Confronting High Health Care Costs Strategies for Prescribing the Best Drug at the Best Price

David A. Nardone, MD

In today’s health care market, many patients with chronic diseases cannot afford the drugs they’re prescribed. Here’s what practitioners can do to ease the financial burden of out-of-pocket costs for their patients.

t is easy to be cynical about the of-pocket pharmaceutical costs our engaged in comanaged care. Patients state of U.S. health care when we patients face. frequently come with requests for learn that Americans spend more The first thing we can do is con- prescribed by primary Iof their income on prescription front the issue of cost head on. At care providers in the private sector. medications than citizens of other present, it is extremely rare for health Education and assistance provided by developed countries1,2; that prescrip- care providers to discuss costs with VA clinicians can prove to be benefi- tion costs increased more than three- their patients.7 According to a recent cial in helping patients learn to weigh fold between 1993 and 20023; that survey, insufficient visit length and their choices and prefer- almost 15% of patients with com- patient discomfort are the two lead- ences and participate actively in their mon chronic diseases underuse their ing barriers preventing these discus- own health care. medications at least once a month sions from occurring.8 Nevertheless, as a result of high out-of-pocket ex- it is possible for providers to sur- Engage Your Patients penses4,5; and that wholesale prices mount these apparent obstacles to Physicians can set the stage for re- of brand name drugs increased, on assist patients in obtaining the best ducing costs by reviewing all of average, over 6% from 2004 to 2005, drug at the best price. their patients’ medications at each at nearly twice the rate of inflation.6 This article presents a series of visit. Medication lists can take vari- Moreover, it’s common for patients practical, easy-to-implement strate- ous forms, from an informal writ- and front-line health care providers gies for accomplishing this goal. ten record to an electronic entry in to feel frustrated with their lack of Included in this discussion are re- a structured personal health record influence over public policy. sources—many available online— (Table). Reviewing the list offers op- In reality, however, we are not that providers can use for such tasks portunities to eliminate nonessential powerless. While most of us might as comparing drug costs, reviewing medications, decrease polypharmacy, have a very limited ability to shape clinical practice guidelines and other recommend less costly but equally legislation or policy at the highest evidence-based data, and referring effective alternatives,9 and discuss re- levels, there are steps we providers patients to sources of financial assis- alistic expectations and indications with prescribing privileges can take tance. At the outset it is important to regarding medication use. to help ease the burden of high out- recognize that, in the federal health The dialogue that ensues is par- system, many of these strategies are ticularly important, as patients and integrated into the daily practice of health care providers frequently over- Dr. Nardone was formerly the clinical director primary care and chronic disease estimate the usefulness of medications for the primary care division of the Portland VA Medical Center, Portland, OR (retired 2002). He management through national for- to treat certain conditions. For exam- currently holds the positions of staff physician mulary revisions, electronic ordering, ple, group A beta-hemolytic strepto- at the Portland VA Medical Center and profes- and availability of pharmacist con- coccus accounts for a relatively small sor emeritus in the division of general internal medicine and geriatrics at Oregon Health and sultants. Nevertheless, VA staff mem- proportion (5% to 15%) of all cases of Sciences University, Portland. bers, in particular, are increasingly sore throat, and the vast majority of

34 • FEDERAL PRACTITIONER • MARCH 2007 Table. Internet resources for helping patients obtain affordable medications

Resource name Web address Content/purpose Engaging patients AARP—Using Medications www.aarp.org/health/rx_drugs Personal health record for Wisely: My Personal Medication /usingmeds/my_personal_ developing and maintaining a Record medication_record.html medication list Oregon Alliance Working www.oregon.gov/DHS/ph Treatment algorithms, toolkits, for Antibiotic Resistance /antibiotics/provider.shtml and other resources for judicious Education (AWARE) use of antibiotics Medication Management and tahsa.org/files%2FDDF% Lists of medications to avoid in Polypharmacy (Beer’s List) 2Fmedbeer1.pdf patients over 65 years of age Prescribing over-the-counter and generic medications Electronic Orange Book www.fda.gov/cder/ob/default.htm Information on drugs with thera- peutic equivalents (generics) Comparing costs Consumer Reports—Best Buy www.crbestbuydrugs.org Drug reports that compare costs Drugs of common medications, Shop- pers Guides to Prescription Drugs publications, and news and alerts about medications AARP—Prescription Drugs: www.aarp.org/health Consumer guide for comparing Cost & Availability /comparedrugs/ efficacy and affordability of drugs West Virginia Attorney General www.wvagrx.com/home.aspx Surveys of prices of commonly Rx Price Website prescribed medications at phar- macies located in West Virginia Reviewing evidence-based data Oregon Health & Sciences www.ohsu.edu/drugeffectiveness Evidence-based data literature University—Drug Effectiveness reviews Review Project VA/DoD Clinical Practice www.oqp.med.va.gov/cpg Clinical practice guidelines Guidelines /cpg.htm endorsed by the VHA National Clinical Practice Guidelines Council Exploring assistance programs VA Health Care Eligibility and www.va.gov/healtheligibility Information about access to VA Enrollment for Veterans /eligibility/ health care, including medication services Centers for Medicaid and www.medicare.gov Information about Medicare Medicare Services medication programs Rx Hope—The Heart of the www.rxhope.com Information on and links to private financial assistance programs

