ACCESS TO MEDICATION FOR THE UNDER INSURED Medication Access and Review Program (MARP) and Other Remedies December 2, 2015 NC Council Conference Pinehurst, NC Billy R. West, Jr., MSW, LCSW Executive Director About DAYMARK Our Mission: Daymark Recovery Services, Inc. is a mission driven, comprehensive community provider of culturally competent mental health and substance abuse services. The Daymark goal is for skilled medical and behavioral healthcare professionals to support citizens of all ages and their families with the greatest opportunity for recovery, independence and the highest quality of life. We are committed to using the most current best practices and effective, research-based treatment programs to assist all citizens working toward achieving optimum health and recovery. DAYMARK Counties 1
Goals of this presentation: Understanding different methods to fund a medical team. Specifically, the funding of nursing services that assist in many non-fee for service billable activities that afford people access to medications and overall improve their health. Understanding different models of patients having access to medications Specifically, understanding the Medication Access and Review Program (MARP). Hallmarks of DAYMARK (DRS) DRS provides care to an excess of 50,000 North Carolinians with Mental Health and Substance Abuse illnesses. DRS hallmarks are providing Advanced Access (walk-in clinic) to care, telemedicine, medical services, crisis services, preventative outpatient care and provision of care that is a low cost per episode. Approximately 80% of the treatment DRS provides is evidenced or literature based care. Key to the success of DRS has been to provide immediate access to care, be payer source blind and assure people have access to medications and other resources. Advanced Access Clinics Community Stakeholders LME STR Consumer/ Family Hospital Facility Based Crisis Mobile Crisis Urgent or Emergent Service service request based on patient report. Likely 70% plus will say they need to be seen today. To avoid an ED visit see the patient same day Triage Routine service request Immediate referral to Advanced Access Go to Advanced Access (left) for immediate engagement or Appointment in 7 days if prefered by patient MCM needed? See MCM Appointment available No appointment available in 7 days? Hallmarks: Open extended hours Access to psychiatry/indegent meds No wait list for services Ability to link to other resources Serves as alternative to ER Right service @ right time on demand Most professional staff with neediest consumers Consumer seen within one hour Services available: Assessment (includes IVC assessment Crisis intervention Psychiatry/Indigent medication Link to evidenced based outpatient treatment and/or enhanced services Referrals to other resources Follow up contacts and referrals after visit until crisis is resolved or appropriately linked to other services Referred to advanced access clinical services for walk-in service at their convenience Referral to one of the following after assessment: Evidence-Based outpatient treatment Community Support/Other Enhanced Combination of both depending upon need 2
Presenting Problem - Most Support and Nursing Services Are Not Billable and Have No Loss Leader To Provide Underwriting At any given time we may have up to 60% of our patients that are without the ability to obtain their medications. While reduced Walmart list medications may be available, even that may be inaccessible for the working poor and homeless. Some medically necessary medications may be omitted. We are contracted with almost all of the MCOs in NC. Each provide various levels of funding, have various priorities for their funding and have a large variance on how much of the funding may be Non-UCR versus UCR. Yet the consistent need in every community is access to psychiatry and access to medications. Our Medical Staff are key to the provision of access to medications. While the prescribing staff is key, it is the support and nursing staff that afford many patients the opportunity to obtain their medications, improve their health between medication checks and extend the time between medication checks to save valuable psychiatry time. PUBLICALLY FUNDED INDIGENT MEDICATION PROGRAMS: IF YOU HAVE SEEN ONE INDIGENT MEDICATION PROGRAM YOU HAVE SEEN ONE INDIGENT MEDICATION PROGRAM How Underinsured Get Access to Medications (varies by location, funding, resources) 1. Emergency (starter/bridge) Sample Medication Programs 2. In-House Pharmacy 3. Pre-Authorization Programs for Medicaid, Medicare and insurance plan medications 4. Medication Access and Review Programs (MARP) 5. Natural Community Supports 3
