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Archived Service Delivery Profile:

Pharmacy Clinics Help Low-Income, Elderly Individuals Access Medications, Leading to Better Adherence and Lower Costs


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Snapshot

Summary

Mercy Medical Group's Pharmacist Review to Increase Cost-Effectiveness (commonly known as PRICE) Clinic uses a pharmacist, pharmacy students or residents, and volunteers to conduct clinics to help elderly, low-income patients access appropriate, safe, cost-effective medications. Clinic staff meet with patients in their providers' offices to review and ensure the safety of their medications. They help low-income Medicare patients select the most advantageous drug subsidy programs, switch to generic drugs, and enroll in patient assistance programs that offer low-cost or free drugs. The program increased medication adherence due to increased access to lower-cost medications and significantly reduced out-of-pocket drug costs, saving the average uninsured patient $1,500 a year and demonstrating significant savings for Medicare participants, even those with Part D drug coverage.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of out-of-pocket drug costs, self-reported medication adherence for high-cost (previously unaffordable) drugs, and use of generic drugs, along with post-implementation data on the percentage of PRICE Clinic clients gaining access to assistance programs, generic drugs, lower-cost therapeutic substitutes, and mail-order services.
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Developing Organizations

Mercy Medical Group; University of California, San Francisco School of Pharmacy
Sacramento, CAend do

Use By Other Organizations

The PRICE Clinic model is now being considered for replication by leaders of other organizations in a position to develop a partnership with medical and pharmacy schools.

Date First Implemented

2001
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Patient Population

The program primarily serves low-income, elderly individuals taking multiple medications for multiple chronic conditions. In 2009 to 2010, 61 percent of Medicare participants were female, and the average age was 68 years old. The typical participant took nearly nine medications, and half were below 150 percent of the federal poverty level. The PRICE Clinic also serves uninsured or underinsured adults and children.Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Impoverished; Insurance Status > Medicare; Age > Senior adult (65-79 years)end pp

Problem Addressed

Although 90 percent of seniors and 58 percent of nonelderly adults rely on one or more prescription drugs on an ongoing basis,1 many do not regularly take their medications as prescribed, often because they cannot afford them. This lack of adherence leads to many costly, unnecessary hospitalizations. Although government programs and other forms of assistance may be available to help, many individuals do not know about these programs or find the premiums too expensive and/or the enrollment process too difficult. Pharmacists have the expertise to help patients, especially low-income and elderly individuals taking multiple medications, find the most cost-effective and clinically appropriate drugs, but their expertise is rarely enlisted to help in this manner.
  • Failure to adhere to prescribed regimen, often due to high costs: Between one-third and one-half of all patients do not take their medications as prescribed, and up to one-fourth never fill their prescriptions—often because they cannot afford them.2
  • Leading to costly but preventable hospitalizations: Lack of medication adherence leads to more than $100 billion being spent each year on avoidable hospitalizations when patients get sicker due to their failure to take medications as prescribed.2
  • Failure of support programs to help: The law that created Medicare's prescription drug benefit, known as Medicare Part D, also established assistance for low-income seniors in the form of a subsidy. But as of 2006, only 63 percent of all eligible seniors and 69 percent of low-income beneficiaries had enrolled in Medicare Part D, leaving millions without coverage.3 Many have not enrolled due to high premiums and to difficulties finding information about the program and navigating the enrollment process. Other programs, including pharmaceutical company assistance programs and low-cost mail order services, can also help to lower costs, but few patients know about them or how to sign up.
  • Unrealized potential of pharmacists: Although physicians often lack the time, information, and expertise to help low-income and elderly patients access needed medications (e.g., by helping them apply for Medicare Part D or other programs), pharmacists are uniquely positioned to help patients in this manner. In fact, use of pharmacists' databases has been shown to improve medication adherence, diagnostic accuracy, and prescription appropriateness, leading to lower drug costs, improved care, and avoided medical costs due to better adherence.3 However, pharmacists seldom participate as part of the patient's health care team and are rarely accessible or available at the same location as the physician.

