As we all know, professional life gets more complicated every passing year. Meaningful use regulations grow more burdensome, even as the medical records we get fill up with electronic medical records boilerplate. To renew my medical license, my state board has me take a course in opioid management and end-of-life issues. Fill in your own examples.
But recently I’ve become aware of a new wrinkle that complicates daily practice life for both doctors and patients in a significant way. I can’t make any sense if it.
I mean the high price of desonide.
When I was student many years ago, my teachers told me that I should prescribe generic drugs whenever possible. This would help hold down medical costs. It was the right thing to do.
Because I am a good person who tries to do the right thing, I prescribe generics because it’s the right thing to do. I also do it for Pavlovian reasons: prescribing brand-name drugs means more prior authorization forms – we have enough of those anyway – and more calls from patients unhappy with high copays or other out-of-pocket costs. Also, fewer threats of sanctions from insurers or hospital purchasing groups over my pricey prescribing habits.
Besides, most patients I prescribe generics for do just fine.
Of course, some of the anomalous realities of generic prescribing filter through at times. Generic terbinafine and finasteride, for instance, may have higher profit margins, but don’t save patients much money.
But lately I’ve been getting complaints from patients about the high cost of desonide. My first reaction to these was, “How on earth is that possible?”
One patient a few months ago insisted that I contact his mail order pharmacy in Nevada to find a cheaper alternative. I considered this an unreasonable demand – I obviously can’t do a cost comparison for every patient, but this time I went along. The pharmacist came up with another nonfluorinated steroid that was much less expensive under that patient’s particular contract.
Then this week it happened again. I prescribed hydrocortisone valerate 0.2% for a groin rash. The patient left a message asking me for an over-the-counter suggestion, since the prescription was going to cost him $52.70 out of pocket.
I asked my secretary to call the pharmacy to get a price for other generic steroid creams. Triamcinolone would cost $14.70. Alclometasone would cost $35.20.
And desonide – generic desonide – would cost $111.70. For a 15-g tube. $111.70 for 15 g of a generic cream that’s been on the market forever! Does that make any sense?
I’ve gotten similar calls, by the way, from patients unhappy with the cost of generic doxycycline.
There are no doubt economic reasons for such pricing anomalies. Maybe generic manufacturers have dropped out of making certain drugs because they don’t make enough money on them, leaving the ones who remain in a position to charge whatever they can get away with. Maybe insurers or pharmacies cut deals with the makers of some drugs at the expense of others.
I don’t know. And that’s the point.
Because I have no way of knowing any more which of the plain-vanilla generic drugs I’ve prescribed forever are going to be fine, and which are going to cost my patients an arm and a leg and encourage them to call back and yell at me – or else not bother to pick up the medication at all – I don’t even know half the time what to recommend anymore. I certainly don’t have the time to go shopping for every prescription I order. There are just too many drugs, too many prescriptions, too many patients, too many pharmacies, too many insurance contracts, each with its own formulary quirks.
If anyone out there has any explanations or suggestions, I’m all ears.
In the meantime, I may try to simplify my life by sending all my patients to the local Russian deli and prescribing topical caviar. It’s likely to be cheaper than desonide.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.