Wal Mart and Caterpillar Team Up for No-Copays

I have said it in meetings, in emails and on Twitter: Wal Mart can revolutionize healthcare in this country. They have the power to change the way patients get and pay for their medications. Already, Wal Mart has changed the pharmacy industry by introducing their $4 generic drug program in the fall of 2006. This program made every pharmacy, from Target and CVS to Farmer Joe and Hannafords, also offer $4 generics to compete.

This program has saved Wal Mart customers $1 BILLION already. THAT is impressive.

One of the programs for aiding the US healthcare system and helping patients become healthier is employer /health plan sponsored lower co-pays and free medication for chronic diseases. This is not my original idea, as several companies have offered these services to their employees, but one that I fully support and believe will make a difference in medication non-adherence. As we know, forgetfulness is the #1 reason, with drug prices, side effects and drug education being the other factors that contribute to this pandemic.

Wal Mart and Caterpillar are taking this idea a step further by offering no co-pays for employees taking Tier-1 generics.

"Caterpillar Inc. and Wal-Mart Stores Inc. have embarked on a pilot drug program that could revolutionize the prescription drug industry, officials from both companies said Monday.

Select salaried and management employees of Caterpillar as well as its retirees and surviving spouses can get Tier-1 generic drugs filled for no co-payment at all Wal-Mart, Sam's Clubs and Neighborhood Market stores now through Dec. 31, 2009, as part of the program that began earlier this month.

The co-payment for the generic drugs is $5 at other pharmacies.

While about 70,000 Caterpillar employees are affected now, that could expand to include union-represented employees who opt into the company's HMO plan beginning Jan. 1, 2009, said spokeswoman Rachel Potts. Open enrollment begins in November."

I think this is another fantastic program and shows the real power Wal Mart has to influence the US Healthcare industry.

"The goal of the pilot program, on which Caterpillar and Wal-Mart negotiated for several months, was to remove unnecessary costs from the health care equation, said Todd Bisping, Caterpillar's pharmacy benefits manager.

It does that by eliminating the middle man, so to speak, in the pharmaceutical management process. Most companies contract with an outside pharmacy benefits manager to set rates on prescription drugs, rates co-payments are designed to cover to defray the company's costs.

Caterpillar negotiated directly with Wal-Mart on the rates, saving it money and enabling Caterpillar to then waive the co-payment for its employees and retirees, Bisping said."

You can read the full story from the Peoria Journal Star.

Compounding Pharmacists - Who knew?

In a lot of my research on medication non-adherence (that is the new accepted term for noncompliance), I come across what researchers deem as the "important role of the pharmacists". Especially in all of the pharmacists surveys and reports! For me (I have taken two or three medications on and off for 8 years) I just pick up my drugs and leave. I recall once, maybe five years ago, the pharmacist gave me the option of getting a generic as opposed to the branded drug - and I think I took it.

BUT after thinking about their role a couple of weeks ago, I started engaging the pharmacist. I had a phlegmy cough in Nantucket over the 4th of July weekend and wondered what I should take - musanex (sp), robitussin, etc... She was very helpful and outlined the pros and cons of each. Helpful, but not exactly prescription help.

So in the last two days I was surprised to find two articles about compounding pharmacists - a job I never knew existed. I have always just gotten my pills as they come from the pharma company. I guess other people are pickier than I am. At least both articles state that it helps with Medication Non-Adherence.

Here are the two articles:

The first from the website Hometownlife by Nathan Mueller:

Kenny Walkup has hands that can turn a solid into a liquid; change the taste of medicine to anything from bubble gum to beef; and change certain aspects of a prescription to remove parts that people or animals are allergic too.
OK, Walkup does not do it all with his hands — some high-tech equipment and technicians also play a role — but they are a key reason Specialty Medicine Compounding Pharmacy has been successful.

"I always liked working with my hands. I should have been a mechanic but I can't fix a car," he joked. "Plus it gives me a chance to be creative." But he can fix medicine.

Walkup's job as a compounding pharmacist is solely based on the individual he is working for. He works with the patient and physician to create a medication that will work for the customer.

