sample_data/psoriasis_study/Dermatologist_04_Rural_Clinic.txt

Interview Transcript - Dermatologist #4
Date: October 20, 2025
Interviewee Type: HCP (Dermatologist)
Location: Rural Health Clinic, Montana
Years in Practice: 8 years
Specialty: General Dermatology
Patient Volume: ~80 psoriasis patients

Interview Content:

Interviewer: Thank you for joining us. Can you describe your practice setting?

HCP: I work in a rural clinic serving a large geographic area - probably 200 square miles. Many of my patients drive 60-90 minutes to see me. I'm the only dermatologist within a 120-mile radius, so I see everything from acne to melanoma to complex psoriasis cases. My patient population is very different from what you'd see in a major city - lower income, less insured, lots of Medicare and Medicaid patients.

Interviewer: How does that affect your prescribing patterns for biologics?

HCP: Dramatically. "In urban academic centers, dermatologists might start with the newest, most expensive biologic without batting an eye. Here, I have to think about whether my patient can afford it, whether they can get it approved, whether they'll be able to travel here for follow-ups." I'd say only 30-40% of my moderate-to-severe psoriasis patients are on biologics. The rest are on methotrexate, apremilast, or just topicals because that's what they can access or afford.

Interviewer: Where does Dermovia fit into your practice?

HCP: I've been using it for about 8 months, and I currently have about 10-12 patients on it. That might sound low, but for my practice, that's actually substantial. "What attracted me to Dermovia initially was the quarterly dosing. In a rural setting, that's huge. Patients don't have to drive 90 minutes every two weeks for an injection or worry about refrigerating medications when they might not have reliable power."

Interviewer: Can you elaborate on the power issue?

HCP: Sure. I have patients living in very remote areas where power outages are common, especially in winter. If you're on a biologic that requires refrigeration and you lose power for two days, your $2,000 medication might be ruined. "With quarterly dosing, patients can come to the clinic, we administer it here, they know it's been stored properly, and they're good for three months. That peace of mind is invaluable."

Interviewer: How many of your Dermovia patients do in-office administration?

HCP: All of them, actually. I don't have any rural patients doing self-injection at home. They prefer to come in, partly because of the storage concerns I mentioned, but also because many of them just aren't comfortable with self-injection. "These are folks who might be comfortable castrating cattle or fixing a tractor engine, but sticking a needle in their own belly is a different story." So we schedule them every 12 weeks, my nurse does the injection, we do a quick skin check, and they're on their way.

Interviewer: What about insurance coverage in your patient population?

HCP: It's a nightmare, honestly. Maybe 40% of my patients have commercial insurance through their employer - ranchers, mine workers, small business owners. Another 40% are on Medicare or Medicaid. The remaining 20% are uninsured or underinsured with high-deductible plans. "For that last group, getting on a biologic is nearly impossible. We're talking about people making $30,000-40,000 a year being asked to pay $5,000 out of pocket. It's not happening."

Interviewer: How do you navigate prior authorizations?

HCP: I have one medical assistant who spends probably 50% of her time on prior auths. It's just me and two staff members, so we don't have the luxury of a dedicated prior auth team. For Dermovia specifically, I'd say we're seeing approval rates of maybe 50-60% on the first try. The other 40-50% require peer-to-peer calls, which means I'm spending 30-45 minutes on the phone with an insurance medical director explaining why this patient needs Dermovia instead of methotrexate.

Interviewer: What do you tell the medical directors?

HCP: I emphasize the practical aspects. "This patient lives 90 miles away. They can't come in every two weeks. They work on a ranch and can't take time off regularly. Quarterly dosing is the only realistic option." Sometimes that works, sometimes it doesn't. I've had cases where insurance will approve an every-two-week injection but not a quarterly one, which makes no sense from a patient care perspective but apparently makes sense to them financially.

Interviewer: Let's talk about efficacy. What are you seeing with Dermovia in your patient population?

HCP: The efficacy has been good. I'm seeing PASI 90 in probably 60-65% of my patients, which is slightly lower than the trial data but still respectable. I think the lower numbers reflect my patient population - many have had psoriasis for 20-30 years, they've been on and off various treatments, their disease is more treatment-resistant. "But even PASI 75 is life-changing for these patients. I have ranchers who can finally wear short sleeves without people staring. I have patients who can go to church without feeling self-conscious. That's success in my book."

