Pharmacist-led financial interventions (part 3)

Possessing expert medication knowledge, pharmacists are in a unique and critical position to identify solutions for patients experiencing financial barriers that can affect medication access or adherence to a prescribed regimen.

As discussed in parts 1 and 2, this is a serious problem…and as prices continue to rise, a growing one that affects the nation’s population health and costs.

According to a National Health Interview Survey regarding ways patients are choosing to save money on prescription drugs, the CDC reported:

  • 15.1% of patients requested that their physician prescribe a less-expensive alternative
  • 7.8% admitted they don’t take their medication as prescribed
  • 4.2% used alternative therapies
  • 1.6% purchased prescription drugs from another country, which can make the efficacy and safety of the meds unknown

Interestingly, adults aged 18-64 (8.5% of the population) were nearly twice as likely as adults aged 65 and over to save money by asking for a lower-cost prescription or not taking their medication(s) as prescribed. Reasons could be a much higher percentage (33.6%-39.5%) of uninsured (PDF) for non-senior adults vs. seniors who have access to Medicare, or the former’s relative confidence in their youthful health.

And keep in mind…any of these stats may be even higher; they reflect the admitted actions (or lack thereof) in each area.

To show the market’s continuous impact, CMS data (PDF) shows that retail prescription drug spending escalated in 2019 by 5.7% to $369.7 billion, with an increasing percentage of that coming out of patient’s pockets. Thus, it’s understandable why so many people are going without, or choosing alternatives that could be unwise. 

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RxLive has identified and uses in our consuls a number of pharmacist interventions pertaining to financial barriers that often impact our patients. For instance, we recommend a 90-day vs. 30-day supply when allowed; switching to a generic, therapeutic or over-the-counter (OTC) medication alternative; referring to another pharmacy that has a lower price for the same medication; identifying a copay assistance card or program; switching to an alternative dose, frequency or combination medication; or discontinuing a medication entirely.

Pharmacist-led financial interventions


Patients are acutely aware of personal financial barriers and the impact expensive medications have on their ability to afford other necessities — and desirables — of life. However, patients may not be fully aware of the potential clinical impact of themselves choosing to veer from a prescribed therapy regimen, or the safety implications of purchasing prescription medications from unregulated online sources or other countries. 

Pharmacist-led financial interventions are driven by their deep knowledge of clinical and financial medication options. In consultations, they can assess the interwoven aspects of a patient’s meds regimen, clinical situation and support, financials, and lifestyle choices…all of which can impact recommendations to help patients achieve optimal results. Pharmacists can help educate them on the health impact of medication nonadherence, cost-effective alternatives, and the importance of purchasing drugs from pharmacies that are sourced from U.S.-regulated manufacturers.

In addition to the pharmacist-led financial interventions explored in Part 1 and Part 2 on this topic, pharmacists can also use their medication acumen to recommend switching to an alternative dose, frequency or a combination medication or, again, to discontinue a medication altogether.

Switching to an alternative dose or form


Forms
— Prescription drugs often come in multiple dosage forms at different price points. The same active pharmaceutical ingredient (API) may be available in tablets, capsules, lozenges, suspensions, suppositories, creams or other dosage forms. One dosage form may be more cost-effective than another, whether it’s commercial or must be compounded.

Many medications are also available in several strengths, often with negligible cost difference between them. The higher-strength medications that can be safely split or administered in smaller quantities can be prescribed as a cost-saving tactic, enabling the patient to pay a single copay for a medication that lasts a longer period of time. 

Pill splitting — The prescribing of high-strength tablets or pills intended to be split into a smaller dose is known as pill splitting. While this can reduce a patient’s costs, caution must be observed. The practice isn’t suitable for all types of prescriptions…or patients, for that matter. Some patients may have problems or no caregiver support to split pills, and some meds (capsules, time-released meds, etc.) should not be split at all. 

If pill splitting is determined by the prescriber to be appropriate, the pharmacist should counsel the patient via the teach-back method on the proper way to split the tablet to achieve the correct dose. We must also emphasize to a patient that when pill splitting, the correct dose is only a portion of the medication unit and should be taken based on directions hopefully written on the prescription label. (An example: for two daily doses of 150mg of hydralazine, a dosage level that currently doesn’t exist, the label should say “take one and one-half tablets by mouth twice a day.”) 

