The tale of the $220 tube of clobetasol cream

A patient with a minimally steroid-responsive dermatosis, vitiligo, recently contacted me to complain that he could no longer afford the medication that I had prescribed for him.  I was puzzled when he informed me that a 60-gram tube of clobetasol cream would now cost him $220, an amount that was far beyond his budget.  The medication was no longer on his insurance plan’s formulary, presumably because it had become too expensive for them as well. At first I was highly doubtful and assumed that the dispensing pharmacy had mistakenly substituted a name-brand product for the generic version I had prescribed.  A quick survey of several local pharmacies confirmed that all were pricing clobetasol above $200.

In this particular instance, I reluctantly substituted fluocinonide cream for the clobetasol, knowing that it was unlikely that he would re-pigment while on this therapy.  To make matters worse, this new medication was now being sold for about $50.00 for a 60-gram tube, when 6 months prior was one of the $4.00 specials at several chain drugstores.

READ: Step therapy stalls appropriate patient treatment

This new economic reality strikes at the heart of the service we dermatologists provide for our patients.  If we can no longer use medications that work best, we may revert to second-rate status medically and only marginally improve the lives of the people we treat.  In a conversation with a recently trained colleague, he indicated that some of his fellow residents intend on not writing any prescriptions, but instead will provide only surgical and cosmetic care.  The rationale for this decision is that it is simply too big of a hassle to fight with third party payers who are reluctant to allow expensive medications to be used by their insured customers.  If this approach to practice becomes widespread our specialty will be reduced to a mere shadow of its former self.  If dermatologists decide against treating skin conditions with effective prescription medications, who will be capable of treating complicated conditions?

How did we get to this state of affairs? Individuals with far more knowledge than me have given several explanations including high costs of developing new drugs, problems with manufacturing and the lack of profit in producing generic drugs as reasons for cost inflation.  Without any particular expertise, but with an advanced case of paranoia, I think it is most likely that big pharma has bought out the smaller manufacturers of generics and has eliminated the competition that has kept pharmaceutical prices affordable. In addition, the Affordable Care Act has mandated that Medicare cannot negotiate lower prices for the medications that they provide. Therefore, drug manufacturers are free to increase prices to astronomical levels without any controls whatsoever. This is probably what the 1880’s felt like when the robber barons were at the peak of their powers.

NEXT: Sanity-saving strategies

Sanity-saving strategies

What are we to do about this situation? I would strongly suggest that we do not give up on providing our patients with the highest quality of care, even when continuing the fight can be exasperating (I hate battling with third party payers over what they will or will not cover). There are several strategies which may help to preserve our sanity and our specialty:

• Absolutely avoid name-brand drugs whenever possible. Paying $2.25 per day for generic minocycline instead of at least $6.00 per day for some branded minocycline products can lead to real savings over many months of treatment.  From another perspective, one often hears the rationale that if the third-party payer will cover such branded drugs, why shouldn’t we prescribe them?  Those who make this argument fail to understand that we all pay higher insurance premiums when more expensive medications are used.

• We can utilize medications in more efficient ways:
• Triamcinolone cream remains a real bargain but is not particularly potent.  However, when used under Saran occlusion or under wet wraps, it becomes as potent as clobetasol.  Often a one-week use of occlusive dressings improves the dermatitis to the point where triamcinolone without the wraps will work quite well. 

• Up until recently, methotrexate tablets at a dose of 15 mg per week cost about $300 per year, but now is at least $850 per year.  However, if the medication can be provided as the solution for injection and ingested after being diluted in juice, there can be very substantial savings.  A 20 ml vial of methotrexate, 25 mg per ml, costs less than $20.  At a dose of 15 mg per week (0.6 ml), there are 33 doses in a single vial. 

• Fluorouracil cream costs at least $230 for a 40-gram tube.  The vials of fluorouracil for injection cost about $5.00 per vial.  By placing the contents of one 50-mg vial into 30 ml of any emollient lotion, one gets approximately a 1.5% concentration, which works as well as the store-bought variety.  If you want to be a very popular dermatologist, try giving this away to your patients who need it. 

Whatever strategies you employ to keep treatments affordable, please avoid the temptation to abandon this battle altogether and no longer give your patients the best opportunity to maximize the health of their skin.