Interviewer: What about speed of response?

HCP: It's pretty quick. Most patients notice improvement by week 4, significant clearance by week 8-12. That's important because these patients have often been suffering for years without effective treatment. They're skeptical that anything will work, so seeing results within the first month builds trust and adherence. "One patient told me, 'Doc, I haven't seen my skin this clear in 15 years.' That was at week 12."

Interviewer: Have you had any safety issues?

HCP: The most common issue is candida - probably 30% of my Dermovia patients have had at least one episode of oral thrush or vaginal yeast infection. I now give all my patients a standing prescription for fluconazole when I start them on Dermovia. Upper respiratory infections are also common, but my patients are pretty stoic - they'll have a cold and just power through it. "I did have one patient develop what looked like cellulitis on his leg about five months into treatment. We stopped Dermovia temporarily, treated with antibiotics, and then restarted once it cleared. He's been fine since."

Interviewer: Have you had to discontinue Dermovia for any patients?

HCP: Yes, two patients. One developed recurrent thrush - she had three episodes in six months despite antifungal treatment, and she just couldn't tolerate it anymore. We switched her to an IL-23 inhibitor, which has a different side effect profile. The other patient moved out of state for work, and his new insurance didn't cover Dermovia. He had to switch to whatever biologic was on his new formulary. "That's the reality of rural healthcare - people move for work, change insurance, and suddenly you have to start over with a different medication."

Interviewer: How do you handle patient education about biologics?

HCP: I spend a lot of time on this. Many of my patients have never heard of biologics before. They're used to creams and ointments, maybe some pills. The idea of injecting a medication every 12 weeks is foreign to them. "I explain it like this: 'Your immune system is overreacting and attacking your skin. This medication tells your immune system to calm down. It's very targeted - it's not going to affect your whole immune system, just the part that's causing the psoriasis.'" I show them before-and-after photos of other patients, which really helps them visualize what's possible.

Interviewer: Do you discuss cost upfront?

HCP: Absolutely. I tell them, "This medication costs about $80,000 a year without insurance. But we're going to work with your insurance and the manufacturer to get your out-of-pocket cost down to something manageable." For commercially insured patients, the copay card usually brings it down to $25 or less per dose, so $100 a year. That's affordable. "But for Medicare patients, it's much harder. They can't use copay cards, and their out-of-pocket can be $3,000-5,000 a year. Some can afford it, many can't."

Interviewer: What happens when patients can't afford it?

HCP: We apply to the manufacturer's patient assistance program, which can take 3-4 weeks. If that doesn't work, we apply to charitable foundations. If all that fails, we go back to older, cheaper options - methotrexate, apremilast if insurance covers it, or just aggressive topical therapy. "It's heartbreaking because I know Dermovia would work beautifully for that patient, but if they can't access it, there's nothing I can do."

Interviewer: How does Dermovia compare to other biologics you've used?

HCP: In terms of pure efficacy, I think it's similar to ixekizumab and secukinumab - all in the 60-75% PASI 90 range in my practice. Where Dermovia wins is convenience. The quarterly dosing is a game-changer for rural patients. "I used to have patients on ixekizumab who would miss doses because they couldn't get to town to pick up their prescription, or they went on a hunting trip and forgot to bring it. With quarterly dosing, those issues are eliminated."

Interviewer: What about injection site reactions?

HCP: Yes, that's common. I'd say 40% of my patients report some redness, swelling, or itching at the injection site. It usually resolves within 24-48 hours. One patient described it as "like a bee sting - hurts for a few hours, then it's fine." Since we do all injections in the office, we can rotate sites and make sure we're injecting properly, which helps minimize reactions.

Interviewer: Do you treat scalp or nail psoriasis with Dermovia?

HCP: Yes, and it works well. Scalp psoriasis is particularly common in my population - lots of patients with thick plaques under their hairline, behind the ears. "I'm seeing good scalp clearance with Dermovia - probably 70-80% of patients get significant improvement. One patient was so self-conscious about the flaking that he always wore a baseball cap, even indoors. After three months on Dermovia, he came in without the cap for the first time in years."

Interviewer: What about nail psoriasis?

