Cost-effective treatment of chronic disease for the uninsured/underinsured patient STFM April 30, 2009 Beth Musil, PharmD, Faculty Pharmacist Racine FMR/Medical College of WI Melly Goodell, MD Medical Director, Healthcare for the Homeless Baltimore County Faculty, Franklin Square FMR
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Cost-effective treatment of chronic disease for the uninsured/underinsured patient STFM April 30, 2009 Beth Musil, PharmD, Faculty Pharmacist Racine FMR/Medical.
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Cost-effective treatment of chronic disease for the
uninsured/underinsured patient STFM April 30, 2009
Beth Musil, PharmD, Faculty PharmacistRacine FMR/Medical College of WI
Melly Goodell, MD
Medical Director, Healthcare for the Homeless Baltimore County
Faculty, Franklin Square FMR
Disclosure
NONE!!!
GOAL
The purpose of today’s lecture is to provide an interactive session…
Objectives
At the end of this session, participants should be able to:
• Define and understand the differences, similarities, advantages and limitations of different available programs for affording medications.
• Appreciate the applicability of cost-effective prescribing to successfully control chronic disease in a homeless and primarily uninsured population, via collected data endpoints.
• Describe and evaluate an educational process for teaching residents and students how to utilize available resources to build efficient, economic prescribing habits.
INTRO
Case 1:Cost-effective Medicine
• 57 y.o WM with multiple medical problems: CAD, HTN, PVD, depression, psoriasis, CHF, high cholesterol
• Released from prison with 30 days of meds, went to prior cardiologist and given refills.
• Came to us for primary care and help with meds
Case 1
Medication Cost for 30 days
Nexium
Coreg
Asa
NTG
Toprol-XL
Plavix
Isordil
Cozaar
Crestor
Zoloft
Elidel
TOTAL
• Estimate cost as written?
• What would you do?
State of the economy and uninsured• Unemployment rate: 8.2%
– Every 1% in unemployment rate – 2.5million people lose their jobs and insurance
– “Options for Expanding health Insurance Coverage and controlling costs” – Congressional Budget Office, Feb. 25, 2009 (http://www.cbo.gov/doc.cfm?index=9911)
• One in five U.S. workers is uninsured– Robert Wood Johnson Foundation
• 80% of uninsured are part of a working household– “The Uninsured and Their Access to health Care” - Kaiser Family Foundation Fact Sheet, November
• uninsured adults have a 25% greater risk of premature death– Franks, Peter; Clancy, Carolyn; Gold, Marthe. “Health Insurance and Mortality. Evidence from a National
Cohort.” Journal of the American Medical Association, 27(6):737-741. 1993
• The poor health and shorter lifespan of the uninsured cost the U.S. economy between $102 and $204 billion in 2006
– http://www.newamerica.net/files/Cost_Of_Failure.pdf. Accessed March 27, 2008
Tell me about you:
• What kind of group do we have today?
• Pharmacists
• Residents/students
• Faculty MDs
• Other
How familiar are you with this topic?
• Very familiar – “I could lead this didactic”
• Somewhat familiar – “This is an important part of my practice”
• Un-familiar – “This is all new to me”
Do they know?:
• How many patients don’t know how much their meds cost until they pick them up?
A. 1/3
B. 1/2
C. 2/3
D. All of them
Do they know?:
• How many patients don’t know how much their meds cost until they pick them up?
How else do they afford meds?Risky patient behavior
• 28% of pts report taking measures to save money by:– NOT filling a prescription– Skip a dose– Take an expired medication– Cut pills in half– Share a prescription
• Which practice do they do most frequently?
Risky patient behavior
• 28% of pts report taking measures to save money by:• Failed to fill a prescription (16 percent). • Skipped a dose (16 percent). • Took an expired medication (11 percent). • Cut pills in half (10 percent). • Shared a prescription (4 percent)• 51% of hispanics do these things!• Separate study: 660 older adults: EACH admitted to
http://www.socialsecurity.gov - Application for help with medicare prescription drug plan costs
SENIOR CARE - state • Gov't pharmacy
assistance program • >65yo• will wrap around
Medicare Part D • 1-800-657-2038
Medicare Part D
• Covers Brand and generic drugs• Resources:
– http://www.medicare.gov OR 1-800-MEDICARE– Medicare Rights Center Part D Web page
• AAFP's Medicare Prescription Drug Coverage Web page – physician-focused information– a standardized Exceptions Request Form – Pharmacist-to-Physician Fax Form– links to the Medicare Prescription Drug Plan Finder.
