ACORN Medication Services: A Quality Improvement Project

Transcription

1 ACORN Medication Services: A Quality Improvement Project Dimple Patel, AA dimplep@ufl.edu Elizabeth Paulk, BS epp@ufl.edu Community Health Scholars Candice King, MBA, MAE, Project Director Executive Director, ACORN Clinic N. SR 235 Brooker, FL Phone: (352) Funded by Suwannee River Area Health Education Center P.O. Box 2157 Alachua, FL Phone: (386) Fax: (386)

2 Abstract The goal of this project was to improve and enhance the many aspects of ACORN s medication services. The project objectives included investigating pharmacy models, reviewing federal programs, evaluating ACORN s unmet needs, and evaluating options to enhance the medication services. The methods included Internet research, literature review, interviews, and visits to clinics. The key findings are as follows: Limited Formulary The formulary was limited in antibiotics, anti-inflammatory meds, and protonpump inhibitors. Possible solutions include a better supply of samples and a potential partnership with Alachua County Office of Social Services (ACOSS). Inventory ACORN had no system for conducting an inventory of formulary meds. An annual system was developed and tested. Drug Interactions & Compliance The clinical pharmacy services could be expanded to include a systematic chart review for drug interactions. This chart review would check for drug interactions and also document the degree to which drug interactions are an issue at ACORN. Additionally, the Personal Drug Therapy software program could be implemented to identify major interactions and monitor compliance. Involvement with UF COP Employing a full-time pharmacist at ACORN would offer centralized drug interaction monitoring, more thorough drug verification, and additional patient education and counseling. Barriers to this option include funding and the involvement of the Board of Pharmacy. Product Information Handouts Handouts currently are written at a 9-10 th grade reading level. Handouts written at a lower reading level are available through Personal Drug Therapy. Discounted Drug Pricing Public Health Sector pricing is available to certain health care entities. ACORN is exploring options to receive this type of pricing. Medicare & Patient Assistance Programs (PAP) Since many PAP patients are also Medicare patients, the new changes to Medicare may affect their ability to receive free meds. Enrollment in 2006 Medicare Prescription Benefits Plan will be voluntary, so PAP should not be compromised. The situation should be monitored. Objectives Alachua County Organization for Rural Needs (ACORN) is a not-for-profit 501(c)(3) rural health clinic. This clinic provides dental and medical services to the working poor. Of the total patient visits to the medical clinic in 2003 (8019 visits), 75% of patients were uninsured, 10% had Medicaid, and 12% had Medicare. 1 Of these 8019 patient visits, 70% of patients were at or below 100% of the federal poverty level, and 99% were at or below 160% of the federal poverty level. 1 Because these patients cannot afford healthcare, they come to ACORN for highquality dental and medical care. The medical care includes comprehensive medication services, 2

3 which provide patients with free or inexpensive medications. Though these services are effective, ACORN has a commitment to continuous quality improvement. Thus, this Community Health Scholars project was submitted. The goal of the project was to evaluate the medication services and investigate ways to improve and to enhance the many aspects of the services. 2 This quality improvement project was timely considering the recent growth of ACORN s medication services, the upcoming changes in Medicare, the potential that ACORN may apply to become a federally qualified community health center (FQCHC), and the College of Pharmacy s interest in increased interaction with ACORN. The project had four objectives to achieve its goal: (1) To investigate other pharmacy models in rural or low-income settings (2) To review current federal programs and their potential impact on ACORN Clinic (3) To evaluate unmet needs in ACORN s current medication services (4) To evaluate options to enhance and improve ACORN s medication services. 2 Background ACORN Clinic treats priority populations such as rural and low-income patients. Due to lack of monetary resources and insurance, these patients have reduced ability to pay for healthcare, which results in decreased access to care. 3 Access to care is further reduced in rural populations by barriers such as lack of transportation and distance to health care services. 3 Decreased access to care has implications not only for the individual patient, but also for society. For example, patients of low socioeconomic status are less likely to receive preventative care for illnesses such as diabetes and, thus are more likely to require hospital admissions. 3 Although hospital admissions and costs could be decreased by preventative care, preventative care accounts for only 5% of the $1.4 trillion spent on healthcare. 4 Thus, by providing preventative care that is low in cost and high in quality, ACORN Clinic not only serves the individual patient, but society as a whole. A key component to preventative care is access to medications. Without such access, controllable diseases such as diabetes and hypertension are left untreated, resulting in unnecessary hospital admissions. ACORN provides medications to its patients from three sources: (1) formulary, (2) samples, and (3) Patient Assistance Programs (PAP). The formulary is limited and contains mainly inexpensive generic medications. Formulary medications are sold to patients with a onedollar mark up. Most of the samples are donated by physician s offices; a small selection are delivered by pharmaceutical representatives. Samples are free to patients. The Patient Assistance Program is the avenue by which the majority of ACORN patients receive their longterm medications. In these programs, pharmaceutical companies mail free medications to patients who meet certain income requirements. ACORN charges the patients a five-dollar handling fee. In 2003, this program provided patients with medications valued at $1,135,903. This figure represents a fold increase since 2001, when its value was $396,444. Of the resources spent on ACORN Medical Clinic, 12% was allocated to the medication services. 5 Methods The first step of the project was to obtain information about ACORN s medication program its services, its organization, its flow and procedures, and the role of its staff. This 3

