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Ruchika Talwar: Hi, everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and I'm a urologic oncologist at Vanderbilt in Nashville, Tennessee. Today I'm really excited to be joined by Dr. Ben Pockros, who is a resident at the University of Michigan. He'll be sharing some of his recent work exploring online tools and how to reduce financial toxicity for our urology patients. Thank you, Dr. Pockros, for joining us.

Benjamin Pockros: Thanks for inviting me. I know this is a topic we're both super passionate about. You've done a lot of work on the Mark Cuban Drug Company, I've done a lot of work on the Part D plan navigator, so this was really fun and rewarding to team up together and make a good pathway for patients and prescribers.

Ruchika Talwar: Absolutely, and I'm really excited to be able to share it with our UroToday community.

Benjamin Pockros: All right, so we published this in Urology Practice. I think expensive drug costs and high out-of-pocket costs are frustrating for patients. It's frustrating for prescribers. Frankly, I've written a lot about this in terms of cancer medications, but I just spent two months on a lot of patients with overactive bladder and urgency and urge incontinence, and I realized how much of a problem this also is for our patients getting prescribed mirabegron or trospium and dealing with those medications.

I think for prescribers, it's hard to know where to start. You want to help, but you don't really know where to start. And I think for patients, it's hard to know where to look. So Dr. Talwar and I, we teamed up together and we made this hopefully very practical and simple framework for both patients and prescribers on how to think about drug costs and get the best plans for their patients.

So here's a summary of it, and I'm going to go into detail more broadly, but there are four tools that we highlight: the Medicare Part D Plan Finder; GoodRx, which I think most people are familiar with; the Mark Cuban Cost Plus Drugs company, which I think a lot of people have heard about at this point; and Amazon Pharmacy, which I'm not sure people are very familiar with.

So I just wanted to highlight that if you go into Urology Practice, we actually included this as a supplemental figure. It attaches QR codes to all of these different tools, and so you could easily print this out in clinic. Your MAs could hand this out in the waiting room. You could hand this out in the clinic. If your patients indicate that they're struggling with paying for their meds or looking for more affordable options, this is a really easy starting point.

So to go more specifically, here's the framework we think about. For any patient that you're thinking about and want to lower the cost, start with point number one. Are they 65 and older and are they insured by Medicare? And if so, I would direct every single patient to know that they can switch their plans in the fall to potentially more affordable Part D plans. So patients with Medicare, they have many different options. All the plans can vary by out-of-pocket costs, and there's a really simple website where they can compare their costs just by plugging in the prescriptions they're used to.

Tool number two is GoodRx, and I think everyone knows about GoodRx, but it's hard to know where this fits into in the context of all these other tools. What we suggest is that you really focus this for patients that need medications urgently. So in urology, patients who you think have a urinary tract infection or they have bad kidney stone pain and they want Pyridium or Toradol, something that they need to get within the next day or two.

I think most prescribers will highlight GoodRx for all the medications that they prescribe, but it does add a lot of work for the clinic. It adds a lot of phone calls, having clinic navigators or MAs or physicians go through all the local pharmacies, all the local options. That's important for urgent medications, but for recurrent refills, it may just make more sense to do a mail-delivery order option, which I'll get to next.

So for less urgent medications and ones that are going to have recurrent refills, there are really two great options, and one is the Mark Cuban Cost Plus Drugs Company. So they do not take any insurance and they mainly sell generic medications, but it's really been Mark Cuban's mission to sell drugs at an affordable cost, and they've proven that and researchers have proven that as well. And so this is an excellent resource to direct your patients and to look yourself to see if they have the prescription that you want to send, especially for patients who are going to need recurrent refills. So things like trospium or Ditropan or Flomax. In the cancer space, abiraterone is a really important example. And other spaces, vaginal estrogen inserts can also be a really good example of that as well.

