Cutting drug costs for patients: key takeaways for urologists

Benjamin Pockros, MD, MBA

The Inflation Reduction Act (IRA) of 2022 included a provision, which took effect in 2025, capping out-of-pocket Medicare Part D prescription costs at $2000. In this interview, Benjamin Pockros, MD, MBA, discusses the cap’s potential impact for patients with urologic conditions such as prostate cancer. He also discusses a Urology Practice paper, “Online Tools to Decrease Out-of-Pocket Prescription Costs for Patients: A Practical Guide for Urologists,” for which he served as a study author. Pockros is a urology resident at the University of Michigan in Ann Arbor.

Please provide an overview of the key provisions of the IRA that specifically benefit Medicare beneficiaries with advanced prostate cancer.

This was passed by President Biden's administration and signed into law in August 2022. There are a lot of economic details involved, but in terms of how it relates to prescription medications and patients with Medicare, I'd say the 3 biggest takeaways to know are, 1) out-of-pocket costs for insulin is capped at $35 per month, 2) annual out-of-pocket costs if you're insured by a Medicare Part D plan is capped at $2000 per year and then 3) for the first time in history, the government's allowed to negotiate drug pricing, so Medicare can negotiate a drug price with companies as well.

How do you anticipate the $2,000 out-of-pocket cap per year will change the financial landscape for patients under Medicare?

Historically—and we've looked at this and published on this—for patients with cancer, if you're prescribed an oral, advanced oncolytic medication, you're paying upwards of $10,000 per year for that medication. Financial toxicity of cancer care is consistently cited as one of the biggest problems for patients with cancer. Even as everything in this world has become political and partisan, prescription cost is actually consistently 1 area where both Republicans and Democrats say, "enough is enough. I can't imagine paying $10,000 for my cancer treatment. "And so to cap this at $2000 for Medicare beneficiaries is a big deal. I mean, it's inherently an $8000 savings. You can also look at the average income for patients on Medicare. This is a population who's older than 65, likely to be retired, and doesn't have a strong annual income anymore from working. They might only be getting a benefit from Social Security. $10,000 really cuts into their life savings and starts to really [make them] reconsider how they can structure [things like] paying for their house. And so I think that the $2000 cap is probably one of the biggest [legislative actions regarding] health care since the Affordable Care Act, and it's going to make a massive difference for patients.

How do you think the provisions of the IRA will influence prescribing practices among urologists and oncologists in the years to come?

This is what's going to be really interesting to track. Every policy has unintended consequences. But if I were to predict and project, a lot of these medications have been cost prohibitive for prescribers, and if the cost is going down, I actually think that we're going to see a lot more of these medications being prescribed. In the prostate cancer space, there are a lot of examples of this: enzalutamide [Xtandi], apalutamide [Erleada], darolutamide [Nubeqa]; historically, these would be $10,000 a year. Now, they're $2,000 a year. I think providers are going to start prescribing them more frequently. There are trade-offs to that. The good news is it increases access. It should reduce the financial toxicity, and hopefully more patients who really need this medication will—when there's scientific benefit—be able to take the medication. The thing that we just need to look out for is we have to make sure there's no inappropriate prescribing by providers. We still need to make sure that it's indicated for a certain population that's going to benefit from the medication.

What role do you see for health policy advocates in ensuring that the benefits of the IRA are maximized for patients beyond 2025?

I think we're seeing in politics now that everything is up in the air and everything is on the chopping block. Physicians and policy makers need to understand that the IRA is helping patients. This is saving patients $8000 a year. We need t to strongly advocate that this administration does not get rid of the Inflation Reduction Act, or else its going to cost patients with cancer by up to $8000 per year." So, for health advocates, there are really 2 key takeaways from this. One, they should see this policy as an achievement and as a big win. I was just in DC advocating for changes. It's hard to make change, and so when big improvements happen for patient care, we need to celebrate that. But number two is we need to be scared that this could be on the chopping block with the current presidential administration. If this does come in as a potential budgetary expense, I think a lot of doctors should strongly be advocating for us to keep this to help protect our patients and help them access the medications that they need.

Looking ahead, what factors will be critical in tracking the long-term impact of the IRA on both drug prices and patient outcomes in advanced prostate cancer treatment?

I hope we study this. There's a lot of good financial toxicity survey tools that have clearly documented that these medications are expensive, [which] causes both mental and physical stress. My hope is that these same survey tools are sent out after the Inflation Reduction Act. That'd be a really good way to study legislation and prove that it's actually helpful for patients. Everything that I've said has basically been hypothesis driven, saying, "The costs go down. That should really help patients and reduce financial toxicity." We need to validate that as well. This law has been in effect since January 1, and so this is happening now in real time, and so we could really start to check in with patients and see if they're seeing differences on their end as well.

In your Urology Practice paper, “Online Tools to Decrease Out-of-Pocket Prescription Costs for Patients: A Practical Guide for Urologists,” you outlined 4 key resources. In your experience, which of these has shown the most immediate and significant impact on reducing financial toxicity for your patients, and why?

