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Frontline Pharmacist

2176 Am J Health-Syst PharmVol 70 Dec 15, 2013


Frontline Pharmacist
The Frontline Pharmacist column gives staff pharmacists an opportunity to share
their experiences and pertinent lessons related to day-to-day practice. Topics include workplace
innovations, cooperating with peers, communicating with other professionals, dealing with
management, handling technical issues related to pharmacy practice, and supervising
technicians. Readers are invited to submit manuscripts, ideas, and comments to AJHP, 7272
Wisconsin Avenue, Bethesda, MD 20814 (301-664-8601 or ajhp@ashp.org).

Experience with a student-run patient
medication assistance service
M
ore than 45 million patients in the
United States have no prescription
drug coverage and are faced with the
nancial burden of medication costs.
1,2
As a result of nancial hardship, pa-
tients underutilize their medications,
a practice that often leads to adverse
health outcomes.
1
Patients may take
their medications less frequently in an
effort to maintain treatment before their
supply is exhausted. Other patients may
accept a prescription but do not ll the
medication or request only a partial ll
as a way to decrease medication costs. In
recent years, several methods to obtain
medications at low or no cost have been
established, including retail pharmacy
discount drug lists ($4-drug lists) and
patient medication assistance programs
(PMAPs) sponsored by pharmaceutical
companies. Free brand-name medica-
tions are available through most drug
companies when patients enroll in
PMAPs. These programs have eased the
burden of medication costs but are not
without their barriers.
Prescribers often struggle to nd cost-
friendly medication alternatives for man-
aging patients with nancial hardships.
Some prescribers, while aware of PMAPs,
may not have the resources to actively
identify patients issues, enroll patients
in the programs, or manage their enroll-
ment. As the medication expert, pharma-
cists can play a pivotal role on the health
care team and are well positioned to
manage pharmacotherapy issues relating
to medication cost and underutilization.
Pharmacists can conduct comprehensive
medication reviews and recommend
cost-effective alternative therapies. When
a less-costly alternative is not available,
PMAPs become a valuable option.
Establishing the medication as-
sistance service. A service to assist un-
derserved patients in obtaining medica-
tions via PMAPs was established in three
clinics. This resource offers an important
benet to the clinics patient population
of mostly uninsured or underinsured,
unemployed, or homeless patients. Pa-
tients ll out an application form, pro-
vide income verication, and receive
free medication if they meet
the specic criteria devel-
oped by the pharmaceutical
manufacturer. Each drug
company has a unique
form and set of qualifi-
cations for patients to
meet to receive free
medications,
which may
require the
completion
of multiple ap-
plications (one for
each drug company) to
supply the patient with the appropriate
therapy regimen. Many of the applica-
tions are several pages in length with
varying complexity. Patient barriers to
the use of application forms include il-
literacy, absence of a home computer or
printer for accessing applications, and
lack of a stable home situation for ship-
ment of medications.
Clinical pharmacy faculty were in-
tegrated into these clinics and asked to
manage the existing service. Pharmacy
students were incorporated into the
service as they began their advanced
practice pharmacy experiences (APPEs)
in their fourth year of pharmacy school.
The students, once trained by the clinical
pharmacists, function independently,
with oversight provided by the pharma-
cist and medical staff as needed.
Clinic settings. This medication assis-
tance service is offered at three ambula-
tory care clinics for the underserved in
southwest Florida.
The medication assis-
tance service is provided at
clinics 1 and 2 via an outpa-
tient medical clinic special-
izing in the care of patients
over age 50 years. To qualify
for care, patients must be
over age 50 years with
limited or no in-
come and resi-
dents of the
county in which
the clinic is located.
Fees are based on a
sliding scale according to
patient need and ability to pay. Clinics
are staffed by volunteer health care pro-
viders, many of whom are retired from
private practice. Services offered at each
ofce location vary but include general
medicine, dentistry, and limited spe-
cialized medicine such as gynecology,
orthopedics, and cardiology. Each site
has approximately 4000 patient visits
annually.
