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Pharmaceutical Safety Net Programs
Jon Rosmann, Executive Director
[email protected]
IOWA PRESCRIPTION DRUG
CORPORATION
501(c)(3)
Established in 2001 to provide pharmaceutical access to Iowans who
cannot afford prescription drugs.
Serve Iowa’s Safety Net Patients - uninsured or underinsured Iowans
with incomes 200 percent of the federal poverty level or below
•
•
•
•
Safety Net Services
Address issues of pharmaceutical access through innovative, non-traditional
partnerships.
Leverage scarce resources and create value for all stakeholders in our
health delivery systems.
Short-term, Gap Assistance
Focus: Safety Net Patients – High cost users
• Uninsured and Underinsured
• Medicare eligible Iowans
• Individuals with Chronic Behavioral Health Disorders
• State and Local Offenders
DRUG DONATION
REPOSITORY PROGRAM
PHARMACEUTICAL SAFETY NET
CASE STUDY – PATIENT SAVINGS
Rates based on data received from the Iowa Hospital Association in 2011.
IOWA DRUG DONATION REPOSITORY
• Administrative Rules established in 2007
• Public Health Department 641-Chapter 109
• Regulated by the Iowa Board of Pharmacy
Overview: Iowans in need of assistance can receive medications and medical
supplies for little or no cost. Donations are received from long-term care
dispensing pharmacies, medical facilities, and individuals. The medications and
supplies are inspected by a pharmacist, distributed to medical facilities or
pharmacies, and dispensed to Iowans in need.
Eligibility: Iowans at or below 200% of the federal poverty level who are
uninsured or under-insured are eligible to receive donated drugs. Any
organization or individual in the country can donate medications in their
original sealed container or in tamper-evident packaging. Any pharmacy or
medical facility with authorization to dispense per State administrative rules may
re-dispense donated medications.
PATIENT ELIGIBILITY
• IPDC’s drug donation repository helps redistribute
medications and supplies to safety-net patients who cannot
afford their prescriptions
• Safety-net patients
• Uninsured or underinsured Iowans with incomes 200 percent of the federal
poverty line or below
• Patients who use high-cost medications but are unable to access them
• Medicare eligible Iowans
• State and local offenders
• Patients with chronic conditions (ex. psychiatric conditions)
DONOR ELIGIBILITY
Any organization or individual in the country can donate medications
• Most common donors
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•
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Long-term care dispensing pharmacies
Retail pharmacies
Medical facilities
Community Mental Health Centers
Federally Qualified Health Centers
• Medication Requirements:
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•
•
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Must be in original sealed container or in tamper-evident packaging
No controlled substances
No expired medications
No medications requiring refrigeration
DRUG DONATION REPOSITORY PROCESS
Receiving
& Sorting
Inspection
Inventory
Processing
Filling &
Shipping
RECEIVING & SORTING
• Once medications are received from
a facility, medications are sorted prior
to inspection
• Drugs not kept:
•
•
•
•
•
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Tablets with no markings
Broken/split tablets
Controlled substances (CS)
Drug/label do not match
Short-dated or expired medications
Unusable packaging
• Unused medications are sent to
incinerator, CS sent back to facility
• Drugs kept are sorted by name,
strength, and dosage form
INSPECTION
• Once sorted, the
pharmacist inspects each
card to determine whether
the drug is correctly labeled
• Drug is identified using Facts
and Comparisons
• Pharmacist looks at pill color,
shape, imprint codes, and NDC
• Disposal of cards
• Cannot use split/broken pills
• Foil backing of card is ripped,
damaged, punctured
INVENTORY
• Following inspection, the number
of tablets or capsules on each
card is counted and entered into
inventory
• Medication and supply inventory
is available online using a
username and password
• An average retail value is assigned
to each unit
• Inventory is then organized and
put on the shelf
PROCESSING
• After inventory, all medications
are processed in accordance with