I'd say the key takeaway of the paper is that actually, all 4 have an important role. That's an important emphasis, because most physicians or prescribers, they may just pick 1 resource, and that's their go-to, and they have a spiel for that and they explain it. But our point is that they all have their own specific niche, and knowing when to implement 1 vs the other can be very helpful. Going over all of them, I think GoodRx is probably the most common and the most popular resource. Most people know about that. The point of GoodRx is you bypass your insurance and you just pay a cash price, and then local pharmacies will show you what they're giving the medication for that cash price, and they can compete and have lower costs. I think that resource is used ubiquitously, but I wouldn't really recommend it unless you need a medication urgently, like antibiotics or pain medication or something to relax your bladder, like an anticholinergic medication, something that you need rapidly. If you're taking a chronic medication that's going to have a lot of refills, based on our research and our review, it probably makes more sense to do 1 of these online pharmacies that can really cut down on costs - and the shipping is so convenient as well. That's where the Mark Cuban Cost Plus Drug Company comes into play, and also Amazon Pharmacy. They're very similar; at the end of the day, Mark Cuban Cost Plus Drug Company is probably a little bit cheaper. But Amazon Pharmacy has a really sleek interface, and if you're taking multiple chronic medications, like for high blood pressure or cholesterol or sugars, Amazon Pharmacy bundles all of them and works really nicely. Finally, there is the Medicare Part D Plan Finder, which should be a prerequisite for every single patient on Medicare. That's what's going to affect all of your out-of-pocket drug costs for the year, and those plans change from year to year. So even if you think you have the best plan in 2025, in 2026 they can change, and they rely on patients not reliably checking their plans and switching. It's not really a competitive market force in that way. That's why we emphasize that actually, all 4 have a really important role.

Given the variability in patient populations and disease states within urology, are there specific urologic conditions or medication classes where you've found these tools to be particularly effective, and conversely, any where they are less helpful?

One big example that Ruchika Talwar [, MD], from Vanderbilt has published on is that abiraterone is generically available, and the Mark Cuban Cost Plus Drug Company offers that medication. In Part D plans, you'd have to pay thousands of dollars in out-of-pocket costs per year. It's capped at $2000 per year now, but still, whereas for the Mark Cuban Cost Plus Drug Company, it can be sold for hundreds of dollars, and for some prescriptions, it's actually in the dozens of dollars. Historically, patients could save thousands of dollars. Now, with the Inflation Reduction Act and that cap, the savings will be less, but still, the take-home point is the same. There are alternative online pharmacies that can provide really affordable medications. If you needed to take an antibiotic, or you needed Ditropan for a week, or some Flomax for a week, etc, GoodRx would be a good option, just knowing which local pharmacies you can go to pick it up tonight. Otherwise, I guess If you were someone that was taking Flomax every day, every year, always refilled, and Ditropan every day for a year, always refilled, then I would strongly look into Amazon Pharmacy and having them ship it right to your door for low costs.

In the paper, you mention a patient-centered framework for navigating these tools. Can you elaborate on the practical steps urologists and their staff can take to integrate this framework into their daily clinic workflow, especially regarding patient education and counseling?

I think the biggest feedback I've heard about a lot of these resources is that physicians are overworked, they're not trained in this, and they don't have time to go over all the resources. I completely agree with that. I think physicians should always be screening patients in clinic, and I think it just comes down to 1 question: Do you ever have a hard time paying for your medications? That can really lead to an interesting conversation and a direction, but I don't think it's a physician's responsibility to go over all these resources. The point of our framework is to really simplify it so medical assistants or nurses in clinics can go over it, or you just print it out and patients navigate it themselves. I really like to always keep things as simple as possible. If a patient's older than 65 or insured by Medicare for some other reason, they absolutely need to be using the Part D Plan Finder, which has open enrollment, usually from October to December every single year. I think physicians, for sure, should highlight that and really advertise that in their clinic. They can even have posters on the wall [reading], "Did you check your latest Medicare Part D plan?" "Did you check your latest Medicare plan or Medicare Advantage plan?" That's 1 cohort of patients. And then, if you have a patient who's taking medications that they're always refilling - Ditropan, mirabegron, Flomax, etc, I would start to look at these online pharmacies and know that they're likely going to be helping the patients with costs. Whether you use Mark Cuban Cost Plus Drug Company or Amazon Pharmacy just get comfortable between the two of them. Mark Cuban Cost Plus Drug Company doesn't take insurance; Amazon Pharmacy does take insurance. Patients might have preferences based on how good their insurance is as well. If you need to send someone for an urgent medication, then know that GoodRx is going to be the best thing in your toolbox because they can go in person and pick it up that night.

Beyond the tools you've presented, what future directions or research do you see as crucial in further addressing the financial toxicity of prescription medications in urologic care, particularly concerning policy changes or innovative patient support programs?

The Inflation Reduction Act was a major step in the right direction. The question now is going to be, are commercial insurers going to follow Medicare and enact the same cap that they have as well. Because if you think about it, if you have advanced prostate cancer and you need to take enzalutamide, and you're 66 and have a Medicare Part D plan, you're protected with $2000 cap. If you're 64 and you have commercial insurance that doesn't have a cap, you might be paying $10,000 still, which is really not fair. And so in terms of health advocacy and policy, I think we could be pushing commercial insurers to follow suit for Medicare, and that's something that we need to keep an eye on moving forward. As for out-of-pocket costs, we've talked a lot about prescriptions. In urology, there are a lot of other areas to look at as well. Advanced imaging has high out-of-pocket costs, and in the prostate cancer world, where patients are getting MRIs and PSMA [prostate-specific membrane antigen] PET scans, that'll get passed down to really high costs for them as well. It's something that we need to take a look at. There's a lot of opportunity in the future for good work to get done.