Cost-effective treatment of chronic disease for the uninsured underinsured

Cost-effective treatment of chronic disease for the uninsured/underinsured patient STFM April 30, 2009 Beth Musil, Pharm. D, Faculty Pharmacist Racine 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 Nexium Coreg Asa NTG Toprol-XL Plavix Isordil Cozaar Crestor Zoloft Elidel TOTAL Cost for 30 days

• Estimate cost as written? • What would you do?

State of the economy and uninsured • Unemployment rate: 8. 2% – Every 1% in unemployment rate – 2. 5 million 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 2004 http: //www. kff. org/uninsured/upload/The-Uninsured-and-Their-Access-to-Health-Care-Oct-2004. pdf 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? A. 1/3 B. 1/2 C. 2/3 D. All of them http: //www. consumerreports. org/health/prescription-drugs/sticker-shock-at-thepharmacy-counter/overview/sticker-shock-at-the-pharmacy-counter. htm

Why don’t they know? • A. B. C. D. How often do MDs talk about cost when prescribing during the patient visit? 1/3 of the time ½ of the time 2/3 of the time Every time Doctors Don’t Talk About Cost American J Managed Care Nov

Why don’t they know? • A. B. C. D. • How often do MDs talk about cost when prescribing during the patient visit? 1/3 of the time ½ of the time 2/3 of the time Every time Pts asked about cost or insurance only 2% of the time Doctors Don’t Talk About Cost American J Managed Care Nov

Why don’t they ask? www. chcf. org/documents/chronicdisease/Rx. For. Affordability. Helping. Patients. Cope. pdf

How do they afford Rx’s? • What are people doing to pay? A. Spend less on items such as clothing B. Cut back on groceries C. Rely more on credit cards D. Postpone paying other bills • What would you do?

How do they afford Rx’s? • What are people doing to pay? A. Spend less on items such as clothing (30%) B. Cut back on groceries (23%) C. Rely more on credit cards (23%) D. Postpone paying other bills (15%) http: //www. consumerreports. org/health/prescription-drugs/sticker-shock-at-thepharmacy-counter/overview/sticker-shock-at-the-pharmacy-counter. htm

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 underusing their meds due to affordability 1. Piette JD, Heisler M, Wagner TH. Cost-related medication underuse: do patients with chronic illnesses tell their doctors? Arch Intern Med. 2004; 164: 1749 -1755 http: //www. consumerreports. org/health/prescription-drugs/sticker-shock-at-thepharmacy-counter/overview/sticker-shock-at-the-pharmacy-counter. htm

Medication Access • How much are you willing to spend per month on drug therapy? – Copays – Cash pay • How do your patients afford to get their medications? • How many of your patients do not fill their medications monthly (or at all) due to the costs?

Methods

So, what can we do? • LEARN about safe money-saving alternatives • TALK to the patients • Individualize med therapy with costs in mind (just like safety, efficacy, tolerability, etc)

So what can we do? • EDUCATE learners – Residents – Students – Colleagues – Staff – Collaborators – Patients

How to teach residents effectively? Strategies to improve assessment of pt’s ability to pay: • pharmacist to help with medication review and MTM • Informatics/EMR prompts (? )/standardized protocols/forms • Education – – Inservices Newsletters Reminders in the room Internal presentations • Continuous interventions/feedback: – Pharmacist in clinic – visual reminder… – Get rid of the samples! – Performance Feedback Dobesh PP, Stacy Z. J Managed care Pharm 2005; 11: 755 -62 Labarere J et al. J Intern Med. 2004; 256: 338 -48 Kucher N et al. N Engl J Med. 2005; 352: 969 -77

High Reliability Strategies • Every intervention should use at least one: – Decision aids and reminders built into the system and presented at point of care (part of the workflow) • Drug pricing binder in clinic • Pharm. D in clinic. . • Discussion of costs EVERY opportunity – Algorithms/protocols built into standardized order sets – Making the desired action the default – Redundancy

Teaching the residents • Didactic intro: – Identify pts in need of assistance – Local matching • • • Non med programs med-specific assistance Govt programs Local overview Teach ubiquitous economic prescribing • Point of Care – Encourage pt to bring meds at every visit – Using the generic program sheets – Helping pts w/PAP paperwork • • Grant help Designated office personnel Med Advocates or med. Bank Teach the staff too! – Handouts in every room

