the big bang (for your buck) theory: establishing value in prescribing medications advanced practice...

Lawrence Carey, PharmD - Christiana Keynote 2014

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The Big Bang (for your buck) Theory: Establishing Value in Prescribing Medications

Advanced Practice Nurse Council APN Pharmacologic Update 2014

Lawrence Carey, PharmD Associate Professor, Temple University School of Pharmacy

________________ Lecturer in Pharmacology/Pharmacotherapeutics

University of Pennsylvania School of Nursing


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Objectives

• List cost-related barriers to successful prescribing

• Identify assistance programs leading to successful obtaining of prescription medications

• Discuss successful strategies utilized to assure sound pharmacotherapeutic regimens based on cost

Lawrence Carey, PharmD 3

Setting The Table


Specific Drug Numbers

• Total yearly drug spending: $325.8 billion• Biggest gains:– Mental health, nervous system disorders, pain,

respiratory agents• Largest declines: – Allergy therapies, antibacterials, osteoporosis

agents• Generic drugs: used in 84% of all prescriptions– This is 28% of total prescription spending


Most Popular CategoriesRank Categories Approximate # of

Prescriptions1 Cardiac 155,000,000

2 Pain management (short-term, acute) 150,000,000

3 Thyroid 96,000,000

4 Antibiotics 46,000,000

5 Respiratory 43,000,000

6 Psychiatry 39,000,000

7 Gastrointestinal 22,000,000


Top Drugs…By PrescriptionsRank Drug Approx # of Prescriptions

1 Hydrocodone/Acetaminophen 129,068,000

2 Levothyroxine or Synthroid® 96,309,000

3 Azithromycin 46,337,000

4 Lisinopril 42,621,000

5 Simvastatin 27,955,000

6 ProAir HFA® 25,384,000

7 Crestor® 25,325,000

8 Nexium® 22,286,000

9 Atorvastatin 22,229,000

10 Ibuprofen 21,560,000


Top Drugs…By PrescriptionsRank Drug Approx # of Prescriptions

11 Trazodone 21,186,000

12 Metoprolol 20,646,000

13 Warfarin 19,173,000

14 Cymbalta® 18,891,000

15 Fluticasone propionate 18,502,000

16 Singulair® No data available

17 Hydrochlorothiazide No data available

18 Advair Diskus® No data available

19 Pravastatin No data available

20 Amoxicillin No data available


Top Ten Drugs…By DollarsRank Drug Dollars

1 Nexium® $5,989,000,000 2 Abilify® $5,870,000,000 3 Crestor® $5,092,000,000 4 Advair Diskus® $4,889,000,000 5 Cymbalta® $4,720,000,000 6 Humira® $4,609,000,000 7 Enbrel® $4,337,000,000 8 Remicade® $3,876,000,000 9 Copaxone® $3,581,000,000 10 Neulasta® $3,460,000,000


Top 11-20 Drugs…By DollarsRank Drug Dollars

11 Singulair® $3,300,000,000 12 Rituxan® $3,197,000,000 13 Plavix® $2,971,000,000 14 Atripla® $2,899,000,000 15 Spiriva Handihaler® $2,833,000,000 16 Oxycontin $2,808,000,000 17 Januvia® $2,670,000,000 18 Avastin® $2,661,000,000 19 Lantus® $2,327,000,000 20 Truvada® $2,305,000,000


Surprises

• Where are all the diabetes drugs?– In terms of total spending, anti-diabetes drugs

garner approximately $22 billion• Metformin is the first diabetes drug to appear on list at

#40 of generics• However, Januvia® appears at # 17 of brand-only list

with Lantus® at # 19 of dollars list

• Mental health: $23 billion– This is third on all-spending list, but not on the top

ten generic list


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Forbes, 8/11/13

• Study: 95% of new medicines fail to be safe AND effective– Lots of strikeouts– But if you hit a home run…it’s a grand slam!


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Great news for big pharma.

But how do I get these medications for my patient, if cost is an issue?


