1.40: Let your pharmacist be your guide- navigating barriers to pharmaceutical access
Introduction
The high cost of healthcare in the United States, spanning from the ability to afford health insurance to paying for medications and medical bills, is a public health issue that hinders access to care and contributes to poorer health outcomes. Over the past ten years, the cost of healthcare services has grown more quickly than the cost of other goods and services. 1 In a 2019 poll, half of US adults reported that they or a family member put off or skipped healthcare or dental care services due to cost. 2 Moreover, 29% of all adults reported that they did not fill a prescription, cut pills in half, skipped doses, or otherwise did not take their medications as prescribed due to cost. 2 Patients reported resorting to other alternatives for care, such as relying on home remedies or over-the-counter drugs. 2 The consequences are detrimental, with three in ten (29%) individuals reporting their medical condition worsened because they did not take their prescription medications as recommended. 2 These barriers are particularly pronounced among those who face added challenges to care, such as patients who do not have insurance, are underinsured, or have serious medical conditions.
Specifically, lack of insurance coverage and underinsurance hinders healthcare access by impacting whether someone receives care, as well as when and where they can receive care. Access to healthcare is further influenced by multi-level factors that impact pharmaceutical care. At the policy level, this includes lack of timely availability of generic alternatives, lack of policies designed to improve medication adherence, and lack of transparency in drug costs. 3 These policies lead to patients paying for higher cost brand name drugs. At the community level, factors include the geographic location of pharmacies and existing transportation infrastructure. Pharmacy deserts, or neighborhoods and communities without a pharmacy or pharmacy services such as home delivery, hinder patients’ ability to get medications. 4 Organizationally, this includes disproportionate distribution of qualified and skilled healthcare workers and under-resourced health systems. These factors influence whether patients have access to a clinic nearby, which adds a notable barrier for rural communities. At the individual level, socioeconomic status in addition to the presence of complex medical conditions pose further challenges, as discussed above.
Several private and publicly funded mechanisms exist to help address barriers to medication access. For example, free clinics are safety-net organizations that often utilize volunteer health professionals to provide a range of medical, vision, behavioral health, dental, and/or pharmacy services to uninsured and underinsured patients. 5 Websites like the National Association of Free & Charitable Clinics (NAFC) and NeedyMeds provide ways to locate the closest free clinic. Federal programs such as the 340B drug pricing program enable health clinics that care for underserved populations to reallocate and stretch limited federal resources. 6 However, these programs are only available to qualified entities and to select patients. For individuals who need assistance with the cost of prescription drugs, prescription drug coupons and discount cards can be found through websites like GoodRx and NeedyMeds. Prescription drugs can also be obtained at little or no cost from pharmaceutical companies through patient medication assistance programs (PMAP). 7 However, the enrollment and refill processes are not standardized, and each manufacturer’s PMAP application may have different enrollment requirements. Many applications require patients to disclose their financial status, provide financial documentation such as federal income tax forms or social security benefit letters, or provide their social security number. 8 Although programs exist to fill in the gaps in pharmaceutical access, unfortunately they are insufficient and difficult to navigate. In addition, not all medications are available, requiring therapeutic substitution. This offers pharmacists the opportunity to play an important role in helping patients navigate the resources available so that patients can obtain affordable medications.
Case
You are a clinical pharmacist at a federally qualified health center (FQHC).
CC: “I want to start treatment for my Hepatitis C before I move.”
Patient: LM is a 56-year-old female (55 in, 82.6 kg) with newly diagnosed hepatitis C virus (HCV) infection who is an undocumented migrant farmworker. Over the past few months, it has been difficult for her to find work in the area, which has made it hard for her to pay for her medications and supplies. She is concerned about this because she knows she needs to take her medications to stay healthy and out of the hospital. Right now, she is holding on to hope that she might be able to find work over the next month or so but shares that she will likely need to move on to another area soon, since the seasons are changing.
HPI: After being diagnosed with HCV, the patient is feeling overwhelmed, especially due to the cost of the new medications. She states “I have heard treatment for hepatitis C is very expensive. Those medicines might cost more than everything I own!”. She is very worried but would still like to begin treatment as soon as possible, as she is unsure of when she will be able to re-establish care after she moves.