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coughs of infectious origin are caused because of the popularity (or noto- For example, at one local pharmacy, by viruses. Yet in 1998, nearly 60% of riety) of the celebrity involved. But esomeprazole (Nexium; AstraZen- patients presenting with cough and what effect does this have on physi- eca Pharmaceuticals LP, Wilmington, over 60% presenting with sore throat cians? In 2005, researchers reported DE) was priced at $4.67 per cap- received antibiotics.10 To decrease an- on a randomized, controlled trial, sule, whereas the OTC stereoisomer tibiotic resistance, expert consensus funded by the National Institute of omeprazole (Prilosec; Proctor & panels recommend that physicians Mental Health, in which simulated Gamble Company, Cincinnati, OH) apply accepted criteria before treating patients portraying symptoms of was $0.64 per tablet. In a 2001 re- respiratory infections with antibiot- either major depression or adjust- view published in The Medical Let- ics.11–13 Strategies to limit antibiotic ment disorder with depressed mood ter on Drugs and Therapeutics, data use represent the best clinical care, the made appointments with primary from trials comparing esomeprazole most appropriate utilization of pre- care physicians and either asked for and omeprazole suggested a possible cious resources, and the least risk to the antidepressant paroxetine by its advantage for esomeprazole in treat- public health. The good news is that brand name (Paxil; GlaxoSmithKline, ing erosive esophagitis but equivalent there has been a decline in antibiotic Philadelphia, PA), made a general efficacy in treating gastroesphageal prescription for respiratory disor- request for medication, or made no reflux disease (GERD).19 Given the ders,10,14 and research indicates that explicit medication request. The re- fact that erosive esophagitis is consid- interactive educational programs for sults showed that physicians were erably less prevalent than GERD, why physicians can succeed in reducing far more likely to prescribe an anti- not use the less expensive OTC alter- inappropriate antibiotic prescribing.15 depressant when patients asked for native (omeprazole) first, based on Reviewing medications with our one (by brand name or as a general the assumption that it will work for patients also gives us leverage in request) than when they didn’t. The most patients? Esomeprazole could counterbalancing direct-to-consumer physicians rarely prescribed parox- be reserved for those patients who do advertising, a $4.35 billion enterprise etine (which was not available in ge- not respond to omeprazole. in 2004.16 Pharmaceutical companies neric form when the study began and In most cases, OTC drugs are con- frequently have utilized nationally was priced higher than generic al- siderably less expensive than brand recognized and respected figures to ternatives, such as fluoxetine) to the name drugs because a physician’s pre- help sell their products. For example, simulated patients portraying major scription is unnecessary, the competi- the drugs rofecoxib (Vioxx; Merck & depression unless they specifically tion among manufacturers is stiffer Co., Inc., Whitehouse Station, NJ), asked for it. The study’s researchers, once the patent expires, and there ramipril (Altace; King Pharmaceu- as well as the author of an accompa- usually—though not always—is less ticals, Inc., Bristol, TN), and silde- nying editorial, concluded that direct- need to monitor adverse effects. As nafil (Viagra; , New York, NY) to-consumer advertising may have providers, we must resist the lure of all have been promoted by popular competing effects on the quality of prescribing a very expensive drug sports figures. And in one advertise- health care—both reducing underuse (esomeprazole) to treat the large ment for meperidine hydrochloride of appropriate pharmacologic ther- number of patients with dyspeptic (Demerol; -Synthelabo, Inc., apy (as in the case of major depres- and reflux symptoms for fear of not New York, NY)—noted in Greg Crit- sion) and promoting overuse (as in treating the infrequent case of esoph- ser’s 2005 book, Generation Rx: How the case of the less severe adjustment ageal ulcer. On the negative side, Prescription Drugs Are Altering Ameri- disorder).17,18 Ultimately, our goal OTC drugs are packaged in a man- can Lives, Minds, and Bodies—the late is to encourage the patient, through ner necessitating removal of each pill U.S. Supreme Court Chief Justice interactive discussion, to move separately. This could represent some William H. Rehnquist tells patients to from passive consumer to informed difficulty for elderly and disabled pa- “insist that your physician prescribe participant. tients. Furthermore, there are times Demerol. You pay a little more than when purchasing the cheaper OTC for aspirin, but you get a lot more Prescribe OTC and actually results in higher out-of- relief.”16 Medications pocket expenses since insurers will Understandably, patients will ask In some cases, over-the-counter cover the more expensive prescrip- physicians about drugs mentioned (OTC) medications can be viable al- tion drug but offer no reimbursement in such advertisements—in part, ternatives clinically and financially. for the OTC drug.

