Kickstart the Cost Conversation
White has seen an increase in the number of topics taught related to pharmacoeconomics, which is emphasized in the curriculum at the University of North Texas Health Science Center College of Pharmacy. “I tell my students that when I was in school, there were very few hours in the curriculum dedicated to pharmacoeconomics topics and now many of these topics are included in Chapter 1 of major textbooks. It continues to be needed,” she said. “We’ve heard it from faculty and students and also from patients. Why are drug prices so high? Why aren’t health outcomes improving given the high cost of healthcare? The majority of schools do cover pharmacoeconomics topics but there is room for improvement. A lot of schools are teaching it later in the program years, the P3 year as opposed to P2 or even the first year. It’s never too early to introduce these topics. Customers are coming into retail settings and asking why isn’t a drug covered or why are prices so high?”
Given that coverage of pharmacoeconomics varies from school to school, White sees a need to develop a standardized approach to teaching this in the curriculum. “We definitely need to increase the number of hours spent on these topics. Don’t wait until the third year because it’s too late,” she added. “I’m an advocate for introducing these topics early on in the curriculum. Some schools may not have faculty that have this as a specialty area and they don’t have the students who are as interested in it. That is a concern, because if you have no pharmacoeconomics in your curriculum, that really is an issue in terms of preparing a student for the future.”
Student organizations are one way to get those conversations going. White suggested that pharmacoeconomics can be integrated into an introductory pharmacy course. If schools don’t have faculty who have a pharmacoeconomics background, guest speakers can be brought in to keep students up to date.
At the University of Toledo College of Pharmacy and Pharmaceutical Sciences, this content is addressed in a P3 course that covers pharmacoeconomics principles, pricing, cost and quality issues, said Dr. Varun Vaidya, professor, Division of Pharmaceutical and Policy Sciences. “Every college in some shape or form is delivering [this content to meet accreditation standards] but most Pharm.D. students don’t think of this as core material. They are more focused on the clinical side,” he noted. “The board [exam] is heavily focused on therapeutics. The exam isn’t testing them extensively on pharmacoeconomics. It’s part of ACPE’s accreditation requirements but I don’t know how much importance student pharmacists see in this. The pharmacy Academy can work on improving that.”
Vaidya offered an example of how he explains to students the ways in which pharmacists can help patients consider cost and improve their health outcomes. “In my class I discuss a new generation of anti-coagulants. The price difference is $400-$500 a month. From an efficacy standpoint all of these drugs are almost equal,” he explained. “The only benefit is convenience. If this is being laid out and patients are educated on the options, they can choose to pay the extra cost. But if it’s someone who cannot afford it, they should be given the alternative. That’s just one example. We can make these recommendations at the patient level that would not only save money for the patient but also the PBM. It is in the PBM’s interest to have pharmacists trained and be compensated for that.”
He believes pharmacists should be trained to understand how we value the cost effectiveness of drugs and make that investment to learn to provide these services and get compensated. “These recommendations will save money and that’s a great value that pharmacists can add,” he continued. “Pharmacists are so accessible. When it comes to reimbursement for MTM services, the insurance companies’ perception is it’s overlapping with what they get from the physician’s office. Pharmacoeconomics in practice settings is a niche area that pharmacists can take advantage of.”
Vaidya supports pharmacists being more involved in discussions with patients about pricing and cost effectiveness. “Pharmacists are in a unique position,” he pointed out. “They have the knowledge about the drugs and how the insurance is covering things, PBMs, Medicaid, but they are also at the cash register. MTM services are mostly focused on the clinical side. That role is going to expand. This is where pharmacists can make their mark. They can advise patients on the clinical and also the cost-effective side. The clinical often gets covered at the physician’s office or with nurse practitioners or with other healthcare providers. For certain medications, such as diabetes and for some chronic conditions, prices have gone up significantly. More patients are turning to pharmacists and I hope they are asking these questions—why are these drugs costing so much, what can be done, what are the alternatives?”
White agreed that the focus will continue to be on decreasing costs without reducing quality of care. “Pharmacists have such an opportunity right now to take a lead role in this area. We have to step up to the plate and really share with different stakeholders in terms of the best ways to navigate this changing landscape of healthcare,” she said. “When you look at AI increasing, big data…at the core of it is still going to be the fact that transparency is lacking in terms of pricing. Patients are telling their stories about outrageous drug costs but pharmacists need to be able to communicate why those prices are high and be more transparent in sharing data across settings. We know that people want transparency and want to understand why prices are so high, so we need to be proactive to answer these questions.”
Advocacy Around Affordability
Efforts to address drug pricing issues are gaining momentum at the state level and some pharmacy faculty are getting involved. In Maryland, a first-of-its-kind Prescription Drug Affordability Board was created in 2019 to take action to make drugs more affordable for state residents; board members were selected in 2019 (four members) and 2020 (one member) based on their expertise in the space as well as strong research and policy backgrounds. Dr. Eberechukwu Onukwugha, associate professor, executive director, Pharmaceutical Research Computing, Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, was chosen as one of the five board members for her expertise in data analysis, health economics and outcomes research.
“We have several tools available to consider—there are multiple options from a policy standpoint to lower costs,” Onukwugha said. “The initial work we are tasked to do in the first year is to get a better understanding of the drug supply chain before getting to the stage of considering appropriate measures to reduce the cost burden. That work is ongoing and is key to gaining more clarity. What’s important is making sure we are evidence based and we are getting a sense of the stakeholders throughout our review of the supply chain. What we think about is the burden—both clinical and economic—families are feeling related to affordability concerns. We are approaching it holistically to think about medical care, not just prescription drugs. We attend public forums and listen to the public at these forums. Individuals and families are making tradeoffs in some cases and forgoing taking their medications. Price is one component but there are other dimensions to it. We want to understand that more fully before thinking about recommendations.”
The board’s executive director, Dr. Andrew York, who is a pharmacist, said the aim is to take a comprehensive look at what affordability means for residents in Maryland. “We are looking at reducing costs, but just as importantly, we are looking at improving access. We are trying not to get tied up on things like ‘price,’ which is a loaded term,” York explained. “There are so many metrics that can be said to be the ‘price,’ but they seldom reflect what anyone in the supply chain actually pays. Instead, we hope to develop a report that is a comprehensive study of the pharmaceutical payment and distribution system. We have decided to take a broad view, and we hope to look at every aspect of the supply chain and look at every opportunity to make drugs more affordable. We are working on understanding the issues by the end of this year. Then, we plan to make recommendations and take action that will materially improve patients’ lives by making their prescription drugs more affordable. We are thinking about the interventions that would make the most impact.”
York added that pharmacists are in a great position to help patients navigate affordability issues at the point of patient/caregiver interaction. “The prescribers may not even know these are issues for the patients. It’s a huge opportunity for pharmacists to help patients by providing the necessary information to the healthcare team and to let them know that they need to take cost into consideration when prescribing,” he said.
Drug affordability is an issue for all states, and York and Onukwugha hope the board’s approach can be translated outside of Maryland. “There’s been a lot of research already conducted to describe and document barriers to healthcare utilization and the impact of the cost burden,” Onukwugha noted. “We aren’t always fully aware of what’s already been studied and documented. It’s important to understand the literature. Something for those who are looking to do more in this space is data-oriented work—study your own populations with surveys or patient interviews.”
Dr. Marta Brooks, chair and associate professor, Department of Pharmacy Practice, Regis University School of Pharmacy, sees an opportunity for pharmacy faculty to play an advocacy role. The school has representation within the Colorado Pharmacists Society to provide perspective from the educators’ side of the equation on policy issues. The Colorado legislature is considering forming a prescription drug affordability review board, which would have the authority to cap the price of certain high-cost drugs.