Source/Disclosures
Disclosures: Garg reports he has served on advisory boards for Dexcom, Eli Lilly, Lexicon, Mannkind, Medtronic, Merck, Roche and Sanofi, and received research grants through his institution from Animas, Dario, Dexcom, Eli Lilly, JDRF, Lexicon, Medtronic, Merck, NIDDK, Novo Nordisk, Sanofi and T1D Exchange. Peters reports she has attended advisory boards for Abbott Diabetes Care (Libre) and received research funding from Dexcom.
May 22, 2020
5 min read
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Filling prescriptions becomes easier for some, harder for others during COVID-19

Source/Disclosures
Disclosures: Garg reports he has served on advisory boards for Dexcom, Eli Lilly, Lexicon, Mannkind, Medtronic, Merck, Roche and Sanofi, and received research grants through his institution from Animas, Dario, Dexcom, Eli Lilly, JDRF, Lexicon, Medtronic, Merck, NIDDK, Novo Nordisk, Sanofi and T1D Exchange. Peters reports she has attended advisory boards for Abbott Diabetes Care (Libre) and received research funding from Dexcom.
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Satish Garg
Satish Garg

As part of an increased reliance on telemedicine to deliver care during the COVID-19 pandemic, providers are also prescribing more medications virtually. Prior regulations, which required an established patient-provider relationship to prescribe some medications online, have been temporarily suspended to meet the needs of the public health emergency.

The federal Drug Enforcement Agency issued COVID-19 prescribing guidance, effective March 31, that allows DEA-registered practitioners to prescribe controlled substances without having to interact in person with their patients; the new rule will remain in effect for the duration of the public health emergency.

The uptick in virtual prescribing has also brought about another advantage for patients — insurance companies and other payors have begun to relax rules allowing for 90-day supplies of medications, according to Anne L. Peters, MD, professor of clinical medicine at Keck School of Medicine at the University of Southern California, Los Angeles.

“We could always prescribe through our EMRs, so that is not new,” Peters told Healio. “One of the things that has expanded, in my experience, is the willingness of all pharmacies to provide 90-day supplies of medications. Due to the pandemic, I want all my patients to have everything they need for whatever disease I am treating.”

β€œFor devices, you have to submit handwritten prior authorizations. My difficulty in doing what was already difficult has gotten higher.”
As part of an increased reliance on telemedicine to deliver care during the COVID-19 pandemic, providers are also prescribing more medications virtually.

‘Meaningful prescriptions’

In an article published in May in Diabetes Technology & Therapeutics, Peters and Satish K. Garg, MD, professor of medicine and pediatrics at the Barbara Davis Center for Diabetes, University of Colorado Denver, wrote that the switch to 90-day medication supplies for people with diabetes — along with removing the barrier to drive to a clinic for a prescription — has directly influenced outcomes and reduced incidence of diabetic ketoacidosis.

“Our long-standing clinic for people with type 1 diabetes and those with type 2 diabetes on U-500 insulin is still held weekly, with providers in clinic and patients largely managed remotely,” Garg and Peters wrote. “Patients, many at home due to the ‘Stay Safe at Home’ directive, are unusually receptive to our phone calls. No longer do they need to take three buses to come into clinic or take a morning off from work. The no show rate has dropped to an unheard of 9% low. Patients do not have to come in to pick up their medications monthly, as they now have a 3-month supply shipped to their homes, with a year's worth of refills.”

Peters said she has seen the benefits of patients receiving several month’s supplies of medications without the need to appear in person at a clinic.

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“In my clinic in East LA, we used to only supply 30 days of medication, and the patient had to come in,” Peters said. “Picking up prescriptions was a barrier. Now every patient gets 3 months of medication at a time, which is delivered to them, because they don’t want the patient coming to the pharmacy. All of a sudden, my patients aren’t running out of medication. It is the first time ever I felt like I could get them a consistent supply of medication.”

Peters said she hopes the changes persist after the pandemic.

“Lifting some of the bureaucracy around getting people 3-month supplies of medication would be wonderful, but I wonder what will happen when the cost structure becomes a concern again,” Peters said. “For now, I couldn’t be happier about the changes in my ability to give meaningful prescriptions to patients.”