3

Frontline Pharmacist
2177 Am J Health-Syst PharmVol 70 Dec 15, 2013
Pharmacy services at the clinics con-
sisted of maintaining a supply of donated
sample medications and assisting patients
in obtaining new medications and rells
for long-term medications. Once phar-
macy faculty members and pharmacy
students were added to these sites, other
services were added, including medica-
tion review and management of chronic
diseases (e.g., diabetes, dyslipidemia).
Pharmacy faculty became essential to
clinics 1 and 2 when grant funding that
had supported a part-time employee was
withdrawn. Time allotment to patient
assistance was accordingly diminished,
affecting patient enrollment in PMAPs.
This was some patients only access to
medications due to nancial hardship.
Clinical pharmacists were able to incor-
porate the medication assistance service
into their daily duties by training APPE
students to obtain and assist the patients
in ling PMAP forms.
The medication assistance service
had previously been a fee-based service;
however, through the use of pharmacy
students and faculty pharmacists, the
service is free of charge to clinic patients.
Additional stafng through the APPE
also allows for full-time services to be
provided by students on rotation.
Clinic 3 provides primary care medi-
cal services to uninsured patients age
1864 years, as patients outside the age
range are eligible for Medicaid or Medi-
care coverage. The target population of
this clinic is homeless patients who can-
not afford services at other institutions
that might provide care on a sliding-scale
rate. Many of these patients cannot af-
ford $4 copayments for prescriptions
through drug discount programs.
This clinic is an interdisciplinary ef-
fort between a pharmacist and a physi-
cian. Both clinicians are faculty at a local
school of pharmacy and osteopathic
medicine. Once a patient receives a diag-
nosis, the pharmacist, along with APPE
students, works with the physicians team
to determine the proper drug therapy
for the patient. Along with working to
choose proper drug therapy, pharmacy
services include management of chronic
diseases (i.e., diabetes, hypertension,
dyslipidemia, asthma, chronic obstruc-
tive pulmonary disorder [COPD], and
anticoagulation) and tobacco cessation,
as well as patient medication assistance.
The goal of the clinic is that every
patient in need receives patient assistance
for medications. Historically, many pa-
tients at the clinic have been noncompli-
ant with their drug regimens due to the
high cost of medications. By providing
most medications free of charge, it is
hoped that compliance will increase in
this population The students, working
under the supervision of the pharmacist,
are responsible for each patient enrolled
in the medication assistance service.
Student responsibilities. The student-
run medication assistance service con-
sists of fourth-year APPE students who
help to identify medications for which
patient assistance could be obtained,
select the appropriate forms for comple-
tion, assist patients with completing the
forms, and provide proper income docu-
mentation. At the start of their four-week
rotation, the students are trained by the
pharmacist in methods for determining
the need for patient assistance, choos-
ing the correct therapy, and enrolling
patients in the PMAPs. Students use
online databases and manufacturer web-
sites as resources whenever necessary.
4,5
The student-run medication assistance
service involves patient referrals to the
pharmacy for evaluation. After patients
receive a diagnosis, students create a drug
therapy regimen that takes into account
patient compliance and availability of
the drugs through a PMAP. The new
regimen is then presented to the clinics
physician team for discussion. Once ap-
proved, the pharmacy students complete
all forms with the patient and mail them
to the companies. If the patient has a
permanent residence, the medications
are mailed there; otherwise, they are
mailed to the clinic. Once received, the
patient is instructed to make an appoint-
ment with the pharmacy clinic to review
how to properly take the medications,
determine if any possible replacement
medications are needed, and discuss the
possible adverse effects of treatment. Stu-
dents also verify patients medication lists
to capture any dose or therapy changes
and conduct medication reviews to de-
termine if any other issues need to be ad-
dressed with the patient or prescriber. In
some cases, referrals to pharmacist-run
disease management clinics are gener-
ated as a result of medication reviews. If
PMAPs are not available for a prescribed
medication and cost remains an issue for
the patient, students identify alternative
cost-effective therapies.
