This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider.
Steven R. Feldman, MD, PhD: Hello. I'm Dr. Steve Feldman. Welcome to Medscape's InDiscussion series on psoriasis. This is our first episode of season 3.
Today we'll discuss insurance and access to care. These are a couple of the most important, serious, and pressing issues in psoriasis management. We have a remarkable guest today, who's been at the forefront of these critical issues.
He's a board-certified dermatologist in Philadelphia and a clinical associate professor in the Department of Dermatology at Lewis Katz School of Medicine at Temple University. He formerly was on the faculty of what I believe may be the absolute top dermatology and health economics programs in the country at the University of Pennsylvania.
Our guest today is a passionate advocate for equitable access to healthcare, particularly for underserved and vulnerable populations. In publications ranging from JAMA Dermatology to The New York Times, our guest has raised awareness of the disparities that exist in healthcare delivery, the high costs of prescription drugs, and the barriers posed by insurance policies.
He's well known for his innovative work on telemedicine, showing how technology can be a powerful tool to bridge the gap for patients in rural and underserved areas. It's my great pleasure to welcome Dr Jules Lipoff. Jules, welcome to InDiscussion.
Jules Lipoff, MD: Thank you for the invitation. It's an honor and a privilege to be invited, and I look forward to talking to you today.
Feldman: Jules, before we get into the nitty gritty of healthcare finance, I want to talk to you about something maybe even more important. I have a chemistry background. I loved organic chemistry because you only needed to know one or two principles of what electrons want to do and you could predict all the resulting chemistry.
It's so powerful — just two principles. You have a background in chemistry and biochemistry too, but you also have this amazing background in comedy, of all things. I think there must be a principle or two of comedy that may apply to how we can or should interact with our patients. Tell us a little about your work in comedy and your thoughts about how it informs your work with patients.
Lipoff: I think comedy is a good study of human interaction. It's about accepting rejection and failures. So, for instance, when I took improv comedy classes at the Upright Citizens Brigade in New York, I learned that in long-form improv comedy, they have this motto, which is "yes, and." Which is, when someone says something or creates a new reality in a scene, you don't quibble with it.
You don't debate what it is, or what it isn't; you accept what has been done and then you just build off of it. Failure can pave the way to success, but you can't mire in it. You can't be frustrated. You can't get into arguments.
You just are forward-thinking and always trying to build and move forward.
Feldman: I love that. I think of that when I'm taking care of delusions of parasitosis patients, and they say something I disagree with, and instead of arguing with them, I go, yes, and we're going to put you on this antipsychotic.
Lipoff: It is about moving forward. In that situation, you could get mired in the weeds and you're never going to talk someone out of a fixed delusion. So why don't we just focus on what is going to make progress? It's like this medication may metaphorically get rid of your bugs.
Feldman: Yes; I just don't use the word "metaphorically" in that sentence with them.
Let's move to telemedicine, because interacting with patients in person is one thing, but it strikes me that telemedicine may be a different beast altogether. Do you think it's a different skill set?
Lipoff: Certainly. I think you have to be a level of tech-savvy to be able to make it work. Even just the IT, self-help aspect of it: setting it up, if one program doesn't work, being able to communicate, connect to someone, have a backup, all this sort of thing.
But also, dermatology is so physical exam–focused, right? Usually, it's the H&P (history and physical exam) in medicine. In dermatology, it's the P&H because the physical is so forward. But in telemedicine, there's barely a physical exam. It's mostly focused on things such as a cursory glance. You can say what something is, and then mostly it's an intellectual cerebral exercise and communication. I think [we're] less likely to pick up on certain nonverbal cues. You can see their face maybe, assuming it's a live video telemedicine interaction. But you can't necessarily get the whole picture; you don't necessarily see them walk into the room. You don't necessarily see how they're acting with staff and other people. You might not pick up on all that.
On the other hand, you get the benefit of maybe seeing the room they're in; maybe you see their workplace. Maybe you see that they're doing this telemedicine visit on a bus or they're a cashier at a convenience store, and they're trying to check people out in the middle of your visit.
Some of that's interesting to get a true glimpse into their world. That's also useful, but it's different. For instance, we sometimes comment that we see certain skin cancers more on the left side of someone. Like when you see a fire department person or a police officer sitting in their car. I think it was an electrician I had sitting in their car recently as they were doing their visit. And I'm like, I think you're getting it on this side of your body because look, it's hitting you right there. So that hit a little harder than if it had been a conversation had been in the room.
Feldman: I've noticed that true glimpse into their world before, but I don't think I fully appreciated it, put into words as you just have. How cool it is that you're doing a home visit, in a sense.
I find telemedicine to be wonderful for psoriasis patients, especially for following up on their biologic treatment because you don't have to see very much. They're clear, and they save so much travel time coming to see me and so much waiting time in my office. I think they just love the telemedicine visits.
