Tag Archives: pharmacy practice

Skeletal Muscle Relaxers Do Not Relax Skeletal Muscles!

Today’s post is an opinion piece. Personally, I think that skeletal muscle relaxers like cyclobenzaprine, methocarbamol and chlorzoxazone are over prescribed for acute and chronic musculoskeletal pain, both in the outside world but especially in corrections. The main reason for this, I think, is that prescribers misunderstand what muscle relaxers do. Contrary to their name, muscle relaxers do not relax muscles, at least as they are commonly prescribed. Muscle relaxers are sedatives, pure and simple, and should be prescribed with that fact in mind. Instead of telling patients (and ourselves) that “I am prescribing a muscle relaxer for you,” in the interest of full disclosure, we should be saying “I am prescribing a sedative for you.”  Continue reading

Price Check! Genital Herpes. How Much is Nursing Time Worth?

It is worthwhile to check drug prices now and then (once a quarter seems about right) to see what is happening in the pharmaceutical world.  When you do this, you will find some drugs that have inexplicably shot up in price.  One recent example was doxycycline, which went from around ten cents a tablet to over two dollars a tablet in a couple of months.

On the other hand, drugs that we think of as expensive in the back of our minds sometimes are no longer expensive.  Olanzapine (Zyprexa) is now cheaper than haloperidol.  Risperidone is cheaper still.

And sometimes, a drug that is a bit more expensive than its alternative is still the most cost-effective treatment based on “the hassle factor,” meaning frequency of dosing, ease of administration, potential for diversion–that sort of thing. Drugs prescribed for outbreaks of genital herpes are like that, in my opinion.  Valacyclovir can be more cost-effective than acyclovir for the treatment of recurrent genital herpes.herpes1 Continue reading

Introducing C.F.O.A.M. (and Other Changes)

It is June, 2012 at a pub in Dublin, Ireland. During a break in an international Emergency Medicine conference, and over a pint of Guinness stout (what else?), several doctors were discussing how much medical information was freely available online. Everyone in attendance agreed that the way that medical information is shared has changed radically in the last 30 years—from a few choice textbooks on the office bookshelf and subscriptions to a few medical journals to the availability of most textbooks and journals instantly, online. Not only that, but instant messaging services like Twitter make it possible to get medical help from experts almost instantly—even if the expert is on the other side of the world! In fact, the main problem now is harnessing the incredible potential of the internet to improve medical knowledge and decision-making. Where are the really good reservoirs of medical information online? How can we more easily communicate with our colleagues and friends when we need help with a vexing case?19970122 Continue reading

Top Posts from 2103 and New Year Resolutions

Thanks to everyone who has read JailMedicine this past year!  I have to admit that when I started writing JailMedicine, I never thought it would be as successful as it has been. Total readership should exceed 200,000 by the time of my second year anniversary later this month.  This just goes to show that Correctional Medicine is growing and, in my opinion, is poised to become medicine’s Next-Big-Thing!  I am especially grateful for the help and free advice that Lorry Schoenly has given me from the very outset.  Thanks, Lorry!

Today, I recap the Top-Five Most Read articles of 2013 and my resolutions for the New Year.20140101 Continue reading

Should Inmates Bring Their Own Prescriptions to the Jail?

In response to my last post, one reader wrote to tell me that the jail where she works does not accept medications brought in by inmates or their families. They consider this a security risk.  All medications are ordered and supplied by the jail.  She asks if I will comment on this. Before I do, I need to define a couple of terms that come up over and over in any discussion of newly booked inmates’ medications.

Verification

UnknownThe first term is “Verification.”  Verification refers to the process of verifying what medications an inmate is currently prescribed and is taking.  There are three ways to verify medications.  The first is to call the prescribing doctor’s office to get a list of currently prescribed medications.  The second is to call the dispensing pharmacy to get a list of all prescriptions they have recently filled for the patient.  Finally, the inmate could bring the medications they are taking into the jail with them in the original pill bottles.  On the label is everything we need to know—who prescribed the medication, when it was filled, dosages–everything.

