Dry eye patients being priced out of better care

Advocacy is needed to improve the situation for both patients and physicians.

Issue: May 25, 2016

ByDarrell E. White, MD

It wasn’t really an epiphany, actually. More like that last bite when your puppy pushes it just a bit past cute and into “ouch!” An epiphany would involve something really big, like a patient asking if $1,200 for a 3-month supply of her dry eye medicine was a lot. It is funny: We deal with that kind of question so many times each day, we have adopted the warped worldview that it is some kind of normal.

No, what finally broke through for me was no fewer than a half dozen consecutive dry eye patients who were not taking any of the over-the-counter tears I had recommended. Each had dropped the very specific brands I had individually specified for them in favor of a generic house brand. Every single one had then suffered a symptom setback.

Why did they switch? Each gave more or less the same answer with varying degrees of indignation: Doctor, the tears you recommended are too expensive. Can you imagine? Tears! My patients are complaining about the price of artificial tears. We have reached the watershed moment at which patients are so beaten down and fed up with both the costs of medicine and the challenges of paying for their treatments that they are balking at the $5 to $7 difference between Walgreens brand and Blink (Abbott Medical Optics).

That playful puppy’s bite got even sharper later on that same day during an interview for an upcoming Ocular Surgery News article. The question was something about the biggest barriers that remain for the wider acceptance of dry eye care as a routine part of eye care. In days gone by, my first (and second and third) answer would have addressed the real and imagined “chair time” required to care for the dry eye patient. However, on that particular day, I had just reviewed how my staff was handling the burden of pharmacy and insurance “requests” for patients filling prescriptions. I discovered that we are taking 40 uncompensated “man-hours” working to get insurance companies to pay for our patients’ medicines.

That is one full-time equivalent employee. Yikes!

At wits’ end

Without a doubt, the all-too-real barrier faced by any eye doctor who contemplates adding end-to-end ocular surface disease care in the clinic is the need for both doctor and staff to spend time on the financial aspects of treating the disease. Even something as routine as the use of artificial tears for symptomatic relief and adjuvant care now requires a financial disclosure.

Part of what has my patients at their wits’ end is the farce that has become the “savings” that come from switching to generic medications. Have you tried to prescribe generic prednisolone lately in order to save your patient a few bucks? How did that turn out for you? I don’t know about you, but my patients are shouldering co-pays for generic medications that exceed the total price of some of our medicines when they had full patent protection. Even very large medical institutions that prescribe only generic medications are now routinely fielding calls from patients and pharmacies about prescriptions.

It almost makes you understand a rebellion against branded tears.

At this point you are probably asking yourself, how is this news, and why is it all of a sudden a big deal? Heck, you have been dealing with this for years with antibiotics and NSAIDs for cataract surgery, right? Well, here is all of that in a nutshell: There are a whole lot of dry eye patients out there, and they are about to be bombarded with advertising explaining that their eyes hurt or their vision is lousy because of dry eye. All of that advertising is going to tell them that the only thing standing between them and getting relief is a simple phone call for an appointment with an eye doctor who will prescribe “the solution.” That, my friends, poses a huge problem because not a single word will appear in those advertisements about the cost of getting relief. Your patients are about to be tossed into pharmaceutical purgatory, right along with you and your staff.

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Come June our reality is going to be four major dry eye medications — Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), AzaSite (azithromycin ophthalmic solution 1%, Akorn), Lotemax Gel (loteprednol etabonate ophthalmic gel 0.5%, Bausch + Lomb) and whatever they call lifitegrast (Shire) — all branded, all patent protected and all expensive. No one — and I mean no one — is going to make that easy for you. Heck, why should they? Every single one of you is doing exactly the same thing as we are doing at SkyVision: Investing the time (and money) on behalf of your patients to make it possible for them to obtain and afford their medicine. Every time you take on the role of ombudsman, you spend time you could have spent with another patient, and someone else banks those 40 hours you pay.

Advocacy needed

I have spent my entire career explaining how important it is that we have a profitable drug and device manufacturing industry providing us with the tools to care for our patients. I held this opinion long before I was paid a penny as a speaker or consultant (I did not start that gig until my mid-40s), and I hold it to this day. Something has to give, though, folks. We run a really tight ship at SkyVision, and frankly we are all at the breaking point with the amount of work it takes to get medicine paid for. Why is it my job to do that? When did I add human resources executive, financial consultant and sales agent to my CV?

There is a storm coming, with waves of new dry eye patients coming over the gunwales of ships already taking on water. Think of this as a distress signal, an SOS, not just from dry eye docs, but from all of us who take care of patients of any type. HR executives are watching pharmacy and insurance companies profit on the backs of their employees. Why are these executives at massive companies allowing “middlemen” to profit so handsomely when their employees cannot afford their medicines? Why no collaboration in the pharma group to address the issue of the real cost of medicines for patients and how it makes it harder for doctors to prescribe? That is more important than policing the lunchrooms and penholders in our offices.

To my professional organizations, the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery, this is a place for you. Step in and broker a solution between the people who buy health insurance and the people who make medicine. A private sector solution is there for the taking; it has to be better than whatever Congress or the president comes up with. Do it with my fellow doctors, our staff members and me in mind. Get us all out of the middle here and let us get back to the already hard enough work of making people better. This is a perfect opportunity for advocacy. We are too busy filling out those insurance forms and making those calls to the pharmacy to do the grassroots thing, and our patients are just too overwhelmed looking for that extra $5 to pay for an artificial tear that actually works.

And someone needs to potty train that frisky puppy.

For more information:
Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.

Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations; is on the speakers board for Bausch + Lomb, Allergan and Shire; and has a financial interest in TearScience.