Money-saving methods • Lifestyle changes – Free • Help pts get access to programs they may be eligible for – Medicaid – Medicare – VA benefits – 340 b programs – Canada? • Choose wisely • Choose generics or OTC equivalents • Substitute w/in a class • Cut pills in half • Utilize generic programs, mail order • Use PAPs

2009 Poverty Guidelines for 48 contiguous States and District of Columbia Persons in Family Poverty Guideline 1 $10, 830 2 $14, 570 3 $18, 310 4 $22, 050 5 $25, 790 6 $29, 530 7 $33, 270 8 $37, 010 For families > 8, add $3, 740 for each person http: //aspe. hhs. gov/poverty/09 poverty. shtml

Government Programs • • Veterans Benefits Great Rx Coverage Limited formulary Progressive Pharmacist involvement • http: //www. pbm. va. go v/default. aspx • 1 -877 -222 -VETS • Native Indian tribes • Purchase at large discounts • Pequot Pharmaceutical Network: http: //www. prxn. com

T 19: MEDICAID: A federal and state program for those w/limited resources • US citizens or resident legal immigrant • Eligibility different by state – – Limited income Pregnant Have children or teenagers at home > 65 yo, blind and/or disabled • http: //www. cms. hhs. gov/home/medicaid. asp • Formulary restrictions – state specific: – http: //www. Fingertipformulary. org – http: //www. Epocrates. org • Rx’s – pt pays a $1 - $3 co-pay

Our State: Senior. Care FOR SENIORS • • • MEDICARE - federal US Residents > 65 yo Disabled, ESRD 1 -800 -MEDICARE http: //www. medicare. gov http: //www. socialsecurity. gov - Application for help with medicare prescription drug plan costs SENIOR CARE - state • Gov't pharmacy assistance program • >65 yo • will wrap around Medicare Part D • 1 -800 -657 -2038

Medicare Part D • Covers Brand 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

340 b 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 T 19 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 • Resources: – www. hrsa. gov/opa http: //pssc. aphanet. org

Money-saving methods • Help pts get access to programs they may be eligible for – Medicaid – Medicare – Va benefits – 340 b 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. • 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. http: //www. gphaonline. org/

Generic price differences overnight Drug Onset Duration 30 day $ Estazolam (prosom) 15 -30 min Intermediate $25 Eszopiclone (Lunesta) Zaleplon (Sonata) 30 min Intermediate $165 20 min Ultrashort $12 Brand: $141 Zolpidem 30 min (ambien) Zolpidem CR 30 min (Ambien CR) Short $18 Short $126 Zolpidem OS 15 min (Zolpimist) Short ? ?

Generics of 2008 • • • • • Cetirizine (Zyrtec) Dextroamphetamine elixir (Dexedrine) Calcium Acetate (Phoslo) Cefuroxime oral susp (Ceftin) Alendronate (Fosamax) Pramipexole (Mirapex) Granisetron oral soln (Kytril) Prenisolone Oral soln (Orapred) Clobetasol foam (Olux) Levalbuterol inh soln (Xopenex) Fluorouracil cream (Efudex) Estradiol/norethindrone (Activella) Donepezil (Aricept) Ramipril (Altace) Venlafaxine (Effexor) Dorzolamide (Trusopt) Dorzolamide & timolol opth (Cosopt) • • • • • Budeprion XL (Wellbutrin XL) Ropinirole (Requip) Calcipotriene (Dovonex soln) Acarbose (Precose) Drospirenone and EE (Yasmin) Fluoxetine (Sarafem) Zaleplon (Sonata) Ciclopirox gel (Loprox) Dronabinol (Marinol) Risperidone (Risperdal) Nicoldipine ER (Sular ER) Mycophenolate (Cellcept) Divalproex DR (Depakote) Eplerenone (Inspra) Galantamine (Razadyne) Pantoprazole (Protonix) Lamotrigine (Lamictal) http: //www. drugs. com/generic-approvals. html and http: //www. accessdata. fda. gov/scripts/cder/drugsatfda/index. cfm? fuseaction=Reports. Re ports. Menu

