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Current Influences on Antimicrobial Cost · The SHEA Podcast

• 0:06
  SPEAKER_00: Welcome to Shay's Podcast.
• 0:08
  SPEAKER_00: I am Dr.
• 0:09
  SPEAKER_00: Jonathan Ryder.
• 0:10
  SPEAKER_00: I'm an assistant professor in the Division of Infectious Diseases at the University of Nebraska Medical Center and a member of the Shea Antimicrobial Stewardship Committee.
• 0:19
  SPEAKER_00: I'm excited today to serve in the role of today's podcast moderator.
• 0:24
  SPEAKER_00: But before we get started, I'd like to introduce you to today's speakers.
• 0:29
  SPEAKER_00: So first up is Dr.
• 0:30
  SPEAKER_00: Jamie Wagner.
• 0:32
  SPEAKER_00: She is a clinical pharmacy specialist in infectious diseases and antimicrobial stewardship at Mount Auburn Hospital in Cambridge, Massachusetts.
• 0:41
  SPEAKER_00: She recently transitioned here from the University of Mississippi School of Pharmacy, where she had previously taught and practiced in infectious diseases and antimicrobial stewardship for almost 10 years.
• 0:52
  SPEAKER_00: Welcome, Dr.
• 0:53
  SPEAKER_00: Wagner.
• 0:54
  SPEAKER_02: Awesome.
• 0:55
  SPEAKER_02: Thanks for having me, Jonathan.
• 0:56
  SPEAKER_02: I'm so excited to be here.
• 0:59
  SPEAKER_00: And next up is Dr.
• 1:00
  SPEAKER_00: Sheena Kendaya, who is a senior physician at Emory University School of Medicine and an associate clinical professor of medicine in the Department of Medicine within the Division of Infectious Diseases at Emory University Hospital, while also managing the antimicrobial stewardship program at Grady Hospital.
• 1:19
  SPEAKER_00: Welcome, Dr.
• 1:20
  SPEAKER_00: Kendaya.
• 1:21
  SPEAKER_01: Thank you for having me.
• 1:22
  SPEAKER_01: I'm really excited to be here as well.
• 1:24
  SPEAKER_00: Well, welcome to the podcast.
• 1:26
  SPEAKER_00: I'm excited to hear your opinions on today's important topic.
• 1:32
  SPEAKER_00: Both of you were two of the co-authors on a recent article about macro and micro influencers of antimicrobial stewardship cost.
• 1:41
  SPEAKER_00: What do stewardship programs need to know?
• 1:45
  SPEAKER_00: And that appeared in one of Shay's journals, Antimicrobial Stewardship and Healthcare Epidemiology, also known as ASHI.
• 1:53
  SPEAKER_00: And so this is a really great topic that I don't think a lot of people outside of the stewardship space think a whole lot about.
• 2:00
  SPEAKER_00: And even within the stewardship space, I think there's still lots to be learned.
• 2:04
  SPEAKER_00: So I'm excited to talk to you all about this today.
• 2:08
  SPEAKER_00: So we'll start with the first question, which is how has the Affordable Care Act impacted access to antimicrobials, particularly for uninsured and underinsured patients?
• 2:20
  SPEAKER_02: Yeah, so I'll take that one first.
• 2:22
  SPEAKER_02: I honestly I think that's a good question to start us off with.
• 2:26
  SPEAKER_02: And I think the ACA really helped these patients and states that decided to expand Medicaid coverage per the act.
• 2:34
  SPEAKER_02: That expansion allowed everyone to have better access to the 340B drugs and close the donut hole for Medicare patients by lowering lowering overall drug costs.
• 2:45
  SPEAKER_02: The 340B program enables covered entities to stretch scarce federal resources as far as possible and thereby being able to reach more eligible patients and providing more comprehensive services.
• 2:58
  SPEAKER_02: Again, though, this 340B program is only available for outpatient services and prescriptions.
• 3:03
  SPEAKER_02: So not necessarily inpatient coverage, but more outpatient.
• 3:05
  SPEAKER_02: So really kind of targeting that patient population.
• 3:08
  SPEAKER_01: I could just add, I think that the ACA was revolutionary for a lot of patients who were especially below the poverty line.
• 3:16
  SPEAKER_01: I am going to say, though, that there are 10 states that did not expand Medicaid, and there are limitations to the ACA.