HCP: Nails take longer, which I always warn patients about. You need 6-9 months to see full nail improvement because the nail has to grow out. But I am seeing results - less pitting, less discoloration, improved nail bed attachment. For patients whose livelihood depends on their hands - ranchers, mechanics, construction workers - nail clearance can be really important functionally.

Interviewer: Do you treat psoriatic arthritis patients with Dermovia?

HCP: I have a few patients with both psoriasis and psoriatic arthritis on Dermovia. It's FDA-approved for both indications. The skin clearance is excellent, and most report improvement in joint pain and stiffness. "One patient is a 52-year-old rancher who was having trouble doing his work because his hands hurt so badly. After four months on Dermovia, he told me, 'I can rope cattle again.' That's meaningful."

Interviewer: How do you monitor patients on Dermovia?

HCP: I see them at 4 weeks, 12 weeks, and 24 weeks initially. At each visit, I do a skin exam, calculate PASI, ask about side effects. After six months, if they're stable, I extend to seeing them every 12 weeks when they come in for their injection. I also do baseline labs - CBC, CMP, hepatitis screen, TB test - and recheck CBC and CMP every 6-12 months. "In a rural setting, getting labs can be a challenge because patients might have to drive to the county hospital, but we make it work."

Interviewer: Have you had patients lose response over time?

HCP: Not yet, but my longest patient has only been on it for 8 months. I know secondary loss of response is a risk with all biologics, and I'm prepared for it. If it happens, I'll switch to a different mechanism - probably an IL-23 inhibitor like risankizumab or guselkumab. "The good news is that we have multiple options now, so if one stops working, we can try another."

Interviewer: What's your first-line biologic choice for newly diagnosed patients?

HCP: If insurance coverage is equal, I lean toward Dermovia or another IL-17 inhibitor for younger patients without major comorbidities. The efficacy is excellent and the speed of onset is fast. For older patients or those with cardiovascular risk factors, I might choose an IL-23 inhibitor because the safety profile seems cleaner. "But honestly, insurance coverage usually makes the decision for me. I prescribe what's on the patient's formulary and what I can get approved."

Interviewer: Do you ever use methotrexate anymore?

HCP: Yes, unfortunately more than I'd like. Methotrexate is cheap and usually covered, so for patients who can't access biologics, it's what we use. The efficacy is mediocre - maybe 30-40% get PASI 75 - and the side effects can be rough. Nausea, fatigue, liver toxicity. "I have patients on methotrexate who say, 'Doc, this stuff makes me feel terrible.' And I tell them, 'I know, and I wish I could get you on a biologic, but your insurance won't approve it.' That's the reality."

Interviewer: What are the biggest barriers to psoriasis treatment in rural areas?

HCP: Access, access, access. Geographic access - patients have to drive long distances. Financial access - many patients can't afford expensive medications. Insurance access - getting prior authorizations approved is a nightmare. "And then there's the education barrier. Many of my patients don't understand that psoriasis is a systemic inflammatory disease that increases their risk of heart disease, diabetes, depression. They think it's just a cosmetic issue, so they don't prioritize treatment."

Interviewer: How do you educate patients about the systemic nature of psoriasis?

HCP: I explain that psoriasis isn't just a skin disease. "I tell them, 'The inflammation causing your skin plaques is also affecting your blood vessels, your joints, potentially your heart. Treating your psoriasis isn't just about improving your skin - it's about reducing your overall inflammation and protecting your long-term health.'" Some patients are motivated by that, others just want their skin to look better. Either way, I try to treat.

Interviewer: Would you recommend Dermovia to a colleague?

HCP: Yes, especially if they have a rural or underserved patient population. The quarterly dosing is a huge practical advantage. The efficacy is solid, the safety profile is manageable. "It's not a miracle drug, but it's a good tool to have in the toolbox." I'd tell colleagues to be prepared for insurance battles, but that's true of any biologic.

Interviewer: Any final thoughts?

HCP: Just that we need to do better as a healthcare system at ensuring access to effective treatments. I have patients who would benefit tremendously from biologics like Dermovia, but they can't get them because of cost or insurance barriers. "When I trained in dermatology, we spent years learning about disease pathophysiology and treatment algorithms. Nobody taught us how to navigate prior authorizations or patient assistance programs. But that's where I spend half my time now." It's frustrating, but I keep fighting for my patients because they deserve the best care we can provide.

Interviewer: Thank you for your time and insights.

HCP: You're welcome. I hope this information is helpful.