Iowa Code 135M.4 and Iowa
Administrative Rule Chapter 109
• All patient information is
removed from each card per
HIPAA compliance
• Drug name, strength, quantity,
expiration and NDC remain on
card
• Medications and supplies in
bottles and all other forms
undergo same process
FILLING & SHIPPING
• Licensed as a Wholesale Distributor
• Medical facilities submit orders to IPDC online or via email
and fax
(http://www.iowapdc.org/drugdonationrepository.aspx)
• Approximately 220+ orders are filled each month
• All orders are filled and shipped via UPS and USPS. In the
event of an emergency, an order will be hand-delivered
• Orders are generally received 1-3 days after being placed
DRUG DONATION REPOSITORY – FISCAL YEAR
PERFORMANCE
3,000,000
2,500,000
2,000,000
Units Donated
1,500,000
Donated Value
1,000,000
Units Shipped
500,000
Shipped Value
0
Year
Units Donated
Donated Value
Units Shipped
Shipped Value
FY 2007-2008
768,311
$786,400.15
492,686
$475,591.62
FY 2008-2009
890,986
$1,316,051.73
629,573
$935,697.87
FY 2009-2010
1,106,003
$1,492,565.20
850,559
$1,234,449.75
FY 2010-2011
1,166,447
$1,634,592.67
931,431
$1,430,735.10
FY 2011-2012
1,075,950
$1,924,487.71
1,095,934
$1,877,496.06
FY 2012-2013
1,230,200
$2,593,314.01
1,147,464
$2,477,716.43
FY 2013-2014
1,395,640
$2,605,365.99
1,105,153
$2,319,463.90
FISCAL YEAR PERFORMANCE
Safety Net Patients Served
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
2007
2008
2009
2010
2011
2012
2013
2014
Fiscal
Year
2007
Patients Served
780
2008
2009
3,011
5,732
2010
2011
6,237
7,300
2012
7,567
2013
2014
8,222
8,605
Over 47,000 Iowans have benefitted from
donated medications and supplies!
DRUG DONATION REPOSITORY – PATIENTS
SERVED
Since 2008:
 Over $13.1M in free
medication and
supplies
 Over 47,000 Iowans
served
*Totals based on number of
patients served quarterly as
reported by participating medical
facilities and pharmacies.
DRUG DONATION REPOSITORY
RETURN ON INVESTMENT
• Iowa’s Drug Donation Repository Program is the largest drug
repository in the country.
• Over 47,000 Iowans have been provided medication and
supplies since the program was established in 2007.*
• Over $13.1 million in free medical supplies and medications has
been shipped to participating medical facilities and pharmacies.
• Over 200 medical facilities and pharmacies receive medications
and supplies from the Drug Donation Repository Program.
• Every $1 used to administer the program yields over $5 in
donated medications and supplies.
*Total based on number of patients served quarterly as reported by participating medical facilities and
pharmacies.
A BEHAVIORAL HEALTH FOCUS
• Although IPDC receives a wide variety of donated
medications, there is a deficit in behavioral health
medications
• Anxiolytics: Buspirone,
• Antipsychotics: Latuda, Seroquel, Zyprexa
• Antidepressants: Sertraline, Cymbalta, paroxetine
• Behavioral health medications are in high demand, but
because of low inventory, many orders go unfilled
• Most frequent form of assistance requested from safety-net
patients
A BEHAVIORAL HEALTH FOCUS
Goal: Significantly increase the inventory of behavioral health medications
in the drug donation repository program
• Outreach and education to community mental health centers and
behavioral health providers
• Development of educational materials to support effort
• Regional meetings with area behavioral health providers
• Participation in behavioral health stakeholder meetings and conferences
• Technical assistance to integrate repository into behavioral health facilities
BENEFITS OF BECOMING A DONOR
• Increase medication management
• Pharmacist will ensure medications are correctly labeled, appropriately
packaged, and within the expiration date
• Healthcare professionals on site will not have to worry about inspecting
medications
• Improve patient safety
• Patient will get medications that are inspected by a pharmacist
• Increase ease of dispensing medications to patients
• All dispensed medications come from a central location
• No need to keep stock of medications on site
SIGNING UP WITH THE PROGRAM
• Visit www.iowapdc.org
• Click “Drug Donation Repository”
• Under Program Resources, click “Medical
Facility Donor Participation Form” to make
donations.
• Under Program Resources, click “Medical
Facility Dispensing Form” to dispense
medications.