Additional student responsibilities
and educational opportunities include
participating in patient visits with the
clinical pharmacist or prescriber, at-
tending journal club, writing newsletter
articles, and preparing presentations to
clinic staff, faculty, and other students.
Clinic sites also offered interaction with
nursing, medical, and physician assistant
students, allowing pharmacy students to
begin developing interdisciplinary prac-
tice skills with peers.
Experience with the medication
assistance service. Two fourth-year
pharmacy students completed the am-
bulatory care APPE each month at clinics
1 and 2 from January 1 to June 30, 2011.
Each student saw patients half a day each
week with the clinical pharmacist. Stu-
dents were at the clinic site four days each
week; the fth day is spent on campus
for journal club, presentations, and other
educational activities.
Clinic 3 had two fourth-year phar-
macy students complete the ambulatory
care APPE each month, seeing 506 pa-
tients from January 1 to June 30, 2011,
with pharmacist interventions occurring
for nearly every patient seen.
The students were responsible for
attending to all patients scheduled for
pharmacy consultations each day. They
also worked with the physician team
to address any immediate prescription
needs. Students saw patients ve days
each week during the clinics hours of
operation. They also completed projects
that involved journal clubs, a new drug
and clinical controversy newsletter, a
case-based disease presentation, and nu-
merous topic discussions.
Data were collected monthly from
the start of each medication assistance
Frontline Pharmacist
2178 Am J Health-Syst PharmVol 70 Dec 15, 2013
program for four to eight months. Data
collected include the number of patients
assisted, number of individual drugs
ordered, types of drugs ordered, approxi-
mate retail cost of medications if the pa-
tient had self-paid, the number of APPE
students each month, and the number
of hours spent by faculty and APPE
students working at each site each
month.
Drug costs were approximated based
on dose and number of units ordered.
Pricing was obtained from Redbook
Online.
6
When drug cost data were un-
available, the information was left out
of the overall estimated monthly cost,
resulting in a lower-than-actual cost
approximation.
A total of 297 medications were ob-
tained via the medication assistance ser-
vice at clinic site 1 over the eight-month
reporting period. Clinic site 2 obtained
63 medications over a four-month re-
porting period. Over a six-month period,
clinic site 3 obtained 78 medications. The
most frequently requested medications
at all sites were for the treatment of dia-
betes, hypertension, COPD, asthma, hy-
perlipidemia, and atrial brillation. The
approximate total retail cost per month
of medications processed via the medi-
cation assistance service ranged from
$6,300 the rst month to a high of nearly
$43,000.
6
Clinic site 1 provided a total
of $130,000 of brand-name medications
over the entire reporting period, with
clinic site 2 reporting just under $23,000,
and clinic site 3 providing $43,600 of
brand-name medications. Clinic site
2 generated 16 referrals for additional
pharmacy services using medication
reviews. Referrals were generated for the
management of patients with diabetes,
asthma, COPD, and dyslipidemia.
Discussion. One barrier to success-
ful medication management for many
patients is medication cost. Discounted-
drug lists have helped to improve this
burden, but these lists are not all-inclusive.
Often, medications on discounted-drug
lists are adequate for initial therapy but
fail to meet the needs of patients who re-
quire more aggressive treatment. Other is-
sues arise when patients cannot tolerate or
are allergic to certain medications and no
therapeutic alternatives are available on
the discounted-drug lists. For low-income
patients and patients without prescription
insurance, these barriers become even
more troublesome. PMAPs are helpful
tools to provide patients with a nancial
hardship with brand-name medications
when cheaper therapeutic alternatives are
not available or appropriate.
Benefits of PMAPs extend beyond
improved health for patients. These pro-
grams offer an opportunity for pharmacy
involvement. Pharmacists and pharmacy
students are excellent candidates to facili-
tate patient enrollment into PMAPs, as
these programs provide the opportunity
for comprehensive medication reviews,
patient consultation, and therapeutic
interventions. The medication assistance
services at all three clinics are student run
under the direction of the clinical phar-
macist. This setup provides a positive
learning environment for the students,
while maintaining continuity of care
from month to month.