• 3:22
  SPEAKER_01: And that has sort of created a coverage gap in some areas, which has contributed somewhat to pharmacal inequity.
• 3:29
  SPEAKER_01: So as wonderful as it has done, it's been for many states, others, it has not been as sort of far-reaching as it could be.
• 3:38
  SPEAKER_00: Great.
• 3:38
  SPEAKER_00: That's a good framework to start off with.
• 3:41
  SPEAKER_00: So the next question is one that I think is quite topical and been in the news a lot lately, which is about the influence of pharmacy benefit managers or PBMs and how they affect uh drug pricing and how their role affects the affordability and accessibility of antimicrobials.
• 4:02
  SPEAKER_02: Well, being the pharmacist of the group, this is a hot topic for me 100%.
• 4:07
  SPEAKER_02: Something that is absolutely got my blood boiling typically on a daily basis.
• 4:12
  SPEAKER_02: But in general, PBMs are the middlemen, essentially, between drug companies, manufacturers, and individual pharmacies.
• 4:20
  SPEAKER_02: So they influence which drugs should be available, what the cost of these drugs are, and what, if any, rebates or benefits may be available to consumers.
• 4:29
  SPEAKER_02: And the initial advent of PBMs was supposed to be beneficial, right?
• 4:36
  SPEAKER_02: And it has shown to be helpful, but it's also been shown to be very hurtful.
• 4:40
  SPEAKER_02: And I think it's now coming to light to be a lot more hurtful to patients, not just in their accessibility to guideline-directed first line therapy as prescribed by their provider, but also in patients' abilities to afford these medications.
• 4:55
  SPEAKER_02: So to give some context and an example, so the guidelines recommend voriconazole as first line therapy for Aspergillus.
• 5:03
  SPEAKER_02: However, uh PBM can elect to prioritize posiconazole as the primary extended spectrum azole.
• 5:10
  SPEAKER_02: And all the patients who have providers prescribing voriconazole per the guidelines now have to swap to posiconazole to guarantee affordability or stay with voriconazole and then the patients have to pay a higher price.
• 5:21
  SPEAKER_02: And so this just is one of the ways to highlight that harsh criticism and investigation into the PBMs and the accusations being lofted at them about profit retention instead of passing the full rebate back to the insurer, the manufacturer, the drug company.
• 5:38
  SPEAKER_02: And this is really most evident in our independent pharmacies.
• 5:42
  SPEAKER_02: The independent pharmacies are able to track the individual line items of cost and reimbursement for every single prescription and then demonstrate how the PBM is not providing the same level of rebate as they once were.
• 5:55
  SPEAKER_01: Yeah, so I like how Jamie started started off with as the pharmacist in the group.
• 5:59
  SPEAKER_01: So I'm going to speak as the physician in the group.
• 6:01
  SPEAKER_01: And I'm going to say that I would say 90% of us don't even know what a PBM is.
• 6:06
  SPEAKER_01: And it's an important piece of information to know, as we are the prescribers of a lot of these antibiotics, they're supposed to be negotiating drug prices and discounts with the pharmaceutical companies to get lower prices for drugs.
• 6:19
  SPEAKER_01: But when they negotiate the rebates and discounts, if there's a higher list price, there's higher rebates.
• 6:24
  SPEAKER_01: So the antibiotics are more expensive.
• 6:26
  SPEAKER_01: And those higher rebates actually equal higher out-of-pocket costs for the patient.
• 6:31
  SPEAKER_01: So there's sort of a trickle-down effect there, and the patients kind of may get the shorter end of the stick there.
• 6:36
  SPEAKER_01: And those reboot rebates never may never actually get to the patient.
• 6:40
  SPEAKER_01: So I think that transparency in those rebates and the drug price negotiations is not there.
• 6:47
  SPEAKER_01: And it's something that is sorely needed to actually demonstrate the benefit of PBMs.
• 6:52
  SPEAKER_00: Thank you all for that explanation.
• 6:57
  SPEAKER_00: Really didn't know much about PBMs until very recently.
• 7:00
  SPEAKER_00: So the next question is how do formulary restrictions and prior authorization requirements impact antimicrobial prescribing?
• 7:09
  SPEAKER_00: And what are the unintended consequences of those for patient care?
