Unemployed. Uninsured. Underinsured. Untreated?
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Physicians can help patients in need receive treatment

With the unemployment rate still hovering around 9 percent, many Americans are experiencing serious issues in paying for necessities. When that happens, medical care is often one of the first things to fall by the wayside. A January 2011 earnings report by WellPoint, the largest insurer in the country, caused Bloomberg to predict continued profits for the company based on the public postponing visits to the doctor due to cost concerns. But for many dermatologic patients, setting aside treatment for an indeterminate amount of time could prove calamitous — especially for those with serious chronic conditions. Fortunately, it’s possible for dermatologists and members of their office staffs to work with patients and their insurers to help patients afford the medications they need to receive the best dermatologic care possible.

Root causes

With high unemployment and stagnant job growth, many patients are finding themselves not only without health insurance, but without the means to pay out of pocket for even necessary treatment. An April 2010 study in the Journal of the American Medical Association found that uninsured and underinsured patients would delay treatment in even life-threatening cases. In the study, half of uninsured patients and 45 percent of underinsured patients delayed treatment following the onset of heart attack symptoms. In addition to the astounding number of uninsured Americans — a figure pegged at 50 million in a December 2010 report by the Kaiser Foundation — an increasing number of patients find their benefits slashed or their insurer passing additional costs onto them. Further, the 50 million figure fails to account for millions more who carry a near-equal burden through poor coverage and a lack of understanding of how to improve their situation.

“I think that I see more patients struggling with costs owing to the changes in the insurance industry, rather than just the economic downturn. In other words, the insurers are pushing more of the burden to the patients — instead of a $10 copayment, they’re requiring higher costs,” said Robert Kalb, MD, clinical professor of dermatology at the State University of New York at Buffalo. “Instead of a copayment tier system, they have percentages — paying for 20-25 percent of their medicine. They have very high deductibles to reach before the insurance company pays anything. Patients may not initially be well informed about the specific nature of their individual plan, often lured by low monthly premiums. It’s more about the insurance changes, although the economy plays an even bigger role for certain patients.” [pagebreak]

Joseph Jorizzo, MD, former and founding chair of the department of dermatology at Wake Forest University School of Medicine, also points out the coverage shortcomings of many plans, saying that physicians will have an increasing need to adapt treatment for the uninsured.

“There are newer plans that I’m finding require up to a $5,000 out of pocket expense before their insurance kicks in. As a result, some patients, even if they’re quite sick and they require lots of treatment, still perceive that from January through June, or whenever they reach that copay amount, that their care is more expensive. They’re hesitant to use even medications that they need during that period where they pay completely out of pocket,” Dr. Jorizzo said. “I think that health care coverage for patients has gotten progressively worse every five years for the previous 20 to 25 years. Things have been a little worse for the doctors and the patients, and I suspect that whether we’re talking Obamacare or a Republican-created care system, that trend will continue no matter who the legislature is or who the president is.”

Identifying patients

The first step toward offering patients help in receiving vital treatment is identifying those patients who may need a physician advocate. Yet unforthcoming patients or those with sensitive egos can often slip through the cracks. Physicians can’t know the extent of a patient’s financial troubles without hearing from the patient, yet patients are often reluctant to ask for help. [pagebreak]

“I think that this creates a situation where, even though in medical school we weren’t taught that it was important to ask this question, we basically have to ask each patient on every visit how they get their medicines paid for, and if they pay for medicine out of their pocket,” Dr. Jorizzo said. “If they’re going to hit the donut hole,’ then we have to recognize that and let them make choices.”

Many of the underinsured suffer because of a perception that they have some coverage, and are thus ineligible for assistance. But this mindset, according to Bethany Wofford, health policy manager at the National Psoriasis Foundation (NPF), is misguided.

“I think the most helpful thing that physicians can do, in addition to being familiar themselves with the pharmaceutical assistance programs, is letting patients know about these programs even if they don’t necessarily bring up the issue,” Wofford said. “Sometimes patients think oh, I have insurance,’ so they don’t think they’ll be eligible to lower a $75 copayment. But often they are. So it’s a matter of understanding that patients may not know to ask that question, but that the information can be really helpful.” [pagebreak]

Identifying patients in need is extremely vital, according to Dr. Kalb, to prevent potential compliance issues.

“Obviously, if they have the medicine, they tend to use it. But what I’ve noticed is that patients end up taking the medication less frequently. Using some of the more expensive injectable psoriasis medicines as an example, they may space out injections from the prescribed once a week to once every 10-14 days,” Dr. Kalb said. “Or whatever oral medicine they’re receiving, instead of taking it every day, they’ll take it every other day or every three days. The patient’s goal is to minimize out of pocket expense by requiring fewer refills.”

Finding and offering help

Perhaps the most familiar method of treatment assistance to both patients and physicians is the varied array of discount programs offered by pharmaceutical companies for patients in need. Yet the differing requirements and difficulty of navigating between all offerings can intimidate both doctor and patient. The NPF has spent recent years hoping to demystify the process through its website, Wofford said. Physicians and members of their practice staff, she suggested, can play a major role in helping patients qualify for reduced cost medications.