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In the May 13, 2004 issue of USA penses,25 the risk that offering brand ing a medication history database; Today, the author of an article on name drug samples will increase providing for adequate labeling; and using generics to cut drug costs in- overall drug costs is high. Once the permitting the pharmacist to offer dicated that, for each 1% increase in supply of the sample is exhausted, counseling regarding dosing instruc- generic medication usage, $1.5 to $2 patients may find that purchasing the tions, adverse events, and drug-drug billion per year could be saved na- same brand name drug is prohibitive. interactions. tionally.20 And a study published in One might wonder whether pharma- June 2005 demonstrated that at least ceutical companies preferentially pro- Compare Costs $2.9 billion per year could be saved vide expensive brand name samples Cost comparisons between drug in the senior population if generics to physicians’ offices, just as they classes, within classes, and among were prescribed more uniformly.21 market expensive drugs on television, retailers offer effective strategies to For example, there is a generic ver- in web site pop-up ads, and in medi- save dollars on medications. For ex- sion of lisinopril (Zestril; AstraZeneca cal journals. ample, when treating hypertension, Pharmaceuticals LP) available, and taking this generic formulation in- stead of the brand name version can save over $250 per patient in yearly drug costs. Similarly, the hypnotic A study published in June 2005 demon- agent zopiclone is available in Canada strated that at least $2.9 billion per year and other countries as a generic drug, but in the United States, eszoplicone, could be saved in the senior population if with the identical chemical composi- generics were prescribed more uniformly. tion but mirror image to zopiclone, is sold as a brand name drug (Lunesta; Sepracor, Marlborough, MA). Not surprisingly, zopiclone sells for $0.54 per tablet and eszoplicone for $3.30 An increasing number of private the cheaper class of drug—diuret- per tablet.22 practice physicians, health care orga- ics—has been shown to decrease car- Many class A generic drugs have nizations, and academic institutions diovascular deaths to the same degree been proven to be of biochemi- prohibit detailing by drug represen- as other, more expensive antihyper- cal equivalence to their brand name tatives. When such interaction is tensive medications27,28 and to reduce counterparts.23 The “Electronic Or- not prohibited, a good approach is renal impairment in patients with hy- ange Book”—available on the FDA for providers to accept and distribute pertension.29,30 web site—is an excellent up-to-date samples of only the less costly medi- A similar case could be made for reference for identifying available ge- cations (especially generics) that are initiating treatment of dyspepsia with neric agents. similar in efficacy and safety to more lower cost histamine-2 (H2) block- expensive, brand name medications ers before prescribing the more effec- limit use of Free Drug and that would not present a hard- tive but certainly more costly proton Samples ship for patients to purchase once the pump inhibitors (PPIs). In a review Providing patients with drug samples samples run out. Another approach is of multiple studies of dyspepsia, there from the office is a common and per- to use prescription vouchers instead were two randomized trials in which haps a well intentioned practice of of free samples.26 Under this system, there was no statistically significant physicians and pharmaceutical com- vouchers for a specific amount of difference in the relief of symptoms panies.24 Despite endorsements of the drug can be taken, along with a pre- between the H2 blocker and the value of drug samples,9 the relative scription, to a pharmacy where the PPI.31 Comparisons at a major na- high frequency of their use in prac- patient receives the medication free. tional retailer indicate that PPIs cost tice,8 and some evidence indicating The drug manufacturer subsequently between three and 4.8 times more that eliminating drug samples in reimburses the pharmacy. The use than H2 blockers. uninsured and underinsured popu- of vouchers preserves the positive There are situations in which, lations increased out-of-pocket ex- value of samples while also establish- within a particular drug class, some