4 information was obtained through interviews with key staff members, including the Medication Room Specialist (Lynda McCarthy, LPN), the Patient Assistance Program Advocate (Dawn Brown, PA), the social worker (Kay Culpepper), and the Medical Clinic Coordinator (Chris Hoffman, RN). Objective 1: After learning about ACORN s operations, the next step was to compare the ACORN model to other pharmacy models for rural or low-income clinics. This comparison was completed by reviewing the literature, searching the Internet, and interviewing other clinics. The clinics that were interviewed (via phone, , and/or personal visits) include the following: Planned Parenthood, Alachua County Health Department, Alachua County Office of Social Services, Bell Medical Clinic, UF Family Practice, Eastside Clinic, Archer Family Practice, Equal Access, Fanning Springs, and Neighborhood Health Services of Tallahassee. These interviews focused on topics such as inventory systems, sources for medications, and funding. Objective 2: Federal programs include federal drug pricing (340B pricing), Medicaid, Medicare, and piece-meal programs such as Silver Savers. All of these programs were researched on the Internet. For further information, contacts were made with key offices such as the Office of Pharmacy Affairs, the SHINE program, and pharmaceutical companies. Objective 3: The unmet needs of ACORN s medication services were evaluated on three fronts: the staff, the practitioners, and the patients. The staff was interviewed and asked about challenges such as patient flow and funding. All the practitioners were interviewed; their responses focused on their assessment of top medication-related challenges, the limitations of the formulary, and patient compliance. The patient perspective was obtained through a Patient Satisfaction Survey, which was conducted under ACORN s Board of Directors as a part of their commitment to continuous quality improvement. The information from these three sources was used to compile a list of ACORN s top medication-related challenges. The challenges were very diverse, ranging from a limited formulary to patient compliance. However, this diversity is to be expected; after all, the goal of the project was to improve the medication services as a whole, rather than one particular aspect. Objective 4: After assessing ACORN s medication-related challenges, the project investigated ways that these challenges could be addressed. Additionally, the project investigated other options to enhance the medication services. These ideas were brainstormed by ACORN staff, ACORN practitioners, other clinics, and University of Florida College of Pharmacy (UF COP) faculty. Thus, the list of top medication-related challenges now contained options to address these challenges as well as additional options for enhancement. Findings: Results and Recommendations ACORN patients are pleased with the medication services. According to ACORN s Patient Satisfaction Survey, when patients were asked what could be done to improve the medication services, 71% of the patients either left the question blank or answered no improvements needed. 6 However, improvement is always possible. Twelve issues will be addressed. (1) Strategies for providing medication to low-income patients (2) Limited formulary (3) Organization of sample medications (4) Inventory system 4

