This a transcript to episode 5 of Health Savings News. In the interest of making the podcast more accessible, we will post transcripts every two weeks as episodes release.
Hello, and welcome to Health Savings News: the podcast about healthcare costs in America and how to save money on the often expensive care all kinds of people need. I’m your host, Evan O’Connor, joined by retired doctors, Rich Sagall and Mike Woods. Each episode we discuss healthcare costs in America, offer tips for saving money, and relevant news that affects and reflects the expensive landscape of healthcare in America. Today’s topic is the role of the pharmacist. Pharmacists are a vital part of the healthcare teams and often rank among the most trusted professions. Pharmacists not only check and dispense medications for patients; they also offer advice on medicine dosage, side effects, and possible interactions between different prescriptions. Pharmacists know about drug therapy effectiveness, and can provide information about medical devices patients use at home. Through managing complex drug regimens, counseling to ensure patients remain adherent, helping navigate insurance and cost concerns, and much more, pharmacists have an irreplaceable role in public health. Pharmacist interventions and clinical pharmacy services are associated with positive economic outcomes. With their unique knowledge of medicines, pharmacists, or central figures and decreasing healthcare expenditures through cost savings on medicines and cost avoidance when an intervention reduces potential future spending. To join us, we have Dr. Don Gudenas, Doctor of Pharmacy. Thank you for joining us today, Don.
Don Gudenas (01:26):
Thank you for the opportunity.
I know Rich has prepared some questions that would be great getting to the role of the pharmacist and how that can help people save on their healthcare costs.
Good morning or good afternoon, Don, depending where you are.
Don Gudenas (01:41):
Hello, Richard. Nice to meet you again, virtually.
Well, we want to start off with some basic questions that we think some of our listeners may have. The first one that I’d like to ask you is: what is the difference between a registered pharmacist and a PharmD?
Don Gudenas (01:58):
Well, that’s an excellent question, Richard. Very happy to answer that. PharmD is an academic degree, whereas a registered pharmacist, that’s a licensing of a pharmacist specific to any state. So in order to become licensed in a state, you have to qualify for the state board examination first. And that usually requires a degree from an accredited university. Initially years ago, you had the option of getting a bachelor’s degree or a more advanced doctor to pharmacy degree, but the entry level for the past almost 20 years now has been the doctor of pharmacy, which is the PharmD, which represents the academic status.
I see. Okay. I’m sure that clarifies the titles for a lot of people. The next question I have is what can pharmacists do when patients say they can’t afford a prescription?
Don Gudenas (02:54):
Oh, that’s an excellent question. Pharmacists are more than happy to help because we can probably understand the options and the tools available to help contain prescription costs better than anybody. Helping people select medications between different options that are available as far as alternatives, and also guiding people through the maze of healthcare to get assistance, whether it’s through manufacturers or through coupons, rebates, et cetera.
You’ve answered this one to a certain degree. What do pharmacists do when a patient can’t afford to pay for a prescription and how do you interact with physicians when this happens?
Don Gudenas (03:35):
Well, for example, when there’s a simple matter of a brand versus generic, legally in any state, you can just simply have the patient get the generic without the doctor being involved at all. But in a lot of circumstances now with brand names that don’t have generics available, there may be an equivalent brand that’s available. So if the medication is considered appropriate by the prescriber, we would need the prescriber to basically change the prescription. So that’s not something that can be just done automatically. It would require intervention with the prescriber.
I remember doing during my training, we were taught because there may be a number of drugs that treat a certain condition to pick one or two and know them well. And I suppose sometimes those one or two the physician picks, may not be the least expensive.
Don Gudenas (04:28):
Exactly. That’s what happens a lot of times. It might be a matter of the drug themselves being higher priced compared to another alternative, or a lot of times you run into a circumstance with the insurance formularies where there will be multiple alternatives but only one of the drugs or two of the drugs might be on the actual insurance formulary and the other ones being excluded. So that’s where you have to get special approvals from the insurance pre-authorizations and exceptions made based on whether or not the alternative is appropriate or in some– in a lot of cases, just a matter of just having the doctor change a prescription to the formulary item.
I have a follow-up question, Don. I know with all the new medications coming out — and we always have preached here at NeedyMeds — that newest isn’t always the best. Do you have any leeway in recommending to prescribing physicians that there is an alternate generic drug that is equivalent to the brand name that does not have a generic equivalent?