MARCH 2007 • FEDERAL PRACTITIONER • 43 CONFRONTING HIGH HEALTH CARE COSTS

drugs cost less than others of similar day, the more expensive drug may be per year by taking one half of a 40- efficacy. For instance, based on a price the best option. mg tablet of lovastatin as opposed to comparison at a local pharmacy, tak- one whole 20-mg tablet, and split- ing fluoxetine for depression instead Review Evidence-Based Data ting the larger dose sertraline tablets of citalopram could result in a per pa- Physicians can expand their knowl- could result in savings of almost $540 tient savings of over $550 per year. edge to prescribe more appropriately per year on average.39 Stafford and Similarly, with regard to angiotensin by becoming more familiar with the Radley, analyzing data from a man- converting enzyme inhibitors, taking published reports from national evi- aged care program covering 19,000 lisinopril instead of ramipril for high dence-based practice centers (EPC).34 patients, projected an annual cost blood pressure could save as much The Agency for Healthcare Research savings of $259,500 ($1.14 per pro- as $370 per patient over one year. If and Quality initiated a network of gram member per month) if patients safety, efficacy, and convenience are EPC centers to conduct evidence- could make a commitment to split similar or comparable, the best rule based reviews for many topics, in- tablets for 11 medications listed on of thumb is to prescribe the drug of cluding drug effectiveness, alternative the .40 In another study of lower cost. medications, and therapeutic de- mental health drugs in the Oregon It’s not surprising that the cost of vices.35 These centers are funded by Health Plan, tablet splitting—along the same prescription medication can 15 states and two nonprofit organi- with dose consolidation—resulted in vary significantly between pharma- zations. The results of these reviews a savings of $32,000 per month for cies. Confirming suspicions in the assist physicians, regulatory bodies, all plan members for a continuous contentious debate over drug pric- insurance companies, and health pol- six-month period.39 As a note of cau- ing in this country compared with icy consultants in making decisions tion, not all tablets may be split safely, others, a review of costs of 44 brand regarding local and regional formu- tablet splitting can complicate care, name drugs purchased from online laries and preferred treatments.36 and it is technically difficult for some pharmacies in Canada versus major The use of evidence-based, clini- patients to undertake this task.8 drug store chains in the United cal practice guidelines also can play a States demonstrated that 41 of the role in cost savings. In a study of over Prescribe a Larger supply drugs were cheaper when obtained 130,000 elderly patients with uncom- In some cases, prescribing a three- from Canadian sources.32 What may plicated hypertension, investigators month supply of a medication, as op- be less well known is that prices dif- projected an annual cost savings of posed to a 30-day supply, can be cost fer even within the United States. A approximately $1.2 billion nationally saving. At the very least, this prac- quick check of two local pharmacies provided physicians adhered to cur- tice saves the administrative costs reveals that 30 esomeprazole capsules rent antihypertensive guidelines.37 of filling a prescription three times at pharmacy A cost $140 per month, instead of one. Exercising this op- whereas at pharmacy B the price is Split Tablets tion, however, is appropriate only if $123 per month. Several web sites For some drugs that treat diabetes, the patient’s condition has proven to offer information allowing patients hypertension, depression, hyperlipid- be stable with the current dosage for and providers to compare prices of emia, and other conditions, patients some time and if the patient’s health common medications.33 can be prescribed tablets that contain benefit plan includes this provision. Practically, there are times when double the intended treatment dose Due to concerns about abuse, con- the most expensive drug is, indeed, and then instructed to cut the tablets trolled substances and psychotropic the best drug because of efficacy or in half and take one half-tablet at each drugs should be restricted to small safety. If using the most expensive administration.38 In some cases, when amounts or, at most, 30-day intervals. drug would likely result in fewer pro- the two doses are the same price, this vider visits and fewer laboratory tests practice is analogous to buying the Explore Assistance to monitor adverse effects, it could medication at a two-for-one discount. Programs very well be the best drug and the Even when there is a small price Depending on eligibility, the VHA best overall price for the condition. difference between the two doses, and the Centers for Medicaid and Or, if it is easier for the patient to take however, tablet splitting still can re- Medicare Services include medica- a medication on a once daily sched- sult in substantial savings. For ex- tions as part of their benefits pack- ule rather than multiple times per ample, patients can save over $150 age. State Health Insurance Programs

