Physician Perspectives on the Effect of Topical Steroid Costs on Patients and Proposed Solutions

Key Points

Question

What factors affect the decision-making process for physicians around topical steroid selection, and how is this associated with physician attitudes surrounding potential solutions to address rising drug costs?

Findings

In this qualitative study of interviews with 16 dermatologists, the results suggested that physicians lack real-time feedback on drugs costs and are unable to incorporate costs in their medical decision-making, and the opacity around drug costs contributes to increased workload for physicians and financial pressures on patients.

Meaning

The study results suggest that alternative systems to improve price transparency or automatically substitute less expensive drugs are needed and may be broadly acceptable to dermatologists.

Abstract

Importance

Rising costs of topical steroids have increased overall health care and patient out-of-pocket costs while increasing administrative burden on dermatologists and office staff.

Objective

To explore factors affecting the decision-making process for dermatologists around topical steroid prescriptions, determine the association of insurance coverage and cost, and assess willingness to implement solutions to decrease out-of-pocket topical steroid costs for patients.

Design, Setting, and Participants

This qualitative study was conducted from June to November 2020 and used semistructured interviews of 16 dermatologists who reflected a mix of physicians in academic, nonacademic, and private practice until thematic saturation was reached. Each interview was independently coded by 2 researchers. Code frequency and interrater reliability were determined using NVIVO software. Data analysis was conducted from November 2020 to March 2021.

Main Outcomes and Measures

Factors influencing dermatologist decision-making around topical steroid selection, outcomes of unaffordable medications on patients, solution recommendations, and perspectives on a system to automatically substitute topical steroid for cheaper alternatives of the same class and vehicle.

Results

Of the 16 dermatologists, 8 (50.0%) were women, 8 (50.0%) were men, 1 (6.3%) was Asian, 2 (12.5%) were Latinx, and 12 (75.0%) were White. The interrater reliability ranged from κ = 0.86 to κ = 0.98, indicating excellent agreement. Most physicians (13 [81%]) thought about costs regularly when making choices about topical steroids. All physicians identified a scenario in which patients could not obtain medication based on cost. In these cases, 15 (94%) reported that they try to find an alternative medication by calling the pharmacist or insurance company. Despite a desire to consider cost at the time of prescribing, physicians reported not knowing medication costs before prescribing because of the variability of insurance coverage (15 [94%]), lack of transparency (12 [75%]), and fluctuating drug prices (12 [75%]). In addition to affecting patients, 14 physicians (88%) reported that a patient’s inability to afford medications increases administrative burden. Physicians suggested that they were open to solutions that focused on increased cost transparency (10 [63%]) and improved electronic health record technologies. Furthermore, 14 (88%) were willing to use a system to allow the substitution of one topical steroid for another of the same class and vehicle.

Conclusions and Relevance

The results of this qualitative study suggest that opacity around drug costs reduces access for patients and is followed by administrative stress for physicians and staff. Dermatologists are receptive to systems that provide greater transparency for drug costs or automate substitution of equivalent cheaper drugs for patients.

This qualitative study examines the decision-making process for dermatologists around topical steroid prescriptions and the willingness to implement solutions to decrease out-of-pocket topical steroid costs for patients.

Introduction

The rising costs of topical steroids, some of the most commonly prescribed medications in dermatology, have placed an increasing financial burden on patients and payers.^1,2 Total dermatologic prescription drug spending doubled from $7.4 billion in 2004 to $14.9 billion in 2013, outpacing the rate of inflation, national health care growth, and physician service reimbursements.^3,4 The primary forces behind this increase in topical steroid costs are thought to originate in the rapid rise in price of generics, consolidation of markets, and absence of cost transparency owing to various factors, such as the fact that copays for the same drug vary despite controlling for time, geography, pharmacy, and insurance company.^2,3 High out-of-pocket costs for prescription drugs are associated with treatment delays and reduced adherence.^5,6

Most proposed solutions to decrease prescription costs fall broadly into 2 categories: (1) facilitating the role of market economics by reducing the barriers to readily access drug cost information at the bedside, thereby incentivizing and enabling selection of more cost-effective options, and (2) creating legislative solutions that allow the federal government to cap rapidly rising prescription costs. To our knowledge, dermatologist perspectives on the effect of out-of-pocket prescription drug costs on patients and their attitudes surrounding solutions for rising cost of drugs, particularly high potency steroids, have not been evaluated.

