As we all know from long experience, hypertension is the single most commonly seen and treated condition in primary care medicine. It is an important risk factor for strokes, heart attacks, kidney failure and overall death. It has been exhaustively studied. And yet there is still significant controversy over hypertension, including how to define it and what the best agents for treatment are.
Against this background, The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults was released last December in JAMA. It was written by the 8th Joint National Committee, and so, of course, is referred to as JNC 8.
JNC 8 has a couple of important and surprising changes from JNC 7. One of these, at least, is controversial enough that some members of the committee rebelled and released a dissenting “Minority Report” (apologies to Tom Cruise). Today’s JailMedicine post is a summary of JNC 8 recommendations and changes to JNC 7.Continue reading →
As you probably know, Sovaldi (sofosbuvir) is an important new treatment for Hepatitis C infection that was released this last December and has been aggressively marketed by its maker, Gilead, ever since. The problem is that Gilead is charging an unheard of, jaw-dropping, $1,000.00 per pill for Sovaldi. This translates into a MINIMUM of $84,000.00 for Sovaldi alone for the simplest course of Hep C treatment. Add on the other necessary drugs and take into consideration more complicated cases, and a single course of therapy for Hepatitis C will cost between $100,000.00 and $250,000.00.
This price has placed prison systems in a no-win situation–and not just prisons, but also Medicaid, insurance companies, and HMOs. On one hand, Sovaldi is a good drug that, in fact, represents a significant advance in Hepatitis C treatment. Lots of Hepatitis C patients could potentially benefit from Sovaldi. On the other hand, no one can afford Sovaldi. Treating every potential Hep C patient using Sovaldi would bankrupt everyone. There is no good way out of this dilemma. Continue reading →
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.
The 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!
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.
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). https://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.
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.
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.
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.
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.
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!
Imagine that you are a healthcare provider in a jail medical clinic. One of the jail nurses comes to you and says “Will you call me in a prescription for my hypertension meds? I have no more refills and my doctor charges $100.00 for a visit just to get more!” Or perhaps it is a detention deputy who asks, “Can I get a few Ambien from you? This shift work kills me and I need them occasionally.” Or “Can I get some Augmentin? I have Bronchitis.”
There 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!
One of the “systems” problems that all jails have to deal with is what to do with medications when a patient is released from jail. Prisons deal with this issue as well but tend to have fewer headaches than jails, mainly because they know exactly when inmates are leaving the facility and can plan ahead. In jails, often we don’t know exactly when a patient will leave. Continue reading →