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.