Methods

Board-certified dermatologists were recruited by email using a convenience sample. Respondents were selected from different practice settings (Table 1). Interviews were conducted from June to November 2020. The initial enrollment target was 16, with plans to expand enrollment as needed until thematic saturation was achieved. The institutional review board of Mass General Brigham approved this study, and participants provided oral informed consent.

Table 1. Participant Characteristics and Demographic Information.

Participant characteristicsa	No. (%)
Academic	10 (62.5)
Nonacademic	10 (62.5)
Private practice (private equity)	3 (18.8)
Private practice (non–private equity)	7 (43.8)
Safety net hospitals	3 (18.8)
Sex
Female	8 (50.0)
Male	8 (50.0)
Age, mean (SD), y	48 (16)
Years in practice after residency, mean (SD)	15 (16)
Geographic location
California	1 (6.3)
Colorado	1 (6.3)
Connecticut	1 (6.3)
Massachusetts	12 (75.0)
Michigan	1 (6.3)
Race and ethnicity
Asian	1 (6.3)
Latinx	2 (12.5)
White	12 (75.0)
NA	1 (6.3)
Overall	16 (100)

Abbreviation: NA, not available.

^a Some dermatologists self-identified as practicing in more than 1 setting.

The development of a semistructured interview guide followed the 5-step approach presented by Kallio et al.^7,8 A standardized web-based survey was used to collect demographic characteristics. Secure video interviews were conducted. Two researchers (B.K. and A.F.) independently coded the first 4 interviews with iterative code revisions until consensus was reached. Once the codebook was finalized, interviews were independently coded using NVIVO software, version 12.1 (QSR International). The NVIVO interrater reliability function was used to generate κ scores to determine agreement among coders. Areas with less than 90% agreement were further discussed until 6 team members independently finalized codes and reconciled discrepancies. Revisions were conducted until no novel codes were identified and thematic saturation, the point at which the interview cohorts no longer introduced new themes, was achieved. Code frequencies were calculated based on reconciled codes.

Results

Thematic saturation was achieved after 16 physicians completed interviews. Interrater reliability between study coders ranged from κ = 0.86 to κ = 0.98, indicating excellent agreement.⁹

Every participant recalled a scenario in which a patient could not pick up their prescription based on cost, with some noting that it happened almost every day (Table 2). All physicians noted that drug costs limited patient access to medications. Many believed that knowledge of drug costs would be beneficial to patient care and clinic productivity while citing frustration with the current lack of transparency (Table 2).

Table 2. Pertinent Quotations.