There’s hope: Patent Expirations for 2009 • Fluticasone and salmeterol (Advair) • Venlafaxine XR (Effexor XR) • Tacrolimus (Prograf) • Topiramate (Topamax) • Stavudine (Zerit) • Ketorolac (Acular) • Anastrozole (Arimidex) • Rosiglitazone (Avandia) • • Sumatriptan (Imitrex) Levetiracetam (Keppra) Lansoprazole (Prevacid) Valacyclovir (valtrex) Orlistat (Xenical) Tamsulosin (Flomax) Miglitol (Glyset) Moxifloxacin (Avelox) http: //www. drugpatentwatch. com/

How do I find out what is going generic? • FDA: – http: //www. fda. gov/cder/ogd/approvals/default. htm – http: //www. accessdata. fda. gov/scripts/cder/dr ugsatfda/index. cfm? fuseaction=Reports. Repo rts. Menu • Drugs. com: – http: //www. drugs. com/generic-approvals. html • Direct email Newsletter: – http: //www. Drug. Patent. Watch. com/newsletter

Barriers to generics • 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%) http: //www. consumerreports. org/health/prescription-drugs/sticker-shock-at-thepharmacy-counter/overview/sticker-shock-at-the-pharmacy-counter. htm

Are they right? • Feb 2009 FDA action: – 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-aboutgenerics/overview/worried-about-generics. htm and http: //www. gphaonline. org/

Safety: are the “new drugs” better? • 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, Rota. Teq… – 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 – 340 b 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

Examples: Antihists and PPIs: Approx cost 30 day Generic (Brand) Cetirizine (Zyrtec) 10 mg $10 OTC Deslansoprazole ? ? (new) (Kapidex) Esomeprazole (Nexium) 40 mg $160 Lansoprazole (prevacid) 30 mg $168 Fexofenadine $80 (Allegra) 60 mg $60 -180 mg Omeprazole (Prilosec) 20 mg $20 OTC $15 OTC Loratadine (Claritin) 10 mg Pantoprazole (Protonix) 40 mg $125 Rabeprizole (Aciphex) 20 mg $179 Desloratadine $125 (Clarinex) 5 mg http: //www. drugstore. com

Pill Splitting… • Opposed by AMA and APHA and drug companies – studies to date have not shown any adverse impact on health • CR Best Buy Recommends: – – NOT safe for all drugs Only Half-split (no 1/3, ¼) ONLY the day of (degradation) Use a pill-splitter, NOT a knife • Allows pt to buy 2 doses for the price of 1 • Works best for drugs that have the same cost regardless of dose: – Statins: Atorvastatin same cost for all dosages – Toprol XL http: //www. CRBest. Buy. Drugs. org “Shoppers Guide to Prescription Drugs “pill splitting”

Which ones? • • NOT to be split: – – – – Chemo Anti-sz meds OCPs Blood thinners Capsules ER, CR, XL, etc Coated pills Bitter tasting, strong colors/dyes BEST BUY “safe pills to cut” list: – – – – – – Amlodipine (Norvasc) Atenolol (Tenormin) Atorvastatin (Lipitor) Citalopram (Celexa) Clonazepam (Klonopin) Doxazosin (Cardura) Finasteride (Proscar) Levothyroxine (Synthroid) Lisinopril (Zestril) Lovastatin (Mevacor) Metformin (Glucophage) Metoprolol (Toprol) Nefazodone (Serzone) Olanzapine (Zyprexa) Paraxetine (Paxil) Pravastatin (Pravachol) Quinapril (Accupril) Rosuvastatin (Crestor) Sertraline (Zoloft) Sildenafil (Viagra) Simvastatin (Zocor) Tadafil (Cialis) Vardenafil (Levitra)

Generic Programs: Wearing my “pharmacist” hat • 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 30 days and some abx and topicals – https: //pharmacy. kmartcorp. com/index. jsp • Wal. Mart/Sam’s Club - $4 - $9 for 30 days – http: //www. walmartfacts. com/articles/4627. aspx • Target - same – http: //sites. target. com/site/en/health/page. jsp? content. I d=PRD 03 -004319 • Walgreens – membership discounts – https: //webapp. walgreens. com/MYWCARDWeb/servl et/walgreens. wcard. proxy. WCard. Internet. Proxy/Rx. Sav ings. RH? • Local pharmacies: strike a deal…

