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• Presentation available for download at the end

• Q&A Box on the right

• Poll questions at the end – Thank you!

• Post-test by July 7, 2017• Please use the same link you accessed the webinar with• After July 7th you will not be able to access the post-test or certificate.

• Email questions or concerns: bsnyder@utah.gov

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Disclosures• The Western Multi-State Division is accredited as a provider of

continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

• Participants must complete the pre-test, attend the entire live event, and complete the post-test with a score of 80% or greater to earn one contact hour.

• No conflicts of interest are involved in this series. This includes no content relevant to commercial interest and no presence of commercial support.

• Please note that due to reporting guidelines, you will have three weeks after the live webinar to complete your post-test and print your certificate. You will NOT be able to access or earn continuing education credits after the three week time frame.

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DIABETES MEDICATION ACCESS FOR THE UNDERINSURED AND UNINSURED PATIENTVictoria Tolentino, PharmDCommunity Pharmacy Resident Smith’s Food & Drug Stores & RosemanUniversity June 20, 2017

Objectives 1. Discuss the prevalence and burden of diabetes in both

the U.S. and Utah 2. Evaluate the state of Utah’s lack of access to care 3. Recognize barriers that exist for patients living with

minimal access to care 4. Identify resources available for patients with limited

access to obtain medications5. Explore the dangers and limitations of obtaining

medications online and beyond borders6. Review strategies for various healthcare providers to

utilize in providing quality care for all patients

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Quiz1. How many Americans currently live with diabetes?

a) 2.9 million b) 9.2 millionc) 29 million d) 290 million

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Quiz2. 1 in 3 Utah adults have prediabetes

a) Trueb) False

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Quiz3. Diabetes is the ___ leading cause of death in Utah

a) 1st

b) 3rd

c) 5th

d) 7th

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Quiz4. Adherence is considered “adequate” if the patient takes

their medication ___ of the timea) 60%b) 70%c) 80%d) 90%

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Quiz5. Many pharmaceutical manufacturers offer free

medications to patients who cannot afford them through Patient Assistance Programs (PAP)

a) True b) False

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Individualized Care • Patient Centered Care

• “Care that is respectful of and responsive to the individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.” –American Diabetes Association (ADA)

• One size does not fit all…• “The science of art and medicine come together when the clinician

is faced with making treatment recommendations for a patient who may not meet the eligibility criteria used in studies on which guidelines are based.”1

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Prevalence of diabetes

Nationwide

• >29 million U.S. adults have diabetes (25% unaware)2,3

• 86 million have prediabetes (90% unaware)2,3

• Prevalence of diagnosed diabetes among black, Hispanic, and poorly educated adults continues to increase4

Utah

• >145,000 Utah adults (1 in 17) are diagnosed with diabetes3

• 1 in 3 Utah adults have prediabetes3

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Prevalence of diabetes

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https://www.cdc.gov/chronicdisease/resources/publications/aag/diabetes.htm

Prevalence of diabetes

https://ibis.health.utah.gov/indicator/complete_profile/DiabPrev.html

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Prevalence of diabetes

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https://ibis.health.utah.gov/indicator/complete_profile/DiabPrev.html

Prevalence of diabetes

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https://ibis.health.utah.gov/indicator/complete_profile/DiabPrev.html

Disease burden • Physical5

• 7th leading cause of death in the Utah• Leading cause of blindness in Utah • ~250 hospital discharges for lower-extremity amputations (toe, foot,

and leg) each year in Utah • ~4,500 hospital discharges for cardiovascular complications (heart

attack and stroke) each year in Utah

https://www.cdc.gov/media/dpk/2014/images/diabetes-report/Infographic1-web.pdf

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Disease burden • Economic6

• Both diabetes and prediabetes cost ~$1.7 billion in Utah each year• Medical expenses are ~ 2.3 times higher for patients with diabetes

vs. patients without diabetes

https://www.cdc.gov/media/dpk/2014/images/diabetes-report/Infographic1-web.pdf

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Barriers• Challenges to goal-based care

• Complex comorbidities1

• Complex treatment regimens1

• Limited English proficiency1

• Fragmented care system• Lack of healthcare access (insurance, proximity to care)• Financial or other social hardships1

• Citizenship (immigrants, refugees) • Food insecurity1

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Inadequate access to care • 2015

• ~265,100 (8.8%) Utahns had no insurance coverage7

• Lack of healthcare and/or inadequate coverage associated with• lower use of preventative services8

• increased risk of overall health decline among late-middle age adults8

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Access to Health Care and Controlof ABCs of Diabetes

Zhang X. et al. Diabetes Care 35:1566–1571, 2012

• Examined the relationship between access to health care and diabetes control

• Observed data from the National Health and Nutrition Exam Survey, 1999-2008 and identified 1,221 US adults (age 18-24) with self reported diabetes