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Cost-Related Barriers

• Estimates: 47 million people in USA have no prescription coverage

• Medicare Part D’s coverage gap (“the donut hole”) may mean patients skip their medications rather than pay out-of-pocket– Estimates: 15% of people skip at this point

• Prescription costs are spiraling out of the reach of many patients

• Help is too complicated for patients to follow!Kaiser Family Foundation


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Top 5 Drugs, One-Month Regimen

• Nexium® 20 mg daily, #30 = $217• Abilify® 10 mg daily, #30 = $758• Crestor® 20 mg daily, #30 = $189• Advair Diskus® 50/250 q12h, #1 = $327 • Cymbalta® 20 mg x 2 daily, #60 = $383

TOTAL COST: $1874www.goodrx.com


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Let’s Consider Replacing A Couple

• Change Nexium® to omeprazole or pantoprazole– Omeprazole 20 mg, #30: $112 (save $105)– Pantoprazole 20 mg, #30: $120 (save $97)

• Consider a H2 receptor antagonist– Famotidine 40 mg, #30: $109 (save $108)


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Let’s Consider Replacing A Couple

• Change Crestor® to simvastatin or atorvastatin– Simvastatin 40 mg, #30 = $156 (save $30)• FDA recommends no doses higher than 40 mg

– Atorvastatin 80 mg, #30 = $150 (save $40)


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Is there any way to help?


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Suggestions to Help

• Generic or alternatives whenever possible • Alert patients to Medicare-based benefits• Call pharmaceutical companies directly to see

if they provide any type of assistance – Visit the company’s website to retrieve contact

information such as email and/or phone numbers • Take advantage of discount programs – Wal-Mart, CVS, Walgreens, Rite Aid, Target


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Medicare Part B Drug Benefit

• Medicare Part B covers a limited amount of these supplies:

• Glucose monitors • Blood glucose test strips • Lancet devices and lancets • Glucose control solutions • Insulin via a pump– If self-inject, goes to part D


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Medicare Part D Drug Benefit

• Optional prescription drug insurance through Medicare

• This drug coverage is available to everyone who has Medicare, regardless of income, health status or how their prescriptions were previously covered– Private companies provide the insurance

coverage; patients choose the drug plan and pay a monthly premium


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Medicare Part D: Terms for 2014

www.Cahealthadvocates.org


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Patient Assistance Programs

• Are available through a lot of manufacturers though terms may differ widely– Estimates are 250 pharmaceutical companies have

these• Issue: – Very few people know about these programs– Those that do often find that applying for them is

a confusing and prohibitive process


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Example of A Patient Assistance Program

www.rxhope.com


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The “4 Dollar” Programs

• Good news: lots of drugs on these lists– Fair number of antibiotics (amoxicillin)– Some decent antihypertensive choices

• Bad news:– No insulin– No inhalers– Very few statins (lovastatin is popular)– Some cardiac meds could be troublesome• Clonidine in an older patient not a great choice


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Delaware Prescription Assistance Program

• Provides each eligible individual with up to $3000 per year toward medically necessary prescription drugs – Does not pay for diabetic drugs or supplies for

Medicare recipients • Medicare currently provides this coverage for both insulin

and non-insulin dependent patients

• Clients must make a co-payment of 25% of the cost of the prescription, or a minimum of $5

http://dhss.delaware.gov/dhss/dmma/dpap.html


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Strategies for Cost-Effective Pharmacotherapeutic Regimens


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Strategy 1

• If you have to use any $4 dollar program, know what is available.

• Look at these AHEAD of time.• Know that these lists may vary between

neighborhoods and states, even if within the same chain.


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Strategy 2

• Sometimes, you must sacrifice user-friendliness in the name of getting any medications at all. – May mean more tablets per day– May mean missing some doses due to accidental

non-adherence– May also mean that at least the patient can get

something instead of nothing.


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Strategy 3

• Know what your government clinics offer• Use websites that provide information on

various patients assistance programs and advertise these to your patients and families– www.needymeds.org– www.rxassist.org– www.pparx.org

http://www.needymeds.org/

http://www.rxassist.org/

http://www.pparx.org/


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Final Thoughts


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Thank you, and have a wonderful conference!

the big bang (for your buck) theory: establishing value in prescribing medications advanced practice...

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