The most common situation he comes across is "patient non-compliance." Many people or animals are allergic to certain parts of a prescription or sensitive to strengths, and a compounding pharmacist can — with physician consent — change the strength, change the form from solid to liquid, etc. and change the flavor. Flavors range from chocolate to pineapple to bubble gum for humans and from apple to catnip to chicken for pets.

"All prescriptions are made from scratch, specific to each patient," he said. Walkup owned both the compound pharmacy and the South Lyon Pharmacy before splitting them in February 2003. He has been in South Lyon since 1998.

A graduate of the School of Pharmacy at Ohio Northern University in Ada, Ohio, Walkup joined the Professional Compounding Centers of America and began training there before opening the pharmacy in South Lyon. His pharmacy is a clinical site for Ohio Northern and the University of Michigan, and he gives lectures and does work for both universities.

"I enjoy (talking to students) but I like being in the lab too," he said. "Most of the new stuff I make myself the first time."
The pharmacy has been so successful that it was recently featured on the Heath Watch on the Channel 4 News. Reporter Rhonda Walker said the pharmacy was the "ultimate when it comes to personalized medicine."

It also touched on a story about a patient, Noel Gelfund, who was undergoing treatments to remove a birthmark and the pain killing cream he needed was discontinued. Walkup got to work and formed a new cream that worked better and cost half as much.

Gelfund was killed in a car accident in 2004 and the cream was named "Noel's Numbing Cream" in his honor.
Walkup donates 20 percent of the proceeds of the sale of the product to the Sturge-Weber Foundation which researches Port Wine Stain conditions.

"I have the best job in the world," Walkup said. "I get to help people and do something I truly enjoy."

Here's the second article from the Salt Lake Tribune by Fitzgerald Petersen

Tad Jolley may have the pharmacy business coursing through his veins, but innovation runs in them, too. Jolley was recently awarded "Innovative Pharmacy Practice" by the Utah Pharmacy Association at their yearly convention. Jolley won for his creation of an in-house program to train pharmacy technicians, who are a critical component to Jolley's pharmacy business.

Prior to the creation of the program, aspiring pharmacy technicians would need nine months of schooling before becoming certified. Jolley's program allows technicians in training to receive a paid education while gaining valuable work experience. Jolley benefits by gaining technicians who know their way around his unique store.

Jolley's pharmacies specialize in compounding, which Jolley calls "a lost art." Compounding is highly specialized and involves mixing ingredients specifically for each patient. Of the hundreds of pharmacies competing to fill prescriptions in the Salt Lake Valley, only a handful offer this special service. Most simply rely on pre-made formulations from big drug companies.

Tad Jolley is the third generation of compounding pharmacists to sit behind the counter of the family business. Joel Jolley opened the first Jolley's Pharmacy in 1954. Fifty-three years and four stores later, the family business is still going strong.

Jolley's Pharmacy employs 30 pharmacy technicians in all, so the in-house program makes a significant impact - and not just for Jolley's. The program has caught on with other pharmacies as well. Jolly has received numerous calls from colleagues asking for his advice on implementing their own in-house training. Jolley acknowledges that his program "does something outside the norm" but, he says, "It's helped a lot of other pharmacists as well."

Though Jolley has been working as a pharmacist since 1980, he still loves picking up his mortar and pestle to serve the community. While his award from the association hangs modestly on a wall in his store, he hopes the positive impact of his training program will be felt for years.

Compounding the cure

Pharmacy compounding is the long-established tradition in which medicines that are specially prepared by pharmacists to meet patients' individual needs. Physicians often prescribe compounded medications when:
* Medications are discontinued by or generally unavailable from pharmaceutical companies.
* The patient is allergic to certain preservatives, dyes or binders in available off-the shelf medications.
* Treatment requires tailored dosage strengths for patients with unique needs.
* A pharmacist can combine several medications the patient is taking to increase compliance.
* The patient cannot ingest the medication in its commercially available form.
* Medications require flavor additives to make them more palatable for some patients, most often children.

XDR-TB in South Africa due to Noncompliance

Here is more news about the deadly new strain of TB - now in South Africa as well. This feels like something out of a doomsday movie. The increased strength of viral strains due to medication noncompliance.

