The Psoriasis “Off-Ramp” Gap

There’s an uncomfortable reality in traditional fee-for-service psoriasis care: the system isn’t built to question long-term biologic use.

Dermatology biologics have transformed care for patients with moderate-to-severe psoriasis. 

For many, a biologic is life-changing—delivering rapid relief and long-term control for a condition that’s both physically and emotionally debilitating. But the high cost, potential safety risks, and long-term treatment burden are often overlooked—even when continued therapy may no longer be clinically necessary.

We’ve gotten very good at starting biologics, yet there are still no clear guidelines for what should happen once a patient improves. 

Driven by non-specific guidelines, lowering thresholds, traditional fee-for-service incentives, and limited access to dermatology providers, biologics are increasingly becoming the default rather than part of a thoughtful, individualized care plan—with no deprescribing plan in sight.

As a result, psoriasis has become one of the largest drivers of specialty drug spend—fueled not just by the high unit cost of biologics, but by how long patients stay on them regardless of remission or clinical need. Dermatology now leads all categories in cost growth, increasing 45.7% year over year. 

Health plans are increasingly paying for biologics as if they are lifelong therapies—even when many patients may no longer need them.

The strain on payers—and patients—is growing. But it doesn’t have to be this way. 

We’re on a Biologic One-Way Street—and It’s Time Exit

In many areas of medicine, treatment plans are designed with an endpoint—or at least built-in moments to reassess once a patient meets clinical goals.

In psoriasis care, these moments rarely exist. Patients prescribed biologics stay on them indefinitely. Not always because they need to, but because the system—particularly traditional fee-for-service models—isn’t built to consider whether deprescription would be beneficial.

When it comes to biologics, standard guardrails are missing:

• Defined expectations for reassessment 
• Biologic deprescription or step-down strategies
• Remission as a trigger for changing treatment
• A point where clinicians are prompted to ask: Do they still need this biologic?

But research shows biologic deprescribing is possible. In a recent study, biologic dose reduction was successful in 75% of patients at 18 months. This means patients who achieve disease control maintain outcomes with less frequent biologic dosing or lower-cost therapies.

Yet psoriasis biologic prescribing continues to grow—fueling runaway specialty drug spend with no off-ramp in sight.

In fact, recent updates to the International Psoriasis Council guidelines have further broadened biologic access. Eligibility thresholds continue to expand beyond what was originally studied. On top of that, non-biologic options receive relatively little focus^,.

But the evidence is clear: there's a better way to approach psoriasis—and it’s time to make it a reality.

The Missing Piece: A Model Built for Deprescription

Biologics will continue to play a critical role in dermatology, but we’re ready to shift from a prescription-first model to one designed for remission—and deprescription.

Zest Health’s virtual care model is solving what traditional fee-for-service dermatology models cannot: Remission-centered care at scale. 

• Continuous monitoring to track disease progression and response
• Clinical decision support that integrates formulary and treatment pathways
• Proactive reassessment and high-access care from day one 

Without change, members will remain on high-cost biologics longer than clinically necessary—driving avoidable specialty drug spend, unnecessary risk, and limited awareness of their options.

And moving forward, a biologic will continue to be the path of least resistance—instead of part of a system that actively manages patients toward remission and beyond.

The Benefit of Moving Beyond Traditional Fee-for-Service Models in Chronic Dermatology

A value-based model for chronic dermatology is not about restricting biologic access—it’s about delivering more personalized care and improving outcomes by combining lifestyle changes and evidence-based treatments, and prescribing—or deprescribing—medication only when appropriate.

In practice, this approach is already making a measurable difference:

• 50% of high-cost members transition to lower-cost regimens
• 94% of members have improved or stabilized disease within 30 days
• Payers see 2-3x ROI, with five-figure savings per member

By rethinking chronic dermatology, we can curb psoriasis specialty drug spend and move away from an unsustainable trajectory—one that ultimately hurts patients most in need of care.

This is the reality the system can no longer afford to ignore.