Drug Classes Covered • • • Allergy Analgesics Anti-inflammatory Antibiotics Antidepressants Antifungal Antipsychotic Antiviral Anxiety Asthma Cardiac • • • Cholesterol Cough/cold Diabetes Gastrointestinal Glaucoma Hormone Oncology Parkinson's Seizure Thyroid Vitamins

Limits • • 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

Samples and Grant monies • Short term solutions; inconsistent supply – Local Grants – Samples: best use is to start a pt w/samples, then once stabilized have them sign up for PAP if eligible • Broader grant applications

Programs: putting it all together • These websites provide info on all PAPs, eligibility guidelines, application forms, faq, etc – www. pparx. org – www. rxassist. org (account required) • Has a learning center w/webnars, Qn. A w/experts, list-serve, “how-to” guides on starting med access program – www. helpingpatients. org – www. needymeds. org • Recently updated to have more resources – http: //Internetdrugcoupons. com – http: //www. ashp. org/Import/Practiceand. Policy/Practic e. Resource. Centers/Patient. Assistance. Programs. aspx

Pharmaceutical Assistance Program Requirements • Controlled and funded by drug companies • 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 • All have different limits • Examples: – http: //www. Together-rx. com • Abbott, astrazeneca, aventis, BMyers, GSK, Janssen, Novartis, Ortho-Mc. Neil – Pfizer Pfriends Card • 1 -866 -706 -240 – http: //www. lillyanswers. com – Many others – Med. Bank US

Patient’s Helping Themselves Phone calls they can make: • Pparx – Partnership for Prescription Assistance – 1 -888 -4 PPA-NOW – Brochure available to handout in English and Espanol – www. pparx. com • Local programs: – Med Advocates – Safety Net providers – 3 rd party to help pts sign up for PAPs for a minimal fee • Med Bank – Baltimore model example

ONLINE “comparison shopping” options for price shopping • Sites that will give you the prices at different pharmacies in your zip code: – Http: //www. Medtipster. com • • Also has live chat w/Rph Nationwide pricing Leaves out some independents Can be a month old – http: //cu. destinationrx. com • Via zip code • inconsistent • Always check an online pharmacy’s standing with the National Association of Boards of Pharmacy at www. nabp. net

Insured but cannot afford co-pays: Resources • Patient Services, Inc. 800 366 -7741 www. uneedpsi. org • Caring Voice Coalition 888 267 -1440 www. caringvoice. org • Patient Access Network 866 316 -7263 www. patientaccessnetwork. org • Chronic Disease Fund (877) 968 -7233 www. cdfund. org.

Med. Bank of Maryland… • • Clearing house for PAPs Onsite pharmacies in MD 3 day turnaround for on-site meds $10 admin fee (per person, per month) – Can be waived for hardship • Funded by state, private foundations, donations, admin fees, local governments • www. medbankmd. org www, medbankus. org

Take-Home TOOLS: comparison sheets: generic formularies: • http: //aheconnect. s 3. amazonaws. com/kov al/pdcb. pdf • Modifiable sheet at FMDRL: (mine) – Excel spreadsheet • Cheat sheet • By class • alphabetical

Real life application: Healthcare for the Homeless Baltimore County • 3 year HRSA grant • Opened 1/08 – 2500 patient visits to date – men, women, children – 20% insured at time of presentation (Medicaid, Medicare) – 20% employed at time of presentation • 2 exam rooms, EMR, 0. 9 PA, 0. 3 NP, 0. 8 MD (0. 2 clinical), case manager (0. 75)

HCH BC background • 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. • 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. http: //www. gphaonline. org/

WMS statistics: 6 mo analysis • • • 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: – Generic: $8. 30 – Brand: $25. 41 – Combined average: $10. 61 (includes $$$$meds) • Average 2. 5 rx per pt=average $25 per pt • Admin costs are 4. 5% of bill (average $65 per mo)

Lessons learned • Can further improve our costs: – – – – – Proair vs Relion ventolin MDI (75% of errors in last 3 months) lovastatin 40 mg (no) 10/20 mg yes, simvistatin Metroprolol tartrate 50 ($4) vs succinate ER 50 ($57) Amlodipine PPI Insulin Lexapro Diclofenac 50 (no-$40), diclofenac 75 (yes-$4) Citalopram 10 (no-$49), vs 20/40 (yes) • Provider education needs to be ongoing – New providers, residents, students – Gradual complacence due to perceived familiarity with $4 list • Wal-mart pharmacist education about process • Patient Education! • Continue to pursue eligibility for benefits if appropriate

