Casey Butrus, PharmD: Hilary, barriers to care can impact patients’ access to medications and patients taking the medications as they’re prescribed. I know from the managed care perspective, cost is a big one that I hear very frequently. What are some of the barriers that you see in your practice and how do you overcome them?

Hilary Baldwin, MD: We’re getting along very well right now, but how do we fix this problem? We both have a common goal—I don’t mean we, but the royal we, have a common goal of patient health. But as you mentioned, we approach it from different directions. I’m very worried about the cost of medicine in the United States, but my highest priority is the patient sitting in front of me and delivering maximal care to that patient who, in this circumstance, may require a more expensive drug compared to the less expensive drug. I imagine that you guys do the same thing I do. I apply the mother rule every time I write a prescription. If this were my mother, what would I be giving her? And I would not be giving her a drug that doesn’t have all the bells and whistles that improve efficacy and decreases tolerability.

Arash Mostaghimi, MD, MPH, FAAD: That’s the mother-in-law rule.

Hilary Baldwin, MD: The mother-in-law rule, right?

Arash Mostaghimi, MD, MPH, FAAD: If you do it the other way, that’s called the mother-in-law rule.

Hilary Baldwin, MD: Oh, I love that. I absolutely love that. So that’s my priority and your priority after safety. I’m not saying that you don’t consider safety, of course, but your next priority, as you said, is cost and keeping it as low as possible. And when that requires me to do step edits, when it requires me to use the generics first, I’m fine with that. I’m fine with prior authorization. I’d rather not, but I’m fine with those. What I’m not OK with is a flat-out categorical denial of a medication 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. Managing costs and managing prescriber consideration and efficacy is something that I think all health plans want to get to. I think the common cause that we see that makes the problem is just the rising cost of drug prices. And a lot of these brand medications have generics available or similar chemicals available coming at a really high price point. So from our perspective, promoting the use of the most cost-effective product, but I agree. I think there’s a point where step therapy may not be the most appropriate mechanism for utilization management if, for example, you’re going to prescribe a drug that doesn’t work to get that approval for a brand medication. That’s 2 co-pays not only for the patient, but that’s also another expense that the health plan is paying for. So from my perspective, I like to keep that in mind when I’m drafting step therapies. Are these drugs that we’re asking to be qualifiers going to work? Or are they used routinely in clinical practice? And if they do try and fail that, are they going to end up on the brand-name drug eventually anyway? So I think for health plans, go back and looking at claims data to see how many approvals eventually got overturned upon denials and appeals to see if the prior authorizations actually are meaningful. Because if all the members are ending up on the drug anyway, then what’s the point of the prior authorization? Maybe there are other mechanisms and tools that we can use to manage costs in this space.

Arash Mostaghimi, MD, MPH, FAAD: I think there’s a difference between prior authorization and step therapy to manage population-level care by making sure that we don’t forget about cheaper options that might work for some people vs it being either not science based where things don’t particularly make sense or honestly, is just a deterrent to the goal. It’s not done in good faith to direct people down a path. It’s like having a sign, like a warning, there’s a dog behind this fence. You just don’t want to go in there to know if there’s a dog there or not. You’re just sick of it. You’re tired of it and you don’t want to do it. And I think Hilary hit the nail on the head here. I do a lot of research on costs and outcomes in dermatology specifically. So I’m sort of keenly aware of how we spend our money. And the challenge is, I think all of us would say, OK, rational distribution of funds to take 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 a societal benefit or a population-level benefit, my commitment to you as a physician is to the individual in front of me. So it’d be my decision to make you the individual sacrifice for this broader societal benefit—a very unusual situation to be in. There are some places in the world where it’s kind of a closed system where that does make sense. So I think if you’re at the VA [Veterans Affairs], for example, there’s a general understanding that things are a little bit 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 reduces the American GDP [gross domestic product] of percentage use on health care. I’m not sure it needs to. It can really, or ethically falls to the level of the physician to do that. So I think we need a rational hand-in-hand approach to move forward.

Casey Butrus, PharmD: I agree. And I think as you mentioned, a lot of times it seems like there are barriers in place just to have a barrier, which isn’t always the intent of having step therapy. It’s to promote a generic, cost-effective product. So I know a lot of payers are reluctant to cover these new branded therapies, maybe due to less efficacious data compared with some of the generic agents.

Transcript edited for clarity.