Medication Assitance Program

The E. Blair Warner Family Practice Center of Memorial Hospital serves a wide variety of patients.   Housed in the same building as Memorial's Family Pharmacy, the Center staff provides health care to 10,000 patients every year.   Dr. Madeline Lewis is Associate Director of the E. Blair Warner Family Practice Residency, and founder of the Medication Assistance Program, also known as M.A.P..   The M.A.P. program helps qualified patients of the Center secure medications with only a small co-pay.   These are often patients who have fallen through cracks in the system and exhausted other resources that might enable them to obtain medications vital to their health.

Dr. Lewis describes the origins of the M.A.P. program: “We have all age groups, a multitude of medical problems, and also several economic groups among our patients.   However, we mostly serve the indigent, or the needier of our population.   And one thing that we noticed working in the clinic is that we have people who have been our patients here for years and years with chronic medical problems.   A lot of them are working poor, or the Medicare poor, as we call it -- they have Medicare, but they don't have coverage for their prescriptions. They were having repeated hospital admissions -- often lengthy, very expensive, complicated hospital admissions -- because they couldn't afford to pay for their medications... We felt that if we could find a way to help get them their medications, for the patients that truly didn't have any other resources, we could avoid some hospitalizations and complexities of their diseases.   We could help them have a better quality of life.”

Dr. Lewis has been with the E. Blair Warner Family Practice Center since 1994, and started thinking about a program like M.A.P. as soon as she arrived.   After about three or four years of investigating funding resources, Memorial's Health Foundation stepped up to approve the concept of the Medication Assistance Program in early 1998.   Dr. Lewis and other staff moved quickly to develop an infrastructure for M.A.P. and on November 16, 1998 , the program officially began.    Not even a year old, M.A.P. has enrolled 47 patients as of late May 1999, and new applications continue to arrive.   Program staff acknowledge that really, this is just the beginning.

Getting Started

M.A.P.'s obvious benefit is to allow patients who face financial barriers to be able to obtain their medications, regardless of whether or not they might be able to afford them in any particular month.   By continuing their medication, patients are more likely to stabilize their health and avoid increasing the risks that come with the chronic conditions that plague them.   The benefit of the program extends to other partners in the M.A.P. program too, however.   “We theorized that if we could save the hospital one admission, we'd be saving thousands of dollars,” says Dr. Lewis.   She describes the program as an experiment that could prove the advantages of consistent medication and regular care in reducing problems much worse, saving both patients and hospitals time, suffering, and money.

M.A.P. is available only to regular patients of the Center, a requirement staff felt necessary given limited funds, the importance of tracking, and program infrastructure.   “We decided that this would be for our established, regular, clinic patients,” says Dr. Lewis, “not just somebody coming into the emergency room, or somebody coming in new to the clinic -- but somebody that we knew well and we knew would be able to participate and work with us.   There is quite a lot of patient compliance that is required.”

Annette Heffelfinger, hired through a state grant, has been the social worker at the Warner Family Practice Center for just over seven months.   She oversees M.A.P. on a day to day basis, facilitating M.A.P. patient cases, and working with residents and the pharmacy to ensure that the program runs smoothly.   Residents refer M.A.P. candidates to Annette, who reviews their needs and arranges to meet with them one-on-one.   The patient is given a list of financial documentation they'll need to bring with them for their appointment, as M.A.P. is available only for patients at 185% of the poverty level or more (see box), criteria that was decided on after local research exploring other community guidelines for assistance programs.   At the meeting, Annette assesses what resources might match a patient's needs.  

An important reward of the program has been the level of assistance Annette has been able to provide to patients, regardless of whether or not the patient qualifies for M.A.P..   Prior to the program, the Family Practice Center had no social worker, a condition Dr. Lewis lamented.   Annette's presence has added greatly to the Center's ability to provide more rounded services for all its patients, even though M.A.P.'s funds are limited to some.   “Our goal was to exhaust community resources first, before having to delve into our pot of funds,” says Dr. Lewis, “We realized that we did have a huge pool of patients who just needed to be hooked-up to community resources, but without ever having a social worker here before we were never able to do that.   She's doing complete social services and it has made a huge difference for many patients.   Some never even get any funds from M.A.P., but Annette has really helped them.”

Annette assists patients in finding transportation to the Center, and will even make home visits if it makes the process of determining their M.A.P. eligibility easier for them.   Home visits offer her more information about her patients as well. Through a home visit, she can take advantage of opportunities to connect them with community resources that might help them with everything from house mantainence issues to free meals, depending on needs Annette might identify while in a home.   A large proportion of those in M.A.P. are older patients who are more likely to have a higher medication need than the general population, and less likely to be able to pay for it.   “Another issue I step into is just neglect,” says Annette, “The elderly are neglecting themselves, and it's not intentional, but that that they can't always take care of themselves -- or can't afford to.”