PMH: T2DM; HTN; HLD; HCV
FH:
- Mother: alive; T2DM
- Father: (deceased; MI); HTN
SH: History of substance use (alcohol)
Medications:
- Insulin aspart (Novolog) 10 units subcutaneously TID ac
- Insulin glargine (Lantus) 45 units subcutaneously daily
- Metformin 1000 mg BID
- Atorvastatin (Lipitor) 40 mg daily
- Lisinopril 20 mg daily
- Hydrochlorothiazide 25 mg daily
Allergies: NKDA
Vitals:
- BP 133/75 mmHg
- HR 78 bpm
- SpO 2 98%
- Temp 97.8°F
Labs:
- HgbA1c: 6.8%
- Hep C screen: reactive
- Hep C quant: 872,974 unit/mL
- Hep C genotype: 3a
- HBsAg: negative
- HBsAb: 95.1 IU/L
- HBcAb: negative
- HIV status: negative
- All other labs WNL
- Imaging/Staging:
- FibroScan: 5 kPa
- Fibrosis Score: F1
ROS:
- General: negative
- Eye: negative
- Ear/Nose/Throat: negative
- Respiratory: negative
- Cardiovascular: negative
- Gastrointestinal: negative
- Genitourinary: negative
- Gynecological: no abnormal bleeding, pelvic pain/discharge, breast pain or new/enlarging lumps on self-exam
- Skin: negative
- Heme/Lymph: negative
- Musculoskeletal: negative
- Neuro: negative
- Psychiatric: anxiety
- Endocrine: negative for symptoms of hypoglycemia/hyperglycemia
Surgical history: None
SDH: LM resides in a trailer home with six other relatives, including her parents, her husband, brother, and two children. She was born, raised, and lived most of her life in Mexico, where she completed only a few years of formal education. Her primary and only fluent language is Spanish. She has worked for the past few years as a migrant farmworker. Some members of her family are documented citizens in the US; however, she is not documented, and she does not have healthcare coverage. Currently, she has no personal income, but a few members of her family have found some temporary work in the area, so there is some money for food and other expenses in their household. Access to fresh foods is challenging and sometimes she struggles to afford her diabetes testing supplies. However, LM can access many of her medications and remain adherent to her insulin because this medication is currently available through the 340B program at her clinic.
Additional context: This patient falls into the category of ‘migrant farmworker’ based on her work moving from state to state to harvest different crops based on the season.
Case Questions
- What would be the best treatment and monitoring plan for LM, taking into consideration all the barriers the patient may face in completing HCV treatment?
- What challenges does accessing HCV medications present generally in the United States?
- How does the fact that LM is a migrant farmworker affect her access to HCV treatment?
- What resources are available to improve medication access for patients who are underinsured or uninsured and how do patients access these programs?
- What programs are available to patients who are not US citizens and/or are undocumented immigrants?
- Given LM’s undocumented status and lack of insurance, what specific programs or resources would you recommend to improve her access to care and help complete HCV treatment?
- In general, what factors influence access to affordable medications at policy, organizational, and individual levels?
- What are the consequences of lack of prescription insurance coverage medication access on patient health outcomes?
Author Commentary
Patients who lack insurance or are underinsured have complicated barriers to healthcare that can be difficult to navigate. Migrant farmworkers have added challenges to accessing adequate and consistent care. These barriers and gaps in care result from the fragmented nature of our current healthcare landscape and contribute to the pervasive health disparities and inequities that exist. Pharmacists will encounter patients who have barriers to care regardless of the pharmacy setting. Consequently, pharmacists play an important role in helping patients access affordable medications by informing themabout the resources available and helping patients utilize these resources.
In addition to resources like the 340B program and PMAPs, pharmacists can help make medication regimens more affordable for patients regardless of insurance status. For example, by recognizing clinically appropriate and cost-effective alternatives for higher cost drugs, pharmacists can recommend therapeutic exchanges. In addition, pharmacists can troubleshoot and find formulary alternatives for medications that are not covered by a patient’s health insurance or require prior authorization. Pharmacists can also provide education on the differences between brand and generic drugs and encourage patients to use generic drugs when appropriate. Modest adjustments, like switching certain drug formulations from capsule to tablet or cutting higher dosages in half, are other cost-cutting strategies pharmacists can recommend. Many patients have trouble affording the medications they are initially prescribed even when they do have insurance. It is important for pharmacists to recognize the responsibility they have in making medications more accessible to patients.