• Access• Current health insurance coverage• Number of times healthcare was received over past year• Routine place of healthcare

• ABC’s = A1C, Blood pressure, Cholesterol

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Access to Health Care and Controlof ABCs of Diabetes

Zhang X. et al. Diabetes Care 35:1566–1571, 2012

• Found 16% to be uninsured• Identified diabetes control to be worse for all 3 ABC

measures among uninsured compared to insured individuals• A1C: >9% (34.1 vs. 16.5%)• Blood pressure: ≥140/90 mmHg (31.8 vs. 22.8%)• Non-HDL cholesterol: ≥130 mg/dL (67.1 vs. 65.4%) (not significant)

• Conclusion• Lack of health care coverage is associated with poor glycemic

control• Low use of health care service is associated with poor glucose and

blood pressure control

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http://health.utah.gov/primarycare/pdf/Primary_Care_Office/mapMUA_Ps.pdf

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Refugees• 1,170 refugees entered the state of Utah in 2015

http://health.utah.gov/epi/healthypeople/refugee/datastatistics/2015/annual%20Arrivals%202015.pdf

2014 = 1,2862013 = 1,1142012 = 1,150

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Homelessness

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https://jobs.utah.gov/housing/scso/documents/homelessness2016.pdfPIT = point in time

Importance of medication adherence • Nonadherence = Public health concern that affects health

outcomes and overall healthcare costs9

• Poor therapeutic outcomes• Progression of disease• Estimated burden of billions per year in avoidable direct health care

costs• Between $100 and $300 billion avoidable health care costs annually (3-

10% of total US healthcare costs)

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Luga AO, McGuire M. Adherence and health care costs. Risk Manag Healthc Policy. 2014;7: 35–44.

Importance of medication adherence • Adherence and barriers to adherence should be assessed

at every visit• Adherence is considered “adequate” if the patient takes

their medication 80% of the time1

• Proportion of days covered

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http://www.pharmacytimes.com/contributor/michael-crowe-pharmd-mba-csp-fmpa/2015/07/do-you-know-the-difference-between-these-adherence-measures

Strategies for improving medication adherence9

• Appropriate education/counseling from all members of the healthcare team

• Engage in team based care • Patient centered medical homes, case management, engagement

of nursing staff and pharmacists• Assess barriers at every visit• Simplify regimens• Prescribe 90 day regimens• Lower out-of-pocket costs• Support from family members• Automated alerts

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Connecting patients with insurance options• Utah Medicaid

• Pays for medical services for low-income pregnant women, children, elderly, disabled, parents, women with breast & cervical cancers.• 1-866-435-7414• https://medicaid.utah.gov/

• CHIP• For children and teens up to age 19 whose families may have too

great an income to qualify for Medicaid but cannot afford health insurance.• 1-877-KIDS-NOW• http://health.utah.gov/chip/

• Medicare• Persons who have a medical condition that has prevented them from

working or prevented to work for at least 12 months may be eligible for Social Security (SS) disability benefits. After 2 years on SS, he/she will be eligible for Medicare, even if <65 years of age.• 1-800-772-1213• www.ssa.gov/pgm/disability.htm#sthash.A9QbBJRB.dpuf

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Connecting patients with insurance options• Primary Care Network (PCN)

• Plan offered by the Utah Department of Health • Health coverage for adults who qualify (uninsured, age 19-64 and

have a dependent child under age 19 living in the home)• Among other services, 4 prescriptions per month • 1-888-222-2542• http://health.utah.gov/pcn/index.html

• BenefitsCheckUp• National Council on Aging• Assists aging adults in identifying eligibility for healthcare• https://www.benefitscheckup.org/#/

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Local Community Health Clinics• Federally Qualified Health Centers (FQHC)10

• “Safety-net providers”• Community health centers, migrant health centers, health care for the

homeless health centers, public housing primary care centers, health center program look-alikes, and outpatient tribal health programs or facilities

• Generally free or require a small fee• Usually offer some sort of eligibility assistance • Find a clinic using zip code, city or state

• https://findahealthcenter.hrsa.gov/index.html

• Pharmacy services• On-site or partner with local pharmacies to provide discount pharmaceutical

services through participating in the Federal 340B Program• 340B: Allows an eligible entity to purchase drugs at discounted prices and can in turn,

provide medications for a lower out-of-pocket cost• https://www.hrsa.gov/opa/eligibilityandregistration/index.html

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Local Community Health Clinics• Community Health Centers, Inc.

