Casey Butrus, PharmD: Hilary, barriers to care can affect patient access to medications and patients taking medications as prescribed. I know that from a managed care perspective, the cost is a lot, which I hear about very often. What are some of the barriers you see in your practice and how do you overcome them?
Hilary Baldwin, MD: We are getting along very well at the moment, but how to solve this problem? We both have a common goal – I don’t mean we, but we kings, we have a common goal of patient health. But as you mentioned, we approach it from different directions. I am very concerned about the cost of medicine in the United States, but my highest priority is the patient sitting in front of me and providing the utmost care to that patient who may require a more expensive medicine under these circumstances compared to a less expensive medicine. expensive drug I imagine you are doing the same thing as me. I apply the mother rule every time I write a recipe. If she was my mother, what would I give her? And I wouldn’t give her a drug that doesn’t have all the bells and whistles that improve efficacy and reduce tolerance.
Arash Mostaghimi, MD, MPH, FAAD: That’s the mother-in-law rule.
Hilary Baldwin, MD: Mother-in-law rule, right?
Arash Mostaghimi, MD, MPH, FAAD: Doing it differently is called the mother-in-law rule.
Hilary Baldwin, MD: Oh, I love it. I absolutely love that. So that’s my priority and your priority after safety. I’m not saying you don’t consider security, of course, but your next priority, as you said, is cost and keeping it as low as possible. And if it requires me to make step-by-step adjustments, if it requires me to use generics first, I’m fine with that. I’m fine with prior permission. I’d rather not, but I’m fine with those. What I’m not okay with is a blanket categorical rejection of a drug that has FDA Phase 3 data demonstrating efficacy and tolerability. I don’t think there should be a drug that is completely unavailable to the patient sitting in front of me. I’m a little pessimistic about our ability to meet somewhere in the middle. Are you?
Casey Butrus, PharmD: I agree with all your points. I think managing costs and managing prescriber discretion and efficiency is something that all health plans want to get to. I think the common cause that we see causing the problem is the rising cost of drug prices. And many of these brand name drugs have generics or similar chemicals available at a really high price. So from our point of view we advocate using the most cost effective product, but I agree. I think there’s a point where step therapy might not be the most appropriate mechanism to manage utilization if, for example, you’re going to prescribe a drug that doesn’t work to get approval for a brand-name drug. These are 2 additional payments not only for the patient, but also other expenses that the health plan covers. So from my point of view, I like to keep that in mind when I design stepwise therapies. Will these drugs that we require to be qualifying work? Or are they commonly used in clinical practice? And if they try and fail, will they still end up on the brand name drug anyway? So I think for health plans, go back and look at the claims data to see how many approvals were ultimately overturned based on denials and appeals to see if prior authorizations are actually meaningful. Because if all the members end up on drugs anyway, then what’s the point of prior authorization? Perhaps there are other mechanisms and tools we can use to manage costs in this space.
Arash Mostaghimi, MD, MPH, FAAD: I think the difference between prior authorization and stepwise therapy to manage care at the population level is making sure we don’t forget about cheaper options that might work for some people versus either not being scientifically supported where things don’t make much sense or honestly is just a deterrent to an end. It is not done in good faith to direct people on the way. It’s like having a sign, like a warning, there’s a dog behind this fence. You just don’t want to go there to know if the dog is there or not. It just makes you sick. You’re tired of it and you don’t feel like it. And I think Hilary hit the nail on the head here. I do a lot of research on costs and outcomes specifically in dermatology. So I am very conscious of how we spend our money. And the challenge is, I think all of us would say, OK, rational distribution of care across the population is the way we want to do it. And I think we all agree with that. If you’re talking about societal benefit or population-level benefit, my commitment to you as a physician is to the individual before me. So it would be my decision to make you an individual sacrifice for this wider social good – a very unusual situation. There are places in the world where it’s kind of a closed system, where it makes sense. So I guess if you are on VA [Veterans Affairs], for example, there is a general understanding that things are a little different. It’s a different situation that you’re in, in some closed health care systems, some community health centers, where it’s much more local. But the idea is that if you don’t get this cream, it will reduce the US GDP [gross domestic product] percentage use in healthcare. I’m not sure it’s necessary. This may actually or ethically come down to the doctor’s level. So I think we need a rational hand in hand to move forward.
Casey Butrus, PharmD: I agree. And I think, as you mentioned, it often seems like there are barriers just to have a barrier, which is not always the intention of step therapy. It is a promotion of a generic, cost-effective product. So I know that many payers are reluctant to cover these new brand-name therapies, perhaps because of less efficacy data compared to some generics.
Transcript edited for clarity.
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