• Fax or email completed form to 515-3275422 or [email protected]
• Call 515-327-5405 for assistance or
additional information
BEHAVIORAL HEALTH MEDICATION
VOUCHER PROGRAM
PHARMACEUTICAL SAFETY NET
A BEHAVIORAL HEALTH CASE STUDY
Case Study: A young female with bi-polar disorder was recently released from the Polk
County Jail. Prior to release, the individual was advised that she could obtain primary care
services and up to 90 days of behavioral health medications at no cost.
Three days after being released the individual was seen at Primary Health Care’s outpatient
clinic. She was in need of Risperidone and was worried about her ability to effectively
participate in an upcoming job interview. The individual was seen immediately and was
provided a 30-day supply of medication. She has stabilized her condition and is currently
working part-time as a Certified Nurse Assistant.
Without access to primary care and behavioral health medications, the individual’s disorder
may have gone untreated, resulting in a subsequent non-violent offense. In Polk County the
average length of stay for individuals with behavioral health disorders is 36 days at a cost of
$2,160. As an alternative, the individual is employed and positively contributing to her
community. This savings is greater than the cost of providing 340B behavioral health
medications to all eligible released offenders in Polk County for one month.
BEHAVIORAL HEALTH VOUCHER PROGRAM
Overview: Provides free access to behavioral health
medications for safety net patients living in Iowa. The program
is designed to help supplement an FQHC’s capacity to serve
safety net patients with behavioral health disorders.
• Provides patient access to critical behavioral health
medications until a patient can be transitioned to community
mental health center or medical center
• Prescription assistance for Iowans between 135-200 FPL with
high deductible (Bronze) plans purchase on the Exchange
• Temporary assistance for patients transitioning to Medicaid or
state and federal programs
BEHAVIORAL HEALTH VOUCHER PROGRAM
Patient Eligibility: Any safety net patient living in Iowa with a
household income up to 200% of the Federal Poverty Level that
is uninsured or underinsured will be able to use this program.
• Patient must seek care at the local FQHC
• No limit on the number of prescriptions/vouchers each
patient is eligible to use.
• Valid only for non-controlled medications prescribed to treat a
behavioral health illness.
• Dispensed in 30 day quantities
BEHAVIORAL HEALTH VOUCHER PROGRAM
• FQHC Requirements: The program is available to any of Iowa’s
FQHCs with an in-house or contracted 340B pharmacy
• The FQHC’s 340B pharmacy will be reimbursed at 340B rates
for the cost of medications dispensed to eligible safety net
patients
• Reimbursements will be made on a monthly basis.
• FQHC enrollment in the program will begin on February 1,
2015
IPDC PRESCRIPTION
DISCOUNT CARD
PHARMACEUTICAL SAFETY NET
IPDC PRESCRIPTION DISCOUNT CARD
• Provides 70-80% cash discount on generic
prescriptions and 10-14% cash discount on
brand prescriptions
• Managed by MedOne Health Systems –
Division of Hartig Drug, Dubuque
• Low processing fee to pharmacies - $2.00 $2.50 range
• Supported by Iowa Collaborative Safety Net
Provider Network
PRESCRIPTION DISCOUNT CARD PERFORMANCE
2014 – Average Savings per RX = $58.01 or 69% Savings
TO REQUEST MEDICATION DISCOUNT CARDS
Contact:
Vicky Witt
[email protected]
515-327-5405
PROGRAMS TO ADDRESS
HIGH RATES OF RECIDIVISM
L O C A L A N D S TAT E C O R R E C T I O N S P R O G R A M S
ADDRESSING HIGH RATES OF RECIDIVISM
•
Iowa DOC: Individuals are given a 30-day supply of all current medications
upon release.
• County Jails: No supply provided at time of release.
• Does not provide an adequate amount of time for the individual to achieve
the following:
• Locate a medical provider.
• Be evaluated by a medical provider to receive new RXs.
• Establish financial and medical assistance.
• Establish source or continuous medication assistance such as Medicaid,
Medicare, Patient Assistance Program, etc.
• Average waiting period to see a behavioral health provider in Polk County,
IA is 80-100 days. In rural shortage areas, waiting period could be greater.
• Corrections Revolving Door.
Polk County Jail
Behavioral Health Medication Assistance
Provide immediate primary care services and up to 90 days of behavioral health prescription
drug coverage for transitioning offenders in Polk County.
Upon Release:
1.
Individuals directed to Primary Health Care, Inc. to be seen on walk-in or
appointment basis.
2.
Medical home is established if not present.
3.
30-day Behavioral Health RX (w/ two 30-day refills) filled at Primary Health Care
340B Pharmacy.
4.
Individual transitioned to Eyerly Ball Community Mental Health Services or
Broadlawns Medical Center for long-term services.
Program launched March 4, 2013
Polk County Jail
Behavioral Health Medication Assistance
Preliminary findings:
• 1) To effectively reduce the rates of recidivism in Polk County, offenders identified as
mentally ill should be targeted.
• 2) A significantly smaller percentage of program participants are returning to jail
(recidivating) than non-participants with mental illness who are released from the Polk
County Jail.
• 3) The longer program participants utilize the program the lower the rate of recidivism
is among that group.
• 4) Persons with mental illness in the Polk County Jail who use the program when they
reenter society stay out of jail longer than persons with mental illness in the Polk
County Jail who do not.
IOWA DEPARTMENT OF CORRECTIONS MODEL
Provide 90 days of behavioral health prescription drug
coverage for transitioning State offenders.
Upon Release:
1.
2.
3.
Individuals given a 30-day supply of all current medications.
Eligible behavioral health prescriptions (30-day RX with one 30-day refill)
are transferred directly from DOC Pharmacy to a participating local
pharmacy.
Extends behavioral health medication benefit period to a full 90 days.
Program launched April 1, 2013
IOWA DEPARTMENT OF CORRECTIONS MODEL
Recidivism Analysis
April 1, 2013 – December 15, 2013:
• 5 of 119 offenders (4.2%) had new charges entered in the Iowa
Department of Corrections database (ICON).
Preliminary data is promising:
• Significant number of offenders were medication compliant
• Mental health adjustment among participating offenders is positive
• Positive mental health adjustment among participating offenders is
strongly associated with success under supervision
ADDRESSING HIGH RATES OF RECIDIVISM
NEXT STEPS
County Jail Model:
• Funding Secured for Years 2, 3 and 4
• Recidivism Analysis: Post 90 Days from Release
• Cost Savings Analysis
• Attorney General’s Office: Multi-county Integration
Iowa Department of Corrections:
• Funding Secured for Years 2, 3 and 4
• Recidivism Analysis: Three Year Study
• Cost Savings Analysis
• University of Iowa: Multi-state Demonstration Project
QUESTIONS OR ASSISTANCE
Contact:
Jon Rosmann, Executive Director
[email protected]
515-327-5405
Laura Sands, Senior Program Director
[email protected]
515-327-5405
Telepharmacy
January 2015
Iowa CCC Update
Kate Gainer, PharmD
Executive Vice President/CEO
Iowa Pharmacy Association
Brett Barker, PharmD
V.P. of Operations
NuCara Pharmacies
Telepharmacy Opportunities
• Remote Order Verification
• Remote Dispensing
• Pharmacist Services (pharmacist as specialist)
• Long term Care
• Other
Current Landscape – Iowa
• Iowa Code 155A.33 and IC 147.107
– Requires AMDS for a remote dispensing site to
operate without a pharmacist physically present
• Board Of Pharmacy rules IAC 657 – Chapter 9
(AMDS and Telepharmacy Services)
– Definitions, PIC responsibilities, QA, P&P,
system/site/process requirements, records, AMDS
• Board of Pharmacy rules IAC 657 – Chapter 7
(Hospital Pharmacy Practice)
– Verification by a remote pharmacist
Current Landscape
• Remote Order Verification
– Widely accepted, implemented statewide
• Telepharmacy as Remote Dispensing
– 5 sites approved by Board of Pharmacy under 3 pilot
project applications
– AMDS requirement seen as barrier by providers
• Telepharmacy for pharmacist services
– Some applications today (eg MTM)
– Greater opportunities exist (eg specialist pharmacists)
– Need for regulation (?) (BOP or broader telehealth rules?)
