How Did We Get Here?
Buchi Neita, PA-C and Shanna Miranti, PA-C open by naming the frustration nearly every dermatology APP feels: learning about the newest, latest, greatest therapy at a conference and then having no idea how to actually get it into a patient's hands. As Miranti points out, access is the first thing clinicians ask their drug reps about, yet it's the last slide in the rep's deck — almost as if it's buried behind the evidence.
Both hosts contrast today's system with the era of paper prescriptions. Neita, 15 years in practice, and Miranti, 23 years in, remember when the hardest part was maybe handing a patient a copay card for a branded drug. Now, Miranti says, the minutes after counseling a patient are spent explaining where they can even fill the medication. She's blunt about box pharmacies: 'friends don't let friends use Walgreens,' because they'll often substitute whatever is on the shelf. In both Florida and Atlanta, the hosts say routing branded and even generic scripts through partner or specialty pharmacies has become standard practice — it cuts phone calls and raises the odds the patient actually gets the prescribed drug.
The Middleman Behind the Curtain
Miranti walks through who is actually responsible for access barriers. Patients often blame pharma for high prices or insurers for denials, but she points to the pharmacy benefit manager — the PBM — as the middleman in the drug scheme. She notes that about three PBMs control roughly 80% of the drug market and make around $315 billion annually through clawbacks and reimbursements, effectively by saying no to patients' prescriptions and steering them to limited formularies.
She adds that drug companies are trying to help through incentive and coupon-style programs that cover the balance the insurer won't — but Miranti cautions that eating that cost doesn't bode well for future research and development. Neita highlights another pain point: the PBMs set rules, clinicians learn to play by them, and then the rules change out of the blue. 'It is definitely a moving target,' the hosts agree.
Prior Authorizations and Real Patient Harm
Neita frames prior authorizations as the bane of clinic existence. She acknowledges they exist for reasons — preventing non-approved uses, avoiding harmful interactions, and controlling costs — but the process creates barriers that lead patients to abandon treatment, which can mean worse disease: acne progressing to scarring and hyperpigmentation, atopic dermatitis costing sleep and even affecting childhood development. For clinicians, the result is burnout, added workload, and unreimbursed staff time.
Neita shares a recent case: a patient with severe HS whom she wanted to start on a biologic. The plan wouldn't cover it but would cover a biosimilar. A glitch in the PA process led to a denial — and because the patient had Medicare, she explains, you get essentially one shot at the PA before you're forced into an appeal or peer-to-peer, dragging out the timeline while the patient was draining, oozing, and messaging her daily. They ultimately bridged him on a branded sample through the manufacturer's patient assistance program. Her point: if something had happened to that patient, who takes responsibility — the PBM or the insurer? Miranti's answer is that stories like this should fuel clinicians' drive to fight for patients who can't fight for themselves, including having patients start their own PAs and getting on peer-to-peer calls to educate the reviewing physician.
Why Drugs Get Denied — and How to Document Around It
The hosts break down common denial reasons: coverage/formulary limitations, off-label use, reauthorization, and documentation. Off-label prescribing, Miranti notes, is 'half of what we do in dermatology,' which is why she urges writing for the FDA-approved indication when possible and respecting age restrictions — even on generics. Her go-to example: generic tretinoin is FDA-approved for 12 and up, so a denial for a 10- or 11-year-old is expected, and citing that fact speeds the PA along.
Documentation is where the hosts spend the most energy. Neita stresses capturing what patients have tried and failed, and Miranti describes 'gamifying' this for her MAs — using pharmacy apps (Publix and other big-box chains in Florida), patient portals, and the EHR to reconstruct prior therapies before she walks in the room. In Modernizing Medicine (Emma), Neita notes you can import patient medications from the clipboard with patient permission. Both emphasize a scoring tool in every note — BSA, IGA/PGA, itch/NRS scores, Hurley stage for HS, or quality-of-life measures — and Miranti favors the diagnosis comment field so tried-and-failed and severity data sit highlighted at the top of the impression. She also builds a 'notes to pharmacist' checklist (IGA, itch score, age, special-area use like face or genitalia) saved to her MAs' iPads to copy into the script before it goes to the specialty pharmacy.
Building a System That Gets Patients Their Meds
If Miranti had a magic wand, every office would have a biologic coordinator — and both hosts insist that if you have one, treat them well, because they're worth their weight in gold. Short of that, train the team: designate a primary biologics contact, teach MAs what to document and what to listen for, and make sure the front desk collects updated insurance cards, demographics, and pharmacy benefit cards.
The hosts offer concrete note-building tactics: use disease- or medication-specific chief complaints in the EHR to prompt the right questions, and always name the impression by the FDA-approved diagnosis. Miranti is emphatic that 'eczema' or 'dermatitis unspecified' will sink a PA — biologics are approved for atopic dermatitis, plaque psoriasis, inverse psoriasis, non-segmental vitiligo, and so on. Document contraindications to conventional agents (methotrexate, acitretin, cyclosporine — including childbearing potential, hypertension, diabetes, alcohol use), keep the medication list current so an archaic drug doesn't trigger a denial, and lean on pharma patient access managers and field reimbursement specialists when time runs short. Finally, Neita closes on patient buy-in: tell patients why they need this drug, warn them to expect calls from the insurer, pharmacy, and hub, and get them to answer the phone — 'we can only lead the horse to water.'