One problem with calling the doctor’s office to verify medications is that the patient often is not taking all of the prescribed medications.  If I remember right, studies show that only around half of all prescriptions are filled.  So you will get a list of prescribed medications, but that may not be what the patient is actually taking.  Another problem with calling the doctor’s office for a current medication list is that doctor’s offices are often closed.  If a patient is booked Friday afternoon of a holiday weekend, you may not be able to get a current medication list until Tuesday.  Finally, many inmates get medications from multiple prescribers.  For example, the patient may have a family physician, but a psychiatrist prescribes their mental health medications and they also use a pain specialist.  And get prescriptions also from ERs and “Doc-in-the-Box” clinics.

Calling the pharmacy may get you more information than calling the doctor’s office.  After all, the pharmacy will only tell you about prescriptions that were filled and can also tell you when the prescription was filled.  If you do call a pharmacy to verify meds, don’t just ask for an “active medication list!”  The pharmacy considers any prescription that they would fill for the patient active, and refills are generally good for one year.  So if a patient may not have taken a certain medication for many, many months, but the pharmacy still considers it “active.”

And like doctors’ offices, pharmacies may be closed when you want to call them.  And inmates often use more than one pharmacy.  Some inmates use mail order pharmacies that are hard to get any information out of.  Or an inmate may not use a pharmacy at all—for example, their medications might be supplied by a psychosocial rehab group.  Finally, it is not uncommon for an inmate not to remember what pharmacy they use, at all!

Authorization

The second term to define is “Authorization.”  I discussed medication authorization in my last post.  Authorization refers to the process of reviewing and inmate’s (verified) medication list and deciding which of those medications will be dispensed at the jail—and which will not.

All incoming inmates taking medications should have their prescription list verified and authorized.  These two processes take quite a lot of nursing time and effort at most jails.

So now we return to the original question.  Which is better, to allow inmates to bring their outside medications into the jail with them or not to allow this and instead verify their medication list and re-prescribe the approved medications ourselves?  The answer is that there is no “right” answer.  Each system has its advantages and disadvantages.  Which you choose to use at your jail depends on several factors, such as the size of your jail, your staffing levels and the sophistication and efficiency of your pharmacy system.

With that in mind, let’s compare each system as to its relative advantages and disadvantages with regard to some of our goals in jail.20130619

Continuity of Care

We want medical care to continue seamlessly from the outside to the inside of the jail.  We want there to be no lapses in ongoing medical care for newly booked inmates.  This means that, ideally, there will be no missed doses of important medications.  This is, of course, easiest to accomplish if inmates brings their medications to the jail in the original containers.  This makes verification, authorization and dispensing to the inmate a simple process.

Contrast this with what usually happens if the inmate does not bring the meds with them.  The current medication list must be verified with phone calls to the doctor’s office and pharmacy.  Even if this goes well (no offices are closed), the medications then must be ordered from the jail’s pharmacy.  Best-case scenario:  the process takes 24 hours.  More commonly, it takes 48-72 hours and the patient has been without medications for 2-3 days.

If the inmate does not bring meds into the jail with them, the only solution for timely administration of most medications is to have an extensive collection of “stock” meds on hand, so that most medications can be continued quickly from stock.  In order to be able to fill the majority of outside medication prescriptions, there must be a lot of stock meds plus protocols for automatic “therapeutic substitution”  (mentioned here).  http://www.jailmedicine.com/the-f-word-formulary/ That is a pretty sophisticated system.

However, even then, no “stock” med collection is going to contain all of the various HIV meds, say.  Or cancer chemotherapy agents.  And these are precisely the medications that we most want to continue without missing a dose!

Clearly, from a “continuity of care” perspective, it is better to encourage inmates to bring in their own, outside medications.

Advantage:  Allowing outside prescriptions.

