have difficulty reaching health care professionals. Additionally, lack of reliable transportation and rigid work schedules create further obstacles, increasing the likelihood that patients will be lost to follow-up.

To ensure equitable treatment for all patients, it is crucial to address the multifaceted barriers to care for chronic immunomodulatory conditions. By acknowledging the financial, systemic, and external challenges that hinder access to biologic therapies, health care professionals can advocate for more inclusive and effective care strategies. It is imperative that physicians remain vigilant in recognizing and addressing these inequities to improve access to care, ensuring that all patients—regardless of socioeconomic status, geographic location, or insurance coverage—receive timely and effective treatment.