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    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

    Norman Levine, M.D.
    Norman Levine, M.D., is a private practitioner in Tucson, Ariz. He also is a member of the Dermatology Times Editorial Advisory board ...


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    • Dr Levine I commend you for making us think about the cost of the medications we prescribe. Maybe you should have a talk with Dr. Draelos. Her recent article "Rx insurance woes" suggests we should be able to prescribe any medication whenever we want, no matter how much it costs. Thank you for being the voice of reason.
    • Anonymous
      I am not sure who is responsible for reducing prices for generics. I know who is responsible for raising prices. I also know that we cannot afford to wait for OTHERS to bring prices down because we do not know how long it can take or whether they will succeed. There is something we can do in the meantime. Let's all dermatologists in the US agree to NOT PRESCRIBE one and the same generic for 1 month. I bet you the pharmaceutical companies would get the message. If they do not, there is more that we can do to make our case.....
    • Dr. Rich
      Enjoyed your article. I share your frustration. However, The responsibility for the governments inability to negotiate lower drug prices goes back to the start of medicare part D. Billy Tauzin was instrumental in that bill's passage and became the poster child of Washington's mercenary culture. He crafted a bill to provide prescription drug access to Medicare recipients, one that provided major concessions to the pharmaceutical industry. Medicare would not be able to negotiate for lower prescription drug costs and reimportation of drugs from first world countries would not be allowed. A few months after the bill passed, Tauzin announced that he was retiring from Congress and would be taking a job helming PhRMA for a salary of $2 million. Gotta love Congress.

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