Virtual hurdles

The shift to virtual prescribing has also meant coming up with creative ways to work with patients who may need a new class of medication, according to Garg.

“The issue has been that, sometimes, when we initiate a new therapy, we give people some samples,” Garg told Healio. “For example, if I start someone on semaglutide [Ozempic, Novo Nordisk], I don’t know if they are going to tolerate the drug, so I will give them the medication to try. We titrate the dose and see if they can tolerate it, and only then would we call in the prescription. So now, we conduct the telehealth visit, and we ask our patients to come to our parking lot where we can give them the necessary medications [samples]. That is a little bit of a hurdle.”

For Peters, issues of prior authorization for diabetes devices have only become more cumbersome when done virtually.

“The hard part is if I am conducting telemedicine visits from home, many of the things I use require prior authorizations, especially diabetes devices,” Peters said. “There is an online ability to fill out prior authorizations, but it is much easier for me to do that in the office. For devices, you have to submit handwritten prior authorizations. My difficulty in doing what was already difficult has gotten higher.”

Connecting patients to resources

By May 21, jobless claims associated with the pandemic rose to 38.6 million, according to U.S. Department of Labor statistics, and the number is expected to grow. For endocrinologists, that could mean a new population of patients potentially losing the ability to pay for their prescriptions — and those patients will need guidance on what to do next, Peters said.

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“I have a lot of patients in my East LA practice who have lost their jobs,” Peters said. “Many lose their access to health care. If you direct people to those patient assistance programs, all of those forms require a doctor’s signature. The forms to get medication under those programs, although they have made it easier, still require interaction with a clinic and a paper form to be signed. That is a real barrier.”

Peters said she tells any vulnerable patients how to purchase inexpensive insulin at Walmart, available for $25 per vial, and connects patients with local free clinics if necessary. Additionally, Peters contacts patients after a telehealth visit via a patient portal and she provides a list of available resources to obtain medications.

“I make sure they have a sense of ‘these are the things you must continue,’ like insulin, and ‘these are the alternatives to get those things,’” Peters said. “I want people to have a sense of prioritizing. Because if people are prioritizing buying food for the family vs. paying for medication, most people buy food. I go through the essential medications with them. Every person needs to know what resources there are for people who run out of their medications and cannot connect with their regular clinic. Where do they go? You need to know the resources locally where you would send people to get help. For anyone, the end of a call should be, even if they seem OK in the moment, ‘Where would you go if you are not ok?’ Know that they could lose access to telehealth with you.”

Garg said the problem of newly vulnerable patients is likely to worsen.

“The real problem is many people are losing jobs,” Garg said. “By this summer, maybe 30% of people will have filed for unemployment and could lose health insurance. The moment a person picks up Medicaid, many of us cannot see them. The net payment for a Medicaid patient is about $30 or $40 per patient for telehealth or in-person visits. Many places won’t take those patients at all. That will be the ongoing challenge.” – by Regina Schaffer

References:

Cardiometabolic Health Congress. Navigating online prescriptions for cardiometabolic patients. Available at: https://blog.cardiometabolichealth.org/2020/04/16/navigating-online-prescriptions-for-cardiometabolic-patients/?utm_content=127761695&utm_medium=social&utm_source=twitter&hss_channel=tw-151184124. Accessed: May 22, 2020.

Peters AL; Garg S. Diabetes Technol Ther. 2020; doi:10.1089/dia.20200187.

For more information:

Satish K. Garg, MD, can be reached at satish.garg@cuanschutz.edu. Anne L. Peters, MD, can be reached at annepete@med.usc.edu.

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Disclosures: Garg reports he has served on advisory boards for Dexcom, Eli Lilly, Lexicon, Mannkind, Medtronic, Merck, Roche and Sanofi, and received research grants through his institution from Animas, Dario, Dexcom, Eli Lilly, JDRF, Lexicon, Medtronic, Merck, NIDDK, Novo Nordisk, Sanofi and T1D Exchange. Peters reports she has attended advisory boards for Abbott Diabetes Care (Libre) and received research funding from Dexcom.