Since some pills are more difficult to split than others by hand alone, a pill splitter is recommended. They’re very inexpensive, typically well under $10. Splitters are easy to use, especially for small and/or coated meds, and provide patients with a more-consistent and accurate dose for the split pill or tablet. Typically, they can be found in the shelves or end caps near a retail pharmacy counter, or are available online from such suppliers as Amazon.com.

Lowering the dose — Lowering the medication dosage is also a potential cost-saving strategy in certain instances. Studies published in JAMA Oncology and Annals of Oncology observed that many chemotherapy agents, for example, are effective at lower doses than typically administered. The latter study reported that strategies such as dose or frequency reduction and therapy substitution could be applied to 33 (62%) of the 53 oral chemotherapy agents evaluated, resulting in a potential savings of 33% to 50%. 

Lower dosages not only can save on costs without affecting efficacy for certain medications, but can also improve patient quality of life via reduced exposure to such things as chemotherapy drugs, which often have debilitating side effects.

Switching to an alternative frequency


Switching to time-released meds is a way to reduce how often a patient needs to take a medication, simplifying their meds regimen and often saving them money. It lowers costs while also reducing side effects through steady-state drug levels. 

Many extended or sustained-released medications are available in more-affordable generic form, where switching offers immediate cost-savings. Unfortunately, many brand-name, extended-release formulations have no generic alternative. This requires using other cost-saving strategies such as use of copay-assistance programs or referring a patient to a pharmacy offering the brand med at a lower price. 

Switching to a combination therapy


In some cases, combination drugs can be used in place of multiple singe-dose medications to save on therapy costs and also promote medication adherence. Combination drugs enable patients to reduce their pill burden and potentially save money by reducing the number of single prescriptions. Ideally, generic combination drugs are used to maximize the potential for cost savings. However, combination drugs may only exist in expensive brand form or completely lack commercially availability, opening the option of referring the patient to a compounding pharmacy that can customize drug products combining APIs per a physician’s request.

Conversely, switching from a combination drug to multiple generic, single-API medications also can save costs when the combination drug is only available as a branded product. Patients’ adherence level and ability to take multiple medications at once must be considered when recommending a switch from combination therapy to multiple-dosage forms.

Discontinuing a medication


It’s well-documented in scientific literature that diet and exercise are risk factors for several chronic diseases, and that disease progression can be mitigated or potentially reversed with lifestyle modifications. Pharmacists can help patients set health goals to discontinue medications by helping them understand and implement lifestyle changes. Using motivational interviewing (MI) techniques in repetitive counseling sessions, pharmacists can stimulate patients’ motivation for behavioral change. That can lead to positive patient outcomes while also reducing costs through cessation — or, at least, reduction of dosage and perhaps cost — of medications for conditions that can be improved through lifestyle modifications.

Summary


Pharmacists are optimally positioned in the healthcare chain to help optimize clinical and financial outcomes utilizing their deep and broad medication expertise as they interact with both patients and prescribers. Again, their recommendations can include recommending a 90-day supply; switching to a generic, therapeutic or over-the-counter (OTC) medication alternative; referring patients to another pharmacy with a lower price for the same medication; identifying a copay assistance program; switching to an alternative dose, frequency or combination medication; discontinuing some medications; or education on a lifestyle modification that can reduce or even eliminate a patients’ need for one or more medications. 

In these ways, we’re proud to help patients — working in partnership with their providers — to overcome financial barriers blocking them from achieving optimal therapy and outcomes that improve their health and their pocketbook. If we can help you as a provider help your patients as members of your extended care team, please let us know.

Resources


Effects of Exercise and Diet on Chronic Disease. J appl physiol

Interventional Pharmacoeconomics — A New Discipline for a Cost-constrained Environment. JAMA Oncology

Motivational Interviewing for Medication Adherence (PDF). American Pharmacists Association

Potential for Value-based Prescribing of Oral Oncology Drugs. Annals of Oncology

Strategies Used by Adults to Reduce Their Prescription Drug Costs: U.S., 2013. CDC

National Health Expenditures 2019 Highlights (PDF). CMS

Author avatar
Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.