• Formulary based on plan
Low-Income Subsidy (LIS)
• Medicare beneficiaries who also are eligible for Medicaid benefits:– Pay no prescription drug plan premiums– $0 deductible– $1/$3 per prescription cost-sharing ($0 in LTC)– No “coverage gap”– Income below $14,355 single/$19,245 couple– Assets below $10,000 single/20,000 couple
Apply for extra help through social security office:
www.socialsecurity.gov
1-800-772-1213
Drugs NOT Covered by Medicare
• Benzodiazepines• Barbiturates• Most OTC drugs• Rx vitamins and mineral products, except prenatal
vitamins and fluoride preparations• Agents used for symptomatic relief of cough and colds• Agents used for cosmetic purposes or hair growth• Agents used to promote fertility• Agents used for anorexia, weight loss, or weight gain• Drugs covered under Medicare Parts A or B
340b discounts• FQHCs• Provides discounts on outpt drugs to covered entities
when pt sees a provider of the covered entity– Limited to certain “safety net” hospitals and clinics
• They purchase outpt drugs at T19 rebate prices– Brands: 15% below AWP– Generics: 11% below AWP– Actual discount: 25-50% off AWP
• Eligible providers can dispense these meds:– In their own pharmacy – In their drug dispensary– Thru a contract w/a community pharmacy
• Help pts get access to programs they may be eligible for– Medicaid– Medicare– Va benefits– 340b programs
• Choose wisely• Choose generics or
OTC equivalents• Substitute w/in a
class• Cut pills in half• Utilize generic
programs/mail order• Use PAPs
Importance of generics…
• 65% of all prescriptions dispensed are generics• only account for 20% of all pharmaceutical expenditures. • Generics cost, on average, 30% to 80% less than their
brand counterparts. • Ave retail price of a generic prescription drug: $34.34. • Ave retail price of a brand name Rx drug: $119.31.
(Source: The National Association of Chain Drug Stores, 2006). • According to a 1998 study by the Congressional Budget
Office, generic drugs save consumers between $8 billion and $10 billion each year.
• How do people feel about generics?– They have reservations
• Think generics have:– Different side effects (27%)– Aren’t as effective (22%)– Don’t meet the same federal standards (18%)– Aren’t as safe as brand name (16%)
– regulatory action against the generic drug maker Ranbaxy Laboratories for falsifying data and test results at one of its manufacturing plants in India.
– FDA sent Genzyme Corp. a warning letter noting "significant deviations" in the manufacture of three branded drugs.
– 2008 Baxter International Inc. recalled certain branded versions of the blood-thinning drug heparin due to increased reports of adverse reactions
• 2004 through 2008: generic drug companies received slightly fewer FDA "warning letters" about problems complying with good manufacturing practices than did brand-name ones
• Generic companies demonstrate bioequivalence by undergoing the same rigorous FDA inspections as brand-name drugs
http://www.consumerreports.org/health/prescription-drugs/worried-about-generics/overview/worried-about-generics.htm and http://www.gphaonline.org/
• FDA – an effective safety officer?– Streamlined– Shortened approvals
• Pts – – enough of a trial to put it on the market?
• May miss unusual or significant side effects• Ex: rhabdo w/statins: 1 in 10,000• Chantix and psych effects
– Wait for more post-marketing experience– Are the pts similar to pts that I see?– Can we extrapolate to other pts?
• How many drugs have been FDA approved and later withdrawn from the market?– Vioxx, Bextra, Rezulin, RotaTeq…– 7 drugs removed since 1993 have been implicated in the deaths of over
1000 pts! – 2008 – NO WITHDRAWALS…
from Lasser KE, Allen PD, Woolhandler SJ, Himmelstein DU, et al. Timing of new black box warning and withdrawals for prescription medications. JAMA 2002;287:2215-2220
Aren’t the New Drugs worth the money?!
• In 2008: How many actual NEW ENTITIES approved?
• A. 10
• B. 20
• C. 30
• D. 40
Aren’t the New Drugs worth the money?!
• In 2008: How many actual NEW ENTITIES approved?
A. 10
B. 20
C. 30
D. 40– All the rest were Me-Toos, and “patent
extenders”
http://www.drugs.com/newdrugs.html and http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm
New and Improved?“Patent Extenders”
• New formulation– Gels, foams, patches
• New indication• New form
– ER, CR, DR• New drug: Ryzolt
– Isomer – Enantiomers– Pro-drugs – Combos
• Can be helpful for compliance, convenience, flexibility, and improved tolerability
Money-saving methods
• Help pts get access to programs they may be eligible for– Medicaid– Medicare– Va benefits– 340b programs
• Choose wisely• Choose generics or OTC
equivalents• Substitute w/in a class• Cut pills in half• Utilize generic programs• Utilize PAPs• Educate the pt and stay
up-to-date with their needs
Substitute within a class
• Have literature to support a class effect:– SSRIs (JAMA Dec 2001)– PPI’s all equivalent (Infopoems 2005)
• Many drug classes have similar actions and side effects
• Big chain solutions are problematic– Coupons for store merchandise– Generic programs– Free antibiotics (during “cough and cold” season)
• Their motivation:– To increase access to meds vs– To increase store sales
• Disadvantages – Price-shopping isn’t best for continuity– Not all Rx and OTCs at 1 pharmacy– Devalues the expertise and professional role of Pharmacists:
compliance, intx check, duplicate tx, coordination of med profile review
Wearing my Residency Faculty Hat: local pharmacy generic programs
• Kmart $10 - $15 for 90 days, $5 for 30days and some abx and topicals– https://pharmacy.kmartcorp.com/index.jsp
• WalMart/Sam’s Club - $4 - $9 for 30 days– http://www.walmartfacts.com/articles/4627.aspx
• No PPIs• Rarely XL, ER forms • Rarely covers combinations (Compliance)• Some doses not covered• Formulary varies• No controlled substances• Birth Control higher copays• Can change at any time
Mail Order Programs
• Rx Outreach– http://www.rxoutreach.