Information Gathering

There is no question that having the original pill bottles sometimes gives you medically important information.  As one example, consider the patient who takes combination lisinopril/HCTZ for blood pressure.  He brings in a bottle that was filled 45 days ago for a one month supply (30 pills).  There are 29 left in the bottle.  His blood pressure is 128/78.  Would you continue the prescription?  I probably would not.  I would, instead, monitor his blood pressure to see if he really needed the medication.

Or say instead, his blood pressure is 180/120.  If I know that he has not been taking his hypertension medication, I would simply restart it in the jail.  But if he had been taking it faithfully, I might consider adding or changing the prescription.

I could give many more examples of similar situation.  Knowing that the patient has (or has not) been taking their prescribed meds is often very helpful clinically.

Advantage: Allowing meds to be brought in to the jail.

Time Management

The issue here is how long it takes nursing staff to verify and approve a newly booked inmate’s medications.  If the inmate brought meds to the jail in the original pill bottles, verification consists of noting the information on the prescription label, verifying that the medications in the bottle match the label and counting them.  Authorization is easy as a phone call to the provider.  And then the medications can be immediately dispensed to the inmate.

If the inmate did not bring meds to the jail, verification will take much more time.  It consists of interviewing the inmate (Who is your doctor?  Which pharmacy do you use?), then calling the doctor’s office, the pharmacy or both (hopefully, there is only one of each!).  If there is a discrepancy between what the inmate says they take and what the pharmacy says they filled, a second interview with the inmate may be required.  Then, after the approval process, the medications must be ordered from the jail pharmacy, delivered, processed and then, finally, they can be dispensed.

Advantage:  Allow meds to be brought in.

Cost Considerations

Consider the case of the inmate who is only going to be in jail for 30 days.  He is willing to supply his own medications for the month long stay.  Among other things, he takes Abilify, which costs approximately $25.00 a pill.  If your jail will not allow him to bring in his own Abilify, then you must either supply it at a cost of many hundreds of dollars for that medication alone, or substitute something else.  Even if patients are on inexpensive medications, these med costs and fill fees add up.

In addition, if your jail charges a fee to fill prescriptions, inmates will complain, because often they get their outside medications for “free” (meaning Medicaid, most often).  I have even had inmates go so far as to call this extortion and refuse to take jail prescriptions because they do not want to pay any money for meds that they are willing to supply “for free.”

Advantage:  Allowing meds to be brought in at booking.

Medico-Legal Considerations

The main medico-legal risk in these situations is disruption of the continuity of care, in this case, patients missing doses of important medications.  If (Heaven forbid!) something bad happens after the patient has missed a dose of medication—like the patient has a heart attack or commits suicide—it will inevitably be blamed on the missed meds by the patient, his family and their attorney.  I have seen this many, many times.

Advantage:  allowing meds to be brought in.

Security Considerations

This is the one aspect of the problem where there is a decided advantage not to allow outside medications into the facility.  Anytime you allow stuff from the outside to come into the jail, there is a potential for a security breech.

One possibility is that inmates might adulterate capsules by pulling them apart, pouring out the real medication and then filling them with cocaine, heroin or whatever.  However, this is not as easy to do as it sounds.  Adulterated capsules don’t look right and, in my experience, are quickly suspected and discarded.  Besides, if you want to smuggle illicit substances into a jail, there are easier methods than trying to pour powder into tiny capsules.

A more legitimate security concern is what to do with medications that were brought in to the jail but then were rejected during the authorization phase and so never dispensed to the patient.  Non-controlled substances can be placed in the patients’ property, but things can go wrong.  For example, the meds, somehow, are not there when the inmate is discharged from the jail six months later.  Where did they go?  The inmate, of course, may demand compensation for his lost property.  Maybe there should be an investigation?

Controlled substances are even worse, especially DEA schedule 2 drugs like methadone and amphetamines.  Like all schedule 2 controlled substances, these properly should be kept under double-lock (i.e., a locked box in a locked room) and should be counted every day with two people witnessing and signing off.  That is a lot of work should the patient stay in jail for a significant amount of time.   And when the inmate is released, you have this dilemma:  should you return these addictive controlled substances to him? What if he overdoses?  What is your risk exposure?