• 7:14
  SPEAKER_01: Yeah, so I'm going to say from a prior physician perspective, you know, to just to be clear, a formulary is a list of medications that an insurance plan covers.
• 7:23
  SPEAKER_01: The prior authorization is a requirement by the insurer or a PBM that the prescribing physician must obtain approval before prescribing a certain drug that may be either non-formulary or have a condition outside the indication or be more of a higher priced antibiotic.
• 7:40
  SPEAKER_01: And ultimately, what it all it really does is it creates delays in treatment.
• 7:44
  SPEAKER_01: We end up switching to less effective drugs because it's easier.
• 7:48
  SPEAKER_01: There's increased resistance, ridiculous amounts of administrative work, frustration on both the provider side and the patient side.
• 7:57
  SPEAKER_01: And then, of course, noncompliance ultimately leading to unintended negative outcomes, which may actually be counterintuitive, where patients may end up getting admitted to the hospital and you're ultimately increasing your healthcare costs.
• 8:09
  SPEAKER_01: So I find these to be extremely counterintuitive when it comes to prescribing antibiotics and compromising sort of the autonomy of a lot of the physicians who are actually using them.
• 8:22
  SPEAKER_02: Yeah, I couldn't agree more on that, Friend.
• 8:25
  SPEAKER_02: Any outpatient formulae restrictions in prior oscan absolutely delay appropriate care.
• 8:31
  SPEAKER_02: And I know in the manuscript, we list several examples, including antifungal therapy for dimorphic molds, as well as antiretrovirals for HIV treatment.
• 8:41
  SPEAKER_02: And then all of these disruptions and delays in appropriate drug therapy.
• 8:46
  SPEAKER_02: So clinically, we know that this therapy is the appropriate and optimal choice for the patient, but either the PBM or the insurance just does not recognize that.
• 8:55
  SPEAKER_02: And now we have to go through, you know, 18 hoops to be able to get the right care for our patient.
• 9:02
  SPEAKER_02: But it those types of infections specifically can significantly alter both short and long-term outcomes and success for that treatment.
• 9:11
  SPEAKER_02: And it's just not the right thing to do for our patients.
• 9:14
  SPEAKER_02: We're all in this to take care of them, and and we just need to make sure that they get the care that they need when they need it.
• 9:19
  SPEAKER_00: I agree with you all.
• 9:20
  SPEAKER_00: Uh certainly hard to keep track of all the different formularies of all the different insurance companies.
• 9:26
  SPEAKER_00: Um I'm just trying to make the right decision for my patients too.
• 9:29
  SPEAKER_00: So another barrier that we face are disparities.
• 9:32
  SPEAKER_00: And so what uh what disparities exist in the access to antimicrobials and in prescribing patterns across different socioeconomic and geographic populations?
• 9:45
  SPEAKER_02: So I'll take that one first.
• 9:46
  SPEAKER_02: And I think this is the good timing on this because I just moved from probably a very poor socioeconomic area to not that, uh, being being up near the Boston area.
• 10:00
  SPEAKER_02: And so just seeing the discrepancy, so to speak, in prescribing patterns and stuff.
• 10:06
  SPEAKER_02: And so inequities and even just access to prescription drugs in not only racial and ethnic minority groups, but also in different socioeconomic situations across the state, these groups are less likely to receive novel and high-cost medications, lower cost generic therapies, and guidelines established for emergency use treatments and preventative or critical care therapies.
• 10:31
  SPEAKER_02: And so the variations in prescription drug plans that offer various cost-sharing strategies undermine efforts to achieve pharmacoequity for all prescription meds, including antimicrobials.
• 10:44
  SPEAKER_02: They're definitely not left out of that.
• 10:46
  SPEAKER_01: Yeah, and if I can add to that, even just geographical limitations, which includes just pharmacy deserts, where just access to an actual pharmacy to pick up antibiotics can be a challenge.
• 10:55
  SPEAKER_01: There may be limited public transportation, there may not be, you know, hours that are conducive to going to pick up antibiotics, which also plays a huge role there.
• 11:05
  SPEAKER_01: So, and then of course we've got our migrant populations who are may are heavily affected by limited access, not just to antibiotics, but also to care in general.
• 11:15
  SPEAKER_01: So I think that we I think we need to do a lot better from that standpoint.