• 6 clinics throughout Salt Lake County and 2 in Box Elder County • Among other services, offer “free and low-cost pharmacy”• http://www.chc-ut.org/

• Mountainlands Community Health Center, Inc.• 5 clinics throughout Utah County• “Pharmacy services only available to active Mountainlands Family

Health Center patients”• http://mountainlands.org/

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Local Community Health Clinics• Fourth Street Clinic, SLC

• Services homeless Utahns• On-site pharmacy services available • http://fourthstreetclinic.org/

• Maliheh Free Clinic, SLC• Services uninsured and those with a household income below

150% of Federal Poverty Level • Offer assistance in obtaining medications through Patient

Assistance Programs • https://malihehfreeclinic.org/

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Patient Assistance Programs (PAP)• Many pharmaceutical manufacturers offer free

medications to patients who cannot afford them

• Each program has specific criteria that must be satisfied in order for an individual to be considered eligible for a financial assistance program

• Inquiries/applications can done directly with the manufacturer (online) or by assistance from an office care coordinator

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Databases with information about Patient Assistance Programs• These databases help patients to find assistance based

on medications they take

• Partnership for Prescription Assistance• https://www.pparx.org/

• NeedyMeds• http://www.needymeds.org/

• RxAssist• Patient Assistance Program Center• http://www.rxassist.org/

• RxHope• https://www.rxhope.com/

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Prescription discount cards• Hundreds of discount cards available

• GoodRx®

• ScriptSave® WellRx• EasyDrugCard™

• Not considered actual insurance

• Discounts offered vary widely from program to program

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Affordable pharmacy options • Walmart® $4 generic drug list (30 day supply)

• $10 for 90 day supply• Medications listed by category• Diabetes medications on list

• Glimepiride 1, 2, 4mg• Glipizide 5, 10mg• Glyburide 2.5, 5, 3, 6mg• Metformin 500, 1000, 500mg ER

• https://www.walmart.com/cp/1078664• Insulin = $24.88 (10mL vial)

• Novolin® N• Novolin® R• Novolin® 70/30

• In many instances the patient’s regular pharmacy may price match

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Affordable pharmacy options • Smith’s Food and Drug®

• Kroger® blood glucose monitoring system (meter, lancing device, carrying case) = $10

• Strips • 25ct = $7• 50ct = $12• 100ct = $23

• KnowCopayEastMax NG• Provides testing supplies at a discounted price • 1-844-521-5042• https://www.knowcopay.com/needymeds/

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Alternative sharps disposal containers• Household containers11

• Ideal when non FDA-cleared container is not available• Features11

• Heavy-duty plastic• Tight-fitting, puncture resistant lid • Upright and stable during use • Leak-resistant • Properly labeled

• “Hazardous Waste Inside”• Disposal12

• “Home health care infectious waste”

• Tightly secure lid with tape• Regular household waste

• Not to be recycled

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https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ConsumerProducts/Sharps/ucm263236.htm

Beware of “rogue websites”• Some drugs sold online13

• are too old, too strong, too weak• aren't FDA-approved• aren’t made using safe standards• aren’t safe to use with other medicines/products• aren’t labeled, stored, shipped correctly • may be counterfeit

• Counterfeit drugs may13

• be contaminated• not help the disease/condition the medicine is intended to treat• lead to dangerous side effects• contain wrong/no active ingredient • contain wrong amounts of ingredients• be packaged in phony packaging that appears legitimate

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VIPPS® verification: https://nabp.pharmacy/programs/vipps/

Beware of “rogue websites”Trustworthy website13 Unsafe website13

Has Verified Internet Pharmacy Practice Site Seal (VIPPS®)/.pharmacy address

Sends drugs with unknown quality or origin

Located in the U.S. Gives wrong/dangerous drug

Licensed by the state board of pharmacy/division of public licensing

May not protect personal information

Has a licensed pharmacist available to answer questions

Offers drugs at dramatically lower prices compared to competition

Requires a prescription from a licensed healthcare professional

Offers to sell drugs without a prescription

Provides contact information and allows you to speak with a person in the event of problems/questions

Does not provide a way to contact the site by phone

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Beware of the border (North/South) • Principal concern = acquisition of drugs without proper

medical examination/diagnosis/supervision14

• Undocumented immigrants may seek “back room care” in fear of revealing immigration status

• Standards and regulations on drugs varies from country to country14

• Drugs approved in other countries are not always approved in the U.S.14

• U.S. Food and Drug Administration (FDA) does not regulate safety and efficacy on drugs not approved for use the U.S. • Responsible only for those approved, marketed and sold in the U.S.

• Interstate shipment of unapproved drugs by the FDA is illegal under the FD&C Act (includes importation)

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Beware of the border (North/South) • Same safety issues apply as those described with “rogue

websites” 14

• Possession of certain medications with no valid prescription from a licensed prescriber may violate federal, state, and local laws14

• Mexico14

• Many drugs that require a prescription in the U.S. are over the counter in Mexico (antibiotics, cardiac medications, diabetes medications, birth control, many controlled substances, etc.)

