Cardiac Nurse Practitioner Lauren Feeney discusses how providers may be able to address accessibility issues and help patients navigate the cost of medications.
Good morning, everyone. Um Thank you for having me. This is my first time doing grand rounds. I'm very excited and honored to be here today. I'd like to talk about a subject that's very near and dear to my heart. Um It's a passion of mine that really started uh when I became a nurse practitioner back in 2018, my docs in the advanced heart failure clinic, as well as my fellow nurse practitioners have been very supportive in helping me get some of these efforts underway and I can't thank you enough for all the support. Um This is titled The Cost of Heart Disease. And my goal here is to help providers. Um not only help their patients but also help the patients help themselves with navigating the cost of their medications through various um insurance vehicles. I have no disclosures. Uh My objectives are number one, help patients access medications in a cost effective manner. Number two, this is really for the providers to help improve our understanding of the different insurance vehicles. And number three, this is the biggest is understand the chance the changes to Medicare that are coming under the Inflation Reduction Act that rolled out in 2022. Some of the highlights here include coverage changes um out of pocket cost caps as well as a new uh program that Medicare is doing, which is a drug price negotiation and those prices will hopefully take effect January 1st of 2026 heart disease in the United States. Um as providers, we are skilled in assessment, diagnosis and treatment of many different cardiac disease processes. Most of our decisions are made methodically and usually in a linear process we have. If this, then that X plus Y equals Z as the years carry on. We're lucky enough to bring new treatment options and different pathways of healing to our patients. However, these treatments are more often than not uh a steeper price for our patients and many can't afford it. Heart disease is the leading cause of death for men and women and most of and people of most racial and ethnic groups in the United States, one person dies every 33 seconds from cardiovascular disease here in the States. That's one in five deaths every year from heart disease. And that's something we all work to prevent here in this hospital. Um And if you think that's a high number, look at the cost $239 billion in one year is the cost that strains our society and for a lot of patients, this cost is just not affordable. In order to know where we're going, we have to know what we're working with. So we have to look at our patient coverage. The first option is usually a commercial coverage. The second option which are fairly newer. Uh We're seeing more of these are these high deductible health plans also known as H DH PS. We also have marketplace insurance options which um many of you are familiar with, maybe the Obamacare or the Affordable Care Act. we have Medicaid and we also have Medicare and then perhaps the daunting one is the uninsured patient and I've got some tips and tricks on how to help this one out. So this is a general tool, but I like um it kind of goes if you look at the coverage type on the left, it'll tell you smiley face means that particular tool um is available to that type of insurance. Um like we copay cards really, that's the only one that, you know, you have to kind of be careful with and some are accepted. Some are not, but it is important to note that all of our patients are open to free trial cards as well as patient assistance programs and foundations. The first thing I'll highlight is the copay card. This is probably one that we don't really understand. We think we know it, we give a patient, the copay card and we say have at it. Good luck. Here's your zero or $10 a month medication. So what is a copay card. This is where the manufacturer usually covers all or at least a portion of the patients out of pockets cost. Um It is a best case scenario. So when you give that patient, their copay card, it says $10 a month, that's actually the lowest that the patient could pay depending on their plan and depending on how much coverage is required um for the manufacturer to offset the cost with your insurance company. It's available only to commercially insured patients. Medicare and Medicaid did not participate in copay card programs. Um because of uh federal anti kick back statute, that was mm gosh, long time ago, but that, that's actually still in effect. And the way that Medicare and Medicaid justify that is they feel that it provides the consumer with a value add and then that value is not passed on to the Medicare that it's actually given just to the patient and that could potentially sway the patient from eventually switching to a generic med later on down the road, which would ultimately save the system as a whole. Um It's also interesting to note that copay cards are not accepted everywhere. They have to be filled at a participating pharmacy. Most of our national pharmacies do have the agreements with the copay cards. Um But if somebody is using a small mom and pop shop, they might not actually be able to use that copay card there because they're not a participating center. Um when that happens or if the patient wants to use a mail order pharmacy, you can actually contact these companies. They have a reimbursement form for patients. So just because you're using a mail order or a nonparticipating pharmacy, your patient can actually get that money compensated from the manufacturer. Oh, um there's also a maximum benefit and this is where it gets a little tricky. So most copay cards have a dollar amount or a time frame with which it can be used or it's both. For example, Eliquis will supplement $6400 of out of pocket cost to the patient over a 24 month period, meaning they'll pick up the gap there. So whatever their copay is versus what they should actually pay to the insurance company, they'll cover it up to $6400 over a 24 month period. Once one of those two is met either in time frame or in cost, you either need a new card or the patient's not eligible until that time period, resets. And you'll have to give them a new card at the end of that 24 months. There's a lot of fine print too on copay