Topic	No. (%)	Quotation
Cost as a factor for steroid selection
Yes	14 (87.5)	“A lot of patients…won't pick up the prescription based on cost, so it’s something we think about on a daily basis.”
No	1 (6.3)	“No. Every insurance is so different that I like to prescribe what I think would be best. And then depending on what the insurance is, changing it if we need to.”
Somewhat	1 (6.3)	“I typically have no idea. If I try to prescribe something, and I realize that this is not covered by insurance, I have this discussion with patients: ‘Different insurance companies have different policies that keep changing all the time. If you go to the pharmacy and it's not covered or is high copay, please call and leave a message and I would be happy to prescribe an alternative.’ And that happens all the time.”
Association of knowing costs of topical steroids with clinical practice
Clinician prescribes cheaper drug	12 (75)	“I would not want to prescribe something to somebody if it was truly going to cost them $800 when I can give them a $20 drug.”
Lower cost for patient	11 (68.8)	“If someone can't pay for the medication, they're essentially leaving your office without anything, and so it changes your entire practice. Because you would only give [medications] that you knew somebody could ultimately get.”
Prevent back-and-forth among patient, clinician, and insurance company	4 (25)	“You'd pick the one that's the cheapest so that you don't have to keep going back and forth between the patient and the insurance company and the pharmacy.”
Improve patient care	10 (62.5)	“I would like the patient to use the best product for them.”
Effect of unaffordable or uncovered medication on clinician
Time consuming	16 (100)	“It's very time consuming. Sometimes I get that message on my desk, deal with it after hours, and call the patient.
Busy work or waste of energy better spent on other things	14 (87.5)	“25% Of my time that I spend dealing with these things, I could spend delivering better care to patients, and so that's just a waste of your time and energy.”
Helplessness	4 (25)	“You want your patient to receive optimal treatment and you feel that your hands are tied and it's not up to you. So there are times that you won’t prescribe something because the insurance company is going to say no.”
Burden for clinician	14 (87.5)	“It definitely is a factor in the burnout of physicians and the aggravation that practicing medicine has become.”
Costly to office	4 (25)	“It would have been a lot cheaper for me to just write a check to give the patient a prescription than to have my staff spend an hour and more on the phone.”
Effect of unaffordable/uncovered medication on patient
Barrier to care	11 (68.8)	“It is definitely a barrier to care for patients. There’s just a lot of unknowns between us and insurance companies, their plan, the patient. There's just not a lot of transparency so I think it makes it challenging for everybody involved.”
Frustrating	10 (62.5)	“I could see myself being a patient at the pharmacy and being very frustrated...‘Why didn't my physician…tell me that this would be something that I couldn't afford?’”
Changing a topical steroid prescription
Amenable	15 (93.8)	“Absolutely, I have no hesitation.”
Amenable with contingency	1 (6.3)	“Generally okay with it, as long as the patient doesn't have a contraindication to the other ones.”

When asked if they felt knowledgeable about which steroids are expensive, 7 (44%) answered “somewhat.” Twelve physicians (75%) reported acquiring knowledge about drug costs directly from patients during follow-up, indicating that patients commonly called and asked for a less expensive drug. Physicians reported not knowing medication costs before prescribing because of the variability of insurance coverage (15 [94%]), lack of transparency (12 [75%]), and fluctuating drug prices (12 [75%]). According to 1 physician, “costs of medicines fluctuate almost as the stock market does.”

Physicians suggested increased cost transparency (10 [63%]) and improved electronic health record (EHR) technologies (10 [63%]) as solutions. Eight physicians named standardizing insurance prices as a solution, with 4 (25%) suggesting that a central national health care system could be a solution. Cost-saving techniques mentioned included coupons (ie, goodrx.com), mail-away pharmacies, and office samples.

Fifteen physicians (94%) said that they would be amenable to change their topical steroid prescription for a cheaper alternative without a caveat. The remaining physician was also amenable, but only if “the patient does not have a contraindication to the other ones.” When presented with a scenario of a system that would allow a pharmacist to automatically substitute one topical steroid for a cheaper alternative of the same class and vehicle, most physicians (13 [81%]) reported that it would increase access to medication (15 [94%]) and affordability (14 [88%]) for patients (Table 3).

Table 3. Substitution System’s Effect on Various Stakeholders.