What They Did

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Description of the Innovative Activity

Mercy Medical Group's PRICE Clinic uses a pharmacist, pharmacy students or residents, and volunteers to conduct "traveling clinics" that help elderly, low-income patients access appropriate, cost-effective medications. Clinic staff meet with patients in their providers' offices, helping them to switch to generic drugs, enroll in patient assistance programs that offer low-cost or free drugs, and/or get their medications through monthly mail-order services that offer lower prices. As part of this free service, the pharmacist also reviews each patient's medications to ensure their clinical appropriateness. Key elements of the program include the following:
  • Referrals to the clinic: Providers can refer individuals to the program who express concerns about prescription drug prices, including those enrolled in Medicare or Medicaid and those without insurance or who are underinsured. Volunteers—usually senior citizens—also periodically visit medical office waiting rooms at designated times to disseminate information about the clinic to low-income and older patients. These individuals can call the clinic's number to make an appointment.
  • Periodic traveling clinics at practice sites: The "traveling clinic" takes place on a regular basis at the office of any provider who wishes to participate. At Mercy Medical Group, the clinic initially took place at each practice site for a half day on a monthly basis. After the group adopted an electronic medical record (EMR) that allows the sharing of drug information across sites, the traveling clinic began operating out of two of Mercy's largest practice sites and one smaller, outlying site, also on a monthly basis. Key activities that take place during a patient's visit to the clinic are outlined below:
    • Initial review by pharmacy student or resident: The patient checks into the clinic and spends approximately 30 minutes with a pharmacy student or resident who collects demographic information (including income), details related to the current medication regimen, health insurance and prescription drug benefit information, and information on current use of local and/or mail-order pharmacies. The student or resident classifies each drug as to whether it is a brand-name, generic, or over-the-counter/herbal medication, and then gives all relevant information to the clinic pharmacist. To facilitate this process and the ensuing pharmacist review (see next bullet), the patient is instructed to bring all medication bottles to the clinic.
    • Medication review by pharmacist: The clinic pharmacist reviews the patient's Medicare plan to see if it is the most advantageous option and performs a thorough medication reconciliation to ensure appropriateness, safety, and access. The pharmacist screens for potential adverse drug reactions and duplicate and/or omitted therapies. The pharmacist considers all medically appropriate cost-cutting interventions, including use of generic drugs, tablet-splitting (a practice that saves money by prescribing double-dosage tablets sold at roughly the same price as the required dosage), therapeutic interchanges in which lower-cost, therapeutically similar drugs are substituted for nonpreferred drugs, and use of mail-order pharmacies. The pharmacist reviews any new medication recommendation with the patient's primary care provider and documents any change in the EMR and in the PRICE Clinic database.
    • Enrollment in appropriate medication assistance programs: The patient is also instructed to bring income and financial information that can help determine eligibility for free- or low-cost patient assistance programs and facilitate application to applicable programs. When eligible, clinic staff help patients enroll in relevant programs, including obtaining any needed physician authorizations for participation. For those enrolled in Medicare, clinic staff review their drug utilization history to see if another plan may be more cost-effective, and assess whether the individual qualifies for a subsidy under the Medicare Part D legislation. If so, the volunteer helps the patient complete and submit a subsidy application.
    • Information to assist after visit: At the conclusion of the visit, patients receive written and verbal instructions regarding their medication regimens and how to use available resources to assist in accessing low-cost drugs, along with information on how to reach the PRICE Clinic in the future if necessary.
  • Integration into care team to serve high-risk patients: Information provided in January 2012 indicates that pharmacists now work as part of care teams that include a physician, nurse case manager, and social worker. Each care team is assigned to three to six primary care practices to offer more intensive care management for high-risk patients, defined as those that are at high risk of hospital readmission due to the presence of multiple comorbidities (e.g., diabetes, cardiovascular conditions, coronary obstructive pulmonary disease, etc.). As part of the care team, each pharmacist is responsible for medication management of approximately 200 to 300 high-risk patients who are covered under a capitated reimbursement system.
    • Patient referral: The pharmacist receives a referral automatically when a high-risk patient undergoes a care transition. The nurse case manager, social worker, and practice physicians can also refer patients subsequent to an outpatient visit.
    • Telephone contact: Within 48 hours of discharge or referral, the pharmacist telephones the patient to perform a general assessment of medication needs and adherence issues and conducts a medication reconciliation.
    • Home visit: If the telephone conversation is insufficient to meet patient needs (particularly with regard to medication adherence), the pharmacist will visit the patient and caregiver at home for a more indepth discussion and intervention to resolve adherence, cost, and insurance issues. At this time, the pharmacist may arrange for free delivery of prearranged morning, afternoon, and/or evening "bubble-packs" of required medications (which replace the patient's multiple pill bottles) to facilitate patient adherence to the regimen.

