The Role of Social Determinants of Health in Epilepsy-How to Get Bang for Your Buck with Antiseizure Medications Particularly for Those Uninsured

Video Transcription

I am Janine Conway, I'm at the University of Minnesota, and I am here not only as an academic pharmacist, but also as a very part-time community pharmacist  with lots of thoughts and feels on some of the challenges we have out there with our patients.  My disclosure, I've done some work with the Cannabinoid Education Working Group, and my main goal today is that people leave with a list of strategies and ways  that they can work with their patient to optimize their anti-seizure medication costs  for those that are uninsured or underinsured.  So before we get into this, let's just take a step back and like how did we get here and why is it such a hot mess? So this is a very United States-centric issue and topic,  just in full disclosure.  Widely, medication prices is unregulated, and really up until a few months ago, there was very little. Stay tuned, the Inflation Reduction Act of 2022  will allow the government to start negotiating for Medicare Part B and D, so this may be a very different talk come next year. But really, companies are allowed to set prices,  they're generally completely projected from competition, partly due to our patent laws, and they have significant negotiating power. Now how do pharmacies get drugs?  They are not primarily ordering directly from the manufacturers, they are working through wholesalers and working through contracts.  Some of our larger organizations have that ability  to negotiate and get medications directly from the manufacturers. And an additional context for us is that prescription coverage, if your patient has it,  is essentially a carved out benefit, separate from the medical insurance, and they are not concerned about total cost of care. They're just concerned about how the price  of your patient's medications.  So there are things we can do, even before we send our patient out with a prescription,  to optimize their cost and optimize their options at getting something more affordable. So we all need to recognize cost is unclear.  There are some electronic medical record resources now that allow you access to potentially pricing, but it's hard to know where those prices came from,  and the market can be very dynamic. You've probably seen news stories over the last several years where, you know, there's one manufacturer and they do wild things with the prices.  So what might be being pulled into your resource may be accurate last week, or it's unknown how often it refreshes. And just because one of your patients  has an insurance policy and your other patient has one that looks the same, they may have very different formularies. So it's even hard to know what your patient has access to.  And certainly if a patient has insurance, they don't have a sense of cost whatsoever, usually of what a drug really costs in real life.  So clearly the first thing you can do is make sure if it's appropriate to prescribe generic medications, particularly medications that have multiple manufacturers.  That's where the competition in the market comes in, and that's where we see drug prices actually decline. So we get into trouble when we end up with one generic manufacturer,  but when we have four, five, six manufacturers, then we see some drop in cost.  If your patient's uninsured and you're comfortable with it, write for a 90-day supply. There are overhead costs that occur every single time a prescription is filled.  So the label costs money, the bottle costs money, the pharmacist verifying that prescription costs money. So if you do that once every 90 days instead of every 30 days,  that's gonna be a modest contribution to decreasing costs for your patient. We also need to be sure to coach our patients on making relationships with the people at the pharmacy  that they frequent.  That pharmacist, that staff can help identify if there's price-matching options or if there's discount programs that your patient may be eligible for.  So today, we're gonna start with government programs and end up with co-pay cards and spend just a few minutes trying to focus on things that don't take a lot of time from the staff  to support patients in doing.  So we know that when the ACA came into play, we saw correlations and decreases in the number of prescriptions filled through prescription assistance program use.  And so if your state has an opportunity to expand to the ACA, I would say advocate for that. That's been part of the theme today is how we advocate for some of these changes  for our patients. Certainly, if you are working with a pediatric population, ensuring they're hooked up with CHIP as appropriate and as they are eligible.  If you're working with an elderly population, states vary, but you may find resources around senior linkages lines or the State Board of Aging.  And then, is it appropriate to partner with a community health center? So community health centers are federally qualified health centers. And so they are 340B eligible  and that allows them to buy medications at steep discounts and potentially pass those on to the patient population. And so there is a searchable website out there  that'll allow you to find urban and rural locations.  Clinics may have a pharmacy on site. They may partner and contract with a local pharmacy that is able to purchase those drugs and then dispense it for their patients  at those decreased costs. And so that is an option at getting patients plugged into medications at significantly lower prices.  So the 340B program is 30 years old now. It's overseen by HRSA and it provides discounted prices to organizations that are committed to taking care of underinsured  and underserved populations.  And it was really intended to allow a healthcare system or a clinic to leverage those savings, to redistribute it, to take care of more people or however they saw fit.  It has come under legal challenge from particularly some pharmaceutical companies because there's no transparency. There's no requirement for the healthcare system  to say how they leverage those savings and they don't necessarily translate directly to decreased costs to the patient.  Nonprofit organizations. So a lot of us have access to local Epilepsy Foundation chapters. The advantage is that they're out there, they're supporting our patients,  but they may have a restricted geographical location that they serve. Organizations may have limited budgets. Your patients can end up on wait lists.  They're not necessarily designed to provide long-term support. It's really an emergency, more fun type situation.  I'd recommend, if you haven't checked out needymeds.org, they index a number of types of services, but one of the things that they have is the ability to search nonprofits,  not only based on Epilepsy Foundation, but also on specific diagnoses. So you may be able to find foundations that you weren't aware of that may have options.  I will say, like all these indexing websites, they're great, but you still gotta verify that the organization's functioning and has funding and can support your patient  and your patient qualifies for whatever.  The other thing you can also do is do an internet search specifically for charitable pharmacies. They vary based on parts of the country, but there are pharmacies out there  that are committed to essentially providing medications at low cost, no cost. The challenge with almost all of these low-cost options is a lot of what they have to offer  is very limited from a formulary perspective.  So third-party coupons, they get advertised on TV.  