• 11:20
  SPEAKER_00: Yeah, so we've talked about a lot of the barriers to accessing antimicrobials and some of the financial uh concerns, but what do we do about it?
• 11:29
  SPEAKER_00: So, what what reforms or policy changes could uh improve the affordability and the equitable access to antimicrobials in the US healthcare system?
• 11:41
  SPEAKER_02: First, I'd like to start by saying I think there's always room for improvement, right?
• 11:44
  SPEAKER_02: Everybody can always get better at something.
• 11:47
  SPEAKER_02: That being said, I would love to see preferred drugs or tier one drugs align with clinical guideline recommendations.
• 11:54
  SPEAKER_02: They don't always do that, and it really impedes care.
• 11:58
  SPEAKER_02: I also think that the entire prior authorization process needs refinement to stop the delays in care from occurring, especially for patients transitioning from the inpatient to the outpatient setting.
• 12:09
  SPEAKER_02: We also need to ensure that access is not a problem.
• 12:12
  SPEAKER_02: And just like Sheena said on the last point and last question that you brought up, like you can interpret, you know, that in a multiple different ways.
• 12:22
  SPEAKER_02: But some ways that I'm thinking of going beyond just costs include physical locations.
• 12:26
  SPEAKER_02: So she had mentioned about pharmacy deserts.
• 12:28
  SPEAKER_02: So getting more pharmacies available for patients closer to their homes, not making things be mail order technology to have telehealth available for all patients, not just patients that have cell phone signal or access to Wi-Fi.
• 12:43
  SPEAKER_02: And then having pharmacies actually stock the guideline recommended therapy.
• 12:47
  SPEAKER_02: I know that that's a real big hot topic right now is that you walk into the pharmacy and they don't even have your drug stocked and you have to wait a couple days before you can start something, even though they should.
• 12:56
  SPEAKER_02: And so that's just a handful.
• 12:59
  SPEAKER_02: I'm not going to go on a soapbox about it though.
• 13:01
  SPEAKER_01: Yeah, I think, I think it's a really complex question.
• 13:04
  SPEAKER_01: I think if we could have solved this problem, we would have.
• 13:07
  SPEAKER_01: There is no simple solution, but there are some things.
• 13:10
  SPEAKER_01: I think the global expansion of insurance coverage, there's 10 of the 50 states in the US that again have not expanded Medicaid.
• 13:17
  SPEAKER_01: I think that would help.
• 13:18
  SPEAKER_01: Other public health programs to help with, you know, whether it be nonprofit or whether it be federal programs to help pay for some of these medications for those that can't afford it and need them.
• 13:29
  SPEAKER_01: Regulating those drug prices, because some of these drug prices are ridiculous.
• 13:33
  SPEAKER_01: And there are guidelines that have had that, there are actually guidelines that have been written to say this is really the preferred drug, but it's really expensive.
• 13:40
  SPEAKER_01: So, you know, this is another one you can use.
• 13:42
  SPEAKER_01: This is an alternative.
• 13:43
  SPEAKER_01: You know, I mean, that's not how we should be choosing our drugs.
• 13:46
  SPEAKER_01: We should be using the the most, the best drug that we can to treat the disease that we're treating.
• 13:51
  SPEAKER_01: Research and development is really, really expensive.
• 13:53
  SPEAKER_01: I get that, but I think we really need more of it because we need more antibiotics.
• 13:58
  SPEAKER_01: Um reducing barriers to market entry for generic drugs, that's actually a really big one that can make a huge difference as far as drug pricing could be drug pricing.
• 14:08
  SPEAKER_01: Some of those generic drugs may actually come from international markets, and that may be a barrier to entering the United States.
• 14:14
  SPEAKER_01: But I think that that is something, especially in those uh lower and middle um income countries, they actually have very cheap generic drug options.
• 14:24
  SPEAKER_01: And then one of the big ones I will have to say is that we have to improve health literacy.
• 14:29
  SPEAKER_01: People do, I am a physician.
• 14:31
  SPEAKER_01: I I don't even understand the ins and outs of my insurance and why I'm getting charged for this and why I'm getting charged for that, what's a facility fee, things like that.
• 14:39
  SPEAKER_01: And I think that it's really important that health literacy is improved around antibiotic use and what they should do if they can't access it.