• Canada14

• Has more strict policies in place set by Canada’s Health Products and Food Branch

• Still not regulated by FDA

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Personalized medication regimen• Questions to consider when developing a medication

regimen for a patient• Is the regimen simple enough?• Can the patient afford it?• Can patient store it appropriately?

• Provide education • Safety

• Interactions, (no) sharing, caution risky sources• Side effects • Adherence

• Advise not to cut in half to stretch supply • Storage

• Insulin

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Strategies for providing equal care• Provide individualized, patient centered, culturally

appropriate care to positively influence patient outcomes1

• Culture, language, literacy and numeracy, finance and insurance, religion, social context (housing stability, transportation, food insecurity)

• Involve the patient in care decisions• Simplify medication regimens• Engage in team-based care

• Pharmacy, optometry, dental, mental health…• Including community health workers, peers, and lay leaders in the

delivery of DSME and diabetes self-management support services1

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Quiz1. How many Americans currently live with diabetes?

a) 2.9 million b) 9.2 millionc) 29 million d) 290 million

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Quiz2. 1 in 3 Utah adults have prediabetes

a) Trueb) False

47

Quiz3. Diabetes is the ___ leading cause of death in Utah

a) 1st

b) 3rd

c) 5th

d) 7th

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Quiz4. Adherence is considered “adequate” if the patient takes

their medication ___ of the timea) 60%b) 70%c) 80%d) 90%

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Quiz5. Many pharmaceutical manufacturers offer free

medications to patients who cannot afford them through Patient Assistance Programs (PAP)

a) True b) False

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References 1. Marathe PH, Gao HX, Close KL. American Diabetes Association Standards of

Medical Care in Diabetes. J Diabetes. 2017;40(Suppl. 1):S64–S74.2. Diabetes. [Internet]. Atlanta (GA): Centers for Disease Control and Prevention.

[cited 2017 May 11; updated 2016 Jul 25]. Available from: https://www.cdc.gov/chronicdisease/resources/publications/aag/diabetes.htm.

3. The faces of diabetes. [Internet]. Salt Lake City (UT): Utah Department of Health. ©2017. Available from: http://health.utah.gov/facesofdiabetes/.

4. Beckles GL, Chou CF. Disparities in the Prevalence of Diagnosed Diabetes –US, 1999-2002 and 2011-2014. MMWR Recomm Rep. 2016 (65)11;1265–1269.

5. Fact Sheet: Diabetes in Utah. [Internet]. Salt Lake City (UT): Utah Department of Health. ©2017. Available from: http://choosehealth.utah.gov/documents/pdfs/factsheets/factSheet_diabetes.pdf.

6. The Burden of Diabetes in Utah. [Internet]. Arlington (VA): American Diabetes Association. ©1995-2017. Available from: http://main.diabetes.org/dorg/PDFs/Advocacy/burden-of-diabetes/utah.pdf.

7. Complete Health Indicator Report of Diabetes Prevalence. [Internet]. Salt Lake City (UT): Utah Department of Health. ©2017. Available from: https://ibis.health.utah.gov/indicator/complete_profile/DiabPrev.html.

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References 8. Zhang X. et al. Access to Health Care and Control of ABC’s of Diabetes.

Diabetes Care 35:1566–1571, 2012. 9. Luga A, McGuire MJ. Adherence and health care costs. Risk Manag Healthc

Policy. 2014; 7: 35–44.10. Federally Qualified Health Center. [Internet]. Washington (D.C.): U.S.

Department of Health and Human Services. Available from: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/fqhcfactsheet.pdf.

11. Sharps Disposal Containers. [Internet]. Silver Spring (MD): U.S. Food and Drug Administration. Available from: https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ConsumerProducts/Sharps/ucm263236.htm.

12. Infectious Waste Management: Guidance. [Internet]. Salt Lake City (UT): Utah Division of Solid and Hazardous Waste Solid Waste Management Program. Available from: https://deq.utah.gov/ProgramsServices/programs/waste/solidwaste/docs/2012/06Jun/Infectious_Waste_Management_Guidance.pdf.

13. The Possible Dangers of Buying Medicines over the Internet. [Internet]. Silver Spring (MD): U.S. Food and Drug Administration. Available from: https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm048396.htm.

14. Imported Drugs Raise Safety Concerns. [Internet]. Silver Spring (MD): U.S. Food and Drug Administration. Available from: https://www.fda.gov/drugs/resourcesforyou/consumers/ucm143561.htm.

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Questions?

Victoria Tolentino, PharmDEmail: victoria.tolentino@sfdc.com

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“Never worry about the numbers. Help one person at a time, and always start with the person nearest you”

~Mother Teresa