cards. A lot of them have expiration dates. I if your clinic is anything like mine, there's probably Xarelto that expired in 2019. Uh We cannot use those ones. We have to get them some new ones. So it's important um that you actually make sure that the, the stuff that you're giving, the tools that you're giving to your patient, they can actually go ahead and use. And many of these manufacturers actually put everything on their website these days. So you can just go straight to the website and print out a valid card. And this is where it gets even more tricky. Are these marketplace and high deductible plans? These are something we're seeing a lot more frequently and Medicaid and or excuse me, C MS said that patients can use these high deductible cards and some insurance plans look at that as that not being a fair benefit because if Eliquis pays that $6000 towards a patients, $5000 copay for their high deductible for the year, essentially Eliquis has paid that patient's deductible and now that patient's getting free care beyond what and beyond what the plan would have wanted. So it's not realized money and realized gain and it ends up costing your high deductible plan in the long run because the patient is now getting free care past that $5000 mark when they should have actually when no actual money came out of the patient's hand and it came from the manufacturer, so it can skew the prices um for the long term for patients. The other thing that's interesting is some of these um high deductible marketplace plans don't allow you to use copay cards or they require that the patient meets their deductible before they can use the copay card. So that means if you have a $5000 deductible, just because you have a copay card doesn't mean that you don't have to pay that cost up front because that insurance company wants that money from the patient. It's very important that they get, that's how these high deductible plans were built. Um And the other thing that they're doing to kind of help offset that is they're using something called copay accumulators where they'll allow your patient to use the hot, the um excuse me, the copay card, but instead of using all the benefit up front, they spread it out over the course of how long that card is valid for. So, for example, with Eliquis, it's a 24 month card. The maximum benefit is $6400 they'll spread out that $6400 on a per month basis. The next thing we'll look at are free trial cards. These are my favorite because they're free manufacturers cover and supply the amount listed and on the card. And that's it. It's available to all patients. Doesn't matter if you're insured Medicare Medicaid, they too have to be filled at a participating pharmacy. Um It's important to note here on the fine print, you cannot give a patient a 90 day prescription and expect 30 days of it to be covered by the free trial card. It actually has to be two separate prescriptions. It'll only fill it for the exact amount that's listed on your free trial card. Some of them are 30 days, some of them are two weeks. Um, so you have to be careful with what you're sending your patients home on and make sure that they have the right prescriptions and the last cost saving tool. Um, kind of in our belt are something known as patient assistance programs. And this was really important when I first started working in advanced heart failure because we had a couple of heavy hitting medications in Ruso and Fara that were named to the guidelines that said all the patients should be on it. However, the cost was exorbitant and you have a Medicare patient who can afford it and say the beginning of the year, but by the end of the year, their copay is too high. So what are patient assistance programs? They're essentially free drugs to those who qualify the difference with patient assistance programs versus something like the extra help program is you can make up to 500%. The um the poverty level, whereas the extra help program is 150%. So it gives you a larger group of people. So that way they don't become medication poor. So it, it allows them to get free drugs. And those drugs are usually sent directly from the manufacturer to a specialty pharmacy. The patient will have an application that they fill out and us as providers, we have a very small portion. A lot of these are in PDF S, they're able to be saved. The process is the same for most of them. It's just a matter of doing a little bit of leg work up front. The specialty pharmacies provide the manufacturer donate medication directly to the patient, which I think is fantastic, especially if somebody has transportation issues, knowing that their medication is delivered directly to their doorstep, really helps with compliance. Um And probably the last thing here, we have a couple of patient assistance foundations which I don't think many of us here are familiar with. Um it's not new per se, but it's very under utilized these foundations. The patient would have to go on to their website and apply, but it provides cash to the patient for their copas. Um The two that I know well are the Patient Assistance Foundation also known as Pan and the Patient Advocate Foundation that does copay relief. And both of those will provide up to $1200 a year in copay assistance for your patients. And it doesn't matter if they're on Medicare, Medicaid or uh commercially insured. And this is just an idea of kind of how easy this form is. This is a five page application for Fara. And really the only thing that us as prescribers are responsible for is that section there. Um It's a modifiable PDF, you can put your information in save it and then print it out and fill out the medication dose and strength and do a wet signature fairly easy. So to recap, we have the commercial, the high deductible and the marketplace, they're all either individual or employer funded. They have preferred formulary medication. So the higher the tier, the higher the cost to patients, Brilinta Fara Eliquis, those are all usually a tier three medication. Um Your co-pays are based on your plan and the tier level of that medication you can use copay cards, free trial cards and the patient assistance with these. And remember that copay cards don't equally affect across the plan. Medicaid. This is pretty straightforward. Your eligibility is uh based on your state