1. Pharmacoeconomics 101: How to Beat the High Cost of Prescription Medications – Resources for you and Your Patients Mark Cucuzzella MD FAAFP (West Virginia University) Heather Congdon, PharmD (University of Maryland)

2. The Old Timey Mountains Potomac R Shenandoah R Maryland W. Virginia Virginia FM

3. “The education of a man (or woman if Lee were around in 2006) is never completed until he dies” Robert E. Lee

4. Objectives Background pharmacoeconomics How to learn drug prices / comparison shop Generic medications Slicing medications…..yes it can be done more than you think Selecting other medications in the same class Use the Government to Your Advantage- non partisan stuff that saves your patients cash Pharmaceutical assistance programs

5. Your Mother 66yo with HTN, DM2, hyperlipidemia, COPD and was recently dc’d from the expensive care unit after an angina episode Her dc meds were clopidogrel 75mg, atorvastatin 80mg, rosiglitazone 8mg, losartan 100mg, Metoprolol Ext Release 100mg, metformin 1000mg bid, fluticasone/salmeterol diskus, and a baby aspirin Depressed by how much this all costs, her PCP prescribes escitalopram She has heartburn from all the meds so he prescribes rabeprazole 20mg. She has Medicare. What is her daily med cost?

6. $37.42 a day or $1122.60 a month Clopidogrel 75mg$4.53 Atorvastatin 80mg$4.06 Rosiglitazone 8mg$6.93 Losartan 100mg$3.03 Metoprolol Ext Release 100mg$1.50 Metformin 1000mg bid (Wallmart) $0.13 Fluticasone/salmeterol diskus$7.03 Aspirin$0.01 Duloxetine 30mg$4.30 Rabeprazole$5.90 Prices from Walgreens.com Oct 2007Walgreens.com

7. More than 80 million Americans have been without prescription coverage sometime in past two years More than 4 million Americans with Medicare lack prescription coverage Spending on prescription drugs has increased >10%/yr from 1994 to 2004, 8% in 2005 Spending on prescription drugs outpaces every other category of public health expenditure 200 Billion spent in 2005 (5x increase over 1990) Source Kaiser Family FoundationKaiser Family Foundation Background - The Ongoing Crisis

8. Background – Knowledge is Power Those caught in the gap between public healthcare coverage and private health insurance suffer the most Those unable to pay for their prescription often return to the clinic or emergency room in even worse condition Knowing how to save money on your drugs can literally be a lifesaver Public information will eventually reverse the trend in prescription drugs costs

9. Doctors Don’t Talk About Cost American J Managed Care Nov 2006 185 audiotaped visits at 2 clinic sites UCLA MDs talk cost only 1/3 time when prescribing….this also includes discussion of generics, insurance, refills Patients asked about cost or insurance 2% of time

10. What costs more? 45 mg of pioglitazone Big Mac, large fries, large coke Pioglitazone $7.36 Big Mac Meal $4.39

11. Which Industry Had the Highest Profit as Percent of Sales or Assets 1995-2005? 1.Oil 2.NBA 3.Big Pharmacy 4.Fashion 5.Fast Food

13. 2006 Fortune 500 Most Profitable Industries: Return on Revenues Big Pharma hurting a little….now # 2 Fortune 500 2006 rankings Mining/Crude oil now #1

14. Background - Big Pharma Basics Median profit margin 17% for top 10 Big Pharma (3.1% average other 490 Fortune 500) 10 Pharm companies had more profit than other 490 combined (Public Citizen)Public Citizen 5 companies US, 5 Euro….but US main profit center Source Marcia Angell MD (former NEJM editor) author Truth About the Drug Companies

15. Big Pharma Basics - “Me-Too” Drugs Minor variations of highly profitable drugs 1997-2003 487 Drugs approved by FDA –379 “appearing to have similar qualities to one or more drugs already on market” –333 not even new compounds- reformulations –Only 67 new compounds felt to be improvements over old ones Innovation is actually rare Source Marcia Angell MD (former NEJM editor) author Truth About the Drug Companies

16. Big Pharma Basics - Marketing For 1990s top 10 pharmaceutical companies –35 % Marketing –11-15% R & D –Profits 19-25% of sales 2002 US $67 B of $217 B in sales Where does this go??? –Promoting drugs –Promoting “disease” (example RLS) Source Marcia Angell MD (former NEJM editor) author Truth About the Drug Companies