Chronic Disease Outcomes • Difficult to study in this population – Transient/long term data difficult – Difficulty in testing endpoint: cholesterol, Hgb. A 1 C due to costs of labs – Pt concern about getting bills, even if charges written off – What happens when they get care elsewhere (less educated providers/more $$ rx) – Pt priority is usually housing/income instead of health

Chronic Disease Outcomes • General Observations: suggestions of improved control – Decreased ED visits for both acute and chronic conditions • Mental health conditions • Hyperglycemia • HTN, Chest pain/CAD – Patients getting refills at predicted times – Improvement in office based outcomes: BP, foot exam, immunization rates (peumovax), office Hgb. A 1 C

Case 1 Medication Cost for 30 days Nexium $150 Coreg $132 Asa $4 NTG $10 Toprol-XL $36 Plavix $136 Isordil $93 Cozaar $66 Crestor $109 Zoloft $100 Elidel $82 TOTAL $918

Case 1: outcome Medication Cost for 30 days Alternative Med Cost for 30 days Nexium $150 ranitidine $4 Coreg $132 carvedilol $4 ASA--same $4 NTG $10 NTG--same $4 Toprol-XL $36 stopped $0 Plavix $136 Plavix ** Samples and PAP Isordil $93 isosorbide $4 Cozaar $66 Lisinopril $4 Crestor $109 Pravastatin $4 Zoloft $100 Citalopram $4 Elidel $82 Fluocinonide $4 TOTAL $918 TOTAL $36

Case 2 • 29 yo female with h/o depression, recently diagnosed bipolar, chronic knee pain, placed on Seroquel by psych after ED visit • Also on Ultram, Zoloft

Case 2 • How much does seroquel cost? • What are alternative bipolar meds and what are their costs? • History elements from patient that would be relevant? – When diagnosed? – What meds tried? – income? Living situation? – Did she fill seroquel? Stable?

Case 2: outcome • d/c seroquel (: pt had not even filled rx, and had never been on this med. Bipolar dx was new. 100 mg bid=$273/mo • Start VPA: 250 tid=$45/mo • Tramadol at wal mart: $17 vs $4 • D/c sertraline (100 mg=$16). Change to citalopram ($4) • Assess degree of debilitation from bipolar. ? eligible for disability • $53/mo versus $306

Case 3 • 58 year old female: DM, HTN, bipolar, c/o poor vision • Uninsured, lives in shelter, no income. • Motivated to be employed, but quit 2 jobs recently b/c of vision (one was in a deli— couldn’t read orders to make sandwiches) • Has not been taking any of her meds for few months, but bipolar was well controlled in past on VPA and trazadone

Case 3 • Initial presumption that poor vision due to uncontrolled DM. Exam suggested cataracts. • 20/400 , 20/70 vision • Restarted meds: metformin (4), lisinopril (4), VPA (40), trazadone (4) • Meter and testing strips • Checked office A 1 C: 7. 2 • Completed disability paperwork based on inability to work based on vision

Practical Applications: sources for DM supplies • Overview of all charitable resources for DM pts: – http: //www. isletsofhope. com/diabetes/assistance/main_1. html • Where to get free meters, test strips: – Accucheck • Meters: customer care: 1 -500 -858 -8072 option 3 • Test strips: Roche Pt Asst: 1 -866 -441 -4090 – Freestyle Meters and strips: • Abbott pt assistance program • http: //www. abbottpatientassistancefoundation. org – Charles Ray III Diabetes Association • http: //www. charlesray. g 12. 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

Case 3: outcome • 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 2 children • Husband is employed under the table, makes $250 per week

Case 4 • • • Sprintec ($9) Fluconazole ($4 for 1 tab) Famotidine (4) Citalopram 40 mg (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

THE END

Thanks! Any questions?

Contact Info • Beth Musil: – bmusil@mcw. edu – 262 -687 -5675 • Melly Goodell – Melly. goodell@medstar. net – 443 -777 -2310