Physicians and their staff members can provide quite a bit of assistance to patients in navigating assistance programs, Wofford said, including working with patients to fill out their paperwork, completing preauthorization documents, and providing information about prior prescriptions. [pagebreak]

In addition to connecting patients with pharmaceutical companies, Wofford also recommends connecting patients with existing patient communities. Many patient groups have strong online presences and informative online forums that not only boost a patient’s outlook, but illustrate an exhaustive catalog of ways to receive the best treatment despite limited finances. The psoriasis community’s ability to find and address issues, Wofford said, has begun to outstrip the NPF’s speed in doing so for assistance programs.

“We’ve done a lot of work in the past couple years to put all of the information about the patient assistance programs on our website. The patient community is really good at educating each other via the online forums about what programs are out there,” Wofford said. “When it comes to the assistance programs, a lot of times the patients are getting to those faster than they even call or e-mail us. I think a lot more patients are getting the information that way.”

Insurance denials often leave the insured as desperate as those without coverage. Victoria Werth, MD, professor of dermatology at the University of Pennsylvania, relies on a skilled and caring staff to serve as advocates for patients unable to afford treatment. This takes the form of both working with the pharmaceutical companies and dealing with insurance denials. “With expensive medications and rare conditions where there may not be a lot of studies that demonstrate efficacy of meds, the insurance companies look for reasons not to cover things,” Dr. Werth said. [pagebreak]

“When people come in, if they can’t afford medicines, I have a secretary who spends much of her time fighting with the insurance companies and trying to get them to pay for things. We try to give reasons for why they should provide coverage for different conditions,” Dr. Werth said. “She also spends a lot of time with people who aren’t covered, trying to see if there are drug company programs that can cover some of the medications as part of the different services they may offer for patients. There are different ways of trying to work in the system to provide care, but it’s full of challenges.”

Dr. Werth’s situation is compounded by the fact that her hospital system does not allow pharmaceutical sampling.

“I think in general, we’re not even allowed to sample in our hospital. And a lot of the medications that people have trouble with are more the oral medications anyway, or the injectables that may not be [available as samples]. That puts patients in a tight spot, and puts us in a tight spot, so we spend a lot of time trying to help them. It’s not really an easy thing to do.”

Dr. Kalb employs the tactic of reserving prescription samples for patients he knows would need the savings, and endeavoring when possible to stick to drugs on the list of affordable prescriptions pioneered by Wal Mart’s much-publicized 2006 “$4 drugs” campaign. [pagebreak]

“We also use the $4 Prescription Program List, which is something that was created by Wal-Mart but carried on in our area at Target and Wegman’s [a large supermarket chain],” Dr. Kalb said. (See sidebar, p. 23.) “Those three will generally honor the $4 prescription list. So we try to stay within that list if the patient can’t afford anything else.”

“If a patient brings this up, I imagine myself going into a physician’s office with no insurance or very limited prescription coverage,” he said. “What would I want done? In that situation I do my best to select the most appropriate therapy while at the same time to make their treatment as affordable as possible.”

Utilizing retailer prescription program lists

Retailer WalMart generated a wave of publicity for itself when the company announced in 2006 that it would begin selling 30-day supplies of selected generic drugs for $4. The chain has since expanded the program to 90-day supplies for $10 for certain drugs. While many of the drugs in the program were already otherwise affordable, even modest savings can mean a great deal to patients. Target honors a similar list of discounted generics, as do a number of other national and regional pharmacy chains. The result is an affordable treatment option for many patients without the necessity of committing to a certain pharmacy chain. Available treatments on WalMart’s list include those below; visit WalMart.com or consult a local pharmacy for information about amounts and concentrations available at the reduced price. Prices for some medications may be higher in California, Hawaii, Minnesota, Montana, Pennsylvania, Tennessee, and Wisconsin.

For skin conditions


Gentamicin (cream or ointment)


Silver Sulfadiazine

Triamcinolone (cream or ointment)

For fungal infections


Nystatin/Triamcin (cream or ointment)

Nystatin (cream or ointment)


Antibiotic treatments




Doxycycline Hyclate

Minimizing treatment costs

In addition to appealing to outside entities, Joseph Jorizzo, MD, former and founding chair of the department of dermatology at Wake Forest University School of Medicine, takes it upon himself to minimize those treatment costs he can control. He applies a set of personal rules to prescription aimed at minimizing the use of unnecessarily expensive medications. The criteria apply to those situations in which he prescribes name brand drugs for patients.

  • 1. “There has to be something that is very special about the formulation that makes it worth the extra money.”
  • 2. “There should be coupons or some alternate arrangement that makes the product more affordable to the patient.”
  • 3. “The patient, over the course of a year, should do markedly better, such that their total cost ends up being less than it would have been if they’d used something else.”



Utilizing retailer prescription program lists
Minimizing treatment costs