17. Big Pharma Basics – Influence on Medical Profession Drug companies support most CME, conferences…. STFM we pay to present…this is good Lunches, perks, dinners JAMA Jan 2006 “Health Industry Practices that Create Conflicts of Interest”…..a call for AMCs to separate from industryHealth Industry Practices that Create Conflicts of Interest Family Medicine Jul-Aug 2006 “Of Doctoring Conventions and Drug Companies”…..a look at our AAFP conferenceOf Doctoring Conventions and Drug Companies

18. Big Pharma Basics – Influence on Government Laws allowing suits to extend patents Publicly funded research with profits to drug companies Prohibitions from drugs crossing borders FDA not requiring to test drugs against old ones in same class Allowing Part D to pass which prohibits Medicare to bargain for lower prices similar to VA, DOD, or other large insurers. 2003 – 675 lobbyists employed

19. Perfect Storm Approaching Big Pharma ? Many blockbusters coming off patent Not many new innovative drugs in the pipeline Negative press on unethical business practices Public awareness of many physician conflicts of interest (Read On The Take)On The Take Consumers becoming more empowered with knowledge (why we are here) Lawsuits hurting finances and public trust

20. True or False Generic drugs are lower quality than brand? It is inappropriate to change a medication if the patient has been on it for a while? There are many assistance programs to help limited income patients with medications? Free samples usually decrease the cost of medications? The sales rep giving you lunch is there with the sole purpose of helping educate you?

21. True or False Generic drugs are lower quality than brand? F It is inappropriate to change a medication if a patient has been on it for a while? F There are many assistance programs to help limited income patients with medications? T Free samples usually decrease the cost of medications? F The sales rep giving you lunch is there with the sole purpose of helping educate you? F

22. What does the drug manufacturer make from these patients? Rank from highest margin to lowest VA patient Uninsured patient HMO patient Medicare patient (incl new Part D) Private insurance Medicaid

23. What does the drug manufacturer make from these patients? Rank from highest margin to lowest 1.Uninsured patient 2.Medicare patient (incl new Part D) 3.Private insurance 4.Large HMO patient 5.Medicaid 6.VA patient

24. The cost of Medicare Part D over 10 years 1 Billion 50 Billion 100 Billion 350 Billion 675 Billion Source Kaiser Family Foundation 2007Kaiser Family Foundation 2007

25. Journal Heath Affairs Feb 2006 Analysis from Centers for Medicare and Medicaid Services Health care spending now represents about 16% of the economy. But in a decade, it will make up about 20% of the economy. Medicare spending will more than double, from $309 billion in 2004 to $792 billion, in 2015 Medicaid spending will grow from $293 billion to $670 billion by 2015 The nation's total health care bill by 2015 will rise to more than $4 trillion

26. How to Learn Drug Prices / Comparison Shopping Informed consumers pay the lowest prices Different segments of the population pay different prices for the same prescription drugs Know the four types of prescription drug prices –Cash Customers –Veterans –Medicaid Beneficiaries –Private Health Insurance Subscribers

27. How to Learn Drug Prices / Comparison Shopping There are several sites with this capability Walgreens Drug Pricing Site Bid RX listen to NPR story on Bid RXBid RXNPR story Pillbot Drugstore One pharmacy won’t always have the best price for a certain Rx drug Wholesalers and online pharmacies are great resources for discounted medication Always check an online pharmacy’s standing with the National Association of Boards of Pharmacy at www.nabp.net www.nabp.net

28. The Future? Humana has a telephone robot named Eliza that calls members to tell them about cheaper drug alternatives. In 18 months it has saved members $11 million USNWR Nov 6 2006 Best Health Care Plans issue

29. Generic Medication Encourage patients to take generic alternatives –Generics undergo the same rigorous FDA inspections as brand-name drugs 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”Consumer Reports Best Buy Drugs Project

30. Generic Medication U.S. brand pharma sales for 2005: $229.5 billion U.S. generic pharma sales: $22.3 billion. U.S. generic sales increased by 20% in 2006. (Source: IMS Health)IMS Health 8,400 of the 11,167 drugs listed in the FDA’s Orange Book have generic counterparts. (source: FDA)FDA’s Orange Book