5 (5) Adherence to prescription regimen (6) Drug verification (7) Drug interactions (8) Product information handouts (9) UF College of Pharmacy involvement (10) Communication between medical and dental clinics (11) Discounted drug pricing (12) Medicare Prescription Drug Benefits Plan and its effect on PAP Strategies for providing medication to low-income patients: A major challenge in health care is to provide low-income patients with their medications. This challenge is addressed in many different ways depending on the medication service or pharmacy model. Most medication services use the following sources: Medicaid, Medicare, federal drug pricing, Patient Assistance Programs (PAP), and samples. Since patients with Medicaid receive prescription coverage, they take their prescriptions to local pharmacies. Patients with Medicare are now eligible for the Medicare-Approved Drug Discount Cards. While these cards have a co-pay, many low-income patients can qualify for free medication through PAP. Thus, ACORN patients are not encouraged to sign up for these cards. In 2006, Medicare plans to start its Prescription Benefits Plan. This plan has a premium, deductible and co-pays that are too high for most low-income patients. For example, premiums are $35 a month, and the patients must meet an annual deductible of $250. However, the Medicare website states that extra help will be available to low-income patients. These guidelines will not be set until Through federal drug pricing (340B drug pricing), eligible entities may buy discounted drugs from wholesalers or manufacturers. Federal drug pricing is available only to certain entities such as Federally Qualified Community Health Centers. This pricing option will be discussed later in the paper. Through the Patient Assistance Program, individual pharmaceutical companies offer free brand-name medications to patients who qualify and complete the appropriate paperwork. However, filling out the paperwork can be difficult. First, the applications are found online, and most low-income patients do not have computer access. Second, since PAP is organized by pharmaceutical companies, the patient must find the company that manufactures the prescribed medication. Although this process can be aided certain websites, the process itself requires computer skills and motivation. A solution to this barrier is to hire a PAP Advocate a person to complete the paperwork for the patient. A new program, Rx Outreach, is PAP for generic medications. This program however, has a fairly substantial administrative fee of $18 for a three-month prescription. 8 Another source of medications is pharmaceutical samples. Samples are easy to obtain if the medical practice has paying patients; this is a little more difficult if the practice serves primarily uninsured patients. Still, samples can be obtained by establishing relationships with representatives and receiving donations from other medical practices. Medication services vary greatly among clinics. Some clinics dispense under dispensing practitioners, some under pharmacists. Pharmacists may be affiliated with a university or hired privately. For example, UF Family Practice pays the salary of a pharmacist who is a professor at the UF College of Pharmacy. Other clinics such as Neighborhood Health Services or Bell Medical Clinic hire a private pharmacist. 5

6 Another model for medication services is offered by the Alachua County Office of Social Services (ACOSS). These services are available to residents of Alachua County who live at 150% of the federal poverty level (with proof of income) and who do not have Medicaid. After the eligible patient is signed up, the patient takes his or her prescription to any retail pharmacy. The retail pharmacies have a contract with ACOSS, which is negotiated through ACOSS s pharmacy benefits manager. The retail pharmacy is paid Average Wholesale Price minus 15% for generics and minus 13% for brand names. ACOSS has initiated cost containment measures such as a $5 co-pay, a $500 limit per prescription, a preferred drug list, and a limit of ten prescriptions per patient. ACOSS also may investigate PAP. Limited formulary: One challenge faced by all the practitioners at ACORN is the limited supply of medications. The medications are limited by several factors. First, the formulary consists primarily of generic medications. Second, the sample selection varies from week to week. Samples are difficult to obtain because pharmaceutical representatives receive little reimbursement from donating to ACORN. Third, PAP provides most of ACORN s patients with their long-term medications; therefore, the practitioner must consider the availability of the medication through PAP before prescribing. This combination of factors limits the practitioners in their choice of treatment. Options to address this challenge include a consistent supply of pharmaceutical samples and a partnership with Alachua County Office of Social Services. The formulary is especially limited in its selection of antibiotics, non-steroidal antiinflammatory drugs, proton-pump inhibitors, and certain diabetic medications. Since antibiotics are generally prescribed only as short-course medications, practitioners should be able to completely treat patients with samples. Thus, pharmaceutical representatives were contacted with the goal of establishing a list of representatives willing to regularly give samples. These samples would allow access to stronger antibiotics such as Cipro, Levaquin, and Omnicef while avoiding the high costs of adding them to the formulary. During the course of the project, representatives delivered a variety of anti-inflammatory medications, antibiotics, and certain diabetic medications like Avandia and Actos. A consistent supply of samples could also address another challenge: initiating therapy in patients who have completed their PAP applications but are waiting for their first supply of medications, which come via mail. Ideally, treatment should be started immediately, but PAP medications often do not arrive until six to eight weeks. A better supply of samples makes this initiation process smoother. Attached (B) is a sheet of pharmaceutical representatives who were amenable to supplying ACORN with samples. These samples may be mailed, delivered to ACORN, or delivered to a physician in Gainesville. For prescriptions not available through the formulary or through samples, ACORN could potentially partner with Alachua County Office of Social Services (ACOSS). ACOSS currently sends its patients to local pharmacies to have their prescriptions filled. ACOSS serves patients who live in Alachua County and are at 150% of the federal poverty level. Many ACORN patients meet these criteria. Possibly, these ACORN patients (in limited numbers) could go to ACOSS if ACORN is unable to provide medications through its formulary or samples. ACOSS is willing to discuss this option with Candice King (attachment A). Organization of sample medications: Because the variety of sample medications changes weekly, the sample shelf can be difficult to navigate. The sample medications were loosely 6