Context of the Innovation

Catholic Healthcare West Medical Foundation's Mercy Medical Group is a 220-provider multispecialty group housed in 8 clinics in the Sacramento area that serve 20,000 Medicare patients and a large number of Medicaid patients. About one-fourth of these patients belong to Medicare Advantage plans offering a pharmacy benefit. In 2001, the largest Medicare Advantage plan eliminated brand name drug coverage. Within weeks, the Mercy Medical Group and the University of California San Francisco School of Pharmacy's Department of Clinical Pharmacy worked together to create the clinic as a way to ensure that seniors continued to get the prescription drugs they needed. The clinic also allowed Mercy to meet Medicare Modernization Act requirements that call for pharmacists and other health care professionals to work together to ensure safe, appropriate, and cost-effective medication use.

Did It Work?

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Results

The program significantly reduced medication costs for Medicare recipients both before and after implementation of the Medicare Part D program, which was designed to cover more prescription drugs costs for seniors. The clinics saved the average participant roughly $1,500 per year, and increased medication adherence, with the bulk of these improvements driven by enhanced access to assistance programs and lower-cost medications (e.g., generic drugs or therapeutically equivalent alternatives).
  • Significant decline in out-of-pocket drug spending: A study of 520 individuals served by the PRICE Clinic in 2002 found that their average out-of-pocket drug expenditures fell from $185 per month before being served by the program to roughly $60 per month afterward—a 68-percent decline that represents an average savings of roughly $1,500 per participant per year. A similar study of 106 Medicare patients in 2009 to 2010 found the clinic saved them on average $1,463 per year.
  • Improved medication adherence: A total of 215 patients (or 41 percent) of those served in 2002 initially reported that they had discontinued—or would soon discontinue—a prescribed drug because of its cost. After receiving PRICE Clinic services, 186 (or 87 percent) were able to continue taking the prescribed drug.
  • Medication reconciliation improves treatment quality: Among Medicare patients in the 2009 to 2010 study, 18 percent had therapeutic drug interchanges to improve treatment, and 17 percent had dosage adjustments or new medications initiated or stopped for therapeutic reasons.
  • Driven by enhanced access to support programs and less-expensive substitutes: The benefits outlined above occurred primarily because of enhanced access to support programs and the ability of clinic staff to substitute less expensive generic or therapeutically equivalent drugs, as outlined below:
    • Enhanced access to support programs: In the 2002 study of 520 PRICE Clinic users, 65 percent signed up for one or more prescription assistance programs (with 336 individuals signed up for 662 programs, nearly two per participant). Among 186 patients who were able to continue adhering to their medication (described above), 87 percent did so by gaining access to an assistance program. In the 2009 to 2010 study, 25 percent of Medicare recipients signed up for patient assistance programs.
    • Greater use of generic and less expensive drugs: Among the 520 individuals who used PRICE Clinic services in 2002, use of generic drugs increased from 51 percent of all prescriptions at the time of the first visit to 56 percent after the receipt of clinic services. Overall, 17 percent of these patients received a generic drug and/or lower-cost therapeutic drug, with the changes being concentrated in lipid-lowering drugs (representing 44 percent of such changes), angiotensin-converting enzyme inhibitors (17 percent), and asthma and allergy drugs (15 percent). Among the 186 patients able to continue adhering to their medication regimen (described above), 9 percent received a generic substitute, 8 percent received a less expensive therapeutic equivalent, and 3 percent signed up for a lower-cost mail-order service. Similarly, use of generic drugs increased 23 percent among patients in the 2009 to 2010 study.
  • Patients enrolled in appropriate Medicare drug plans: Among the 106 Medicare recipients in the 2009 to 2010 study, 15 percent were not enrolled in any Medicare drug plan before attending the clinic. As a result of the intervention, 27 percent either enrolled in a plan for the first time or enrolled in a lower-cost plan that reduced their out-of-pocket expenses. Clinic staff helped 35 percent of the patients enroll in Medicare's low-income subsidy program.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of out-of-pocket drug costs, self-reported medication adherence for high-cost (previously unaffordable) drugs, and use of generic drugs, along with post-implementation data on the percentage of PRICE Clinic clients gaining access to assistance programs, generic drugs, lower-cost therapeutic substitutes, and mail-order services.