Effect	No. (%)	Quotation
System's effect on patients
Increase access to medication	15 (93.8)	“It would cut down on patients not receiving prescriptions in a timely manner.”
Affordability	14 (87.5)	“It would facilitate them to use it at the rate at which I wanted them to, and getting it refilled when they needed to, as opposed to, you know, paying their rent and not find their medicine.”
Decreased burden for patient	11 (68.8)	“Patients wouldn't have to go back and forth with the office.”
Time-saver for patients	11 (68.8)	“It could be a time saver for patients...because the patient would get to the pharmacy and her prescription would be sitting there waiting for her.”
Better patient care	6 (37.5)	“Ah, the patient will get better and anything when the patient gets better helps me. That's what I went to medical school for.”
Increase patient-physician relationship	5 (31.3)	“[Patients] would be less likely to generate negative feelings toward the physician’s office who prescribed the drug. That would be a win win win.”
System's effect on clinician
Improved quality of life	13 (81.3)	“It would save a lot of time, a lot of energy [and] provide the same level of care for patients.”
Enable physician to help patient	13 (81.3)	“If that decreases premiums for patients, it allows me to just do my job better, instead of dealing with things that are really not helping the patient in any way.”
More satisfied patients	7 (43.8)	“My patients would appreciate getting their medicine and having the medicine be there when they want it.”
Increased access or less barriers to care	6 (37.5)	“Obviously it takes away the burden of having to make decisions with people who don't understand why we're doing the things that we do. It would make it more uniform for me to know what to do.”
System's effect on office
Improve workflow	12 (75.0)	“Cut down meaningless work, such as the time they're filling out paperwork for prior authorizations.”
Decreased inefficiencies	8 (50.0)	“When you're dealing with thousands of patients... the support staff... are critical. They are providing a lot of this care along with you and anything that makes them less efficient, makes your office less efficient.”
Deliver better care	2 (12.5)	“More time for direct patient care, if they didn't have to deal with messages and prior authorizations.”

Discussion

Although costs are an important consideration for dermatologists who are prescribing topical steroids, physicians do not have sufficient real-time data to consider costs when making point-of-care decisions for patients. In contrast, they rely on patient feedback to understand drug costs, often in the forms of complaints around medications that were too expensive or unaffordable. Instead of proactive decision-making, physicians spend considerable personal and staff time and effort to address patient care issues associated with drug costs. This delayed feedback loop contrasts sharply with the stated preference of physicians for point-of-care cost transparency at the time a prescription is written.¹⁰

The inability for physicians to access cost information at the bedside affects patients and is followed by decreased adherence or treatment delays.¹¹ Ultimately, the administrative tasks are pushed to office staff, who bear the burden of dynamic drug market changes via increased phone calls, patient messages, and prior authorization requests.¹²

Proposed solutions at the physician level that may decrease out-of-pocket costs for patients include using coupons, mail-away pharmacies, and offering office samples.¹³ System changes that were mentioned include moving to a single-payer health care system or incorporating an EHR-based system to increase price transparency at the time of writing the prescription.¹⁴ Although improved EHR technologies could provide a cost estimate before prescribing medications and may enable physicians to make informed decisions in real time, this information is still often unreliable and not current. On a legislative level, increasing penalties for price fixing and reducing barriers to entry for generic manufacturers may be considered to limit rising drug costs. Alternatively, a system that would allow pharmacists to substitute cheaper prescribed topical steroids of the same class and vehicle with the physician’s consent would preserve physician autonomy while also naturally increasing competition between generic and brand manufacturers.²

Substitution systems may also help address the lack of transparency of prescription drug costs by allowing for instantaneous shifts in prescribing patterns that consider rapid cost fluctuations, therefore minimizing treatment delays, reducing prior authorization requirements, and lowering total and out-of-pocket costs. Prescribing the cheapest same-class topical steroid could have saved an estimated $448.3 million in 2015 alone.^1,15

Limitations

Future studies should build on these findings to corroborate their importance among a broader spectrum of stakeholders. Future studies should also include a more diverse cohort.

Conclusions

Opacity around drug costs reduces access for patients and is a source of administrative stress and burnout for physicians and staff. The lack of real-time feedback on drug costs prevents physicians from being able to adjust their prescription decision-making. Dermatologists are open to solutions that improve price transparency while also integrating into their current workflow. Furthermore, dermatologists seem receptive to a system in which pharmacists algorithmically substitute topical steroids for others of the same class and vehicle, but at a cheaper cost to the patient. Additional research is required to explore a system to improve medication accessibility for all patients.