7 organized by drug class; however, these borders were vague. To make these borders more obvious, the shelf was re-labeled and color-coated according to drug class or organ system. This organization will make it easier to find a desired type of medication as well as see all available options in a specific drug class. The re-organization will also help new practitioners who are not as familiar with ACORN for example, the specialists and internists that come in on Tuesday nights. Inventory system: Auditors want to know the value of medication on ACORN s formulary shelves on the last day of every year. A variety of inventory systems from other clinics were investigated daily working inventories, quarterly inventories, and annual inventories. Working or quarterly inventories offer benefits such as monitoring shrinkage and assisting with reordering medications. However, ACORN is not currently concerned with shrinkage. Also, the current re-ordering system is basic yet effective: the formulary medications are assessed visually and when low, are reordered. The recommendation is that for ACORN s purposes, an annual inventory would be most cost and time effective. An inventory sheet (attachment C) was developed using an Excel spreadsheet. The spreadsheet was presented to and approved by the medication room specialist, who would be responsible for conducting the inventory. Inventory was taken in August to test the proposed system. The inventory consists of counting the number of closed stock bottles on the shelves and the number of units in open containers; these numbers are then entered into two separate columns. Formulas comprised of the price per each medication are included in the spreadsheet, which automatically calculates and totals the value of each medication. Potential challenges with the proposed inventory system include the variability of quantities available from the wholesaler Allscripts; the purchasing of new and different medications, since these medications would not already have an entry with automatic formulas entered on the spreadsheet; and price fluctuations of current medications throughout the year and since the development of the spreadsheet. The spreadsheet will require updates to keep the prices, quantities, and manufacturers current. This called for a brief but informative tutorial on how to edit and update the Excel spreadsheet. A quick reference how-to on Inventory Updates was developed (attachment D). Samples are tracked by lot numbers found on each batch of medications; these numbers help locate individual medications manufactured during a certain time frame in the case of a recall. ACORN currently has no system to record which samples go to which patients. A Sample Tracker was developed from an Excel spreadsheet to log the lot numbers and patient information (attachment E). Since the proposed Sample Tracker would be very time-consuming, and ACORN has never been faulted for lacking such a tracking system, it is recommended that the clinic not initiate the Tracker until further directed by the Agency of Health Care Administration. Adherence to medication regimen: Low adherence was identified by practitioners as a significant drug-related challenge. Practitioners noted multiple barriers to compliance. These barriers include issues such as complicated dosage regimens, side effects, mental health disorders, transportation, and literacy. Cost is also a substantial barrier to many patients. However, ACORN has overcome this barrier by providing low-cost or free medications. To increase compliance, current interventions include pre-filled pill boxes and counseling with pharmacy students. 7