Don Gudenas (05:30):
Well, yes, like I said earlier, that’s exactly what we want to do. We want to consider all other options. You’re exactly right. About the newer medications being more expensive. There’s a process called step therapy. That is something that’s even required by certain insurances where you basically use some older, tried and true therapies that have been around for a long time and a lot less expensive and then reserve the more expensive newer medications when the older medications are either not working or there are maybe other reasons why they’re inappropriate and a patient should go right away to the more newer, expensive medications.
What have you found that prevents pharmacists from helping patients find alternatives for their prescriptions?
Don Gudenas (06:17):
That’s an awesome question. And it’s really a simple, a matter of time, more often than not. Pharmacists are able to help, pharmacists want to help, but do they have the time in the traditional settings, for example, in a typical community pharmacy where there’s just a lot going on there is an extensive crunch on time. So offering the patients the time needed is where it gets to be a barrier. You obviously want to do more than just simply give someone a phone number or a website to refer them to. You want to be able to walk ’em through the process a little more in detail. And that’s the million dollar question: how to answer the time question.
One of the approaches NeedyMeds takes is when, whether it’s a prescriber or a pharmacist, find somebody who can’t afford the medicines. All you have to do is refer them to NeedyMeds and we’ll help them the best we can. We hope pharmacists remember that.
Don Gudenas (07:14):
And that’s what we want to do as pharmacists to help refer to organizations such as NeedyMeds, which is an awesome resource for patients to guide them through the mazes of opportunities to lower their prescription costs, whether it’s through assistance through manufacturers or rebates, et cetera. But that is obviously something that we want to make sure patients are aware of, that opportunity to save some money that way through NeedyMeds.
For a long time, I’ve thought that pharmacists are one of the least utilized members of the healthcare team, because so many of them are in the community and have the issues you just mentioned. They don’t have the time to help people when they would like to.
I have a question, Don. Now that most pharmacists are PharmDs, meaning they have a more detailed education, how has that changed the role in what pharmacists are doing for patients?
Don Gudenas (08:05):
Well, that’s an excellent question. That’s something that we’re trying to address in terms of basically utilizing that extra training that all students now get to take care of patients, you know, the economics of the business basically force higher volume and less time with patients and trying to balance out making patients be able to connect with a pharmacist is the issue we’re all trying to address in terms of making time available and making sure all the resources that a pharmacist has at their disposal, through their education, through their training and affiliation with people with like NeedyMeds, basically using all that skill and knowledge and giving it to the patient. That’s what we’re trying to do.
Do you ever do medication reviews with patients?
Don Gudenas (08:58):
All the time. That’s a crux of what pharmacists do, you know, we’re always, you know, in the nature of the way pharmacy works, we’re trying to always be on top of the combination of medications people are using. And that’s another area that gets to be considered as far as risk with medications, because we want to give people options for getting their medications as affordable as possible. But when a person has to get medications from more than one source, that’s where the risks start to expand because nobody’s keeping track of all the medications that a patient’s getting. So a person who has to save money by using mail order, for example, for certain medications, or has to go to different pharmacies based on other cost factors, you know, that that gets to be dangerous for a patient because more than one source of medications means nobody has all that complete list. So having one pharmacist to reconcile and keep track of all that is an invaluable tool to reduce risk.
That’s something that we talk about when people are getting prices of drugs using our drug card. It’s amazing the difference in price you will see from pharmacy to pharmacy using the same drug discount card. We tell people to shop around, but we also warn them that if you do shop around you lose this medication review function that many pharmacists perform for the patients.
Don Gudenas (10:28):
Well, it’s a matter of balancing out the cost and balancing out the risk. So absolutely Richard, that’s what we want to make people aware of that, you know, they do need to shop around because there is an ex— I really can’t justify it. The price differences are not modest by any stretch. You know, we’re talking exponential differences sometimes between one supply and another of the same medication
Definitely see that all the time. How negotiable are drug prices?
Don Gudenas (10:58):
That’s an excellent question. And it really depends on who’s doing the negotiating. A patient doesn’t have the ability to negotiate, the manufacturers can negotiate with insurance companies and the like, and they come up with prices where the patient basically is stuck in the middle. When a patient has a copay, there is no negotiation there. And when pharmacies have to purchase medication for manufacturers, you know, there’s no leeway there either. So basically, from a patient perspective, it’s it’s not a flexibility, but it’s a matter of the source of the medication being whether they’re getting it from a different pharmacy or from a mail or et cetera, and also how they’re paying for it, getting the person to understand the difference between using their insurance versus using a discount program like through NeedyMeds. You know, that’s where their flexibility is as far as it is. I wouldn’t call it negotiating. It’s a matter of being a smart consumer.