• 14:46
  SPEAKER_01: What is the what is the next step?
• 14:48
  SPEAKER_01: How do they how do they move forward?
• 14:50
  SPEAKER_01: Things like that are both uh things like that are really important as far as trying to optimize the the equitable access to antimicrobials.
• 14:59
  SPEAKER_00: Those are all uh great suggestions that could definitely make a huge improvement in our overall issues with uh cost of antimicrobial.
• 15:08
  SPEAKER_00: So we've kind of talked about this on a more national level.
• 15:12
  SPEAKER_00: Uh let's talk about it on a little bit more local level.
• 15:15
  SPEAKER_00: So, how does how does do all of these policies and issues affect and impact your role as an antimicrobial steward at your institution?
• 15:25
  SPEAKER_00: And how do you work with patients and prescribers to find solutions to these barriers and these problems?
• 15:32
  SPEAKER_02: Yeah, that's a great question.
• 15:34
  SPEAKER_02: I think most of us start by going immediately to the cost factor and what is it going to cost the institution?
• 15:42
  SPEAKER_02: What is it gonna cost potentially the patient upon leaving?
• 15:46
  SPEAKER_02: And I think the latter, unfortunately, tends to be on the back burner for the time that they are inpatient.
• 15:53
  SPEAKER_02: But I do like to keep that in mind because I truly think that the most effective drug is the one that the patient is actually going to take.
• 16:01
  SPEAKER_02: And so I usually like to take a peek at what is their insurance status, their what does that mean?
• 16:07
  SPEAKER_02: Can I look it up and see is this drug that we're looking at going to be a tier one?
• 16:11
  SPEAKER_02: Does it need a prior auth?
• 16:12
  SPEAKER_02: How do we do that?
• 16:13
  SPEAKER_02: Can we handle it now while they're still inpatient because we're already thinking ahead and take care of all of that now?
• 16:20
  SPEAKER_02: Maybe and you know, include case managers or social workers in to go ahead and handle, help us handle that administrative load to go ahead and get that drug for that patient.
• 16:28
  SPEAKER_02: If there's a vile replacement program because we're doing outpatient IV antibiotics, what does that look like?
• 16:34
  SPEAKER_02: How does that have to get done?
• 16:36
  SPEAKER_02: Does a patient know how to administer things at home?
• 16:39
  SPEAKER_02: Do we need to send them to uh an infusion center to get things done?
• 16:43
  SPEAKER_02: What does all of that look like?
• 16:44
  SPEAKER_02: And so at the end of the day, really truly, as long as the patient's gonna get that drug when they need it and will take it the whole time, then that's the one that matters.
• 16:53
  SPEAKER_02: And that's what really needs to be on the forefront of our mind.
• 16:57
  SPEAKER_01: I 100% agree.
• 16:59
  SPEAKER_01: I am gonna tell you from a provider standpoint, I love listening to Jamie talk from a pharmacy standpoint, because she's got all those things that she's thinking about.
• 17:06
  SPEAKER_01: And I think as antibiotic stewards and infectious disease physicians, I do think that we do think about those things.
• 17:12
  SPEAKER_01: But you know, for the non-steward is where it really becomes a challenge.
• 17:16
  SPEAKER_01: For the non-infectious disease physician, it sort of becomes a challenge.
• 17:19
  SPEAKER_01: They are still prescribing antibiotics, but things like knowing what's on an insurance formulary, there's 12 different insurance companies.
• 17:26
  SPEAKER_01: How are you supposed to know what's on formulary?
• 17:28
  SPEAKER_01: Knowing how to run a test claim, I don't know how to do that.
• 17:31
  SPEAKER_01: Thank you, Jamie, because all of you guys do that for us.
• 17:34
  SPEAKER_01: But you know, providers don't know how to run a test claim to see if an antibiotic will be covered or not.
• 17:38
  SPEAKER_01: So they'll just prescribe because they think that's the best drug for the patient and not really know what the implications are of the patient, um of the patient acquiring it as an outside.
• 17:46
  SPEAKER_01: The administrative load is so heavy for prior authorizations.
• 17:50
  SPEAKER_01: It takes time away from managing the patient effectively.
• 17:53
  SPEAKER_01: That is such a huge issue.