• LTC and other
– Opportunities exist, growing
2014 Iowa Telepharmacy Task Force
• IPA and BOP convened joint task force in early 2014
• Consensus recommendations:
1. To pursue legislative changes in 2015 to IC chapters 147 and 155A, amending the current requirement for AMDS in
telepharmacy practices.
2. To revise telepharmacy rules in 657 IAC, re-defining telepharmacy services and establishing necessary criteria.
3. To state the purpose and intent of telepharmacy rules, providing that telepharmacy is intended to increase access to
pharmacist and pharmacy services, and enhance the care and communication between patients and pharmacists.
4. To create an application form and process for telepharmacy practice sites to be approved by the Board of Pharmacy for
each applicant.
5. To recommend continuing education and training for pharmacists and pharmacy technicians providing patient care
services through telepharmacy.
6. To maintain rules relating to hospital pharmacy remote order verification in board rules regarding hospital pharmacy
practice (657 IAC Chapter 7).
7. To further explore opportunities for telepharmacy applications in other pharmacy practice settings.
Next Steps
• 2015 Legislative Priority for IPA
• Board of Pharmacy pre-filed language
– Amend 147.107 and 155A.33 (add language “when a
pharmacist is remotely supervising a certified pharmacy
technician practicing in a telepharmacy site approved
by the board of pharmacy”
• Advocate for broad language in statute
• Subsequent rules by BOP
• Monitor activity / success in other states
NuCara Zearing Telepharmacy Pilot
• Operated by NuCara Management Group
• Community telepharmacy remote dispensing
site
– Located on Main Street in Zearing
– Strongly supported by and located adjacent to
Story Medical Zearing rural health clinic
– City of Zearing purchased and renovated building
– Approved by Board of Pharmacy in 2012
– Opened in permanent location July 2013
Landscape before NuCara
• Zearing (pop. 554) located in rural Story County
• Story Medical Clinic – Zearing operated an Instymed robotic
dispensing system
– Limited formulary
– Operated at a financial loss to the organization
– Lack of pharmacist interaction
• Story Medical Clinic – Zearing employed one full time nurse
practitioner
• Empty building on Main Street
• Nearest pharmacy was NuCara in Nevada more than 20
miles away
• Many patients served by mail order services
Zearing Overview
•
•
•
•
1000 Square Feet
Open Monday through Friday
Staffed with Certified Pharmacy Technicians
Provides access to prescriptions, OTC products,
immunizations (e.g. shingles), Medication Therapy
Management (MTM), home medical equipment, prescription
compounding, and respiratory therapy through NuCara
network of Story County locations
Telepharmacy process
• Working with Iowa based technology start-up
Telepharm to provide telepharmacy system
• Pharmacist verification, oversight, and
counseling provided by NuCara in Nevada
• Pharmacist receives an array of images
alongside patient information for verification
• All prescriptions dispensed require the patient to visit
the counseling station
• Pharmacist counsels patient through secure audio /
visual connection. Goal is to provide same high level of
pharmacist – patient interaction and patient centered
care as traditional NuCara Pharmacies.
Current experience
• 3rd Quarter 2014 data:
– Daily average of 36 prescriptions dispensed
– 2 errors were corrected by the pharmacist in the
verification process
– To date, zero errors known errors have reached a
patient
• Clinic hired second full time provider in 2014
NuCara’s Next Steps
• Continue to improve process and increase
accepted counseling rates
• Continue to work with Telepharm on technology
improvements
• Expansion of clinical services provided
• Modest volume growth to reach long-term
sustainability
• Engage with stakeholders and policymakers to
continue to evolve unique and innovative care
delivery models
Next Steps – Hybrid Model
• NuCara Hybrid Telepharmacy Model Pilot
Project in State Center
• Begins May 2015
• Allows for partial on-site pharmacist while
providing full-time business hours
• Tool to grow pharmacist presence in the
community
• Long-term goal to expand pharmacist on-site
availability
Questions
Brett Barker
VP of Operations
NuCara Management Group
[email protected]
Medication Access
Discussion points
What
is working for regions?
What challenges do regions
face?
How are regions addressing the
gap coverage concerns?
Contact Information
John Swegle, PharmD, BCPS, BCACP
Clinical Associate Professor
University of Iowa College of Pharmacy
Mercy Family Medicine Residency
641-428-7182
[email protected]