Advantage: not allowing out-of-jail medications in the facility.

In the end, which system you eventually put into place for incoming inmate medications depends on how important the security angle is to you and how well you can create and use a stock medication system.  To some degree, this depends on jail size.  The smaller the jail, the more important continuity of outside care becomes because the small jail’s medical staff may not be there all the time.  Large jails are better able to develop sophisticated stock medication systems where most incoming prescriptions can be quickly and easily filled from stock.  But even big jails should have exceptions in place for expensive specialty medicines, like chemotherapy agents, immune-modulators and HIV meds.

Does your jail allow incoming inmates to bring their medications to booking?  Do you like the system your jail uses?  Please comment!

Reader Question: Medication Approval

My friend Al Cichon recently asked the following questions:

UnknownWhat ‘authority’ does a jail provider have to change the prescription of an inmate coming into the jail?

I have been asked when I would not approve an existing prescription – non-compliance (over / under); diagnostic mismatch (extreme example anti-viral for bacterial infection); – can you think of others? Continue reading

Price Check! Estrogens.

I don’t have a lot of women in my jails who take estrogen.  The post-menopausal women I see usually are not prescribed replacement hormones by their outside doctors very often.  mareThe main reason for this is the momentum generated by the landmark study Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial published ten years ago in JAMA which said that the risks of hormone therapy following menopause outweighed the benefits.  Most of the major women’s groups  (here is one example) have backed off a little from this, saying now that for some women, post-menopausal hormones are OK, but should be done for as short of a time as possible.

Nevertheless, most of the women who are taking replacement estrogen are younger women who have had a total hysterectomy.  Since these women are young, it is appropriate for them to take replacement estrogen.  Since they do not have a uterus (for the most part), they do not need to take progestin.  But which estrogen should be on our “Preferred Drug List” (otherwise known as a Formulary)?

In many drug categories, ACE inhibitors, say, there are several options that are equally effective and equally priced.  I don’t care if a patient is taking lisinopril or enalopril.  They are equivalent.

That is not the case with estrogens.  It turns out that in the estrogen department, there is a clear winner.

Here is the price-per-pill breakdown.  The doses listed are the typical standard doses for adult women.

Estrogen Dose Price Per Tablet
Esterified Estrogen (Menest) 0.625mg $1.11
Estradiol (Estrace) 1 mg $0.04
Synthetic conjugated estrogens (Cenestin, Enjuvia) 0.625mg $3.27
Conjugated equine estrogen (Premarin) 0.625mg $3.09
Estropipate (Ogen) 1.5mg $0.24

Premarin has been around since 1942 and for many years, was the only available estrogen product, to the point that  “Premarin” became almost synonymous for all estrogens in the same way that people say “Kleenex” for all nose-blowing tissues.  Premarin continues to be the most prescribed replacement estrogen.

In fact, however, all of the estrogens are therapeutically equivalent.  The only differences are these:

1.  Premarin (conjugated equine estrogen or CEE) is derived from pregnant horse urine.  That is the only thing (except price) that sets it apart from the others.

2.  All the others, including synthetic conjugated estrogen, are made from plant proteins.

3.  17-beta-estradiol (usually just called estradiol, brand name Estrace) is the only formulation that is “bio-identical” to human estrogen.

So there you have it.  By curious happenstance, the one estrogen that is bio-equivalent to human estrogen happens to be the one that costs 4 cents a tablet.

Estradiol should be the preferred estrogen in your facility.

Do you still use Premarin in your facility?  Why or why not?  Please comment!

 

 

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What Makes a Good Medical Scoring System?

20050629My good friend Al Cichon wrote the following comments to me about my article on the 10 Point Pain Scale.

Use of a ‘scale’ to measure subjective factors is a true oxymoron (heavy on the moron part). The ‘fifth vital sign’ is a misdirected effort to solve a true quality care problem – in my opinion. Vital Signs are objective (as in measurable) indicators that have been demonstrated to provide consistently valid data for patient care.