From The Chronicle Newspaper (Lilongwe) by Moses Kaufa.

In Malawi, Tuberculosis (TB) is closely linked to the HIV epidemic. Of the 28,000 cases of TB reported in the year 2005, approximately 70% of the patients tested HIV positive.

Although TB can be cured, the recent surfacing of an Extensively Drug Resistant-TB (XDR-TB) in South Africa is cause for concern.

With the current official rate of 14% HIV infection in Malawi and the link between HIV and TB, the need to put TB firmly on the political agenda of the country has become more necessary and urgent.

The government, through the Ministry of Health and the National TB Control Programme has committed to making sure that there a plan in place to respond effectively should any cases of XDR-TB surface in Malawi.

Advocacy, Communication and Social Mobilization (ACSM) an initiated component of the Malawi National TB Control Programme, seeks to create awareness, facilitate community involvement and participation and promote activities that will inform the public on the importance of adhering to treatment and medical advice for Tuberculosis in an effort to avoid the possible development of the fatal, Extremely Drug Resistant TB (XDR-TB).

Henry Chimbali, the Communications Officer of the National TB Control Program, ACSM has embarked on an advocacy campaign involving activities designed to place TB high on the political and development agenda.

The campaign also aims to increase financial and other resources on a sustainable basis as well as hold authorities to account. Additionally, the campaign seeks to ensure that pledges are fulfilled at the local level.

A major and very important part of the campaign is to prevent the possible development of the deadly XDR-TB in Malawi.

Reports indicate that XDR-TB probably developed because cases of normal TB are not treated properly. TB that is not effectively treated will resurface with resistance to the drugs used in the treatment and become Multi Drug Resistant - TB (MDR-TB). Concerns are high that XDR-TB could develop if patients are not aware of the importance of following the strict medical regime necessary to treat MDR- TB.

Records indicate that no one knows yet exactly how many cases of XDR-TB exist but surveillance shows that countries most affected by TB are those that are poor.

Chimbali told Health Check that XDR-TB mostly develops in patients who at one time used the drugs for other ailments or if they had defaulted in the treatment of TB.

However, the infection of XDR-TB is transmitted in the same way as the standard TB.

He says the intervention embarked on by ACSM seeks to prevent any possible occurrence of XDR-TB in this country and the further spread of infections should it occur.

"The program will be looking at adherence and compliance of treatment. This will be achieved by ensuring that all TB patients are under closely supervised treatment and all health workers have adequate knowledge on TB treatment guidelines. There will be a need to engage more health care providers in TB treatment monitoring, strengthening treatment monitoring systems at all levels and intensifying proper diagnosis of all TB suspect cases," Chimbali said.

He said the program is also focusing on prevention and control of the transmission of XDR-TB to health workers and the public.

"This will be achieved through early diagnosis of all TB treatment failures, relapses and tracing of all treatment defaulters and the establishment of special treatment centers for XDR-TB," said the Communications Officer.

XDR-TB is said to be very difficult to treat as it involves a regime that lasts for a long period of time. Drugs to treat the infection are extremely expensive making access to treatment of XDR-TB impossible for many under-privileged people

MDR-TB in Pakistan Directly Linked to Noncompliance

From the Daily Times of Pakistan by Urooj Zia

KARACHI: Medication for Multi-Drug Resistant Tuberculosis (MDR-TB) is generally smuggled into Pakistan from parts of India, sources in the federal health department and medicine-vendors in Karachi told Daily Times.

MDR-TB is a “higher form” of TB, and is a lot more difficult to cure than regular TB, mostly because the bacteria in this case have become resistant to most drugs used in the first line of treatment for (regular) TB. Medication for regular TB is provided free by the government, under the WHO-sponsored DOTS programme, run by the National TB Control Programme (NTP).

MDR-TB develops mainly due to non-compliance with the first line of treatment, which lasts around six to eight months. A number of patients, however, stop taking medication after the first three months (around the same time that TB symptoms disappear). “The bacteria are still there, though. They just become dormant, which is why the symptoms disappear. People think they’re cured, and stop taking the medication. The treatment during the next few months, however, works towards killing these bacteria, so the disease doesn’t make a comeback,” doctors said.