Don. Are there any ways that you can give feedback to physicians that will help improve patient care? One of the things that I would— as a physician I would frequently get notices from pharmacists that somebody was using their rescue inhaler too often and probably needed to be on a controller inhaler. Are there other situations like that you come across that can help with patient care?
Don Gudenas (12:20):
Well, absolutely. When we’re dealing with chronic care there are core components of the care that basically require proper understanding on the patient’s part and adherence. So it starts with patient education. An example, a perfect example is like you said about the inhalers with a person that has a respiratory condition such as asthma, you want to prevent those episodes of acute breathing mishaps. So a person has to understand, for example, the value of using a maintenance medication to prevent those issues and then thus reducing the reliance on a rescue inhaler because the rescue inhalers, they work fast, which is, you know, the patient’s looking for quick relief, but then there’s adverse consequences with overuse. When a person, for example with the albuterol inhalers, there’s persons using more than eight puffs per 24 hour period, we are risking increasing their heart rate and other issues that can cause harm in other ways. So starting with just educating the patient, making sure that they understand the adherence as far as the directions go, and then also proper technique. An inhaler is a perfect example of where a pharmacist can intervene to help showing a person the proper technique of inhaling. Because if a person doesn’t get the inhaled medication into their lungs and only swallows it into their gut, that medication’s not going to have its proper effect.
Does the opposite occur as well, where patients are not refilling their prescriptions often enough?
Don Gudenas (13:48):
Oh, that’s a huge issue with adherence. This ties in exactly what we’re talking about today with NeedyMeds with the cost of medications, we find a lot of times where a patient needs to take something on a regular consistent basis and they’re not taking it because quite simply they can’t afford it. You know, they’re cutting doses, either eliminating doses or taking half a dose that they’re supposed to, et cetera, just to save money. That’s where basically getting the medications more affordable can help improve adherence to the proper directions for the medication.
Do you think, Don, that most pharmacists are aware of the pharmaceutical patient assistance programs?
Don Gudenas (14:29):
I would think most pharmacists are aware of it, how much they utilize that resource goes back to what we discussed earlier. It’s about time. In a very busy retail environment, for example, I’ve seen patients come to a pharmacy, unable to afford something. They might be handed a phone number or referred to a website that says, Hey, you can maybe check with this organization or company to see if you qualify for assistance, but going that extra mile is invaluable because just that whole process with the red tape involved with the manufacturers is an ordeal in and of itself. Trying to get a person to fill out the right forms, determine their eligibility. And then at that point, if they’re not eligible, making sure that they understand that there are other options.
What is the biggest waste of money that you as a pharmacist see, and how can you help alleviate those problems?
Don Gudenas (15:26):
One of the— well there’s multiple ways we see waste of money as far as healthcare goes. Number one obviously is making sure that a person’s getting the full benefit of their medication. If they’re not using it properly, that’s a waste of money. If they’re using something that they don’t need, that’s a waste of money. But also in terms of just the way— the marketing of prescription drugs, the whole environment with that right now, where you see new drugs, something that comes out identified as a new drug that’s really not. It might be just simply a medication that combines two older ingredients that have been around for a long time and they market it as a brand new ingredient that costs or brand new medication that costs a lot of money. And there are actually medications out there that are touted as a brand name drug that’s new, but it’s actually a combination of two older ingredients that are actually available over the counter without a prescription. So buying those two ingredients as a non-prescription product, comparing it to the price of the one single agent that’s prescription only, you could see literally exponential, hundreds of dollars cost savings in that alone. And that is a big waste of money.
How about unused medications? How big a problem is that for instance, physicians prescribe opiates after surgery and most patients don’t need them for anywhere near the amount of time that the prescription would’ve gone for. How much over prescribing do you see that contributes to that kind of waste?
Don Gudenas (16:59):
it’s gotten better over the years with, especially with the opioid crisis. There’s a lot of restrictions that are placed on prescribers now, so it’s not as bad as it used to be. And then there’s a lot of insurance interventions that basically restrict the person from getting the larger quantity. So bottom line is it’s not as bad as it used to be, but it’s still an issue where, sometimes a person only needs a two to five day supply of an as-needed pain medication and yet they’re getting a prescription for a supply that’s going to last a lot longer than that. That’s not only dangerous, but it’s obviously waste a lot of money spending money on prescriptions that aren’t needed.