How They Did It

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Planning and Development Process

Key steps in the planning and develop process included the following:
  • Creating partnership with academic medical center: The pharmacy utilization director at Mercy Medical Group, who also served as a health sciences clinical professor at the university's School of Pharmacy's Department of Clinical Pharmacy, worked with colleagues to forge a partnership with the university to develop the PRICE Clinic after the Medicare Advantage plan stopped covering brand name drugs.
  • Recruiting and training staff and volunteers for clinic: To meet the demand for PRICE Clinic services without hiring additional staff, Mercy Medical Group trained two elderly volunteers, seven university pharmacy students, and two university residents. Pharmacy students received training as part of a 6-week managed-care clerkship during which they were overseen by pharmacists. Residents received training on how to perform the full array of clinic interventions.
  • Shifting mission in response to Medicare changes: When Medicare Part D reduced the need for patient assistance programs in 2006, the clinic expanded its mission to include helping patients find the best Medicare Part D plan to meet their needs.
  • Integration of pharmacist review into medical home model: Information provided in January 2012 indicates that the program expanded pharmacist services to the high-risk patient population to better integrate these services into the medical home model.
  • Application for funding: Information provided in January 2012 indicates that the program has submitted a Centers for Medicare and Medicaid Innovation Center application for funding to formally evaluate PRICE's care team model and expand it beyond the capitated patients to serve Medicare fee-for-service patients.

Resources Used and Skills Needed

  • Staffing: Staffing for the clinic typically includes one pharmacist, one resident, and two pharmacy students who work about 2.5 days per month, seeing 35 to 40 patients. When the program began in 2002, it required an average of 14 hours per week (roughly one-third of a full-time equivalent or FTE) of a pharmacist's time, which was filled by reassigning existing Mercy pharmacists to the PRICE Clinic. Each Mercy site that hosts the clinic dedicates some administrative time to scheduling appointments; this function takes roughly 15 hours per week (a little more than one-third of an FTE); existing staff also took responsibility for these duties. In addition, volunteers provide additional staffing support during clinic hours.
  • Costs: Program costs are minimal, because Mercy reassigned existing personnel and relies on volunteer staff (including pharmacy students and medical residents) for the program. The program works most effectively in conjunction with an EMR or equivalent system that allows for electronic refilling of prescriptions and easy communication with providers about prescription changes and program authorizations.
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Funding Sources

Mercy Medical Group
Mercy Medical Group funds the clinic.end fs

Tools and Other Resources

Cutler D, Everett W. Thinking outside the pillbox — medication adherence as a priority for health care reform. N Engl J Med 2010;362(17):553-55. [PubMed] Health Care Reform Center. 10.1056/NEJMp1002305. Available at: http://healthcarereform.nejm.org/?p=3280