Once a patient drops out mid-treatment, the disease comes back with a vengeance, in the form of MDR-TB. These bacteria are resistant to the first line of treatment, and a different combination of drugs has to be used to combat them. These drugs are extremely expensive in Pakistan. Treatment generally lasts around two- to two-and-a-half years, and the total cost of medication alone comes up to around Rs 200,000,” Sindh TB Control Programme director, Prof. Iqtedar Ahmed, said.

Moreover, even a patient who has never contracted TB before can contract the drug-resistant form of the disease, if infected directly by a person suffering from MDR-TB. Four major drugs are used to combat MDR-TB – Cycloserene, Oflobid (a wide-spectrum antibacterial), Pas, and Ethomid.

Each of these medicines costs less than Rs 10 in India. After being smuggled into Pakistan, however, the cost increases to between Rs 50 and Rs 75 per capsule. An MDR-TB patient is expected to take at least two of each daily for the duration of the treatment. The total cost of treatment depends on the combination of drugs being used – all four medicines are not used at the same time.

Interestingly three of the four medicines are also produced locally in Pakistan, “but they are produced by multi-national companies (MNCs), so the difference in cost isn’t much,” a shopkeeper at the Medicine Market in Katchhi Gali # 2 (behind M.A. Jinnah Road) told Daily Times. “MNCs have their own costs of production to look at too.” “Locally-produced” versions of Pas, however, cost Rs 375 for a box of 50 tablets (Rs 7 per tablet). Ethomid costs Rs 476.85 for a pack of 30 tablets (Rs 16 per tablet), and Oflobid costs Rs 115 for a pack of 10 tablets (Rs 11.5 per tablet).

A cheaper variant of Ethomid is sold under the trade name “Marbital.” These are available at Rs 175 for 100 tablets (Rs 1.75 per tablet). Both versions are “legal” – the more expensive Ethomid is produced in Lahore, while the cheaper Marbital is produced in Karachi.

Cycloserene is produced in Seoul, Korea, and is marketed by a firm in Karachi. It is available at Rs 59 for a pack of 30 tablets (Rs 2 per tablet).

These are the prices that are generally applicable. “Most of the time, the supply of the locally-produced medicines falls short in the market, and drugs smuggled in from India have to be used,” medicine-vendors said. “That is when prices shoot up. If a patient has to take these medicines for two years, he or she will find the cheaper versions readily available for merely three to four months out of a total of 24. The rest of the time, the patient’s family will have to search hard and long for even the Indian versions of the medicines. This is how the treatment costs for MDR-TB shoot up. The government should subsidise the production of these medicines, so they are readily available, at cheaper rates.”

Another factor pharmacy salespeople and owners brought up was the fact that the availability of these medicines in rural areas is next-to-zero.

The WHO has a programme for treating MDR-TB. This programme is referred to as DOTS+. It is yet to be implemented in Pakistan, however. “Right now, we are concentrating on implementing the DOTS programme completely. We have been advised by the WHO to not touch MDR-TB as a programme yet,” Sindh TB Control Programme director, Prof. Iqtedar Ahmed, told Daily Times. “Keeping our human resources, financial resources, and technical resources in mind, our first priority is the first line of treatment for TB (under the DOTS programme). Our next target is paediatrics (incidence of TB in children under the age of 12).”

The National TB Control Programme has started to work on a protocol for implementing a programme for MDR-TB too, Prof. Ahmed said, adding however, that implementation will take time. “It could take anywhere from two to six months, I can’t be sure at this time,” he said.

The incidence of MDR-TB is equal all over the country, he added. “According to WHO reports, the incidence of the disease in Pakistan is somewhere around two to three percent. It is higher in more populated areas, and lower in relatively more affluent suburbs, where a lesser number of people share the same living space.”

The problem with the government sponsoring MDR-TB treatment is that the prognoses (results) of the treatment are around 50 percent, Prof. Ahmed said. “At the end of the day, looking at financial constraints, it is more feasible to spend that money on the first line of treatment, so that the disease is nipped in the bud.”

He did agree, though, that some level of coverage should be given to MDR-TB by the federal and provincial health departments.