Commentary: Pharmacists, insurers limit scope of practice, prescription choices

September 1, 2008

I had a recent personal experience that shocked me into re-examining what we dermatologists do and what our future will be as a specialty.

Key Points

I had a recent personal experience that shocked me into re-examining what we dermatologists do and what our future will be as a specialty.

For many years, I have been taking a name-brand cholesterol-lowering agent. Because of the high co-pay, I decided to switch to a generic version in the same drug class.

Rather than bothering my internist, I asked my friend, the ophthalmologist, who is in the next office, to write a prescription for this medication.

This was news to the ophthalmologist, who deals with the problem of high cholesterol in his patients every day. No amount of discussion, cajoling, threatening or pleading could move the pharmacist from his position.

Could it be that the newest arbiter of medical practice is going to be the druggist at the neighborhood Safeway supermarket?

In fact, this happens very frequently already. Many prescriptions that we write are challenged by the pharmacist, not only for legitimate reasons, such as potential drug interactions, but also because he or she does not like the choice of medication or the dosage that is chosen to treat a given disease.

Limiting scope of practice

This phenomenon goes well beyond the pharmacy.

Many insurance plans limit the use of certain classes of drugs to practitioners in a few select specialties; this can greatly impact how we practice dermatology.

I have an interest in psychosomatic medicine, and care for a fair number of patients with delusions of parasitosis. We all know that the treatment of choice for this disorder is pimozide - a medication that I have prescribed hundreds of times. Some third-party payers in our community will only allow psychiatrists to prescribe this compound.

To complicate the problem, it is often extremely difficult to get an appointment with a psychiatrist, and most of these patients reject the notion that they have a mental disorder anyway.

Thus, they will routinely refuse to go this route, even if given the chance.

Much of the evolution of this problem has been out of our control, and may be related to the pernicious situation in which insurance carriers do better financially when access to medical care is restricted.

In the short run, a lack of medical care is cheaper than supposedly high-priced specialty intervention. In the long run, this is extremely poor economic thinking.

Many patients with serious dermatologic disorders, such as delusions of parasitosis, wind up being managed in emergency rooms. Patients may also be admitted to the hospital for extensive evaluations, which must cost considerably more than an office appointment with a dermatologist.

Expanding the derm's role

Some of this has evolved because of the way in which dermatologists have altered their practices.

Many years ago, Dr. Marcus Conant spoke at the American Academy of Dermatology on the imperative that we become general practitioners at the skin as it relates to patients with HIV disease. He warned that if members of our specialty do not accept the responsibility for caring for the needs of these individuals, other specialties would almost certainly fill the gap.

For the most part, his prediction has come to pass; infectious disease specialists treat Kaposi's sarcoma, chronic cutaneous herpes simplex virus infections, psoriasis, seborrheic dermatitis and other skin disorders in patients with HIV disease - largely because they are willing to do so and skin specialists are not.

Now is the time to start taking Dr. Conant's advice seriously with regard to many other skin disorders, and, in fact, to expand what we do as physicians beyond dermatology, when necessary.

We should be willing and able to do some simple manipulations of blood pressure medications in patients being treated with cyclosporine. We can manage the arthritis that often accompanies psoriasis. The use of anxiolytic agents and antidepressants can be important therapeutic tools for dermatologists. And, yes, we can prescribe cholesterol-lowering drugs in patients who need this form of therapy.

Our patients will benefit from extra attention to their medical needs, and that is what this is all about, after all.