and your national residency. Um There's other eligibility requirements that have to be met but those are state dependent. They operate off of something called a PDL A preferred drug list or also known as common core formulary to some. If it's not on the preferred or the common core list, the odds of the patient getting the drug are very low. So it's important that when we're writing these drugs for these new heart medications that we're stressing to these companies, why we think it's important that the patient is on this medicine, that we're not doing it just to drive up cost, but that there's a real benefit for the patient and for the insurance in the long run, most people on Medicaid do not have a copay. However, there is a gap, there's a, um, if you make a certain amount of money, it's usually between 100 and 35 to 100 and 50% of the poverty level. You might have a sliding copay. That's usually between 1 to $4 per month. And that's on a brand name drug. Usually generics are covered at whole. These patients are eligible for free trial and patient assistance. You have to remember Medicaid, they have to reapply every year. If they don't do their due diligence, they will lose coverage and they have specific open enrollment periods that do not line up with Medicare. This is the meat and potatoes, I guess portion of the of the talk that I'm excited to give. So Medicare prior to 2024 in heart disease, most of our patients are Medicare based patients based on their age and kind of the comorbidities that come with it. They are typically 65 years of age or older in order to qualify for Medicare unless they have end stage renal disease or a OS formulary varies by plan. Your tier one has the lowest copay all the way up to tier three with the higher copay and the specialty tiers. Those are usually reserved for cancer type agents. There's four phases to Medicare prior to 2024. It's the deductible period, the initial coverage period, the coverage gap also known as the donut hole as well as the catastrophic uh coverage zone. These patients are available to get free trial cards as well as patient assistance. They have an annual enrollment period and that falls from October 15th to December 7th every year. So it's really important in your clinics that your patients know. This is also a time that you could guide your patients to maybe switching a plan. Maybe your patient was on some generic medications in the past all of a sudden, they had a heart attack. They now need to be on say Benta. And that's a really high cost medication for them. They can actually search different part D coverage plans to change what their copay would be. Um, there are free, there's a state health insurance assistance program that patients can call and get free advice. They don't sell you anything but they will walk you through based off of your medications, what you need, what the best plan options for you would be. You can also call the Medicare Support hotline at 1 800 Medicare if the patient has any questions about their plan and there's a lot of Medicare Advantage plans that we work with difference between regular Medicare and Medicare Advantage Medicare. If you do your individual plan with your individual part D supplement, you're in control, you're picking the best coverage that suits your specific needs with your part D plan. An Advantage plan. It's super easy. It's the blanket plan, right? Oh, this one offers some dental. It offers a little, this, it offers a little of that. However, those are the ones with usually the most restrictive drug plans and they're the ones that come with the super steep donut hole coverage. And most of our patients are put into advantage plans because they're easy. They're very easy to sell. They're very easy to get dropped into. And you're like, oh, this is cool. I have dental on my Advantage plan and I wouldn't have had dental had I not gone with the Advantage plan and lo and behold, their biggest issue is their cardiac medication cost. And here we are with high cost, they can eat and they're definitely not getting to the dentist anytime soon. Ok. So these are the phases. This first phase here is 100% deductible. So based on your Medicare plan that you choose your patients at the first of the year are gonna have to meet their deductible. So that's anywhere from 0 to $505 depending on your patient's plan. That is their out of pocket and the cover they have to meet that money before they'll get any Medicare coverage. The next phase is the initial coverage page, the patient, that's when they get their stable copay. That's kind of the, the nice zone for the patient. And it's important to note that it's a maximum of 25% of the cost to the patient. Most of these plans don't abide by 25%. A lot of them are significantly lower, usually in the 5% zone that they, so that way the cost to the patient is not outrageous. Um This period ends when the patient and the insurance company have spent about $4000 and that's when you hit your coverage gap. This is actually when the patient has to pay 25%. This is when they say Doctor Battier, I went to pick up my entresto and my copay went from $40 to $400. This is why right here because now they're actually having to pay that 25% of the drug. And you can see that the part D plan it went from in the initial coverage page, it was paying 75% of the cost. Now it's only paying 5%. The drug manufacturer has to pick up the rest of the cost and then the patient picks up the last 25%. This continues until they have paid almost $11,000 out of their pocket for the year and then they'll hit the catastrophic coverage phase. The patient right now will pay 5% of the drug cost for the remainder of the year. There's no change in the copay. But if you have a high cost medication, it also means that your patient will not stop paying out of pocket until the year resets. And remember they're then met with the deductible on January 1st. So the way that this system is devised, it almost sets your patients up for failure. Um And there, there's not much we could, we could do about it until the big Medicare changes 2024. We're coming with big energy. There's now no copay after the catastrophic cap is reached. So you remember, they had to pay 5% for the remainder of the year and even in the catastrophic cap. Now, once they reach that cap, the