And I love making patients happy, but at the same time, there are trade-offs. I find telemedicine horribly inefficient. And with no procedures ever with telemedicine, it seems like it turns a well-paid dermatologist into something very much more like a poorly compensated primary care provider. Am I missing something?
Lipoff: You're thinking of telemedicine only through the lens of live video visits. There are a lot of different types of visits. During the pandemic, the way reimbursement was structured and the loosening of HIPAA, everything was geared towards the live video. But there are also different types of models. It's not just one flavor.
There are also store-and-forward models, which unfortunately are not well reimbursed, but they would allow you to answer at your leisure without a scheduled appointment time, with clinical information and photos, and you wouldn't have to have a long, extended conversation with a patient that isn't necessary.
It could be a lot more transactional and move through cases very quickly, possibly a minute per case or something like that, If you're efficient. That would allow you to help a lot of people very quickly.
To your point, we need to make sure that this is at least cost neutral. No one would be losing money in this way. Maybe they wouldn't gain more money by doing more telemedicine. But I think if you design a system of triage in the right way, it works well.
For instance, I put all of my Accutane and acne follow-up visits into these visits, and given those rarely would have had procedures anyway, it can be a lot more efficient. Especially if you have a bunch of visits back to back. In my office, we're keyed up to check on pregnancy test labs and refill things very quickly. And then you're set up to triage to get people into clinic for the procedures. You don't have to waste a lot of time. You can say, this is a pigmented lesion I can't adequately assess; you should have a full skin check anyway. That looks like a cyst; that would require a visit. You're triaging it so that your in-person visits are going to be more highly proceduralized, so it evens out.
Feldman: I love that. Are there any other insurance factors I need to be thinking about with respect to telemedicine?
Lipoff: I think it's still an evolving landscape. Not every state has parity laws that guarantee you get paid the same on video as in person. I do think that there's an assumption that telemedicine cannot be as good. I think as a gold standard, when you evaluate the physical exam of a person, in-person is generally better.
But you have to think about the whole person. For instance, when I had a 70-year-old woman with pyoderma gangrenosum on her leg, she would have to drive an hour both ways. And it was just a wound check. It was not necessarily in the patient's best interest to go all that distance unless I felt it was necessary.
We could put them in not only the time but other risks. The goal is excellent patient care, and we should use whatever tools and methods we have at our disposal to achieve that. Now, I wouldn't want an insurance company to say, seeing that telemedicine costs them less, for instance, to require you to have a telemedicine triage visit first. I think everyone should always have the right and the ability to be seen in person if they want to be seen in person. I do think some situations lend themselves better to telemedicine than in person and the other way around.
Feldman: These insurance issues must factor into other aspects of psoriasis care. Is cost a common issue for patients filling — or should I say not filling — their prescriptions?
Lipoff: Cost is an issue. I'm sure you've heard about this all the time. I also know you've written on related topics yourself. We published a paper in JAMA Dermatology a few years ago. I think you may have written a reply to it, about reasons that people are not filling their acne prescriptions, and the copays were a significant reason why they were not filling.
Unexpected copays are a big reason for not filling prescriptions, prior authorizations, and all of this. Certainly, there are side effects and other concerns that hold people from filling their prescriptions, but cost is a main driver. The burden on this healthcare system of biologics and other new medications is incredible.
They're just ridiculously expensive, and we're stuck in a situation ethically of weighing what is appropriate for the person in front of us vs which is better for the financial health of our entire population. And that's quite impossible to figure out in general. I think we do the best we can with the tools we have for the patient that's in front of us, but it may not be sustainable if we keep spending money recklessly.
Feldman: I think in settings like this podcast discussion, we tend to focus a lot on the societal aspects, which is great. But when I'm sitting there with a patient in front of me, you phrased it perfectly. We do the best we can with the tools we have for that patient. I don't really worry about society at all when I've got that patient in front of me, because you just got to do what you can for them.
How else can we help patients concerning cost?
Lipoff: I think we can help in a lot of ways. When something is really much more effective and is much more expensive, I think it's something that we can maybe justify, but there are a lot of things that are more expensive that aren't necessarily better.
For example, a topical lacquer for onychomycosis. It's not very effective, but it's very expensive. So that might be inappropriate. I think Vicks VapoRub is just as good as efinaconazole, I don't know that it's appropriate to do the more expensive thing.
But beyond making smart choices about what will be efficacious will be getting you the best bang for the buck, you can think about where you fill prescriptions and how you send them. I've done a particular focus on, say, medications for androgenetic alopecia and how we fill them. There's a lot of quirks, for instance, around finasteride and how it's prescribed. For many years, I would have patients split 5-mg tablets into quarters instead of taking 1 mg because of how much more expensive the 1-mg tablet was. And now I'm more aware of different options for filling prescriptions at Costco — a discount pharmacy that does not even require membership to use their pharmacy, a fact that most patients don't know. There, you can get a year's supply of finasteride for like 50 bucks, whereas it might be $25 a month elsewhere.