8 Two possible interventions include Dr. Annis proposed compliance studies and a computer program entitled Personal Drug Therapy. Personal Drug Therapy was offered to ACORN Clinic by Dr. Dan Robinson of the University of Florida College of Pharmacy. Designed to improve the outcomes of drug therapy, this program is a prototype that could be molded to fit the needs of ACORN. For example, ACORN practitioners noted compliance as a significant issue in patients with diabetes, hypertension, and dislipidemia. The program could be tailored to follow patients on medications that treat these conditions. Personal Drug Therapy organizes patient information such as demographics, adherence patterns, personal medication calendar, list of medications, and major drug interactions. Several aspects of the program can help with compliance. For example, the program provides a personal medication calendar with a dosage schedule based on time of day. Thus, patients have a complete list of which medicines should be taken in the morning, which should be taken in the evening, and so on. The program also monitors adherence, which is defined as the number of days late the patient picks up his medications. Additionally, the program provides a complete list of medications, including dosage. To implement the program, patient data must be entered. Since ACORN currently utilizes Medical Manager in Windows, it is possible that the programs could be linked and information easily transferred from Medical Manager. If the data must be entered manually, this could be a task for the pharmacy students. This exercise would be very educational the students would become more familiar with drug names, indications for use, and drug interactions. This program could be piloted in a subset of patients who are identified as being at high risk for drug-related problems. For starters, this group could be any patient on more than six long-term medications. Additionally, Dr. Laura Annis of the UF College of Pharmacy plans to do future studies on compliance at ACORN clinic. Drug verification for formulary medications: Because ACORN s current medication services do not include a pharmacist, the clinic does not have a central person responsible for prescription verification, drug interaction checks, and medication counseling. Instead, these responsibilities are left to individual practitioners, who are licensed as dispensing practitioners. The practitioner must be present when dispensing occurs and must personally certify filled prescriptions for accuracy prior to patient receiving, according to the State of Florida Agency for Health Care Administration. 9 This agency has always approved the practitioners at ACORN. ACORN s system is analogous to a retail pharmacy the technician fills the prescription, and the pharmacist verifies the prescription. At ACORN, the medication room specialist fills the prescription, and the practitioner verifies. A retail pharmacy has a set system for verification. However, at ACORN, the system is subject to time constraints and flow challenges. An example of a flow challenge is as follows: when the clinic is busy, the prescription may be filled while the practitioner is in another room. One way to make prescription verification more systematic would be to develop written guidelines outlining the responsibilities of dispensing practitioners as well as options to improve flow. Prescription verification is a key component to patient safety. Drug interactions: Unlike a retail pharmacy, ACORN does not have a central mechanism to check for drug interactions. However, drug interaction checks at retail pharmacies are not perfect: the pharmacy may not have an accurate list of the patients medications due to multiple 8

9 pharmacy visits or undocumented over-the-counter medications, herbals or vitamins. In contrast, ACORN patients generally receive all of their medications through the clinic; therefore, practitioners generally have a complete list of medications and thus have the ability to check for interactions. One way to address the challenge of drug interactions is by using a computer program. Currently, ACORN does not have a program to identify drug interactions. Many such programs complicate matters unnecessarily by listing all drug interactions, even minor ones. However, Personal Drug Therapy is simplified it only identifies the major drug interactions. An additional option is to expand the services of the PharmDs to include a systematic chart review for drug interactions. This type of extra pharmaceutical care has been shown in the literature to decrease medication interactions and simplify treatment regimens. 10 This chart review could be done at the request of a practitioner and also randomly on patients whose treatment includes more than six long-term medications. The chart review could be done as a project for the PharmD students under the supervision of their attending Dr. Laura Annis. This chart review may simplify and improve treatment regimens. Additionally, the chart review would document the extent to which ACORN patients experience drug interactions. This documentation would be important as ACORN evaluates the advantages to having a full-time pharmacist. Furthermore, the chart reviews would be a useful educational tool for the PharmD students. The reviews could be implemented rather easily; the students could block off half of a day on Mondays. The chart reviews may be combined with Personal Drug Therapy; since the chart reviews and data entry will be done primarily by pharmacy students, the patients whose charts are reviewed may be the same patients who are entered into the program. Thus, the recommendations to decrease drug interactions may be combined with the recommendations to increase compliance. Product Information Handouts: Patients are currently given product information sheets when they receive a new medication. However, these information sheets are written on a fairly complicated reading level. The reading level for a general audience should be no higher than 6 th grade; 11 however, for ACORN s patient population, this level should ideally be lower. To determine the reading level of ACORN s information sheets, three methods were used: the Fry Readability Graph, the Smog Readability Formula, and the Flesch-Kincaid Grade Level Index. 11,12 Each method is slightly different, but for the most part, they involve counting the number of words, sentences, and/or syllables. Each method was used on the same three passages. The Fry reading level averaged 9.6, the Smog reading level averaged 11.3, and the Flesch-Kincaid reading level averaged 8.9. Despite this variation, the results indicate the passages are written at a 9 th -10 th grade reading level, which is too high for a general audience. The average education level of ACORN s indigent patient population should be considered, and the educational material should be further tailored to meet their needs. Other low-income clinics were contacted to locate a source of patient information handouts written at lower reading levels; however, such information was not easily located. Handouts written at approximately a 4 th grade reading level are available through Personal Drug Therapy. Additionally, if a practitioner suspects that a patient does not understand the therapy or the risks or benefits, the patient can be referred to the pharmacy services for further counseling. Although such verbal communication is important, patients want more written information. When patients were asked what options could improve the medication services, 9