31. Generic Medication National Association of Chain Drug Stores 2004 –Average cost of a brand-name script is $96/mo –Average cost of a generic is $28/mo Generics were 56% of all scripts in 2005 (IMS Health data) but less than 13.1% of every dollar spent on prescription drugs. Generics cost 30% to 80% less than brand counterparts 2006 the top 10 generics: Hydrocodone/APAP, Amoxicillin, Lisinopril, Hydrochlorothiazide, Atenolol, Furosemide Oral, Alprazolam, Albuterol Aerosol, Azithromycin, Metformin. (source: Drug Topics, 2007)Drug Topics

32. Generics- The Future Looks Sunny The generic industry sales grew by roughly 20% in 2006. (Source: IMS Health) Blockbuster products coming off patent are valued at $27 billion in 2007, and $29 billion in 2008. (Source: Bain & Company)

33. How many generic drugs are awaiting FDA approval? 50 100 200 400 800

34. Generic Drugs Hit Backlog At FDA No Plans to Expand Review Capabilities Washington Post Saturday, February 4, 2006; Page A01 At a time when the use of low-cost generic drugs is being embraced as one of the few ways to rein in skyrocketing health care costs, the Food and Drug Administration has a backlog of more than 800 applications to bring new generic products to the market -- an all-time high……

35. Which of the Following are Available Generic? Fluoxetine Lovastatin Metoprolol Clopidogril Ciprofloxacin Metformin

36. Drugs Coming Off Patent 2007- 2009 Lotrel Jan. 2007 Norvasc Jan. 2007 Imitrex June 2007 Coreg 2007 Tequin Dec2007 Zyrtec Dec.2007 Fosamax Feb. 2008 Effexor/XR June 2008 Risperdal June 2008 Advair Aug. 2008 Serevent Aug. 2008 See Drug Topics for full listingDrug Topics Here are just a few

37. What are these seniors doing? Hint….they are from Minnesota

38. Data from AARP

40. Slicing Medications Many drugs have this Dose-Response Curve

41. Slicing Medications Lipitor Dose Price per 100 Tablets Price per 10 mg Dose 10 mg$232.07$2.32 20 mg$322.27$1.61 40 mg$323.47$0.81 80 mg$327.47$0.41

42. Slicing Medications – Which of the following cannot be split? 1.Atorvastatin (Lipitor) 2.Metoprolol Ext Release (Toprol XL) 3.Sildenafil (Viagra) 4.Esomeprazol (Nexium) 5.Paroxetine (Paxil) 6.Pioglitazone (Actos)

43. The Slicing Bible

44. Same Class Medications Most literature supports a class effect over a specific brand SSRI’s equivalent (JAMA Dec 2001)JAMA Dec 2001 PPI’s all equivalent (Infopoems 2005)Infopoems 2005 We really are comparing…

45. Same Class Medications - Nonsedating Antihistamines Brand Name Generic Name Monthly Cost AllegraFexofenadine$67.29 ClarinexDesloratadine$65.67 ClaritinLoratadine$20.33 ZyrtecCetirizine$60.19

46. Getting the Government to Help Your Patients Cartoon may be true when it comes to IT….. but the Gov’t can get cheap drugs

47. Veterans Programs Veterans who qualify for government healthcare receive some of the best prescription drug coverage. VA Home pageVA Home page –VA Form 10-10EZ; “Application for Benefits” –VA Health Benefits Service; 877-222-VETS

48. Medicare and Medicaid 2006 -OMB estimates that $578 billion will be spent on Medicare and Medicaid.

49. Part D Basics Info for FPs and patients –Medicare's Web siteMedicare's Web site –Medicare Rights Center Part D Web pageMedicare Rights Center Part D Web page AAFP's Medicare Prescription Drug Coverage Web pageMedicare 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. Medicare Part D 2007 Formulary Changes

50. Medicaid Know the ins and out through Kaiser Family Foundation Medicaid Information Page.Kaiser Family Foundation Medicaid Information Page In most state budgets, Medicaid spending has surpassed that assigned to education.