Patient Approaches and Opportunities
Navigating our complex healthcare systemcan be a challenging and confusing process for many patients, particularly for those who have added barriers such as uninsurance or underinsurance, lack of citizenship, unemployment, lack of transportation, or low health literacy. Programs like the 340B program enable qualified health clinics to provide care to patients who are uninsured on a sliding fee scale based on income, and PMAPs can help patients gain access to otherwise unaffordable medications such as long and rapid-acting insulin, GLP1 inhibitors, inhalers, direct acting antivirals, and direct oral anticoagulants. Although resources and programs are available to help improve access to care or lower prescription drug costs, there are wide variations in ways to enroll in programs and application processes, respectively. Furthermore, there is no standardized way to access all available resources. Consequently, many patients are not aware of the resources available or do not access them.
As the medication experts, pharmacists can help patients navigate these complex barriers and obtain affordable medications. Beyond that, pharmacists can help refer patients to other available programs. Because many patients may not know that these options exist, it is important to proactively broach this conversation in a sensitive and respectful way when red flags are present (i.e., inconsistently filling/refilling prescriptions, extended absences in care, or frequent emergency department visits for preventable conditions). By establishing rapport and building trusting relationships with patients, pharmacists may become increasingly aware of patients’ unique needs and identify opportunities for intervention that would otherwise have gone unnoticed.
Related chapters of interest:
- Plant now, harvest later: services for rural underserved patients
- Saying what you mean doesn’t always mean what you say: cross-cultural communication
- An ounce of prevention: pharmacy applications of the USPSTF guidelines
- Sweetening the deal: improving health outcomes for patients with diabetes mellitus
- Prescription for change: advocacy and legislation in pharmacy
- Uncrossed wires: working with non-English speaking patient populations
External resources:
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Websites:
- Partnership for Prescription Assistance. http://www.pparx.org
- Rx Assist. www.rxassist.org
- Needymeds. www.Needymeds.org
- Bureau of Primary Health Care. https://bphc.hrsa.gov/
- Office of Pharmacy Affairs. https://www.hrsa.gov/opa/340b-opais/index.html
- 340B Program. https://www.hrsa.gov/opa/index.html
- 340B Prime Vendor Program. www.340bpvp.com
- National Association of Free and Charitable Clinics. https://www.nafcclinics.org/find-clinic
- RxHope: www.RxHope.com
- Medicare Part D. https://www.medicare.gov/drug-coverage-part-d
- Health Insurance Marketplace. https://www.healthcare.gov/marketplace/individual/
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Journal articles:
- Kesselheim AS, Huybrechts KF, Choudhry NK, et al. Prescription drug insurance coverage and patient health outcomes: a systematic review. Am J Public Health 2015;105(2):e17-e30.
References
- Consumer Price Index – December 2020. www.bls.gov/news.release/cpi.nr0.htm . Accessed February 3, 2021.
- Kirzinger A, Munana C, Wu B, et al. Data note: Americans’ challenges with health care costs. June 2019. https://www.kff.org/health-costs/issue-brief/data-note-americans-challenges-health-care-costs/ . Accessed February 3, 2021
- Kesselheim AS, Huybrechts KF, Choudhry NK, et al. Prescription drug insurance coverage and patient health outcomes: a systematic review. Am J Public Health 2015;105(2):e17-e30.
- Pednekar P, Peterson A. Mapping pharmacy deserts and determining accessibility to community pharmacy services for elderly enrolled in a State Pharmaceutical Assistance Program. PLoS One . 2018;13(6):e0198173.
- Darnell JS. Free clinics in the United States: a nationwide survey. Arch Intern Med 2010;170(11):946–53.
- 340B Drug Pricing Program. https://www.hrsa.gov/opa/index.html . Accessed December 21, 2020.
- Drug company programs help some people who lack coverage. Washington, DC: U.S. General Accounting Office, 2000 Nov; report GAO-01-137. https://www.gao.gov/products/GAO-01-137 . Accessed December 21, 2020.
- Chauncey D, Mullins CD, Tran BV, McNally D, McEwan RN. Medication access through patient assistance programs. Am J Health Sys Pharm 2006;63(13):1254-9.