Vs. Learning Objectives. Food or Drugs? Pharmacotherapy 5/1/2013. Medication Resources for the Underinsured. Jodie Elder, PharmD, BCPS May 7, 2013

Transcription

1 Pharmacotherapy on a Dime: Medication Resources for the Underinsured Jodie Elder, PharmD, BCPS May 7, 2013 Learning Objectives Identify medication assistance resources for the uninsured or underinsured Compare the strengths and limitations of generic programs, 340B pricing and prescription assistance programs Given a patient scenario, recommend an affordable treatment regimen Food or Drugs? Vs. Inability to pay for drugs premature death, loss of work time and decreased quality of life Costs fall on local hospitals Low cost or free meds improve adherence Decrease hospitalizations and ED visits References 1 5 1

2 Cost of Nonadherence Both insured and uninsured patients have reported cutting back on doses or not filling Rx Increased ED visits and other unnecessary health care use Estimated to cost US healthcare system up to $100 billion /year References 6 9 Focus on Low Income Uninsured About 70% of Michigan s uninsured population 1,250,584 people have incomes below 200% of the Federal Poverty level (FPL) * Rough Reference 10 5 Medication Resources Generic drug Programs Pharmacy based discount program 340 B pricing Prescription Assistance Programs County Health Plans Other Resources 2

3 Generic Drug Programs Deeply discounted medication (DDM) list By 2008, 70 million Americans had obtained at least one prescription from DDM Major pharmacy chains and retailers Pricing war started in 2006 ( Kmart, Wal Mart) Membership and/or fee required 30 or 90 d supply for $4 or $10 loss leaders Reference Who is Using Generic Programs? Wal Mart estimates 30% of $4 list customers are uninsured Same price to all patients regardless of insurance status 1/3 of top 100 generics ( from Top 200) are on Walmart s program Many include approx 300 medications Cardiovascular, analgesic antidepressant, antibiotic, antidiabetes, oral contraceptives Reference 11,14 Generic Drug Programs Chronic Disease meds Thiazide like diuretics ACE I Beta blockers Metformin Loop diuretics Other CV Pravastatin SSRI s Oral contraceptives Acute Meds NSAIDs Antibiotics Antifungals Allergy, cold & flu Topicals Muscle relaxants cyclobenzaprine 3

4 What s Missing? Asthma/ COPD controller meds Atypical antipsychotics ARBs Insulin Wal Mart has ReliOnN, R and 70/30 for $24.88 Diabetes testing supplies Prime Meter $16.24 (Wal Mart) Prime Strips 50 ct $9.00 Generic Drug Programs Concerns Potential for suboptimal prescribing? Inappropriate meds Most the drugs are effective a la carte pharmacies Incomplete medication profiles 90 day supply waste VA study compared benefit of 30 vs 90 day 5% of prescriptions d/c d within 90 days of initiating Reference 12 Generic Programs Limitations Meds do not count toward donut hole Need studies to determine if avoiding urgent care or hospitalizations Insurers and PBMs can t do DUR or disease management Long term implications? 4

5 340B Drug Pricing Program Provide discounts on outpatient prescription drugs to select safety net providers Front end discounts Same discount as rebates to state Medicaid 15 60% savings on drug costs using 340B program for health centers Pts > 200% FPL = full pay Pts % FPL= sliding fee scale Pts < 100% FPL= minimal charge Reference 15 Example 340B Price Calculations Generic/ OTC drugs Average Manufacturer Price (AMP) 13% List price is $15; AMP $10 340B: 10 13% or $8.70 ( 58% of list price) Brand name drugs AMP 23.1% OR best price (whichever lower) List price is $30; AMP is $20 340B: $ % or $15.38 (51.3% list price) Reference B Programs Limitations 340B prices recalculated quarterly Health centers that use a wholesaler may face additional fees Must be patients of the qualifying entity to get 340B pricing Health centers are responsible for making sure no double dipping occurs with Medicaid rebates 5

6 Prescription Assistance Programs (PAPs) Provide access for uninsured and unable to pay for meds Income from % of Federal Poverty level 82% of Top 200 entities offered by PAPs Health care institutions can reduce bad debt by implementing their own PAPs. Reference 16 Prescription Assistance Programs (PAPs) Qualification standards Many exclude insured or Medicare Part D patients Citizenship Income Submission criteria Mail, fax, online Supporting documentation required Tax returns, bank statements, award letters Provider Costs for PAP Programs Medical assistants completed applications Personnel time (more than half of cost) Supply/submission costs Total application costs Average was $25.18 Range: $7.73 to $58.13 Average time to complete forms was 6 min 20 sec Range : 3 min to 34 min Reference 17 6