Emergency (starter/bridge) Sample Medication Program RN/MD/NP/PA contacts Drug Rep to determine if samples will be available Drug rep delivers samples to MD/NP/PA who signs for them, RN receives sample meds, logs them in, RN/MD/NP/PA maintain an up-to-date running log of sample meds in and out and to whom and number they have been given, RN/MD/NP/PA disposes of any expired/unusable sample meds according to policy when out of date or contaminated by dropping, etc., per MD/NP/PA order, the specified type, dosage and number of sample medications are packaged, reviewed and approved in writing by the MD/NP,PA and dispensed with clearly labeled instructions to clients as a stop gap or bridge when medications are initially ordered or before MARP client-specific medications or other programs are available, medication education regarding any samples given is provided at the time the samples are dispensed to the client. RN/MD/NP/PA documents the type, dosage, and number of samples given to each client in the client-specific Infoscriber (OrderConnect) information. The same procedures may be followed when the MD/NP/PA is available via telemed and has the ability to directly review, approve and sign for any medications dispensed with the assistance of the on-site RN. Note: In addition, some pharmaceutical companies distribute medication coupons that can be given directly to clients by the RN/MD/NP/PA and can be taken to any pharmacy and redeemed for prescribed medications. In-House Pharmacy Programs Pharmacy options vary widely. Our County operated pharmacy tends to be the most accessible for our staff and patients as a resource. Private pharmacy options are excellent too but often require a critical mass of patients with a payer source to set up shop in a clinic. Some pharmacies also have dispensing fees that need to be covered by the patient, MCO and/or provider. Pre-Authorization Programs for Medicaid, Medicare and insurance plan medications Based on requirements, RN (primarily) with written orders from MD/NP/PA must submit pre-authorization requests to Medicaid (children, every 3 months, and adults annually and/or when meds are changed); Medicare primarily the first 3 months of the year and as indicated based on particular Part D plans; and insurance based on brand name and other specifics require that we submit pre-authorization requests that often require inclusion of MH/SA history, most current supportive data, unsuccessful trials, etc. in order for a prescribed med to be approved for a client. Typically not activity that clients or families could successfully complete and takes medical knowledge and access to organizations such as NC Tracks. All applications and responses must be documented in Infoscriber.. 4
MARP Through the Medication Access and Review Program (MARP), North Carolina is a national leader in increasing access to free prescription programs for uninsured and underinsured patients. The MARP software system analyzes pharmaceutical company applications and eligibility procedures and creates company-specific applications to access free prescription medicine for uninsured and underinsured patients. More than 120 clinical sites in North Carolina obtain their prescribed medications through MARP, serving 53,000 medically indigent patients. MARP software is located in at least one clinical site in 87 of the 100 N.C. counties. Since its inception in 2003, MARP has accessed over $500M in free medications for more than 100,000 people. MARP accesses a database of more than 3,000 constantly changing free prescription medications offered by pharmaceutical companies. MARP can then investigate the safety of the requested medication based on the patient's medical conditions and allergies, identify companies that offer the drug, and track the prescription through physician signature, order submission, delivery to the physician or practice, and pick-up by the patient. MARP also generates re-order reminders. MARP has recently been reconfigured into a web-based system, which will reduce the IT burden on local clinic personnel and hardware. This new version of MARP has been funded through a grant from The Duke Endowment. MARP is operated by the N.C. Office of Rural Health and Community Care and NCFAHP. The MARP software is owned and maintained by the NC Foundation for Advanced Health Programs. Medication Access and Review Program (MARP) As part of medication prescribing and client education, staff will discuss medication cost with the client, Patients needing assistance in paying for medications will be referred to the RN/LPN/PAP assistant with primary responsibility for assisting clients and families in applying for financial assistance for medications, Patients will be assisted in completing applications for any medication patient assistance programs when eligibility is anticipated or unknown, The RN/LPN,PAP assistant will finalize the application(s) and obtain the signature of the prescribing MD/NP/PA, PAP coordinator receives confirmation of client s eligibility and approval, RN receives PAP meds, logs them into running log of client s PAP meds, RN/MD/NP/PA will record each time s/he removes a supply of the client s PAP medication from his/her personal storage bin and will sign them in and out including the number they have been given, RN/MD/NP/PA disposes of any expired/unusable PAP meds according to policy when out of date or contaminated by dropping, etc., per MD/NP/PA order, an RN/MD/NP/PA prepares/packages the specified type, dosage and number of PAP medications that are and approved in writing by the MD/NP/PA and dispensed with clearly labeled instructions to clients, medication education regarding any medications given is provided at the time the PAP meds are dispensed to the client, RN/MD/NP/PA documents the type, dosage, and number of PAP meds given to each client in the client-specific Infoscriber information. BY THE NUMBERS DAYMARK MARP- 2007-2015 (to date) Total Patients: 3,022 Total Medications Delivered: 14,255 Total Saved By Patients: $17,245,427 5
