Access is the issue
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Have you ever seen Jeff Dunham, the ventriloquist, perform?
My daughter Megan introduced me to him about 15 years ago. Megan can recite any stand-up routine after hearing it once. Pretty handy to have her at the dinner table when you get one of those awkward silent stretches. (That is, unless one of her routines was the cause of that silence, but I digress.) Anyway, Dunham has multiple characters who “appear” with him during his act. I have found myself channeling Walter, a grumpy old man with a receding hairline and bushy eyebrows who wears a bow tie.
I mean, I have more hair than Walter, and I prefer to think of myself as “elderly adjacent” rather than old. I am not usually considered all that grumpy, but I am frankly fed up with all the talk about drug prices. If all you ever talk about is the price of a drug, either the retail list price or the wholesale acquisition cost, and you do not reference how these values lead to what a patient actually pays out of pocket, you are a direct cause of my grumpiness.
Medical care in which drugs play a role is all about access. Access precisely equals out-of-pocket cost. Period.
Once upon a time, this part of health care was straightforward. If you were a drug manufacturer, all you had to do to get in the game was prove that your drug was noninferior to whatever was already in the market and then charge the same or less than the established drug. In order to gain a market advantage, you did not fool around with silly stuff such as coupons or specialty pharmacies — you made a drug that worked better.
Let me say that again: You made a better drug.
Let me give you an example. In the Wild West days of the ’90s and ’00s, ophthalmic pharma was all about market share in antibiotics used to prevent endophthalmitis. The game was played in the laboratory, where bacterial coverage and kill rates for commonly cultured bugs were how you kept score. Looking back, this was pretty silly, especially now that we have the Aravind studies out of India in which they actually studied real rates of endophthalmitis in something like 1.2 trillion consecutive cases, but thems was the rules here in ’Merica. Ocuflox (ofloxacin) ruled the day until Zymar (gatifloxacin) ushered in the era of fourth-generation fluoroquinolones. For almost 10 years, Zymar and Vigamox (moxifloxacin) ruled the world because they were more effective in the lab at killing the bugs that caused endophthalmitis.
Why am I talking about the relatively ancient history of topical antibiotics used to prevent endophthalmitis in a dry eye column? Because better, no matter how you define it, does not matter anymore. This is why I am cranky. At least twice I have recently opined that we do not need another branded cyclosporine in the dry eye marketplace. A more accurate way to state that would actually be: We do not need another super-expensive branded cyclosporine, even if it is a little bit more effective; it will be just one more medicine that takes way too much effort and time to prescribe because of all the insurance hoops you and your practice must jump through in order to discover that your patient cannot afford the prescription.
Listen, I get it. You spent years of your life working to get your drug approved and to show that it is a bit better than what is out there now. Maybe even a lot better. This goes for everything, not just cyclosporine in dry eye. Some cranky old man wearing a bow tie and sitting in front of a laptop writes that we do not need your new juice, and you instantly jump up and down wanting to talk about how much better your new thing is. I am really, truly sorry, but that is no longer the point.
My patients cannot afford your drug.
As if that is not quite bad enough, it often takes an hour of staff time to ultimately determine that my patient will not be taking your drug because they cannot afford it. I am sure that you are starting to see why I am cranky. Whether we are talking about an older, well-established drug such as Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) or Xiidra (lifitegrast ophthalmic solution 5%, Novartis), a relative newcomer such as Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharmaceutical) or Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals), or a wet-behind-the-ears rookie just called up from Triple A (phase 3 for you non-baseball fans) such as Tyrvaya (varenicline solution, Viatris), Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb) or Xdemvy (lotilaner ophthalmic solution 0.25%, Tarsus Pharmaceuticals), the pricing strategy is the same: Bow to the pharmacy benefit manager (PBM) demigods and set an astronomical list price. Why? Well, so that you can give generous alms in the way of a kickba–, er, rebate to the PBM.
So, Dr. Crankypants, why should you care about a price that is going to be drastically cut anyway? Here is the rub: The price is cut for the PBM and not for the patient. Our patients all have their copays calculated as a percentage of the original list price. Yes, you read that right; the copay is not a percentage of the discounted, rebate-applied price — it is a percentage of the egregious list price.
To be fair, there are a number of commercial (read: non-Medicare) insurance plans that are fairly reasonable with coverage of dry eye medications if you, the doctor, are comfortable with moving between options in a given category (eg, immunomodulators or steroids). Interestingly, this often goes for newer medicines as well. But (and here comes Dr. Walter Crankypants again) if coverage is skinny, then you, your staff and your patient are now dependent on the mercy of the drugmaker and usually also the competence of the specialty pharmacy through which your prescription will need to be processed.
Let me say for the record that my staff and I truly appreciate the efforts made by drugmakers to try to find a way around this jungle. Coupons, cash-pay workarounds, “free” medicine while the prior authorization is being adjudicated, and the now ubiquitous use of specialty pharmacies are nice efforts. What makes me a bit cranky about all this is that it creates lots of confusion for our patients (“Why can’t I just go to Costco like I do with everything else?”) and a ton more work for our staff (explaining why you cannot go to Costco to get your dry eye medicine), especially if the specialty pharmacy experience has a hiccup (“I know your real price is $89; I have no idea why they told you the price is $685.”). Here is the bottom line, though: I am a dry eye disease doctor. My staff and I are committed to helping our patients get the care they need. If we are struggling with all of this, everyone else is either really suffering or just giving up.
Dry eye patients are already thoroughly fed up. Ya gotta wonder how long it is before all the Walter B. Crankypants, MDs, out here feel the same way.
- For more information:
- Darrell E. White, MD, of SkyVision Centers in Westlake, Ohio, can be reached at dwhite@healio.com.
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