JCAHO has imposed the ‘Pain Scale’ in an effort to assure that the assessment of pain will be factored into patient care. Unfortunately, it is a bureaucratic response to a clinical situation – if it can be made to be measurable (regardless of practical validity) it can be enforced. My apologies to proponents and defenders – but no matter how well intended; it is still dysfunctional.

Yet, we are obliged to employ some process of assessment to determine the impact of subjective symptoms in an efficient / effective manner. The many schemes (Pain 1-10; Cardiac pain 1-5; etc.) developed have achieved relative success / adoption / adaptation. It does seem that these processes have provided some benefit – yet they all suffer from the same susceptibility – subjectivity. Whether you are working in corrections (where any subjective report must be verified) or the community (where verification is not always considered) any of these schemes has the same risk – because there is no objective validation.

One possible option to stabilize the use of any such scale is some method of anchoring the initial or end point of the scale. That would then provide a somewhat stable reference for guiding care and transmitting information (about the patient) to other providers. Also, this mechanism can be employed in other subjective areas.

Begin with asking the patient – ‘What is the worst pain you have ever experienced?’ (the response is usually associated with fractures, renal calculi, child-birth, etc.) Now, lets’ label that as a 10 (or 5) and now –‘What is the discomfort you have now in comparison to that prior event?’ Then document the exchange in the record: Worst Pain: fractured wrist – 10); Current Pain: pulled muscle – 7. Now, no matter the number system you have an ‘anchor’ to both the scale and the present condition that can be related to the care process and others. It is important to document the ‘source’ of pain too – as this may be quite useful if you are explaining the case later (DOC, court, etc.)

One variant of this is: If you had a ‘bucket labeled depression and a stick marked off from 0 to 10 what is the worst you’ve ever felt and when”? The response will then provide an anchor (9 when I was admitted to the hospital after trying to kill myself). Additional questions are: How deep is that bucket now? Has it ever been at 0? If I could make it happen (wave magic wand) and get you released and home now – what would it be? (interestingly it can go up with release for many reasons)

When you ‘anchor’ the ‘pain scale’ it establishes the assessment in a relatable setting and can be quite helpful in guiding patient care. The ‘anchor’ can also be quite useful in discerning the ‘historical validity’ of the case as well – ‘Doc when I had that car accident with multiple fractures it was a 10; now my sprained (non-swollen, non-bruised) ankle is a 10 too!’

Clinical judgment is always the most important skill in any patient care situation. The data subjective & objective is helpful but must be understood / applied in the clinical context.

Also confounding the assessment is the different types of acute / chronic discomfort (myofascial, neuropathic, visceral). As important as assessing the level of pain is the type – physiologic source – since it is critical in guiding treatment.

As noted – ‘chronic pain’ is better measures by an assessment of the patients ADL (what daily activities are disrupted and is that new). If a patient can function (nutrition, hygiene, elimination) and participate in some activities then treatment of the physiologic cause is the most important clinical consideration.

Thanks, Al!  Excellent comments.  Let’s summarize:

  1. The 10-Point Pain Scale is not the only scoring system in medicine for subjective complaints. There is the Hamilton Rating Scale for Depression, for example.  Also, the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) for alcohol withdrawal.   There are scoring systems to rate abdominal pain and chest pain and the likelihood of pulmonary embolism.  I could go on and on.  All of these systems have the same limitations and liabilities, though some do a better job than others.
  2. Just because you assign a number to a complaint, that does not make it objective.  Because each of these scoring systems assigns a number to the complaint, there is a tendency to think of them as objective rather than subjective.  But as Al points out, this is not the case.  There is no real difference between someone who says his pain is “a six” and someone who says that he has “moderate pain.”
  3. In order for a subjective scoring system to work, it needs to be “anchored” in some way.  Al anchors the 10-Point Pain scale on the patient’s own worst experience.  Another commonly used clinical pain scale, the Visual Analogue Pain Scale, anchors the scale onto facial expressions.  The more “anchored” a system is, the better it is.  The less anchored it is, the less useful it will be.Unknown
  4. The more numbers in the scoring system, the less reliable it becomes.  Let’s say instead of a 10-Point Pain Score, we used a 1000-point pain score and were asking patients “would you say your pain is a 671 or a 672?”  Of course, a pain score of “672” gives us no more useful information than a “6.”  In fact, it gives us less useful information because it is more confusing.  In a scientific sense, the more numbers a subjective rating system has, the less “inter-rater reliability” that system has. The simplest subjective scale has only two scores, “None (zero)” and “Some (one),” as in “Do you have pain or not?”  The subjective scale perhaps used most often in daily life (Like when you go to a Thai restaurant and are asked how hot you want your food to be) is a four score scale:  None, Mild, Medium, Severe.  The Visual Analogue score is a 6 point scale.  CIWA-Ar uses 8 points.  And the 10-Point JCAHO Pain Scale uses 11 points (zero plus one through ten). Is the 10-Point JCAHO scale more accurate than a simple “mild-moderate-severe” system?  Probably not. In fact, no “probably” about it.  No.
  5. Subjective scoring systems work better at evaluating changes over time than the initial severity of a symptom.  If a patient says his pain is a “6,” I may not know exactly how that is different from a “7” or even a “4.”  But later, when the same patient now rates his pain as a “5,” I am pretty confident that his pain has decreased, at least by a little.
  6. Subjective scoring systems only work if the patient understands and is cooperative with the process.  Al helps the patient to understand the process with his excellent “anchoring” technique (which I will be adopting, by the way).  But the system still will not work if the patient always, no matter what, says “my pain is a 10.”   That is the main problem I run into in my jails; deciding when patients are exaggerating their symptoms.  For example, if a patient complains of “severe” constipation, what weight do I give to their use of the word “severe?”
  7. There are two types of subjectivity in scoring, the patient’s and ours.  The patient is subjective when rating her own pain or depression or whatever.  Then we clinicians make our own subjective assessments.  How sick does the patient look?  Often, the two assessments do not coincide, as when the patient rates his abdominal pain as a ten while munching on Cheetos and looking bored.  If I do not trust the patient’s own subjective assessment, sometimes I must substitute my own clinical judgment.
  8. Scoring systems for pain perform worse for chronic pain than for acute pain.  For chronic pain, a more useful assessment tool is to evaluate how the chronic pain affects Activities of Daily Living (ADLs).  Is the pain too debilitating to hold a job?  Play golf?  Go to the store?  Walk?  ADLs are usually much easier to assess in a correctional facility than in the outside world.  You can go down to housing and watch the patient.  How easily does the patient sit, stand, walk?  Does the patient go to recreation?  Sit for long periods of time playing cards or watching TV?  This sort of assessment is very useful for gauging the impact of chronic pain.

Any thoughts?  Please comment!

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Understanding Pharmacy Prices. Can It Be Done?

20130206There are several good reasons to know what your pharmacy is charging you for each of the drugs you order. You need to know actual prices in order to assess the value of similar drugs, like two different first generation cephalosporins. In fact, you will have to know this in order to be able to set up a Pre-Approved Drug List. You need to know when a particular drug has a sudden price decrease or increase so you can switch to the most cost effective drug. Finally, you want to know that you are being charged fairly. If a pharmacy sells you a drug for 5% more than the price they paid to the wholesaler to obtain it; that seems fair. But if they jack up the price literally by 46 times, well, that does not go down so well. (See story below)!

Unfortunately, pharmaceutical prices are among the most convoluted and hard to understand of all drug prices. They are kind of like airline ticket prices. Have you ever heard of the game in which passengers on a commercial airline flight compare what each of them paid for their ticket with the lowest price being crowned the winner? (Their reward is the deep satisfaction that comes from knowing that everyone else is jealous of them). Airline tickets are kind of a unique item in the economy in that the price varies depending on many factors like when you book, how you book, how often you fly, how many bags you check and on and on.

Who Can Understand Pharmacy Industry Jargon?