51. The BIG Picture- Medicare and Medicaid

52. Pharmacy Assistance Sources Pharmaceutical companies Drug discount programs $4 generic drug program Medicare Part D

53. A 52 y.o. male presents to a family medicine clinic for a physical after not seeing his physician for 10 years. In the past, his employer did not provide health benefits, however, they recently started doing so. As part of his physical, he was given a lab slip for blood work and was found to have diabetes (FBG 350) and hyperlipidemia (LDL 145; trigs 700), and also was found to have a blood pressure of 156/96. Patient was given Rx’s for Avandamet 2/500 bid, Altace 5mg qd and Lipitor 20mg qd. Patient then goes to pick up his prescriptions at the local Walgreens and the total amount is $293 Although patient has recently received health benefits, his employer does not provide prescription coverage. How can we help this patient?

54. Pharmaceutical Company Programs http://www.needymeds.com http://www.rxassist.org (account required)http://www.rxassist.org http://www.pparx.org

55. Click here to begin

56. Select “L”, then Lipitor

57. Click here to link directly to application

59. Requires account

62. Drug Discount Programs http://www.rxoutreach.com (generics only)http://www.rxoutreach.com http://www.togetherrxaccess.com

63. Click Here Click here

65. Rx outreach income requirements

66. Income requirements

67. $4 generic drug program Wal-Mart ( www.livebetterindex.com/4drug.pdf ) and Sam’s Club www.livebetterindex.com/4drug.pdf Target Giant Eagle / Giant Costco (200 generics for $10/100 tablets) ******************************************************************* Drug savings regardless of insurance coverage Currently available in select states only $4 for 30 days supply (except Costco) Approx. 320 generic medications available through the program

68. $4 Generic Drug Program – Medication 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

69. Happy Days or a Big Mystery?

70. Who Can Get Part D Coverage? All Medicare beneficiaries – people >65 years of age, certain disabled persons, and those with ESRD – are eligible for Part D coverage Most beneficiaries must actively sign up for a Medicare prescription drug plan Beneficiaries with prescription drug coverage from an employer or union that is at least as good as the standard Medicare coverage can keep it

71. Phase 3: YOU PAY $2.15 FOR EACH GENERIC, OR $5.35 FOR EACH BRAND NAME, OR 5% OF THE TOTAL OF EACH PRESCRIPTION, WHICHEVER IS THE HIGHER NUMBER. EXAMPLE: A $200 DRUG COSTS YOU $10.00. THIS 5% ARRANGEMENT CONTINUES ONLY UNTIL DECEMBER 31, 2007 Medicare Part D 2007

73. Drugs NOT Covered by Medicare Benzodiazepines Barbiturates Most OTC drugs Prescription 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

74. Help for People with Limited Income and Resources Apply for extra help through social security office: www.socialsecurity.gov 1-800-772-1213

75. Low-Income Assistance 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”

76. Back to the Sample Patient… Patient’s annual household (2 people) income is $32,500 This makes him ineligible for most “free” pharmaceutical programs What about the discount programs Suggestions for drug regimen improvement –Rx Outreach $60 for ALL THREE medications for NINETY DAYS $20 for one month supply vs. $293 with brands –Together Rx Patient is eligible (<$40K income) and would receive a 25- 40% discount on the medications prescribed by his doctor

77. Conclusions You will make a big difference in someone’s life by helping make medications more affordable and accessible Informed consumers ask the right questions and puts downward pressure on the price of prescription drugs Share this information with your colleagues; knowledge is the first step to change!

78. Your Primary Toolbox Pharmacy assistance programs –http://www.needymeds.comhttp://www.needymeds.com –https://www.pparx.orghttps://www.pparx.org –http://www.rxassist.orghttp://www.rxassist.org Drug discount programs –http://www.rxoutreach.comhttp://www.rxoutreach.com –http://www.togetherrxaccess.comhttp://www.togetherrxaccess.com Other –http://nofreelunch.orghttp://nofreelunch.org –http://www.crbestbuydrugs.org/http://www.crbestbuydrugs.org/ –www.drmichael.comwww.drmichael.com –http://www.gphaonline.org/http://www.gphaonline.org/ –http://www.fda.gov/cder/ob/default.htm (Orange book)http://www.fda.gov/cder/ob/default.htm

80. The End