patient has no out of pocket cost. Now, manufacturer subsidized drugs cost will count towards the cap. So where in um the donut hole section that 75% that the manufacturer was paying didn't count towards your patient's catastrophic. It now will, so it helps patients reach that catastrophic cap a little sooner. There's also the expansion of the Extra Help program. The way that it worked was if you made between 100 and 35% and 100 and 50% of the poverty level, you had a tier and you had to pay into the system more than somebody that was living below the 135 percent. You got partial benefit. Now, what will happen is anybody that makes 150% or less of the poverty level will automatically qualify and get full benefits as opposed to the partial benefits that had before. And they also put a cap on how much your premiums can increase every year. So it used to not be capped. You could see your plan, your base plan change by 10 20%. And that's why patients would change coverage to something that was less expensive, even though it might have been the right plan for them to begin with. But they're like, oh, my base premium is gonna go up by 20%. Let me go ahead and change plans. Now, this caps it at 6% annually 2025. We're coming with big big energy goodbye donut hole maximum out of pocket now drops down to $2000 for your patient. And last but not least, enrollees will be able to spread out the cost in equal monthly payments. So now that 5% that they used to have to pay in the wrong section here. So the entire phase of the coverage gap is completely erased, there will not be a period of time where your patient has to pay that 25% and Medicare won't be paying anything. There was no cap before, like I said on drug cost to patients and let's go to the next slide here. This is what it looks like. So in 2024 everybody will still have to pay that deductible. There'll be a little bit of initial coverage and there's that teeny tiny amount of the coverage gap, but most people will not incur expenses more than about $3000 for this year. And this is kind of the last year that we have to get through this donut hole in 2025 as you can see, they'll still pay the deductible, but they're only gonna have an initial coverage period and the most that they'll pay for the entire year out of pocket is $2000 which like I said, it can be spread out then in a monthly payment, your patient's not gonna have to pay all of that up front on the first of the year or with a particular prescription. Um This is what 2023 is where we were 2024 is where we are 2025 is where we're going. So nothing changes on the deductible. Everybody's gonna have to pay their deductible. Now, they could pick a plan that doesn't have an out of pocket cost to them or they can, you know, pay the 500 bucks. The coverage gap is gone in 2025 and then the catastrophic coverage. That's the biggest change for 2024. Once a patient hits, they're not gonna pay anymore. And then down here, you can see that Medicare itself, the part D plans are picking up the majority of it. This is new drug manufacturers. People that want us to use their brand name drugs because that's what's available on the market. Now have to subsidize your Medicare patient, 20% of your intreo Fara beta. That money is gonna be funneled from the manufacturer back into your Medicare plan. So now Medicare will not have to cover that 40%. They're only gonna be covering 20% of the cost of those higher medications. And the reason they did that was to kind of help spread out long term Medicare coverage. There's no way that the system can sustain the way that it was going where Medicare and the economy picked up the, the bill all the time. So here they're getting some drug manufacturer responsibility once you hit that catastrophic cap. And next up, there's a Medicare drug price nego negotiation. So this came about where pharmacies can directly negotiate prices of medications and they can get discounts. And you've seen kind of, you know, Mark Cuban's website where he gets a $4 prescription where CV S has to pay $8 for it. Medicare is now coming to the game with that. So in 2023 they identified 10 different medications that were the highest cost to our consumers and five of them are cardiac medications. Eliquis, Xarelto, Jardiance, Fara and Entresto. These medications alone cost the Medicare system billions of dollars a year. However, we know the good things that they do for our patients, keeping them out of the hospital, helping with their chronic diseases. We want these patients on these medications because we know that they work better in the long run. So Medicare has contracted and all of them have accepted. So all of the manufacturers for these astrazeneca bristol or not? Is it Bristol B? MS? Um Novartis have all agreed to enter in discussions for price negotiations with these medications. They're not set to actually complete until 2024 early 2025 which is why the price will take effect in 2026 January 1st. But what this is gonna do is actually cap the brand name copay. So it used to be on a sliding scale, a maximum of 25%. But the goal of this is to max the copay at say $20 for the patient. Like it'll never, even if you haven't met your catastrophic cap, it will never cost your patient more than 20 dollars because the manufacturer is gonna subsidize the rest of this. And this is probably the most important slide I think up here because it shows how the game is gonna change for the future as we continue to have new treatments, new drugs and we know things work. We need our patients to be able to have access to this and having caps on exactly how much it's gonna cost them, makes better predictability for your patient. It'll also give you an idea of whether the patient's really gonna be able to afford the medication. And then using those different tools that we talked about. Our patient assistance foundations, our patient assistance programs to help offset the cost for your patient. So not only can they stay alive, but that they can live, that they can have quality of life and then they're not medication or health care poor because they need these life saving medications. Quote from Walt Disney, the way to get started is to quit talking and to begin doing so, I will stop talking any questions or concerns.
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