Pharmacy prices are similar to this. What you pay per pill for drug X at your facility may be far different than what the facility down the street pays. The system is so convoluted, in fact, that it sometimes can be hard to even find out what your pharmacy is charging you and how they derive this price.

Pharmacies have their own professional jargon that can be hard for outsiders to understand—just like us! We say, for example, that a patient has an “erythematous urticaria” when we mean “itchy red rash.” Pharmacists say “I’m charging you the Average Wholesale Price minus 12%.” What the heck does that mean?

It turns out that there are many pricing systems in the pharmaceutical industry. You only really have to know about two of them, but it is worthwhile to peruse a list of the others:

Average Wholesale Price (AWP)
Actual Average Acquisition Cost (AAC)
Wholesale Acquisition Cost (WAC)
Average Manufacturer’s Price (AMP)
Maximum Allowable Cost (MAC)
Federal Supply Schedule (FSS)
Federal Upper Limit (FUL)
Estimated Acquisition Cost (EAC)
Average Sale Price (ASP)
Usual and Customary Charge (UCC)

And that is not all of them! The problem is that each of these pricing systems can give amazingly different prices for the exact same medication.

Fortunately, you only have to know about two of these pricing schemes; one that you don’t want to use and one that you do want to use. Forget about all of the others.

Average Wholesale Price (AWP)

The one that you don’t want to use is the Average Wholesale Price (AWP). Historically, this is the most common price system used by pharmacies. The problem is that it is a misleading term. You would think that the “Average Wholesale Price” would be the average price that the wholesalers charge for a drug. Well, you would be wrong. AWP is not a wholesale price and it is not an average. It is just a price set by the pharmaceutical industry. It is debatable exactly where that price comes from. However, AWP is, on average, 20% higher than the true wholesale price. But can be as much as 120% higher!  That means if a pharmacy says to you “I’m going to charge you AWP less 12%,” that means that they will be making somewhere between 8% and120% profit on these sales.  (They were probably smiling when they said it).  And that is in addition to their “Fill fee,” which I will discuss in a future post.

In addition to being an inaccurate representation of wholesale costs, AWP is quite hard for the typical consumer, like you and me, to find. You can’t just look up AWP online. AWP are listed in certain pharmacy trade publications like The Red Book, but access to the Red Book is quite expensive. And even if you get one, you will find that a certain medication, say ranitidine 150mg, has not just one AWP like you would expect, but a bewildering array of AWPs that range in price from one cent a tablet to well over one dollar a tablet. Some AWPs apply only to hospitals, some to huge bulk purchases like Wal-mart would make. It is often almost impossible to decipher what would apply to your situation. I know. I have tried.
Some pharmacies really like to use AWP and I can see why. It has many advantages for them. AWP overestimates wholesale costs to the advantage of the pharmacy. The pharmacy understands it, but you don’t. In essence, AWP is what the pharmacy says it is! How are you going to know differently? If possible, do not deal with the AWP!

Average Actual Acquisition Cost (AAC)

The price that you want to use instead is the Average Actual Acquisition Cost (AAC). AAC is an estimate of the actual wholesale cost your pharmacy pays for medications. Instead of being head-scratchingly hard to understand, AAC is easy to understand. It is the true wholesale price. And instead of being almost impossible to find out, you can find out the AAC in one of two easy ways. First, you can ask your pharmacy for the AAC of medications you commonly order. Some pharmacies will give this information to you, no problem. If you have a pharmacy like this, consider yourself blessed. Other pharmacies can be quite loathe parting with this information.

Fortunately, there is a second way to find AAC prices: You can look them up online. Most state’s Medicaid programs utilize AAC to set Medicaid drug prices and publish the AAC on their website. If your state does not offer online access to AAC, feel free to use Idaho Medicaid’s AAC website, found here.

How Much Difference Does It Really Make?

Is the difference between AAC and AWP really that important? Here is a true story that illustrates the difference.

