Cost savings analysis of prescription assistance programs at a student-run free clinic

Abstract

The Free Clinic at Lubbock Impact (TFC) is a student-run, volunteer free clinic affiliated with Texas Tech University Health Sciences Center in Lubbock, Texas, that provides free weekly health services to the local uninsured patient population. The clinic also helps patients enroll in prescription assistance programs (PAPs) from pharmaceutical companies, which supply eligible patients with certain medications at little or no cost. This study presents a cost savings analysis of TFC patients enrolled in PAPs from February 2019 through February 2020. Cost savings were calculated by matching medication doses and units with the cost per unit for each brand-name medication listed on GoodRx.com at Walgreens pharmacies located in TFC’s zip code, 79410. Sixty-one patients received 23 different medications with a total cost savings value of $222,563. Medications were sorted into diabetic, respiratory, and miscellaneous disease categories, for which cost savings totaled $114,110, $60,219, and $48,234, respectively. This study highlights the value of utilizing PAPs at a free clinic to address the barrier of medication cost for uninsured patients in Lubbock, Texas, and surrounding areas.

The cost of purchasing prescription medications has risen significantly over the past few decades,¹ which is particularly concerning for uninsured patients. An estimated 19% of the nonelderly uninsured population, compared with 6% of insured individuals, postponed or did not get a necessary prescription drug due to cost.² Medication nonadherence ultimately contributes to a higher disease burden and avoidable healthcare costs for both the individual patient and overall healthcare system.^3,4 Understanding these barriers, The Free Clinic at Lubbock Impact (TFC), in conjunction with Texas Tech University Health Sciences Center, provides free weekly medical care and specific prescription medications to uninsured adults aged 18 to 64 through completely volunteer-based efforts. Limited clinic funding prevents the in-house pharmacy from providing patients with expensive patent-protected medications. Thus, the clinic began utilizing prescription assistance programs (PAPs), offered by pharmaceutical companies, to supply eligible patients with such medications at little or no cost. While studies have determined the frequency of PAP utilization in the free clinic setting⁵ and have explored PAP cost savings in other clinical settings,^6,7 to the authors’ knowledge, no study has detailed PAP cost savings at a student-run, volunteer free clinic. The purpose of this study was to describe the disease processes, medications, and estimated cost savings associated with PAP utilization at TFC.

METHODS

Two medical students serve as PAP coordinators to support program enrollment and facilitate communication between patients, physicians, and pharmaceutical companies. Each coordinator needs an estimated 6 hours per week to complete all PAP responsibilities. When TFC physicians prescribe a medication to a patient who cannot afford it, the patient meets with the PAP coordinators to discuss PAP enrollment requirements. The coordinators then ensure that companies receive a completed application and all required documentation, such as prescriptions and income verification when necessary. Refill requests and annual reapplication forms are frequently submitted to maintain a consistent source of medication.

We conducted a retrospective review of TFC’s PAP database of uninsured adults aged 18 to 64 years old who received at least one medication through PAPs at TFC in Lubbock, Texas, from February 2019 through February 2020. The specific medication, dose, number of medication units (e.g., 3 inhalers, 30 tabs, etc.), and date of medication delivery were recorded for each encounter. Cost savings, defined as the monetary amount saved by patients not having to use personal funds to purchase medication from retail pharmacies, were calculated by matching medication doses and units with the cost per unit for each brand-name medication listed on GoodRx.com. Prices obtained from GoodRx.com were selected based on Walgreens pharmacies located in TFC’s zip code, 79410, on July 31, 2021. If a medication had no pricing information available, it was assigned a value of $0. The total cost savings value was subsequently categorized by disease: diabetes, respiratory, and miscellaneous.

RESULTS

From February 2019 through February 2020 at TFC, 61 patients received a total of 23 unique medications from PAPs. Fourteen patients received two different medications, and four patients received three different medications. The total PAP cost savings value was $222,563, which equates to an average of $3649 per patient (Table 1). Diabetic medication cost savings totaled $114,110, respiratory medication cost savings totaled $60,219, and miscellaneous disease medication cost savings totaled $48,234.

Table 1.