10 13% chose drug information handouts, and 10% chose more time spent discussing medications. 6 Although these percentages seem small, 71% of patients reported no suggestions. Therefore, of the 29% that had suggestions, 80% of the suggestions involved communication, be it verbal or written. Therefore, if Personal Drug Therapy is not initiated at the clinic, it is recommended that a future project team develop product information handouts that are written at a 4-6 th grade reading level. UF COP Involvement: Another possible option is a more extensive partnership with the University of Florida College of Pharmacy (UF COP). Leslie Hendeles, PharmD, and David Brushwood, PharmD, JD, of UF COP were interviewed to discuss ideas and legal issues. The College of Pharmacy would need a business plan detailing a payer source. If a payer source could be obtained, the UF COP would most likely be interested in providing a pharmacist and students. Students could benefit from seeing pharmacy services in a rural setting like ACORN. However, ACORN currently does not generate enough prescriptions to warrant a full-time pharmacist there are a maximum of around fifty prescriptions written each day. Dr. Brushwood suggested a mail-order pharmacy that would be open for a few hours each week. During that time, a pharmacist could dispense the week s prescriptions. The prescription could either be mailed to the patient s home or picked up by the patient. If a patient chose the mail delivery option, the patient could be started on samples until their prescription arrived. Dr. Henedeles suggested having a volunteer pharmacist and students come in for a halfday per week. During this time, the pharmacist could dispense prescriptions and counsel patients on medications. The purpose of this half-day pharmacist would be to pilot the idea of a future partnership with the COP. However, during a half-day, the amount of prescriptions written is so small that the pharmacists time could be better utilized in other ways. Furthermore, if a pharmacist is dispensing (whether paid or volunteer), then the Board of Pharmacy must be involved to grant the clinic a pharmacy permit. The Board of Pharmacy has very specific rules and regulations. For example, if pharmacists and practitioners were both dispensing, then two separate rooms would be required one for the pharmacist ( pharmacy ) and one for the dispensing practitioners ( medication room ). Tim Rogers, PharmD at Eckerd Pharmacy, is very receptive to the idea of ACORN becoming a pharmacy (attachment A). He has volunteered to discuss the clinic s plans and then present them to the Board of Pharmacy on behalf of ACORN. Factors such as the low prescription load and the Board of Pharmacy involvement make any association with dispensing pharmacists complicated. These complicating factors are not worth the benefit of a one-day-a-week pharmacist. However, if ACORN had enough prescriptions to warrant a full-time pharmacist, then the benefits of a pharmacist would outweigh the costs. The clinic could have enough prescriptions if the medication services were extended to serve patients beyond ACORN, i.e., other low-income patients. If ACORN were to expand its services to this larger population, it is likely that more sources of funding would become available; this funding could pay for a full-time pharmacist. Medical & Dental Clinics: For the most part, ACORN Medical Clinic and ACORN Dental Clinic function independently of each other. The Dental Clinic does not utilize the medication services provided by the Medical Clinic, even if the patient had also seen an ACORN medical practitioner. Most of the medications prescribed by the Dental Clinic are fairly inexpensive; thus, patients do not have much difficulty getting prescriptions filled. The Dental Clinic has a 10