And then finally, Amazon Pharmacy. I think this is less well known, but it's pretty similar to Mark Cuban Cost Plus Drugs, but they actually do accept insurance. So if patients have good insurance plans, they can input it and see if that's any better than the Mark Cuban plan. They also have this pretty incredible offering called... I think it's Prescription Pass or RX Pass. And for patients who take multiple affordable generic drugs like lisinopril and metformin and tamsulosin, they bundle those all together for $5 a month and they'll ship it to the house once a month for that low cost.

And so really, in summary, a lot of people are passionate about this and now there are great new websites that are making it their mission to lower prescription costs. And we know it can be complex and confusing, but hopefully this framework is simple for both prescribers and patients, and something that you can introduce in the clinic to see if patients are interested in it.

Ruchika Talwar: Thanks, Dr. Pockros. That was a really important overview of four pretty accessible tools that physicians can use and patients can refer to when ordering or picking up their pharmaceutical medications. I think that there are a couple of things I wanted to point out.

First, you mentioned that GoodRx is an option for patients who might have an acute need that they need their medication today. For example, antibiotics to treat a UTI or pain medication postoperatively after surgery. You may not have the ability to wait five days for the medication to get shipped to you. But it's important to remember that GoodRx coupons are only valid for a short amount of time and only valid at specific locations. For example, if you have two Walgreens near you, the GoodRx coupon may work at one but not the other. So I think that giving that to physicians as an option to bring up with patients is great, but it's important to remember those limitations.

And you brought up some really great points about Cost Plus and Amazon Pharmacy as being ways to fill those chronic medications almost on an auto-refill basis. But tell me... A lot of clinicians think about this, but feel they don't have the time in the middle of their busy day to actually have these sorts of conversations, asking patients, "I'm going to send you this medication. Is it something you can afford?" And along the same lines, patients don't always feel comfortable bringing up cost concerns to physicians. There's stigma, there's embarrassment, etc. So what is your advice to the urologic community on how to tackle some of these issues in the middle of a busy clinic day?

Benjamin Pockros: It's a great question, and I've seen a lot of literature that the conflict, A, patients are really concerned about drug costs, and B, patients aren't sure or comfortable about talking about it with their physicians. My advice would be, seeing how much patients are concerned about it, to quickly bring it up in clinic. It's a really simple screening question. "Hey, I prescribed you this. How's the medication going?" We always ask about side effects, if they're tolerating it well. "Was it too expensive? Were you able to afford it okay?" And I think a good substantial portion will say, "Oh, it was no problem." But you may identify patients who say, "God, it was really expensive. I mean, I'll take it if I need to, but it was really tough."

I don't think it's the urologist's responsibility to necessarily go through all four options or spend 20 minutes on how to navigate it, but at least you can highlight patients who are identifying themselves as struggling with this and want to learn more options. The other thing that a urologist can do with the framework you made is just share it with their nursing staff, share with their MA staff. I mean, I've been amazed to see how many phone calls are generated with every prescription, and at least at Michigan, it's usually shielded away from the urologists and sent towards the call center, and they spend a ton of time talking to patients. And so even if urologists are hesitant about taking the time, funneling this information to their staff and their team, I think, can make a big difference.

Ruchika Talwar: Absolutely, and I think that's one of the great things about having our QR code insert in the article. That can be provided to patients, and often, if they end up at the pharmacy and say, "Huh, I may not be able to afford this long-term," they'll even have the ability to check out some of the other resources that you've provided them. That empowers the patient to reach out and say, "Can you switch my Flomax prescription to Cost Plus, actually?" So I couldn't agree more. All of this is a team sport.

Well, Dr. Pockros, it was really a pleasure working with you on this, and I know that this information is really integral for both urologists and patients who we treat out in the community. So thank you for taking the time to chat with us, and I'm glad we're able to share it with our UroToday audience.

Benjamin Pockros: Me too. It's always a pleasure to work with you, and I really hope it's helpful for patients and the urology team. I really do.

Ruchika Talwar: Great. Great. Well, thanks again. And to our audience, thanks so much for joining us. As always, we'll see you next time.