Estimated patient total and categorical medication cost savings from utilizing pharmaceutical company prescription assistance programs at The Free Clinic

Illness category	Pharmaceutical company	Medication	Categorical cost savings
Diabetes	Sanofi	Insulin glulisine (Apidra) Insulin glargine (Lantus, Lantus Solostar, Toujeo)	$114,110
	Novo Nordisk	Insulin aspart protamine/insulin aspart rDNA origin (Novolog 70/30) Insulin detemir (Levemir)
	Merck	Sitagliptin (Januvia)
Respiratory	GlaxoSmithKline	Fluticasone propionate/salmeterol (Advair) Fluticasone furoate/vilanterol (Breo Ellipta) Fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta) Albuterol (Ventolin)	$60,219
	AstraZeneca	Budesonide/formoterol (Symbicort)
	Merck	Mometasone furoate/formoterol fumarate dihydrate (Dulera) Albuterol (Proventil)
	Boehringer Ingelheim	Tiotropium bromide (Spiriva)
Miscellaneous disease	AbbVie	Adalimumab (Humira)	$48,234
	Allergan	Linaclotide (Linzess)
	Bristol-Myers Squibb	Apixaban (Eliquis)
	Gilead Sciences	Emtricitabine/tenofovir disoproxil fumarate (Truvada)
	Eli Lilly and Company	Olanzapine (Zyprexa)
	Novartis	Carbamazepine (Tegretol)
	AstraZeneca	Ticagrelor (Brilinta)
	Genentech	Vismodegib (Erivedge)
Total cost savings: $222,563

DISCUSSION

A reported 77.3% of surveyed free clinics utilized PAPs to address high medication costs for uninsured patients.⁵ However, to the authors’ knowledge, no studies indicate the specific medications obtained and the associated cost savings of PAP usage at volunteer free clinics. In a 13-month period at TFC, 61 patients received 23 different medications from PAPs, with a total cost savings value of $222,563 and $3649 per patient. The majority of savings came from diabetic and respiratory medications. Therefore, this study suggests that it may be beneficial for clinics to focus PAP-related resources on medications targeting commonly encountered diseases and on obtaining multiple medications per patient if necessary.

The cost savings value per patient from our study is greater than the findings reported from other clinical settings. A cancer center reported that using PAPs saved an average of $3072 and $2963 per patient in 2011 and 2012, respectively.⁶ An ambulatory care pharmacy reported a cost savings to the hospital of $31,028 over 6 months from the use of PAPs.⁷ However, these cost savings do not account for part-time and full-time employee personnel costs, which are estimated to be $22.26 per patient.⁸ TFC’s personnel costs are minimal due to volunteerism. If TFC’s cost savings value is compared to its 2019 to 2020 total funding of $68,981, it would have had to raise at least triple the amount of money to provide a similar assortment of medications to patients. This study suggests that a student-run, volunteer free clinic can achieve high-value savings for its patients with lower financial investment in areas such as personnel staff.

While PAPs are one strategy to address medication access and affordability, some critics note that PAPs can divert attention from creating effective solutions to drug pricing and falsely portray drug accessibility. The cost of PAPs is ultimately offset by high prices forced on cash-pay patients and insurers.⁹ Other criticisms of PAPs relate to changes in program requirements without notice and the unrealistic income-documentation requirements for indigent patients.¹⁰ However, our study shows that in the short term, PAPs are an established resource to provide many high-value medications to patients, such as those at TFC, who would likely have difficulty accessing these medications without PAPs. One study even reported that uninsured individuals receiving PAP assistance with pharmacist involvement were more likely to reach diabetic goals and have better cholesterol values compared with persons with prescription insurance.¹¹ Future studies can further assess the efficiency of PAP application processing, through the time needed to obtain patient approval, and PAPs’ impact on disease state management.

Limitations of this study include the manual documentation used to record PAP patient encounters in the PAP database and the use of GoodRx.com medication pricing for calculating patient savings. GoodRx.com pricing is dependent on location and may fluctuate over time. These factors could lead to underestimation or overestimation of patient count and cost savings related to PAP. Additionally, because patients receive brand-name medications through PAPs, the cost savings calculations include brand-name medication prices. However, if patients were to instead purchase medications from a retail pharmacy and could afford the generic alternative, they likely would pay a lower price. Furthermore, this cost savings analysis does not incorporate operating costs such as the value of a medical office visit, volunteer time, utility cost, and equipment cost that would more comprehensively represent the value of PAPs.

In summary, addressing the barrier of high medication cost is critical for uninsured and indigent patients. TFC utilizes PAPs to provide its patients with free brand-name medications. This study emphasizes the value of supporting the PAP enrollment process, which helps TFC reach its goal of improving medication adherence and health outcomes in the uninsured communities of Lubbock, Texas and surrounding areas.