• 17:55
  SPEAKER_01: And um, as an antibiotic steward and an infectious disease physician, it is painful.
• 18:00
  SPEAKER_01: So physicians need to be thinking about alternative plans, providers, I should say, APPs, whatever they are, they need to be thinking about alternative plans when a drug is not covered.
• 18:10
  SPEAKER_01: Or, or, you know, they need to be thinking about whether the patient can access a pharmacy to pick up their antibiotics.
• 18:15
  SPEAKER_01: And I think it as stewards, the best thing we could do is actually work with those non-steward providers and make them stewards, basically.
• 18:22
  SPEAKER_01: And, you know, I I'm so grateful for pharmacists.
• 18:26
  SPEAKER_01: And I think it's critical that every clinic or, you know, hospital should have a clinical pharmacist to help with some of these things because I think that is how patient care gets improved and it decreases a lot of the administrative burden on providers.
• 18:39
  SPEAKER_01: One thing that Jamie did say when she was talking about discharge preparation at Grady Hospital, I'm actually really proud to say that our patients get discharged with their antibiotics in hand before they leave the hospital, which I think is so critical to adherence to the medications and you know, decreasing readmissions and negative outcomes.
• 18:59
  SPEAKER_00: Those are all great practices that I think I can take and incorporate even into my own uh practice going forward.
• 19:06
  SPEAKER_00: So, what what do you all think that the future holds comes to antimicrobial costs?
• 19:11
  SPEAKER_02: Well, A, I think that's a very loaded question right now.
• 19:16
  SPEAKER_02: But quite honestly, I think the future's up in the air.
• 19:21
  SPEAKER_02: I I we have a lot of pressure on our healthcare system in general, but specifically on drug manufacturers.
• 19:28
  SPEAKER_02: And I'm fearful that things are gonna get worse before they get better.
• 19:32
  SPEAKER_02: But I would like to be optimistic that the volume of much needed reform will inspire change on all levels, but I think that requires everyone to notice that the current system is not designed to keep the patients at the forefront.
• 19:48
  SPEAKER_02: It's designed to make money.
• 19:50
  SPEAKER_02: So um I I heard that one time of it's not broken.
• 19:54
  SPEAKER_02: It's just not designed to help somebody.
• 19:57
  SPEAKER_02: It's designed to make somebody else money.
• 20:00
  SPEAKER_02: And it functioning as a business is the problem.
• 20:02
  SPEAKER_02: And so when we try to keep the patients in mind, and how do we get them better and how do we keep them out of the hospital because it's better for society, then I think that's when real change is going to happen.
• 20:14
  SPEAKER_01: Yeah, I I I mean, I'm gonna say right now, temp, I hopefully temporarily, I'm worried, especially as Medicaid funding takes a hit.
• 20:23
  SPEAKER_01: I'm worried about those patients that won't forget about accessing antibiotics.
• 20:26
  SPEAKER_01: I'm afraid that they won't be presenting their providers.
• 20:29
  SPEAKER_01: I I'm I'm worried, but I wouldn't say that the future is necessarily bleak, but I will say that it's uncertain.
• 20:37
  SPEAKER_01: And I do think that it's time that all of the healthcare providers who, you know, who really have the patient at the center of their mind have to really step up and contribute to policy and advocacy, some of many of who are doing it at Shay.
• 20:53
  SPEAKER_01: But I think it's it's time that the healthcare community, you know, did a little bit more.
• 20:59
  SPEAKER_00: All right.
• 20:59
  SPEAKER_00: Well, thank you very much, Drs.
• 21:01
  SPEAKER_00: Wagner and Kendaya, for sharing your perspectives and experiences.
• 21:05
  SPEAKER_00: I I encourage the audience to check out their article that was published in Ashie not that long ago.
• 21:11
  SPEAKER_00: Uh, all of this is such a timely discussion for such a critical topic.
• 21:16
  SPEAKER_02: Yeah, well, thank you so much for this opportunity to speak.
• 21:19
  SPEAKER_02: I think this was a really wonderful and collaborative discussion, and I hope that our audience was able to learn something today, too.
• 21:26
  SPEAKER_01: Thank you so much for having us.
• 21:28
  SPEAKER_00: All right, that concludes this episode of the Shea podcast.
• 21:31
  SPEAKER_00: Thanks for tuning in.