Types of Medication Unduplicated Patient Count Patients Served Number of Requests Received AWP Delivered AWP Antidepressants Cymbalta capsule,delayed release 506 506 2,065 1,310,669.05 1,143,417.65 Lexapro tablet 333 333 1,442 441,282.48 379,198.03 Pristiq tablet,extended release 210 210 929 468,868.14 416,387.83 Effexor XR capsule,extended release 179 179 1,000 633,570.27 583,165.37 Zoloft tablet 136 136 574 281,052.77 243,308.60 Wellbutrin SR tablet,sustained-release 104 104 543 333,955.18 299,273.21 Remeron tablet 103 103 330 105,129.93 74,660.41 Wellbutrin XL 24 hr tablet, extended release 83 83 362 204,401.86 162,801.76 Prozac capsule 56 56 171 201,264.50 189,488.74 Celexa tablet 24 24 47 16,441.49 16,067.18 trazodone tablet 14 14 14 367.04 146.92 Paxil CR tablet,extended release 10 10 36 22,508.37 18,590.32 Aplenzin tablet,extended release 9 9 26 11,828.23 10,448.95 Wellbutrin tablet 9 9 28 14,388.06 10,489.72 Symbyax capsule 8 8 25 31,344.07 25,116.25 citalopram tablet 7 7 7 1,241.87 6.45 Fetzima capsule,extended release 7 7 20 11,776.34 11,776.34 Paxil tablet 6 6 29 10,803.91 10,437.10 amitriptyline tablet 2 2 3 8.59 8.59 mirtazapine tablet 2 2 2 81.46 81.46 doxepin capsule 1 1 1 0.00 duloxetine capsule,delayed release 1 1 1 0.00 Emsam transdermal 24 hour patch 1 1 2 3,522.06 1,761.03 fluoxetine capsule 1 1 1 160.09 0.00 fluoxetine tablet 1 1 1 0.00 paroxetine tablet 1 1 1 79.28 0.00 Remeron SolTab disintegrating tablet 1 1 1 0.00 Subtotals for Antidepressants : 7,661 $4,104,745.05 $3,596,631.90 Types of Medication Unduplicated Patient Count Patients Served Number of Requests Received AWP Delivered AWP AntiPsychotic Abilify tablet 576 576 2,284 5,820,978.51 4,969,635.70 Seroquel XR tablet,extended release 476 476 1,735 1,898,022.75 1,726,049.76 Seroquel tablet 281 281 1,418 1,178,514.72 1,056,696.17 Depakote ER tablet,extended release 240 240 915 568,082.94 509,384.37 Risperdal tablet 153 153 680 418,924.58 391,412.12 Geodon capsule 144 144 619 771,210.17 662,293.34 Zyprexa tablet 133 133 500 967,649.36 849,875.85 Latuda tablet 75 75 210 305,741.40 276,649.80 Depakote tablet,delayed release 24 24 84 71,516.59 68,434.48 Saphris (black cherry) sublingual tablet 14 14 30 17,166.65 17,166.65 Tegretol tablet 6 6 15 5,559.98 3,529.74 Zyprexa Zydis disintegrating tablet 5 5 10 10,042.00 10,042.00 Haldol Decanoate intramuscular solution 4 4 15 1,984.63 1,769.77 Risperdal M-TAB disintegrating tablet 3 3 4 1,427.97 861.77 Lamictal ODT disintegrating tablet 2 2 3 1,324.74 662.37 Lamictal Starter (Blue) Kit tablets in a dose pack 2 2 2 238.33 0.00 lithium carbonate tablet 2 2 3 0.00 0.00 risperidone tablet 2 2 3 30.35 15.17 carbamazepine tablet 1 1 1 0.00 clozapine tablet 1 1 2 0.00 Depakote Sprinkles capsule 1 1 3 1,335.24 1,335.24 Equetro capsule, extended release 1 1 1 171.88 0.00 haloperidol tablet 1 1 2 0.82 0.82 Lamictal ODT Starter (Orange) 1 1 1 0.00 0.00 tablet,disintegrating Lamictal Starter (Orange) Kit tablets, dose pack 1 1 1 487.71 0.00 lithium carbonate capsule 1 1 1 17.46 0.00 Orap tablet 1 1 1 0.00 0.00 Tegretol XR tablet,extended release 1 1 1 0.00 Subtotals for AntiPsychotic : 8,544 $12,040,428.80 $10,545,815.14 Types of Medication Unduplicated Patient Count Patients Served Number of Requests Received AWP Delivered AWP Misc Agents Depakote ER tablet,extended release 240 240 915 568,082.94 509,384.37 Vistaril capsule 179 179 487 167,948.27 128,864.37 Strattera capsule 97 97 314 230,152.87 197,832.39 Vyvanse capsule 25 25 39 0.00 0.00 Depakote tablet,delayed release 24 24 84 71,516.59 68,434.48 Concerta tablet,extended release 13 13 27 0.00 0.00 Nuvigil tablet 7 7 29 34,772.74 32,277.54 Aricept tablet 5 5 10 2,489.89 2,489.89 Intuniv ER tablet,extended release 4 4 6 5,343.26 4,017.10 clonazepam tablet 3 3 3 311.73 236.82 hydroxyzine pamoate capsule 3 3 3 43.88 21.94 Provigil tablet 3 3 9 3,535.71 3,535.71 benztropine tablet 2 2 3 79.02 0.00 Focalin XR capsule,extended release 2 2 2 0.00 Lunesta tablet 2 2 2 0.00 Namenda tablet 2 2 8 1,770.90 1,217.24 Requip tablet 2 2 2 849.58 907.53 Restoril capsule 2 2 2 0.00 Depakote Sprinkles capsule 1 1 3 1,335.24 1,335.24 zolpidem tablet 1 1 1 0.00 Subtotals for Misc Agents : 1,949 $1,088,232.63 $950,554.62 6
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