11 small supply of medications, mainly antibiotics such as amoxicillin and clindamycin. These are given to patients for pre-medication. The Dental Clinic purchases the antibiotics from Sullivan- Schein Dental catalog at institutional pricing to give to the patients. The prices from Sullivan- Schein were compared to Allscripts, the wholesaler for ACORN s medication room; the medications, specifically clindamycin, were much less expensive when ordered from Allscripts. It was suggested that the Dental Clinic purchase these antibiotics from the medication room at Allscripts formulary prices rather than ordering them from Sullivan-Schein. Another option is for dental patients who are also ACORN Medical patients to fill their dental prescriptions in the medication room. The issue here is that the Medical Clinic s physicians are all dispensing practitioners they are responsible for writing, reviewing, and dispensing each prescription. The dentists are not dispensing practitioners, and even if they were to apply for this certification, it would not be feasible for them to go to the medication room every time they wrote a prescription so they could review and dispense it. Also, because the Dental Clinic prescribes inexpensive medications such as antibiotics and ibuprofen, a workable option is to continue sending patients to pharmacies and save formulary medications for patients who cannot afford a retail pharmacy. Another option was for the Dental Clinic to set up a separate account with Allscripts under the Dental Clinic s director Tom Thompson. This account would offer them lower pricing than the dental catalogue. However, since the Dental Clinic would not be ordering a large amount of medications, it may be more practical for the Dental Clinic to just buy the few medications they need from the medication room. Discounted Drug Pricing: A less expensive way to purchase medications is through the federal drug pricing program Section 340B of the Public Health Service Act. These drug prices are lower than what ACORN currently pays Allscripts. After comparing a few medications, savings anywhere from 30-45% were seen with 340B pricing. 13 Federal drug pricing is available only to certain types of entities. These include Federally Qualified Community Health Centers (FQCHC), FQCHC look-alikes, black lung clinics receiving certain types of funds, and Family Planning Programs receiving a grant or contract under Sec of the Public Health Service Act. 14 All eligible programs are listed in the Office of Pharmacy Affairs database. 15 The Office of Pharmacy Affairs is a division of Bureau of Primary Care within the US Department of Health and Human Services. The Family Planning Program is sanctioned under the Public Health Service Act, Title X. The program is administered by the Office of Family Planning, a division of the Office of Population Affairs. 16 Family planning programs are divided up by regions. According to the Florida regional office (located within the Florida Department of Health), Family Planning Clinics receive 340B pricing on birth control and may also receive 340B on other medications. However, these arrangements are made with the individual pharmaceutical company. If deemed appropriate, the recommendation is that ACORN proceeds with the CHC application. However, this process is competitive and should only be attempted if CHC status is likely. If ACORN applied for but was not granted CHC status, it could still become a FQCHC look-alike. Though look-alikes receive 340B pricing, they do not receive federal funding. Additionally, ACORN has a contract with Alachua County Health Department to see Primary Care Patients. These patients live in Alachua County and are at or below 150% of the federal poverty level. Perhaps this contract could be extended to allow ACORN to use the state 11