Lots of people like using the websites. They index very quickly prices across pharmacies, but those cost estimates are likely not accurate unless that coupon is issued,  the patient decides to use it. And generally, a lot of the large chain organizations will accept those coupons.  The challenges and the cons are you can't use it with your Medicare Part D deductibles. So particularly for our older patients, they're at the point of the year  where they may be in the donut hole and they need to still process that prescription for their cost to apply to that deductible to get out of the donut hole.  You bypass that system when you use a coupon so that money essentially doesn't get attributed to their deductible.  It can't be used in combination with Medicare and Medicaid. And there's been concerns about privacy with these third-party coupons.  And I read one of the company's privacy statements. And they do state that they're gonna use the information that the patient enters to get the coupon.  They're gonna essentially get into the information flow between the pharmacy and know what got dispensed to that patient. So that information that's usually HIPAA-protected  between the pharmacy and the insurance company is now being intercepted by a third-party coupon. And they openly say they're gonna use it for analytics and tracking.  And so from a patient perspective, they may be misled as to what pharmacy will accept the coupon. And so if a pharmacy is losing money on a prescription,  they will probably decline to accept the coupon.  There's a new phenomenon out there, online discount pharmacies.  There's a sports team owner that started a pharmacy. I do an internet search. The advantages are that they buy directly from the manufacturers.  They're very transparent as to what the patient's getting charged in terms of the markup, in terms of the shipping.  The formula is very limited. And so the challenge, of course, is that it may just not be the product your patient needs. So they have one option for carbamazepine.  It's chewable carbamazepine. There's no extended release. There's no immediate release tablets. I was just looking, you can get extended release,  leave a tract stamp, but not immediate release. So it really depends on if it's the right thing that your patient needs, and then the right match from a cost perspective.  They don't accept insurance, so it's just a straight cash type situation.  And you need to plan ahead, because they're very open. They charge for shipping as well.  There are also pharmacy saving programs out there. You may remember about a decade ago, four dollar lists became a hot thing. Walmart led the top of that.  There are now a number of organizations that do that.  They often will say a 30 day supply is four dollars, 90 day supply is 10 dollars. But there's a lot of, you gotta look at the fine print,  a lot of what these pharmacies deem a 30 day supply is not what most of our patients need. They're not taking oxcarbazepine 300 milligrams twice a day.  So you've gotta make sure that it works, or that price is gonna get increased based on what they need.  A membership may be required. So that's the other thing. There are all these discount options out there, but then there's like side fees that aren't immediately apparent  in terms of what your patient's gonna have to spend money on. So whether it's the shipping costs from the online discount pharmacy, whether it's the membership fee,  but there's still ways that patients are getting nickeled and dimed. Pharmacies may offer their own discount card. These are not always well publicized,  because pharmacies are already struggling with insurance companies clawing back  the costs from them. So they may not openly market them. But if you have a conversation and get to know your pharmacist, that may become a part of the conversation  between the patient and the pharmacist. So smaller pharmacy organizations and independent pharmacies have more control over how they can negotiate pricing  with the patient versus a large mass marketer that has a very top down approach with that. Needy Meds, again, interesting website, very helpful, also indexes all these.  You can search it by state or by pharmacy and see what their options are.  Patient assistance programs. I saved this for later, because often this does require support from clinic staff to help patients navigate this process. There are programs provided  by the pharmaceutical companies. Again, not gonna be available for generics. It's gonna be for your brand of medications, which some of our patients may absolutely require.  Really, every program is a little bit different. So it may or may not be allowed in combination with government insurance. It can be time intensive to complete those applications.  And a yearly reapplication is typical. So it's never a super long term solution for patients.  And then finally, we're gonna wrap up with co-pay cards. Again, provided by pharmaceutical companies, generally for brand of medications.  Again, may or may not be allowed with your government insurances.  All of them have different fine print. So how much they'll allow a person to be discounted.  There's some fine print usually on how much that is. They may also allow a discount if the patient's not insured. They are often time limited. So the coupon card's only good for,  or the co-pay card's only good for a year, or a number of refills. So again, often a way to help patients afford things initially, but may not be a good long term solution.  It may be just a temporary fix.  And so to wrap up, medication pricing is dynamic and opaque. And shortages can rapidly change cost. And that's partly what makes even accessing these databases  and various decision making tools we have out there, it's a challenge. If my pharmacy can order something in last week, and then the wholesaler doubles the price,  then it's a different answer the next week. Really get to know your local pharmacist. They can absolutely be a resource to you and your patients.  And consider smaller pharmacy organizations and independent pharmacies, because they do have more flexibility in pricing and working with patients.

Video Summary

Janine Conway, an academic and community pharmacist, discusses strategies for optimizing anti-seizure medication costs for uninsured or underinsured patients. She addresses issues in the U.S. regarding unregulated medication pricing and how pharmacies obtain drugs. Strategies include prescribing generics, considering 90-day supplies to reduce costs, and encouraging patients to build relationships with pharmacy staff. She covers options like government programs, community health centers, online discount pharmacies, and third-party coupons, while noting their limitations. Conway emphasizes the importance of understanding patient assistance programs, co-pay cards, and building connections with local and independent pharmacies for better pricing flexibility.

Asset Subtitle

Presenter:

Jeannine M. Conway, PharmD, BCPS, is the Associate Dean of Professional Education as well as an Associate Professor in the department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota. She received her BS in pharmacy and PharmD from the U of MN and completed a fellowship in neuropharmacology. Her interests include anticonvulsant pharmacokinetics and educating future pharmacists and neurologists how to best optimize pharmacotherapy. She provides clinical pharmacist services in an adult epilepsy clinic and the interprofessional comprehensive facial pain clinic at the University of Minnesota.

Keywords

anti-seizure medication

uninsured patients

medication cost strategies

patient assistance programs

pharmacy pricing flexibility