7 Evidence for PAPs Clinical disease indicators and adherence Review of literature of PAP programs Significant improvement in A1c and LDL Economic evaluations suggest PAP medications offset health care institutions cost for uncompensated medications Heterogeneous data More rigorous research needed to establish clinical and cost effectiveness Reference 18 Assistance Programs Limitations Complex process 2 8 weeks processing 3 month supply Delivery of medication Many require quarterly application Little incentive for health professionals Medicare Part D? County Health Plans Adult Benefits Waiver (Plan A) Age Household of 1= $594 / month Household of 2= $731/ month $1 copay on medications Meds < $35 per month do not need PA Requires PAP utilization for some medications $0 copay on medical supplies Open enrollment in April 7

8 County Health Plans Kent Health Plan B Income < or= 150% poverty Not eligible for any government sponsored healthcare program Non U.S. citizens ARE ELIGIBLE Prescriptions $4 generic $10 Brand Some brand drugs require PAP Some covered up to 90 days through community medical fund County Health Plans Limited access to care/ clinics Enrollment limitations Not really insurance Patients may have to go to the health plan office to get glucose meter Limited list of participating pharmacies YMCA Veggie Van Funded by 1.5 million grant from the WK Kellogg Foundation Lifestyle Resources for Patients Mobile farmers market Once a week, several stops in Grand Rapids Fresh fruits and vegetables Reduced cost Bridge card and WIC double dollars 8

9 Other Resources Lists drug assistance programs by state Public & private programs that offer discounted or free meds 888 ASK HRSA ( community health centers) (Area on Aging) Discount cards GSK orange Card; LillyAnswers Card; Pfizer for Living Card; TogetherRx Card See needymeds.com/discountcomp.html More Useful Websites Lists PAP programs and discounts available Includes eligibility criteria and application form Free resource links to formularies for Medicaid, commercial and Medicare Part D plans Includes links to many prior auth forms Conclusions Identify patients in need direct questioning Develop a treatment plan with the patient Accept imperfection Document, provide patient with drug list Follow up Collaborate with other providers Cost effectiveness comparisons 9

10 Questions? References 1. Parker Oliver D, Crandall L. Medication Assistance program: University of Missouri Health Care Dpeartment of Social Services. Health Soc Work. 2002;27: Heisler M, Langa KM, Eby EL et al. The health effects of restricting medication because of cost. Med Care. 2004;42: Chishom MA, Dipiro JT. Pharmaceutical manufacturer assistance programs. Arch Intern Med. 2002;162: Strum MW, Hopkins R, West DS et al. Effects of a medication assistance program on health outcomes in patients with type 2 diabetes mellitus. Am J Health Syst Pharm. May 15k 2005;62(10): Dent LA, Stratton TP, Cochran GA. Establishing an on site pharmacy in a community health center to help indigent patients access medications and to improve care. J Am Pharm Assoc 2002;42: Kaiser Family Foundation. Prescription drug costs. Available at: modules/prescrition drug costs/background.aspx 7. Piette JD, Heisler M, Wagner. Cost related medication underuse among chronically ill adults. Am Journ Pub Health.2004;94(10): Osterberg L, Vlaschke T. Adherence to medication. N Engl J Med. 2005;353(5): Salas M, Hughes D, Zuluaga A et al. Costs of medication nonadherence in patient swith diabetes mellitus: a systematic review and critical analysis. 10. The Uninsured in Michigan: A Profile. Accessed at _ ,00.html 11. Rucker L. $4 generics: How low, how broad, and why patient engagement is priceless. J am Pharm Assoc. 2010;50: Czechowski JL, Tjia J, Triller DM. Deeply discounted medications: implications of generic prescription drug wars. J Am Pharm Assoc. 2010;50; National Conference of State Legislatures. Generic drug pricing and states. 14. London P. J Am Pharm Assoc. 2010;50: National Association of Community Health Centers Section 340B drug pricing program b drug pricing program.cfm 16. Chu C, Lal LS, Felder TM et al. Evaluation of patient assistance program eligibility and availability for Top 200 brand and generic drugs in the United States. Innovations in Pharmacy 2012;3(1): Clay PC, Vaught E, Glaros A, et al. Costs to physician offices of providing medications to medically indigent patients via pharmaceutical manufacturer prescription assistance programs. J Manag Care Pharm.2007;13(6): Felder T, Palmer N, Lal L, et al. What is the evidence for pharmaceutical patient assistance programs? A systematic review. NIH Public Access Manuscript. Published in J Health Care Porr Underserved. 2011: