Speaker 1 (00:04):
Welcome to 340B Insight from 340B Health.
David Glendinning (00:11):
Hello from Washington, DC, and welcome back to 340B Insight, the podcast about the 340B Drug Pricing Program. I'm David Glendinning with 340B Health. This is a milestone episode of 340B Insight. We are celebrating our one year anniversary. On May 18th, 2020, we launched 340B Insight with our President and CEO, Maureen Testoni, interviewing Admiral, Krista Pedley, the Health Resources and Services Administration Office of Pharmacy Affairs Director. Over the course of this momentous year, we have released 27 episodes. We're immensely grateful to all of you who have listened in as you work tirelessly to help your patients navigate, and in many cases, survive the pandemic.
David Glendinning (01:00):
For today's special episode, we are discussing a top issue for 340B providers and their patients. Our guest is Anne Webster, a nurse practitioner at UnityPoint Health Methodist in Peoria, Illinois. Anne has a powerful story to tell about how several drug companies decisions to cut off 340B pricing for drugs dispensed to community-based pharmacies have affected her patients living with diabetes. But before we go to that interview, let's take a minute to cover some of the latest news about 340B.
David Glendinning (01:40):
The dispute between drug companies and covered entities over contract pharmacies continues to be a top issue for the 340B Program, one that is being debated at the highest levels of government. In a recent motion filed in a federal court in Delaware, government lawyers systematically rejected every legal argument that the drug company AstraZeneca is using to try to stop the administration from enforcing the 340B law on this issue. This case is one of several lawsuits brought by some of the drug companies that have cut off 340B access through community pharmacy arrangements. In the recent motion, attorneys representing the Department of Health and Human Services wrote, "This case culminates a brazen strategy by a cohort of large, highly profitable pharmaceutical companies unilaterally to upend the decades old, settled operation of a statutory program that provides discounted medications to safety-net healthcare providers and their uninsured and underinsured patients." You can read the full government brief as well as the brief that 340B Health and allied organizations filed in the same case in the show notes.
David Glendinning (02:48):
The disagreement has gained attention at the state house level as well. Arkansas recently became the first state to say it will block drug companies from refusing to offer access to or discounted pricing on drugs dispense through contract pharmacies based in that state. The policy change is part of a broader 340B Non-discrimination Law that is now on the books in Arkansas, making it one of about a dozen states that protect covered entities from inequitable reimbursement policies by pharmacy benefit managers. Check out the show notes for more.
David Glendinning (03:30):
And now, for our feature interview with Anne Webster. Anne has been working at UnityPoint Health Methodist for five years and is very familiar with the importance of 340B savings to caring for patients with diabetes, as well as what happens to that care when those resources go away. Here's Myles Goldman with that conversation.
Myles Goldman (03:50):
Thank you, David. I'm joined by Anne Webster from UnityPoint Health Methodist Hospital. Anne, I appreciate you taking the time to join us to provide an on the ground perspective of drug companies denying 340B discounts when drugs are dispensed at community pharmacies. This is one of the most important issues specifically facing 340B hospitals and their patients right now. Welcome to 340B Insight, Anne.
Anne Webster (04:18):
Thank you. I'm very happy to be here.
Myles Goldman (04:20):
In your role as a nurse practitioner, you are focused primarily on caring for diabetes patients. Tell us about the diabetes care you and your colleagues are providing.
Anne Webster (04:31):
I am a nurse practitioner in an endocrinology practice. It's a specialty that focuses on the endocrine system. I am a nurse practitioner that mainly focuses on diabetic management. I usually have patients that are not your average diabetic. They might be a little more complex. I have a lot of Type-1 diabetics. I have very insulin resistant Type-2 diabetics. They're people that don't fit the normal mold of your average diabetic. So when they come to us, they're typically complicated individuals with lots of comorbidities. And we provide all of the newest technology such as continuing glucose monitors, insulin pump therapy, all the newest medications available.
Myles Goldman (05:24):
Tell us more about where your patients are coming from and what their personal circumstances are.
Anne Webster (05:30):
My patients come from all over Illinois. I have some patients that drive two hours one way to see me. The reason they have to drive so far and come from all over is they're typically underinsured in their area. Their insurance is not covered by any health system that is nearby their place of living. So I have over 5,000 patients that we manage for Type-1 and Type-2 diabetes.
Myles Goldman (05:56):
What is the connection of 340B to the work that you're doing with your patients?
Anne Webster (06:01):
340B is an extremely important component to my care for my diabetic patients. I am one of very few providers in the 340B Program in the area I live. I have a office that is hospital-based, so it's a hospital based clinic and it met criteria so I could be a provider in the 340B Program. It's been a lifesaver for my patients. They can get very expensive medications at a price they can afford. This is very important for individuals on fixed incomes that are in a coverage gap or people that have no insurance whatsoever. They can actually obtain medications they would never be able to otherwise.
Myles Goldman (06:46):
An important part of your 340B Program is the Community Pharmacy Partnerships UnityPoint Health Methodist has established. Prior to drug manufacturers actions last year cutting off the discounts, can you describe what the hospital's pharmacy partnerships looked like and how patient care benefited?
Anne Webster (07:05):
Yes. UnityPoint Health Methodist has a Walgreens located in the hospital. That is the pharmacy I prescribed all of my 340B prescriptions through. In fact, since 2018 to 2020, I sent 2000 prescriptions there just for 340B for 800 individuals overall. And so, that was where all my patients would go for 30 day supplies of very expensive medications they could not get anywhere else for those prices.
Myles Goldman (07:39):
Tell me a little more about the benefits that patients have told you they receive from being able to stop by that Walgreens right on their way home.
Anne Webster (07:48):
Well, absolutely there's an ease of access to medications having a Walgreens right there in the hospital. Many times uninsured patients were admitted to the hospital for inpatient care, and I could prescribe meds and they could have it delivered to their room and they would leave with everything they need. Also, my clinic is very close to the hospital, so my patients can leave with their visit with myself or one of the physicians I work with and go right across the street to Walgreens and get all of the medications they need. So I ran some numbers, and in 2020, our uninsured and underinsured patients, they save 1.2 million in out of pocket expenses by accessing 340B pricing from the Walgreens inside the hospital.
Myles Goldman (08:40):
That's an incredible number to hear. I want to take a step back now to when this all began. Eli Lilly was the first company to refuse discounts. How have their actions affected the care you provided diabetes patients? What was the hospital's initial reaction when you first heard?
Anne Webster (09:04):
Well, I was unable to obtain Eli Lilly meds as early as last summer and into last fall. I use they're medication, theirs is very frequently as a very high concentrated insulin. It's an excellent medication. It's very expensive. But I prescribed it to countless individuals. When they pulled out, I had to switch people back over to less concentrated insulin which provided worst glycemic control. It also causes people to have to inject a huge volume of fluid under their skin which can lead to other problems. And I had a lot of patients that were very upset when they had to make this change because it affected their diabetic control. So them pulling out was the beginning of other companies pulling out, which even impacted my practice more.
Myles Goldman (09:59):
Were they still able to pick up their prescriptions from the Walgreens? Or did they have to go elsewhere?
Anne Webster (10:05):
When Eli Lilly pulled out, they had no alternative, so they get their medication anywhere else. So that's an expensive insulin and there's no way else that they could have gotten it for that price. So then, also Novo Nordisk pulled out at the first of the year. That was a huge impact also. NovoLog and Levemir insulin are insulins that I prescribed multiple times a day to the Walgreens in the hospital through 340B. When Eli Lilly and Novo Nordisk pulled out, it was detrimental. In fact, it was sad. I felt emotionally devastated when Novo Nordisk pulled out because I knew what it was going to do to some of my patients. I knew it could lead to their demise in worst case scenarios. I had to go back to NPH and regular insulin through Walmart, which are $25 vials. They're vial in syringe. So if someone has vision problems or dexterity issues, they have trouble drawing up the insulin.
Anne Webster (11:11):
The insulin does not control blood sugars as well as Lily or Novo Nordisk insulins did. And the insulins are $25 a vial. So if someone is requiring high doses of insulin, it is still expensive for them. So people had to go there, they had to go to Walmart. But the big problem was the cost and the quality of the insulin. If people can find affordable insulin, they will go wherever they can to get it. That's why it pays driving two hours as one way to my clinic. So when they were not available anymore, the good insulins, and Walmart's the alternative, it's a poor alternative.
Myles Goldman (12:00):
How much did their price go up roughly?
Anne Webster (12:04):
When I was prescribing Lily and Nova Nordisk insulins, they were all available as insulin pens, which is very nice, most people prefer that especially if they have vision or dexterity issues, they could get their whole month's supply of one insulin would be $15.34. So they're on two insulins, which most people are. It would be under $40 a month for both insulin in insulin pen form. People were thrilled. If they go to Walmart, they get a vial, it has a thousand mls in one vial.
Anne Webster (12:41):
So I have patients that use up so much insulin every month, they might need three vials of each kind, so that's $150 costs there. And it's a vial in syringe. It's just not the same quality of insulin either. It's a poor alternative. It's an older insulin, NPH and regular. It's a mix insulin. The peak times of the insulin are different. They don't control spikes and blood sugar as well as the other insulins do. Some people are more prone to severe hypoglycemic episodes with the insulin they're getting at Walmart. I'm just happy I have Walmart to go to now. It's an absolute, desperate move, but that's what I've been forced to do.
Myles Goldman (13:29):
Can you tell us about one of your patients who has been affected by these drug companies actions?
Anne Webster (13:35):
I have two patients that I think of right away, both of them I've been seeing for several years. One is a retired police officer, the other is a retired factory worker. They have insurance with Medicare. However, they fall into the coverage gap every year very quickly, or the medications still cost them a significant amount of money even with their insurance. So my factory worker that retired, he was on Eli Lilly's insulin, which is called Humulin U-500. It's a very high concentrated insulin. He's very insulin resistant. He was thrilled when he switched to this insulin. He was not having to inject such a large volume of insulin under his skin for six times a day. He only had to inject twice a day and the volume was much less. So when Eli Lilly pulled out, I had to call him and say, "I have to put you back on U-100 insulin, which is Levemir and NovoLog through Novo Nordisk. You can still get it through 340B at Walgreens in the hospital. It's still a good cost."
Anne Webster (14:39):
He wasn't thrilled because he had to inject now five times a day as opposed to twice a day, and the amount of volume that he had to inject every day was five times more. So he went on to the other insulin, and then that insulin was gone at the end of the year. I sent him to Walmart at first. And then we went through the drug programs and found some assistance for him, but that took a long time to happen. And in the meantime, he had a lot of stress and worry about obtaining his medication.
Anne Webster (15:13):
My other patient, the retired police officer was using 340B for other medications not just insulin. He could get a GLP-1 medication from AstraZeneca called Bydureon. It was an excellent medication for him. It helped with his blood sugar control. It helped his weight control. It helped reduce how much insulin he needed every month. AstraZeneca pulled out, that medications no longer available. He is now using a drug company to use their assistance program as well. That took a long time, but we finally got it covered for him because he met the needs, their requirements they have for patients.
Anne Webster (15:57):
However, once again, it was almost humiliating for both of these people to have to go through that. And the embarrassment of not being able to afford their medication, I felt bad for them.
Myles Goldman (16:12):
It's interesting that you brought up the Patient Assistance Programs that drug companies offer. Overall, how are these Patient Assistance Programs helping to fill the gaps that your patients are experiencing?
Anne Webster (16:26):
The Patient Assistance Programs, I am thankful for them because they do help many people. However, you have to be very low income to qualify. It takes a couple of months sometimes to qualify. You have to obtain all kinds of paperwork and proof of income and many hoops to jump through. Not every patient is capable of completing tasks like that, not everyone is. Especially people that are uninsured, they're not people that can fill out paperwork and go through the motions to get the assistance they meet.
Myles Goldman (17:11):
Before we end, I wanted to see if you had some suggestions based on your experience for colleagues who are listening and trying to determine how to keep their patients access to medications as normal as possible even as 340B discounts are blocked.
Anne Webster (17:30):
There's $4 med lists that you can use through Walmart. You can get the $25 vial of insulin through Walmart. That's a way to get diabetic medications for your patients that are uninsured or underinsured. The thing is, with a lot of those drugs, they are obesogenic. They cause obesity, a lot of them. And some of them have also severe side effects. There's one that is very affordable, it's probably $4 a month, but it can cause fluid retention that can lead to exacerbation of congestive heart failure. I mean, they're not great medications, okay? But that's what you have to do if you have no other choice.
Myles Goldman (18:09):
I'm sure our listeners, Anne, appreciate and may have also experienced many similar situations to the ones you've described. Anne, thank you for taking the time to share the stories of how UnityPoint Health Methodist and your patients have been harmed by drug company actions.
Anne Webster (18:28):
It was my pleasure to speak on behalf of my patients. I really support the program. I've been very grateful to be a prescriber through 340B. And my patients, the effect is detrimental that they cannot obtain their meds there any longer. And I want to make sure lawmakers know what it's doing to people.
David Glendinning (18:49):
Our thanks again to Anne Webster for sharing her story and for helping her patients with diabetes navigate through these difficult times with access to the insulin and other care they need to survive.
David Glendinning (19:01):
How were the drug company restrictions on 340B pricing affecting your ability to serve your patients in need? Please email us at podcast@340bhealth.org to tell us your story. We also welcome your episode ideas and feedback at that email address. We'll be back early next month. As always, thanks for listening and be well.
Speaker 1 (19:29):
Thanks for listening to 340B Insight. Subscribe and rate us on Apple Podcasts, Google Play, Spotify, or wherever you listen to podcasts. For more information, visit our website at 340bpodcast.org. You can also follow us on twitter, @340BHealth, and submit a question or idea to the show by emailing us at podcast@340bhealth.org.
Transcript source: Provided by creator in RSS feed: download file