Davidoff A, Stuart B, Shaffer T, et al. Lessons learned: who didn’t enroll in Medicare drug coverage in 2006, and why? Health Aff Millwood. [PubMed] doi: 10.1377/hlthaff.2009.0002. Available at: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2009.0002

Smith, M, Bates D, Bodenheimer T, et al. Why pharmacists belong in the medical home. Health Aff Millwood 2010;29(5):906-913. [PubMed] Available at: http://content.healthaffairs.org/cgi/content/abstract/29/5/906

Rx Outreach: Rx Outreach is a mail order pharmacy used by the PRICE Clinic. Available at: http://www.rxoutreach.com

Rx Assist Patient Assistance Program Center. PRICE Clinic uses this online directory of pharmaceutical companies’ patient assistant programs. Available at: http://www.rxassist.org

Adoption Considerations

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Getting Started with This Innovation

  • "Sell" initiative to key stakeholders as way to provide better care: Health system leaders and clinicians will be more likely to support the program if they understand its potential to lead to better and more coordinated care, especially for elderly, complex patients taking multiple medications.
  • Anticipate physicians' concerns about oversight role: Because the clinic also reviews prescriptions for their clinical appropriateness, Mercy doctors initially viewed the initiative with suspicion. However, over time, these busy physicians have come to appreciate the clinic's ability to assist with medication oversight and care coordination for complex, nonadherent patients, and now readily accept clinic recommendations.
  • Recruit patients with promise of cost savings: Patients may initially be skeptical of the program if they believe it will be performing a pharmaceutical oversight or drug adherence function. To overcome this skepticism, promote the cost savings potential for patients, and make sure doctors know how to explain the program's potential benefits to any patient struggling to pay for prescriptions, and to those taking six or more medications.
  • Leverage other personnel if students/residents not available: Organizations without nearby access to a pharmacy or medical school should consider use of pharmaceutical technicians or other ancillary health care personnel to support the pharmacist.

Sustaining This Innovation

  • Consider integration into medical home model to secure funding: Most public and private health plans do not currently reimburse for pharmaceutical medical management services. A medical home model, however, may be eligible for funding to cover such services.
  • Maintain communication with providers: Regularly communicate with providers about prescription changes and less expensive drug options. Make sure providers feel actively involved, so they view the clinic as a valuable resource for them and their patients.
  • Consider integration into charity-care programs: Several Mercy Medical Group physicians regularly provide free medical care to uninsured patients. This type of program represents a valuable resource for those served by these charity-care activities.

Use By Other Organizations

The PRICE Clinic model is now being considered for replication by leaders of other organizations in a position to develop a partnership with medical and pharmacy schools.

More Information

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References/Related Articles

Stebbins M, Kaufman D, Lipton H. The PRICE clinic for low-income elderly: a managed care model for implementing pharmacist-directed services. J Manag Care Pharm. 2005;11(4):333-41. [PubMed] Available at http://www.amcp.org/data/jmcp/contemporary_333_341.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Footnotes

1 The Medicare Prescription Drug Benefit Fact Sheet, Kaiser Family Foundation. Available at: http://kff.org/medicare/fact-sheet/the-medicare-prescription-drug-benefit-fact-sheet
/52&parentID=68&imID=1
2 Cutler D, Everett W. Thinking outside the pillbox—medication adherence as a priority for health care reform. N Engl J Med. 2010;362(17):15523-5. [PubMed] Available at: http://healthcarereform.nejm.org/?p=3280
3 Davidoff A, Stuart B, Shaffer T, et al. Lessons learned: who didn't enroll in Medicare drug coverage in 2006, and why? Health Aff Millwood 2010;29(6):1255-63. [PubMed] Available at: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2009.0002
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Original publication: October 13, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 07, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 11, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.