Like many doctors, I have a little black bag with some doctor tools and medications that I can use in urgent situations. One such “stat” medication that I keep in my black bag is ondansetron (Zofran), which is, of course, used to treat nausea. A couple of weeks ago, I went to a local chain pharmacy to get some new ondansetron for my black bag. I had looked up the AAC online before I went to the pharmacy and found that the AAC of generic ondansetron 8mg tabs was 15 cents apiece. For 30 of them, the total AAC would be approximately $4.50. Figure in a percentage markup and a fill fee and I thought I would be charged approximately $10.00-$15.00 for this prescription.
Instead, the pharm tech looked me in the eye and said “That’ll be $235.43.” The pharmacy had calculated the price using AWP!

$10.00 vs. $235.43. Now that is the difference between AWP and AAC in a nutshell. What would your facility have done had it been charged $235.43 for this prescription? Paid it without question, I suspect.

So getting back to the original question: Is it possible to understand pharmacy prices? The answer is Yes! As long as you use the Actual Average Acquisition Price. You can understand the numerous other pharmacy pricing schemes only if you understand their relationship to AAC.

Do you have a good relationship with your pharmacy? What do you pay for your pharmaceuticals?  Please Comment!

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Interesting Articles of the Week: Prescriber’s Letter and Medical Letter

20121128The saying goes that just half of what we were taught in medical school is wrong.   Also half of what we think we know about medicine now is wrong.  The problem is that we don’t know which half!  But this does mean that keeping up-to-date with the current medical literature is very important.  Why just yesterday I read that maybe leeches and purging aren’t such good treatments for headaches after all!

Two of my favorite sources of continuing medical education are the Prescriber’s Letter (found here) and the Medical Letter (found here).  Both provide evaluations of medications and changes in medical thinking that are unbiased by marketing from Big Pharma.  Both are subscriptions services (which they have to be since they don’t accept advertising) but both are well worth the money.

Recent editions of both publications have some really interesting information that I would like to share here.  Because I don’t want to infringe copyrights, I will summarize the information presented instead of “copy and paste.”  Those who are interested can look up the originals!

Prescriber’s Letter, January 2013

Beta Blockers for Hypertension?  Not for most patients!

Beta-blockers are no longer a preferred drug for uncomplicated hypertension.  Even though they do lower blood pressure, beta blockers are less effective in preventing long term bad outcomes like heart attacks and strokes than alternative medications like  diuretics, ACE inhibitors/angiotensin receptor blockers (ARBs) or calcium channel blockers. Atenolol appears to be the worst offender in this regard.  The one population in which beta-blockers should still be used are those patients who have had heart attacks or otherwise have known coronary artery disease.  So if your patient has had an MI, use metoprolol or carvedilol.  If not, use something else for hypertension.  Get rid of atenolol entirely.

The Medical Letter, Dec. 24, 2012

Can you use cephalosporins in patients with penicillin allergies?  Yes, in most patients.

I was taught in medical school that patients with a true penicillin allergy had a 10% risk of also being allergic to a cephalosporin.  It turns out that this is not true.  The true incidence of allergic reactions to cephalosporins in patients who relate a history of penicillin allergy is only 0.1%.

There are two reasons for this.  First of all, if you skin test all people who say that they are allergic to penicillin, only a small minority will be found to be truly allergic (I have heard less than 10%).  Second, even those patients who are proven to be allergic to penicillin by skin testing have only a 2% chance  (not 10%) of also being allergic to cephalosporins.

Chemically, penicillins and cephalosporins do share a common beta-lactam ring, but it is the side chains of the molecules, not the central ring, that cause allergic reactions.

So if a patient has almost died from a penicillin allergic reaction, i.e, Stevens Johnson Syndrome or toxic epidermal necrolysis or the like, I would not risk the 2% chance of repeating the event.  But if the patient gives a history of a vague rash thought to be due to penicillin, the risk of using a cephalosporin is very, very low.

Do you still use beta blockers for uncomplicated hypertension?  Why or why not?  Please comment.

Do you give cephalosporins to patients with a stated penicillin allergy?  We would like to hear your comments!

I have only listed two of my many favorite resources for Continuing Medical Education.  What are yours?  Please comment.