Annette follows a flow chart of steps to find the best-matched help for each patient she meets with (see box). The steps include a financial evaluation, assisting a patient in applying for Medicaid, and exploring the services that other local community organizations might offer.   With Annette's assistance, patients may also explore the options offered by pharmaceutical companies.   “There are quite a few pharmaceutical companies who do have an indigent program, which is sometimes a very lengthy process of filling out the forms.   And everyone has a different form, and a different way of doing it,” says Annette, emphasizing the importance of assistance for patients tackling any number of complicated solutions to their medication issues.

M.A.P.ing Day to Day

Dr. Lewis recognizes the importance of developing the research and evaluation tools to show a conclusion she believes in anecdotally: “Each patient that meets with Annette just once, feels already much more positive about their life.   They feel like there's hope.   We get letters and notes and doctors tell us that it has just made a huge difference to them...I have patients of my own who are enrolled -- and to hear them -- they are feeling better and staying out of the hospital.   It's amazing.”

After Annette has gone through her checklist with a potential M.A.P. candidate and that patient has qualified for the program, she notifies the patient's doctor and Memorial's pharmacy.   Currently, M.A.P. patients are required to use only the Memorial pharmacy to get their medications.   This has made communication and tracking between M.A.P. and pharmacy staff much easier.   As a M.A.P. patient begins to use the pharmacy, the real “cost” of their medications is tracked by the pharmacy staff and billed to Memorial.   In this way, M.A.P. can assess the types and prices of medications its participants .

Maxie Bolden, Pharmacy Manager, in the small and well-lit room adjoining the Family Practice Center, interacts with Annette almost daily.   The pharmacy keeps a computer record of each patient, and every month they give M.A.P. staff a summary of patients who used the pharmacy and what medications they received.   Tracking M.A.P. patients and medications is a fraction of what he does, but Maxie's connection to the program is invaluable to keep things running smoothly between enrollment stages and when patients actually receive their medication.  

Maxie describes some of the patient issues he's familiar with in the M.A.P. program.   “In the underprivileged and elderly population we get a lot of diabetics and hypertension,” he says, fixing the hardware of a pharmacy computer among aisles of bottles and boxes behind the counter.   “Patients might pay a hundred dollars a month in jyst hypertension medicine...For diabetes, some of the newer meds cost four dollars per tablet. Just these two disease states alone are very expensive in terms of medications.”

Maxie puts medication costs in a larger perspective by noting that pharmaceutical prices have outpaced inflation for several years now.   Newer medications can be especially expensive, often driving patients and doctors to seek out cheaper alternatives.   Maxie says, by and large, M.A.P. patients “have been very grateful.”  

A M.A.P. core team meets regularly to review pharmacy summaries and patient charts, identifying other social and physician concerns as they come up.   Members of this committee include: a Geriatric Nurse Practitioner, a Perinatal Nurse Practitioner, the Pharmacy Manager, the Clinic Manager and Director, Office Manager and others.   The group convenes quarterly.

Challenges

The program has not been without challenges, but even throughout its short life span, noticeable improvements have smoothed its path.   What follows are the most important issues that have come up for M.A.P. staff:

The Co-Pay Question .   Program planners decided early on that a five-dollar co-pay for M.A.P. participants, with a limit of twenty-five dollars would be an asset to the program.   “We had a lot of discussion about it,” says Dr. Lewis, “ but we felt it was necessary that patients contribute something, and most of the patients want to contribute something.   This was a way of saying they still have some responsibility for the medications.   Annette, as the coordinator, has the authority to waive that fee if the patient truly cannot afford it.   And we do have patients who truly cannot.”

Maxie Bolden, Pharmacy Manager, says that of the few complaints he receives about M.A.P., many are about the co-pay issue.   In some instances, patients have shown up to pick-up medication, but have brought no money.   “It becomes a problem every once in a while,” he says.   He also mentions that the cap of twenty-five dollars logistically created some new issues for them in terms of tracking.   If a patient has more than five medications, the co-pay is not assessed more than five times, but still, all medications must be tracked, which, Maxie says, could have the potential for technical problems.

Medications cost big bucks, plain and simple.   M.A.P. began with $10,000 to use for medication purchases.   After six months a mere $400 is left from that allotment.   Memorial has given assurances that the program can continue to assist its patients. However, the rate at which the funds were dispensed was discouraging.   “One pitfall,” says Annette, “is how really expensive the medications truly are.”   With the potential of program growth, this issue will be more and more important.   Questions like how the program might limit itself, or how more funding can be secured are critical in being able to afford the ever-increasing costs of medications.   Annette and Dr. Lewis are hopeful that in the future they might expand partnerships with pharmaceutical companies to offset costs as well.  

Patient Compliance .   Currently, anyone enrolling in M.A.P. is required to sign a Medication Assistance Program Agreement.   The Agreement states the criteria that must be met to receive M.A.P. assistance (see box). Annette advises that stressing the Agreement helps promote compliance.   “Their health care should be number one for them too,” she says.   In instances where patients fail to stick to the Agreement, “It can make it hard for us to do our job.”