12 of Florida rate when purchasing medications. If deemed appropriate, talk further with Alachua County Health Department about receiving their state of Florida rate. Medicare Changes & Effect on PAP: Since many of ACORN s Medicare patients receive patient assistance, one concern was how the new changes to Medicare would affect their enrollment in PAP. To be eligible for PAP, the patient must not have prescription insurance. Prescription insurance was not part of Medicare prior to June 2004; thus, patients could receive Medicare benefits as well as PAP benefits. In June of this year, Medicare contracted with many pharmaceutical companies to offer a variety of prescription discount cards. Through these cards, Medicare patients receive a reduced rate on medications. Most of ACORN s patients, however, are already receiving their medications free of charge through PAP. Since the temporary discount cards are voluntary, patients are not being encouraged to enroll. Once the permanent changes to Medicare are made in 2006, will all Medicare patients be automatically provided with prescription coverage? This plan will require a co-pay, which in the case of many ACORN patients, would render their medications unaffordable. As of January 1, 2006, all people on Medicare will be able to enroll in a voluntary prescription benefits plan. This will offer significant savings for seniors and disabled patients. There will be extra help for patients with the greatest need; patients with very low incomes and limited assets will not be responsible for the premium or deductible. These patients will only have to pay a small co-pay for each medication. Other patients with limited incomes will receive help by being responsible for a lower premium and deductible. The income limits for determining who falls into which level will be set in So long as each pharmaceutical company is continuing their individual Patient Assistance Programs, ACORN s Medicare patients should not see any changes in Certain companies are discontinuing some of their other discount programs already. For example, Pfizer s Share Card has been combined with the temporary Medicare Discount Card and has become the UShare-Card, which now has a small charge of $19 along with the $15-copay. Pharmaceutical companies were contacted and asked about their future plans for PAP. None of the companies contacted were anticipating any changes. The PAP situation should be monitored since pharmaceutical companies may withdraw support at their prerogative. Conclusion The key challenges at ACORN Clinic were each addressed in many different ways. Recommendations were made after gathering information and evaluating the options. Information was provided as to why the recommendations were made either for or against certain ideas. It was the goal of this project to identify all possible options for improvement or enhancement with reasonable strategies to implement any necessary modifications. Acknowledgments This project would not have been possible without the financial support of Suwannee River Area Health Education Center or without the guidance of Richard Davidson, MD, MPH, Community Health Scholars Program Director, and Laura Guyer, PhD, RD, Associate Director of SRAHEC. Additionally, the staff at ACORN Clinic was so warm and always found time to 12

13 answer our many questions a big thank you goes to Chris Hoffman, RN, and Lynda McCarthy, LPN. Laura Annis, PharmD, provided great ideas and new directions for our project. Thank you to the following faculty of the University of Florida College of Pharmacy: David Brushwood, PharmD, JD, Leslie Hendeles, PharmD, and Dan Robinson, PharmD. And finally, thank you to Mina Willis, PharmD, PA-C, from Bell Medical Center for all your valuable information on federal programs and pricing. References 1. ACORN Medical Clinic Patient Statistics King, Candice. Community Health Scholars Project Proposal National Healthcare Disparities Report: Summary. (February 2004). Agency for Healthcare Research and Quality, Rockville, Md. Retrieved 7/28/04 from 4. National Healthcare Quality Report: Summary. (December 2003). AHRQ Publication No. 04-RG003. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved 7/28/04 from 5. Statistics based on Acorn Management Report, Resources allocated to ACORN Medical clinic include operations, salaries, social services salaries, and social service operations. Resources allocated to the medication services include salaries of the LPN and PAP advocate, medication expenditures, and 2% of the operations. 6. ACORN Medical Clinic Patient Satisfaction Survey The Facts About Upcoming New Benefits in Medicare. Retrieved on 7/28/04 from 8. Frequently Asked Questions. Rx Outreach. Retrieved 7/28/04 from 9. State of Florida Agency for Health Care Administration. Investigative Services Inspection Form for Dispensing Practitioners. May 16, Taylor CT, Byrd DC, Krueger K. Improving primary care in rural Alabama with a pharmacy initiative. Am J Health Syst Pharm Jun 1;60(11): Smog Readability Formula. Patient Education Materials: An Author s Guide. Retrieved 7/28/04 from Schrock, Kathy. Fry s Readability Graph: Directions for Use. Kathy Schrock s Guide for Educators. Retrieved 7/28/04 from 13

14 13. Willis, Mina. ACORN Clinic. to Dimple Patel. 9 June Programs Eligible to Participate in 340B. U.S. Department of Health and Human Services, Bureau of Primary Care, Pharmacy Affairs Branch. Retrieved on 7/28/04 from Covered Entity Date Extract. U.S. Dept of Health and Human Services, Office of Pharmacy Affairs. Retrieved 7/28/04 from Office of Family Planning. Office of Population Affairs. Retrieved on 7/28/04 from 14