Survey reveals limited coverage for outpatient care and biologic therapies, highlighting need for chronic disease financing reform
A RECENT survey by the Psoriasis Association of Malaysia (PAM) has highlighted significant gaps in insurance coverage for Malaysians living with psoriasis and psoriatic arthritis.
Although most insurance plans provide coverage for inpatient hospitalisation, support for outpatient care and long-term treatments, including biologic therapies, varies widely across policies, leaving many patients with inadequate protection.
The survey also found variations in underwriting approaches across insurers, suggesting that more consistent and structured solutions may be possible.
The findings underscore a broader challenge in healthcare financing: Many insurance products were originally designed to address acute and episodic illnesses, rather than chronic conditions that require continuous, long-term management.
Psoriasis is often perceived as a skin condition. In reality, it is a chronic immune-mediated disease that can affect multiple organ systems and significantly impact quality of life.
A substantial proportion of patients may also develop psoriatic arthritis, a progressive inflammatory condition associated with pain, disability, emotional distress and increased risk of cardiovascular disease, diabetes and depression.
Medical advances over the past decade have significantly improved outcomes for patients with moderate to severe disease.
In particular, biologic therapies have transformed disease control, enabling many patients to return to work, maintain productivity and improve overall quality of life. However, access to these treatments remains financially challenging for many patients in Malaysia.
Key findings
The survey highlights several recurring themes:
Limited scope of coverage for chronic care
While insurance coverage is available in many cases, it is often concentrated on inpatient care. Coverage for outpatient consultations, long-term medication and biologic therapies remains variable across policies. As a result, patients may still face substantial out-of-pocket expenses even when insured.
Challenges related to pre-existing conditions
Psoriasis and psoriatic arthritis are frequently treated as pre-existing conditions. This may result in waiting periods, premium adjustments, policy exclusions or limitations on coverage. In some cases, access to comprehensive coverage may be restricted following diagnosis, particularly for newly diagnosed individuals.
Sustainability and risk management considerations
Insurers participating in the survey generally indicated that concerns are less about the condition itself and more about long-term cost predictability. Key issues include uncertainty around disease progression, the sustained cost of biologic therapies, comorbidities and the availability of long-term actuarial data.
These findings reflect a broader structural reality. Many insurance systems have historically been designed around short-term, hospital-based care while chronic diseases require continuous outpatient management and long-term therapeutic support.
Why this matters
The implications of these gaps are significant. Delayed or inconsistent access to appropriate treatment may result in disease progression, irreversible joint damage, reduced functional ability and increased long-term healthcare costs.
From a system perspective, inadequate early intervention may also contribute to higher downstream utilisation of hospital services.
Sustainable and inclusive solutions
The findings do not suggest that insurers are unwilling to support chronic disease care. Rather, they highlight the need for more structured and sustainable approaches that balance patient access with long-term financial viability.
There is growing opportunity for innovation in this space. Potential approaches may include:
structured chronic disease benefit riders;
tiered-coverage models based on disease severity;
co-payment arrangements to support shared responsibility;
defined caps or pooled funding mechanisms for high-cost therapies; and
public-private partnership models for selected advanced treatments.
Several of these approaches were suggestions from industry participants during the survey, indicating openness to collaborative solutions.
Strengthening national data systems on treatment outcomes, disease prevalence and healthcare utilisation would also improve risk assessment and support more accurate pricing of chronic disease coverage over time.
Equally important is continued dialogue among stakeholders – including regulators, insurers, clinicians, patient organisations and health economists – to explore feasible pathways for improving access while ensuring sustainability.
Shared opportunity for reform
As Malaysia continues to develop its health financing architecture, including the proposed Malaysia Health Insurance/Takaful framework, there is an opportunity to better align insurance design with the realities of chronic disease care. This is not solely a question of expanding coverage but of rethinking how risk is shared across individuals, insurers and the broader health system.
Given rising healthcare demands and treatment costs, long-term healthcare financing will increasingly require collaboration between the public and private sectors. What is important is not only affordability but also sustainability and access to appropriate care for patients who need it most.
With continued dialogue and the right policy framework, all stakeholders – government, insurers, healthcare providers, industry and patient groups – can contribute to building a more inclusive and resilient healthcare system.
Psoriasis and psoriatic arthritis may not always be highly visible conditions but their impact on patients and families can be profound. Strengthening access to appropriate and sustainable chronic disease coverage is not only a healthcare priority but also an investment in productivity, social well-being and the long-term resilience of our health system.
Dr K. Thiruchelvam is the advisor to the Psoriasis Association of Malaysia. Comments: [email protected]
