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Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. Today I'm joined by Dr. Ben Pockros, who is a urology resident at the University of Michigan. We're going to be discussing one of his studies that covers an incredibly important topic for shared decision-making and counseling as it relates to the cost of drug medications. And his study was published in Urology Practice entitled, Out-of-Pocket Costs for Prostate Cancer Medications Substantially Vary by Part D Plan: An Online Tool Presents an Opportunity to Mitigate Financial Toxicity.

Dr. Pockros, I'll hand it over to you.

Benjamin Pockros: Well, thank you for the invitation, Ruchika. I'm really grateful to be here and talk with you. This is obviously a topic that I know that you're extremely passionate about. It's a topic that I'm starting to become very passionate about, and I'm hoping that we can share our work to other urologists, to patients, to any provider, really, and talk about how to make drugs more affordable. So this is the title of our study. Out-of-Pocket Costs for Prostate Cancer Medications Substantially Vary by Part D Plan. And we highlight how an online tool could save patients truly thousands of dollars using this plan finder.

So I think as most providers know, definitely what most patients know, cancer medications in this country are pretty egregiously expensive, and it's actually particularly true in urology. So a study out of Brigham this year showed that launch prices for all 2021 new urologic oncology drugs have tripled over the past decade. And at least for me, and I think a lot of providers, we like to point our fingers towards pharma or legislation, those issues. But the reality is we as physicians also play a role. And so studies have shown that only one in five doctors can accurately estimate out-of-pocket costs for their patients.

So our study focused on Medicare. And Medicare is a really important insurer for patients with advanced prostate cancer. Most patients with advanced prostate cancer are diagnosed after the age 65. And so therefore, most of those patients are going to be insured by Medicare and most of them are going to have Part D plans.

So as a brief reminder, those four parts of Medicare A and B, and these cover inpatient care or outpatient care and infusion medications. And these fortunately have really affordable, fair, standardized cost sharing mechanisms for patients. Part C is Medicare Advantage, which is really complicated, I'm going to gloss over. But Part D is what this study focuses on, and this is the voluntary outpatient prescription drug benefit for Medicare enrollees. And unfortunately, these have the most variable out-of-pocket requirements because there's different premiums and deductibles and copays depending on the plan that you select.

So I always assume that Medicare was just a one-stop shop. Oh, this patient has Medicare, it must be the same for everyone. And that's really not the case. In fact, patients in this country sometimes have up to 27 different Medicare Part D plans to compare. And I already told you that these vary based on out-of-pocket costs. And so if you have so many options, you would think maybe there's an element of competition, maybe there's a way to compare costs just like you would for buying a used car or getting an Airbnb or a flight or whatever, and there actually is. And so this is called medicare.gov/plan-compare it's online, it's free, it's available to use for anyone. You can Google search it right now after this. And I just want to walk you through what we have here.
So it shows the name of the plan up top. This is based on a patient zip code. It'll show you your estimated annual out-of-pocket costs for a local pharmacy, but also for a mail order pharmacy. And then I'll just compare it with all the other available plans in that area as well. And so I was amazed that this information existed. I never heard of it before and a lot of people I talked to had never heard of it before as well. And so I wanted to see if it could be useful in urology because that's what I'm training in and excited to pursue in my career. It could be really particularly useful for drugs like abiraterone and enzalutamide, which are oral anti-androgen medications. These were approved in 2011 and 2012, and they really have completely changed the standard of care for advanced prostate cancer.

So in our study, if we wanted to see if we could use this online plan comparison tool and see if there were variations or differences in out-of-pocket costs between the available plans. And then if there were, you can imagine this would be a pretty easy way for patients to save a ton of money.

So for my methods, I record a video of exactly how to use this tool and, Ruchika, this is what I'm most excited to share with you today because patients and physicians and any provider family members, you can go ahead and do this on the internet as well. And so search up that just Medicare.gov/plan-compare, type in the zip code of where the patient lives. And so this is Ann Arbor where I'm training right now. Click on Part D plans and there's a lot of financial assistance programs, exclude those. And then type in the drug that you're interested in. So this is abiraterone. It will give you the recommended dosage based on just standard regimens. And then you can click on the mail order pharmacy. And then this is the university's cancer specialty pharmacy as well. And then it'll sort you drugs based on the lowest out-of-pocket costs from most affordable to most expensive, and you can compare these plans and ultimately when it's time to pick your drug plan every year, pick the most affordable plan.