Do you keep track of guidelines for different diseases? I know as a pediatrician, I saw a lot of treatment regimens for antibiotics evolve over time. The biggest one that stands out is no antibiotics for kids with the ear infections over two. The other one is the treatment for UTIs. I remember treating them for 10 days now. Now I believe the treatments are usually one day worth. Do you see providers that are sort of not keeping track of those guidelines and prescribing antibiotics or other medications according to how they were trained?
Don Gudenas (18:10):
Well, you’re absolutely right. I mean, guidelines change. Everybody is not complying with those changes. There’s prescribers that are… I don’t know if you’d call it in a habit of doing what they’ve been doing for a long time, but, did changes do not come automatically just because something was said at a national protocol level. So yes, we do see patients that are getting antibiotics inappropriately all the time, whether it’s too long, a supply like you refer to, or just simply a matter of demand from the patient or person comes in with a virus, for example, and the person puts pressure on a prescriber to give them something and doesn’t accept the fact that they’re just supposed to go home and rest and eat properly with proper fluid intake. They feel they’re being cheated unless they get a prescription in their hands. So we do see incidents where a person gets the antibiotic when antibiotic would be totally inappropriate most for virus situations. So that is still an issue.
Do you feel like as a pharmacist, you can contribute to that situation in a positive way?
Don Gudenas (19:18):
Well, again, it go back gets back to patient education. So when we see a patient in an ideal circumstance, you’d get a prescription with a diagnosis so that you know what it’s being used for to start with. And then at that point, having the time to address why the patient’s taking it and how they’re taking and all that are something that ideally every pharmacist could do with every transaction. But unfortunately the reality of the business of pharmacy these days is people do not get that time that’s needed. And we’re not even taking into account. The fact that, you know, a lot of people go into a drug store these days either they’re going through drugstore in the drive through where that’s not an environment conducive to conversation with the pharmacist or people that come into the store. A lot of times more often than not, they have a cell phone in one hand and they’re picking up the prescription with the other hand and they’re really not giving their full attention at the at the pharmacy that they really should.
Yeah. So now you have somebody at the pharmacy that’ve come in and the person working the cash register calls you over and says, “this patient says that they really can afford their prescriptions.” What can you take us through what goes through your head and what you might do for the patient when you hear that from a person in your pharmacy?
Don Gudenas (20:34):
Well, the first thing that goes through our head is we want to help. So now the next question is, can we help? And then, NeedyMeds is a great place to start with, you know, just being the resource to address our options, whether it’s a matter of simply seeing what the cost would be by processing a prescription using an NeedyMeds card. And if that doesn’t answer the the need for the patient, obviously addressing alternatives, whether there’s another brand that we can have the prescriber contacted the change to, or contacting the manufacturers to see if a patient’s eligible. Those are all steps that we want to do, but it goes back to giving the time to the patient to address all that. And in a typical very busy retail pharmacy, that’s an ideal that isn’t met in reality anywhere near as often as it should be.
Another question related to this: Do pharmacists have the ability to refuse to fill a prescription?
Don Gudenas (21:36):
Yes, they have the ability. They not only have the ability to— they almost in a lot of circumstances — almost legally implied that they need to do that. For example, if a medication presents that it’s not in compliance with basic legal guidelines, whether it’s a matter of legitimacy of the prescription or appropriateness, there are obligations not to fill it. If there’s a contraindication for the medication, for example, where we know that the patient’s taking another medication and the combination is going to be an issue. That’s something we’re going to have to not move forward with the dispensing until the prescriber acknowledges understanding of what the issue is, and then gives their specific recommendation on how to address it, whether they don’t consider it to be clinically significant or whether or not there’s been other issues that have been addressed that the pharmacist may not be aware of. For example, if there’s a drug interaction, a lot of times the prescriber may have addressed that already by telling the patient to suspend use of the offending agent or between the collaboration with the pharmacist they can identify that as being an option to move forward. So communications is the key.
Speaking of side effects. When you listen to most commercials about medication, they list all these serious side effects, most of which are pretty rare. How often do you need to calm patients down once they’ve heard one of those commercials and they’re taking that medication?
Don Gudenas (23:09):
In reality, it doesn’t really come up in conversation as much as you think it would. I mean, you hear that list of, you know, rapid fire information coming off the commercials. It’s frightening know when you actually pay attention to what they’re actually saying, but in reality, most people don’t seem to really pay attention to the risk as much as they should.