It's about being aware of little shortcuts. I might even go so far as to argue that we're so focused on efficacy and safety in our patients, we don't really value cost. But I think cost does impact the safety of our patients. A lot of our patients are on fixed incomes or have limited budgets.
If they're spending more money on one thing, it's got to come from somewhere else. We have to be respectful of that and realize that when we suggest something that might be expensive, patients may not feel like it's optional and they may feel that it's necessary. I'm sure some of us have had patients who have filled medications that we thought, oh, maybe it'll work and then it cost $200 out of pocket. We didn't realize it. And then we feel terrible that they spent that money. It's important to make sure that they know that there are alternatives, or to call if something is going to be unexpectedly expensive.
Feldman: I remember when oral terbinafine used to be over $1000 for a course of therapy, and then Costco had it for $10, for a prescription. It was amazing. I've begun to use GoodRx.com to try to identify costs proactively when I think it's going to be an issue. Is that a good resource? Are there other platforms I should be thinking about?
Lipoff: I do think GoodRx is worthy of some serious discussion. We just published an article in JAMA Dermatology about prescription cost–saving platforms, and GoodRx is the best known of them. I've used it a lot. I've had a lot of success saving patients money with it, and it's been very useful, but it's not a cure-all.
It's not a panacea; GoodRx has some issues. They have been accused of mishandling patient data, and they settled a case with the Federal Trade Commission. They've also reportedly shared personal prescription data with third parties for advertising and analytics. It's important to the extent that we can, be aware or be transparent with patients that it's not perfect. Whatever information you give to GoodRx is not protected by HIPAA, for instance.
Other things are developing in this area. For instance, the Mark Cuban Cost Plus Drug Company is interesting. GoodRx is basically pretending to be insurance to help negotiate prices with pharmacies down. CostPlus is directly manufacturing and shipping out drugs, and they're transparently marking up 15% of their cost for their revenue. They have a more limited selection of things, and we have yet to see what the issues may be in the long term, but it does seem like that is an interesting model to explore. There's a lot of markup on a lot of medications and companies taking money from all sorts of different interactions.
I think we need to be aware of the cost and be as transparent as possible. I hope that maybe with AI and other tools, we'll be able to better predict and direct patients to save money when they're trying to fill medications.
Feldman: As we start to close, are there any other access-to-care issues you want to leave our listeners with?
Lipoff: I think in dermatology, we have a real issue with access to care. We have a bad reputation for how difficult it is to get in. But also, there are a lot of patients who can't get in. Our specialty does not have the best reputation for accepting government assistance patients, Medicaid.
There's a lot of need there. It makes sense financially. There's no incentive to do that, and there's no incentive for someone to start taking Medicaid if they're going to be the only game in town taking it and then they get flooded with it. But I would like to find ways to make it mutually beneficial for everyone to help the most people.
It's frustrating that the people who often need the most help make you the least money. It would be better for everyone for that to be a little more aligned.
For instance, I have an active grant program. I'm working with a federally qualified health center where we're using telemedicine to support patients living with HIV and LGBT communities. We are doing telemedicine, to support these communities, but also we're trying to pair with federally qualified health centers, they get enhanced reimbursements, pretty competitive reimbursements because they're government-supported. Maybe there's a way to pair subspecialists with them — for instance, if it's part of a primary care visit that they're doing, they can get a competitive reimbursement and then separately subcontract with a decent rate, and a subspecialist to support that care, perhaps by telemedicine.
I think some innovative models can make it financially sustainable while also supporting the people who need it most.
Feldman: Jules, thank you. Today, we've had Dr Jules Lipoff discussing insurance and access to care in the treatment of psoriasis. You can learn more about Jules and his work at www.juleslipoff.com. Some of the key points we covered included telemedicine and its use to help patients get access to treatment.
We discussed alternative pharmacies, and pharmacy information systems we now have online may help us with that. I think Jules makes the most beautiful point that people who need the most help may be the least financially remunerative patients to care for. Fortunately, I'm basically on a straight salary, which lets me take care of the folks I need to take care of.
Thank you so much for joining us. I hope you'll join us next time when we discuss obesity care and psoriasis with Dr Robert Kushner. This is Dr Steve Feldman for InDiscussion.
Listen to additional seasons of this podcast.
Resources
Ciclopirox Nail Lacquer Topical Solution 8% in the Treatment of Toenail Onychomycosis
Efinaconazole in Onychomycosis
Medscape © 2025 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Cost, Coverage, and Psoriasis: Overcoming Care Barriers - Medscape - Mar 18, 2025.
Comments