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(SHIPS) counselors provide assis- in practice, lacked specific knowl- macists in the primary care setting.51 tance and education regarding ben- edge.45 Of the physicians surveyed, It appears, unfortunately, that physi- efits. In a comparison between the 80% were unaware of medication cians who are solo practitioners or VHA and Medicare, costs to VHA pa- costs, and their estimates of costs for work in small groups are less likely to tients were significantly lower for 49 33 commonly used medications were have access to pharmacists compared of the 50 medications reviewed, and accurate in only 45% of the cases with those who work in large groups the median price difference per drug presented. In another survey, which or hospital settings. per year was over $200 to the benefit followed interactive conferences of VHA patients.41 The greatest price and distribution of guides with pric- in summary differential was $770 for pravastatin ing references, Korn and colleagues Providers and patients have the tools (Pravachol; Bristol-Myers Squibb learned that physicians were more to be more assertive in ensuring that Company, Princeton, NJ) 40 mg, and likely to query patients about “out- they use the best drugs at the best the lowest was $5.33 for furosemide of-pocket” medication costs after the price. Collaborative efforts among pa- (generic) 20 mg. interventions.46 tients, primary care providers, and, In 1999, over 50% of the 200 most In a VA setting, pharmacists work- when possible, pharmacists can result commonly prescribed medications ing collaboratively with primary care in real savings—not only for patients in the United States were offered physicians were able to reduce the as individuals but also for insurers through assistance programs spon- average number of prescriptions per and taxpayers. By being aware of and sored by pharmaceutical companies.42 patient by 2.4 and the average doses judiciously utilizing the many op- Although eligibility criteria vary from per day by 6.9.47 In an academic tions, strategies, and resources at our one company to another, categories group practice setting, pharmacists disposal, we providers can make an common to many are: (1) lack of ade- were able to reduce costs substan- impact on the lives of our patients. quate insurance, (2) assessment of in- tially by participating in a medication Perhaps, by effecting seemingly small come and assets, and (3) ineligibility clinic, reviewing data to develop a changes in this way, we can influence for a federal assistance program. The formulary, analyzing trends, dissemi- those with greater power in govern- challenges for patients are that each nating information, conducting qual- ment and industry to take more dra- manufacturer requires completion ity assurance, and providing outreach matic steps toward reigning in health of a different application form and to physicians.48 Another study com- care costs nationwide. ● many require a new application for pared a managed health care plan’s renewals.43 Furthermore, an existing monthly per-member drug costs for Acknowledgements antitrust law prohibits collaboration, physicians from general medicine The author thanks Dr. John Santa and cooperation, and uniformity between clinics who were exposed to varying Erin Stone for comment and critical re- pharmaceutical companies in admin- degrees of interaction with pharma- view, Mary Ellen Nardone and Mara istering their assistance programs.49 cists: no new interactions (control), Wilhelm for technical library assis- With the initiation of a pharmacist-conducted presenta- tance, and the staff at AARP Oregon for in 2006, many drug companies have tion, or the presentation followed by consultative advice. severely curtailed their assistance pro- ongoing face-to-face meetings. The This work was presented in part on grams. Nevertheless, these programs results showed that the more inter- November 16, 2004 at the “Prescrip- remain options to be explored. action that occurred, the greater the tion Drug Forum, Campaign to Lower reduction in drug costs.49 Finally, a Costs,” sponsored Consult With Pharmacists collaborative model involving pa- by AARP Oregon and the Washington Pharmacists have an excellent un- tients, who monitored their blood County (Oregon) Department of Dis- derstanding of clinically relevant pressure at home, and pharmacists, ability, Aging, and Veterans Services, pharmacoeconomic issues and drug who reviewed the data and made rec- at Tualatin Health Education Center in formulary policies, and, as such, they ommendations to the treating physi- Hillsboro, OR. can provide practical tips on patient cian, resulted in improved diastolic adherence issues and tablet splitting. blood pressure control.50 Author disclosures In a 2001 report, investigators found The American Society of Health The author reports no actual or poten- that physicians, though predisposed System Pharmacists has published a tial conflicts of interest with regard to to embrace cost-effective principles statement outlining the roles of phar- this article.

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