If you were to speak to a bunch of prescribers or other healthcare providers, what suggestions would you make to them to help them save prescription costs for their patients?
Don Gudenas (23:42):
Well, I guess the first step would be just collaboration and utilizing the resources we have. And one of the best would be to make sure that all prescribers are aware of what a pharmacist can do and work together. So between the two sets of healthcare providers between the pharmacists and everybody writing prescriptions, just by communicating amongst each other could go a long ways towards helping patients with medication costs. Because as I stated earlier, just the maze of different brands that are available and every insurance is different. There might be three or four brands that are basically therapeutically, identical, but one insurance might have it on tier one and the other one might have it on tier three and the other insurance might not include it at all. And all those factors can contribute dramatically to the out of pocket expenses for the patient.
I have one final question, because I know we’re running out time. How do you feel about having to recommend over the counter medicines that you know are inappropriate or effectual or stores that sell homeopathic preparations, for example?
Don Gudenas (24:48):
Well, that’s an individual choice for any practitioner. Me personally, as a pharmacist, I would not recommend anything that’s inappropriate. Whenever somebody asks me about anything over the counter, I would always start off, first of all, by asking additional questions: identifying who the patient is, what their other medications are, what their other relative health conditions are. And then at that point, what’s appropriate, what’s gonna be based on evidence based medicine, I guess is the best way to describe it. If a medication has a good track record and clinical evidence to back it up, then it’s gonna be something that’s gonna have my support. If it’s something that’s just hyped. You know, for example, in the newspapers, it used to be routine that every Monday there’ll be a big full page ad on the latest thing that’s gonna help people with arthritis pain, or weight loss or something like that that’s got no clinical evidence to support it. It’s just a big advertising gimmick basically to move a product. And I would basically, as a professional, make a patient aware of that part of the business and make them aware that they want to be smart with how they spend their money.
I want to thank you for joining us today. I’m sure we could come up with enough questions to go for another half hour, but we’re limited by time and hopefully we’ll have you back again soon. Thanks so much, Don.
Don Gudenas (26:09):
I appreciate that opportunity. I would welcome talking again, Richard. Thank you very much. Thank you, Evan and Dr. Mike.
Thank you/Thank you so much for joining us.
Don Gudenas (26:17):
The last segment of each episode, we suggest some of the culture, art, entertainment, and social causes we’ve been engaged with to each other and our listeners. Due to our release schedule, sometimes hitting certain awareness dates can be difficult. But since this is June, I did want to do a shout out for Pride Month with an organization called Summer of Sass. It is nonprofit started by a comedian and activist Kristen Becker that offers life-saving support to young LGBT-identifying adults struggling in hostile areas of the country and helps stabilize them in Provincetown, Massachusetts — also known as P-town — a summer tourist destination known for its acceptance and celebration of all things that make each of us unique. Summer of Sass subsidizes costs of travel and initial housing, connects people to local employers, and offers overall support as they widen their perspective, build their confidence, and are shown what it means when people say that “it gets better.” You can support Summer of Sass at summerofsass.org.
I have a recommendation of a movie that’s on (Amazon) Prime Video and Tubi. It’s a movie called Science Friction, and it’s a documentary about scientists who get misrepresented by the media. They show how producers will change the meaning of what people have to say. It’s an excellent movie. I’d like to mention that it’s produced by Skeptoid Media, which is a nonprofit educational organization, and I serve on the Board of Directors. I highly recommended it. It’s called Science Friction.
Thank you so much for joining us for this episode of Health Savings News, please subscribe, rate, and review us on Apple Podcast or wherever you’re listening to the show, it really does help. You can follow @NeedyMeds on Twitter, Facebook, Instagram, LinkedIn, YouTube, and you can follow @HealthSavingPod (no S at the end of saving) on Twitter for updates specific to this podcast and send questions, comments, and topic suggestions to email@example.com. Our music is composed by Samuel Rulon Miller. His music can be found at musicisadirtyword.bandcamp.com. Health Savings News podcast is produced by me, Evan O’Connor. All the sources we used in our research can be found in the episode’s podcast description on our website or your podcast app of choice. Health Savings News is not intended to substitute for professional medical, financial or legal advice. Always seek the advice of qualified healthcare, professional, or appropriate professional with any questions. Views express and Health Savings News are solely those as the individuals expressing them. Any views expressed do not necessarily represent views in health savings, news, other contributors to organization or staff. Thanks again for listening. See you in two weeks with our next episode.