So let's talk about the research for this a little bit. This graph here on the Y axis, this is the annual out-of-pocket costs for abiraterone for one-year prescription. And on the X axis here I show 12 cities with prominent urologic oncology hospitals. And I've highlighted Ann Arbor, of course, because that's where I am. And on the graph here you look at the box plots, each plot represents a different drug plan that's available. So in Ann Arbor, Michigan, there's 24 different drug plans available and they range, the bottom represents the most affordable, the top represents the most expensive. And recognize that patients, they don't know better, they pick any one of these plans, they don't know what's cheaper or not. Sometimes they just arbitrarily pick. But if you pick the lowest dot on the graph here, a patient could save up to $10,000 in annual out-of-pocket costs from abiraterone. It's pretty significant. And then we perform this for all 12 cities, and you consistently see for abiraterone potential savings to $5-10,000 in consistently among all 12 cities. We did this for enzalutamide and the range and affordability is a little bit smaller, but still patients can consistently save up to $3,000 if they are strategically picking their best drug plan.

And then finally, I wanted to compare them head to head. And you see abiraterone, heres on the left, enzalutamide is on the right. And most folks think just because a drug is generic it's going to become more available. There's more competition, it should be more available. Boom. And interestingly, we weren't expecting to find this, that's actually not the case. In fact, on the left here, you do see overall there's more affordable options compared to enzalutamide. But notice that there's still plans that require extremely high out-of-pocket costs, sometimes inexplicably even higher than enzalutamide. And so the point is that when we talk about affordability for drug costs, there's a lot of factors, but transitioning to generic is not just an automatically one.

Really, for patients to save the most amount of money, especially if they're insured by Medicare Part D, they need to strategically pick the most affordable plan available for them. And so really all this research leads us to, how are we going to start educating and empowering our most vulnerable patients with cancer to pick the most affordable plans for them so that they can start financially saving money on really important medications.

There's a lot to discuss with this study, but three big takeaways that we want to highlight is, one, people should recognize that patients with Medicare Part D plans have dozens of potential plans to compare and that they should compare them to select the most affordable one. This Part D plan finder is incredibly easy to use and it's free and it's on the internet, it's extremely accessible, and I highly encourage everyone to show their patients this resource. And then three, the next step is, how are we going to start incorporating this into cancer centers? I'm really lucky at the University of Michigan to have incredible pharmacists and social workers, but those resources don't exist everywhere. And so how can we start incorporating plan navigation into every comprehensive care center?

Ruchika Talwar: Thanks so much, Dr. Pockros, for that comprehensive overview. So first of all, congratulations on a great study. Not only is this informative, but I think it's a simple way to demonstrate the capacity for cost savings that there is once patients are informed. And that brings me to my question for you. In places that may not have patient navigation services like at your hospital, what are ways that physicians can encourage patients to navigate these sorts of programs? Because it's not always a concern that faces everyone, and not everyone is reliant on Medicare Part D plans, a lot of people do have private insurance or employer sponsored insurance. But patients don't always feel comfortable bringing these concerns up to us. So what's your advice for the urologist who prescribes these medications?

Benjamin Pockros: Yeah, I mean, I think it first starts with a conversation, with a discussion and a brief screening in clinic to see if the cost of medications may be an issue with patients. There's a lot of work on this already that a single question in clinic just saying, do you have any issues with purchasing your medications, with refilling your medications at the pharmacy, can trigger an alarm that says, yes, they do have issues with this and you need to start addressing it.

I don't think physicians are appropriately trained in our current setting to talk about costs, to talk about the financial implications of treatment. We're uncomfortable with it, which is I think why we defer from not doing it. But we know from studies and from the literature that patients are kind of screaming for help here. They want to talk about it, and they want to know what resources exist. And so there's a lot of roles for potential benefit with legislation, organizationally, but really we as a physicians, it can all start as a discussion point in clinic.

Ruchika Talwar: Yeah, I could not agree more. And I think that's why research like this is so incredibly important to get these conversations started and to make physicians aware of the resources that are actually out there. So congratulations again on your study. Thank you so much for chatting with us here at UroToday. And most importantly, I want to stress to people go back and rewatch that navigation on how to get to this website. And it's even something that you can discuss with your patients or refer them to this video if they're interested. So I definitely encourage all of our watchers and listeners to do that. And thank you again, Dr. Pockros, for being here today.

Benjamin Pockros: Thank you for inviting me. I mean, I think both of us will have a lot more work to do in this in the future, and hopefully in the next 10 or 20 years we'll really see a big difference in the way we're prescribing medications.

Ruchika Talwar: Absolutely.