While establishing a new practice
site, pharmacy services used the PMAP
as a patient recruitment tool for disease
management clinics. An extensive chart
review was conducted for each patient
in the medication assistance service. Em-
phasis was placed on review of pertinent
laboratory values and medications and
overall management of diabetes, dyslip-
idemia, asthma, and COPD. If patients
had any of these diseases and their condi-
tions were uncontrolled based on current
guidelines, a pharmacy referral request
was made for physician approval. Using
the medication assistance service as a
recruitment tool was successful in the be-
ginning stages of establishing a new prac-
tice site. During the rst three months of
service at the new clinic, 16 referrals were
made, and three pharmacist-run disease
management clinics were established.
While PMAPs offer multiple ben-
ets to patients, students, and pharmacy
service development, these programs
are not without challenges. One major
complication associated with PMAPs is
the time lapse from application submis-
sion to receipt of the medication. While
each program is slightly different, most
require an application to be submit-
ted along with proof of income and a
prescription via mail or facsimile. Once
approved, the PMAP mails the requested
medication to the provider. This process
can take anywhere from one week to one
month or more if any documentation
is missing or incorrect. This time lapse
can be problematic if the medication
is needed immediately. Another com-
mon challenge associated with PMAPs
is accessibility and communication with
the prescribing physician, as any new
application or change to medication
therapy will require physician approval.
Finally, record keeping can be a daunting
task as the number of patients enrolled
in PMAPs increases. Several computer
software programs are available to assist
with keeping track of medication orders,
lling out applications, and sending re-
minders when rells are necessary, but
most of these programs have a subscrip-
tion fee.
The medication assistance service
at these three clinics provides access to
medications for patients who might not
otherwise obtain their medications due to
nancial hardship. The students involved
in this service learn to effectively com-
municate with patients and health care
providers, hone medication review skills,
and gain knowledge of low-cost alterna-
tives for nancially challenged patients.
These skills can be applied in nearly any
pharmacy practice setting. In addition,
prescribers collaboration with pharmacy
services for PMAPs helps to boost refer-
rals for pharmacist-managed clinics for
diabetes and smoking cessation.
1. Heisler M, Wagner TH, Piette JD. Patient
strategies to cope with high prescription
medication costs: who is cutting back on
necessities, increasing debt, or underusing
medications? J Behav Med. 2005; 28:43-51.
2. Dvorcek JJ, Cook KM, Klepser DG.
Student-run low-income family medicine
clinic: controlling costs while providing
comprehensive medication management.
J Am Pharm Assoc. 2010; 50:384-8.
3. Senior Friendship Centers. Centers for
Healthy Aging medical and dental clin-
ics. www.friendshipcenters.org/Services/
t abi d/ 68/ ar t i cl eType/ Ar t i cl eVi ew/
articleId/16/Centers-for-Healthy-Aging.
aspx (accessed 2011 Jul 15).
Frontline Pharmacist
2179 Am J Health-Syst PharmVol 70 Dec 15, 2013
4. RxAssist Patient Assistance Program Center. Homepage.
www.rxassist.org (accessed 2013 Feb 28).
5. NeedyMeds. Homepage. www.needymeds.org (accessed 2013 Feb
28).
6. Redbook Online. Greenwood Village, CO: Thomson Reuters
Healthcare. Updated periodically.
Melissa Murn, Pharm.D., PA-C, Assistant Professor
Physician Assistant Program
Elon University
Campus Box 2087
Elon, NC 27244
mmurn@elon.edu
Ryan Wargo, Pharm.D., BCACP, Assistant
Professor of Pharmacy Practice
Alejandro Vazquez, Pharm.D., Assistant Professor
of Pharmacy Practice
Lake Erie College of Osteopathic Medicine School of Pharmacy
Bradenton, FL
The authors have declared no potential conicts of interest.
DOI 10.2146/ajhp120753