com/
– Can be NON-CITIZEN– Based solely on
income (no proof needed)
• < $32490 single• < $43,710 (2), etc
– $20 – 90 to 180 days supply
– Up to $95 for 90 days of some meds
• Xubex• http://www.xubex.com/• Must be US resident• offer diabetes kits• Other chronic illness
services offered• New “30 day free”
– Part of brand discount pgm– 1 -2 wk turnaround– Auto-refills
• Patient has no income or is significantly below the poverty level (250%)
• Patient still needs to prove financial need
• Patient needs to supply copy of last Federal tax return, letter of denial for Medicaid, and/or statement of Benefits from SSA
PAPs: pros/cons
• Benefits:– Expands the access to new, expensive meds– Better med compliance– Gives us another resource
• Challenges:– Requirements change w/out notice– Unrealistic income documentation req’ts– Need to track and reapply – takes time/effort/personel– Each company has different forms
Discount Rx Cards – from manufacturers
• Can help w/co-pays, or can discount branded products
• 200-250 visits per month• Estimated 6000-8000 people experiencing
homelessness in Balt County in a given year
• full scope primary care• Full range of medical needs and
conditions• HRSA grant provides some funding for
medication needs
Paying for Medications
• Comprehensive assessment of patients ability to contribute to Rx costs– Income from various sources– Need to take some responsibility for health– Encouragement to decrease smoking etc– Varying terms of coverage of Rx costs by
clinic
• Utilize all methods discussed in presentation to cover
Wal-Mart Stores (WMS)
• Contracted with WMS to provide prescription “plan” and bill HCH for costs monthly
• Brand name: AWP-13%
• Generic: AWP-45%
• $4 list
• 50 cent administration fee per rx
Importance of generics…
• 65% of all prescriptions dispensed are generics• only account for 20% of all pharmaceutical expenditures. • Generics cost, on average, 30% to 80% less than their
brand counterparts. • Ave retail price of a generic prescription drug: $34.34. • Ave retail price of a brand name Rx drug: $119.31.
(Source: The National Association of Chain Drug Stores, 2006). • According to a 1998 study by the Congressional Budget
Office, generic drugs save consumers between $8 billion and $10 billion each year.
• We pay rx costs for 70-80 pts per month**• Average total bill $1527 per month• Average 136 rx written/mo to walmart• 775 generic of 819 total= 95% generic• Average cost per rx:
– Freestyle Meters and strips:• Abbott pt assistance program• http://www.abbottpatientassistancefoundation.org
– Charles Ray III Diabetes Association• http://www.charlesray.g12.com/
• Where to get free syringes/pen needles– BD– http://www.bddiabetes.com/us/hcp/index.aspx – http://www.bddiabetes.com/us/hcp/main.aspx?cat=3066&id=3122
• Disability denied, despite detailed notes on affect of AODL’s
• F/u visit, vision worsened. Now 20/400 in both eyes• Case manager success: Eyecare America—legally blind
Also called disability. They said file an amendment• Ophtho exam covered (also church member) • Now anticipate both qualifying for disability, and getting
surgery! Either she’ll get benefits so have medical coverage, or she’ll get surgery and be able to return to work.
• Persistence!
Case 4
• 35 year old female
• GERD, depression, chronic back pain
• Also c/o yeast infection and desires birth control
• In shelter with husband and 2 children
• Husband is employed under the table, makes $250 per week
Case 4
• Sprintec ($9)• Fluconazole ($4 for 1 tab)• Famotidine (4)• Citalopram 40mg (4)• Tramadol (4)• Ibuprofen (4)• Cyclobenzaprine (4)• Total=$33• We paid half of costs, pt to pay other half
Great Resources…Consumer Reports Best Buy Drugs Project provides
“consumers and their doctors with information to help guide prescription drug choices–based on effectiveness, a drug's track record, safety and price”
www.drmichael.com– Author of “Drugs for Less”– Website covers what we won’t get into here today:
buying online, comparing prices, buying in bulk, going to canada
– www.fda.gov/oc/buyonline/default.htm - using online pharmacies