Standardizing the program.   From the beginning, M.A.P. staff researched ways to ensure program consistency -- streamlining qualifying criteria for patients and understanding the law.   “One of the biggest stumbling blocks,” says Dr. Lewis, “was how to do it legally...We didn't want to make it look like we were giving any kind of discriminatory care, or that we were offering something to some patients and not to others.   We met with representatives of the hospital from risk management and legal services to make sure some of our basic ideas were going to be following the letter of the law.   One of our biggest challenges initially was what criteria to use to qualify patients.   What we discovered was that across Memorial Health System, a zillion different criteria were being used, and nothing consistent.   That's maybe one of the things that I think we've been able to say is maybe a branch of this project -- that we've learned the system has to come up with a consistent form of financial criteria.”   M.A.P. planners surveyed other community agencies and organizations to find out what criteria they used in evaluating applicants to receive resources.   “We sort of took a blend of that and tried to be consistent with what the hospital was using too,” says Dr. Lewis.

Shaping perceptions of the program.   Although M.A.P. has been well received by both community and hospital, there have been cases where other physician offices or departments have wanted to access M.A.P. for patients not of the Warner Family Practice Center.   “I think there are some misunderstandings among people in the system that this is an emergency medication fund, a kind of stop-gap,” says Dr. Lewis, “There is certainly a need for a program like that, but it wasn't our goal with this limited amount of money.   With the Emergency Room, we have had some miscommunication because they would like us to be able to provide medication, but we can't do that at this point.   If we could expand, great, but right now we're keeping our limited focus.”   Medication assistance for patients everywhere is such a strong need that M.A.P. receives requests they simply don't have the infrastructure to meet.   Creating an accurate understanding of the program, while at the same time encouraging the growth of other resources and expansions to help people get the medication they need, is another important challenge.

M.A.P. Documenting .   It's logical that patients with chronic illnesses who are able to take their medications as directed and follow-up with a doctor regularly are less likely to be hospitalized or develop further complications than those who don't.   The premise of M.A.P. depends on this assumption.   As the program continues, efforts will be undertaken to show that that's in fact what happened for patients receiving medication assistance.   The complexities involved in showing this result is another program aspect requiring additional time and resources.   “It's difficult to get this information, and it's going to be difficult for us to glean what we want to out of it, and we don't have anyone to help us,” says Dr. Lewis, although they are taking steps to recruit a volunteer who might compile some of the records.   “In order to qualify for additional funding we need to show some proof of the program.   Measurement has been a very difficult issue for this whole thing.   [The program] makes good sense to us, and it seems like it's logical -- it's preventive, trying to keep our patients healthy and give them a better quality of life -- but we do need to have some measurements.   Financial measurement is one criteria, and another would be quality of life issues.”   Although not yet implemented, M.A.P. looks toward employing a survey for patients in the future to gather some data about their quality of life before and after M.A.P. involvement.   Dr. Lewis emphasizes the importance of having a stable program that can be duplicated “The hospital would like to take this [M.A.P.] system and apply it to other clinics in Memorial, and in order to do that we have to have something that is reproducible and solid, and as defined as possible.”

Growing Pains.   “I was giving referrals today,” says Annette, “The program is continuing to grow.”   Similar programs across the country spend hundreds of thousand of dollars a month in medication purchases for patients who need assistance in a month.   Comparing efforts like these to the $10,000 available for M.A.P. for a year adds a worrisome perspective.   Also, the processing involved in enrolling and tracking participants is time consuming for just one person.   Annette, the social worker of the Center, has duties not at all related to M.A.P. as well.   In the future, M.A.P. staff hope to streamline the pharmaceutical process, and come up with a computerized system that makes some of the paperwork easier, without sacrificing any of the personal touch that now infuses the program.   “There are still a lot of uphill battles that we're going to have to fight,” says Annette.

Perspectives on M.A.P.

Internally, the program has been well received. “Better than I expected, really,” admits Dr. Lewis, “I think everyone knew there was this need, but we didn't have any way to attempt to meet that...I think our doctors and our nurses all have been very receptive.”

Dr. David Wolken is a resident physician at the Center who has referred patients to M.A.P..   “It's really offered my patients the possibility of giving them some assistance...If they hesitate with the medications I prescribe I ask them right up front if they're going to have trouble affording this, and if so, we might have a program....And I

get a good response.   A lot of patients say, ‘No that's okay, I can squeeze it out.'   It's not like they think it's free money.   The patients who have gone on the program are people who really need their medications, and have a lot of medications -- expensive ones -- that we can't alter or change.”

Annette has noticed a difference in patients who have gotten into the M.A.P. program as well.   “I like to see how they're doing better, that they can go out and buy the extra loaf of bread they wanted or get a matchbox car for a child's birthday gift...There are a lot of rewards in it that way.   Just to hear them say, ‘I can finally get out of bed in the morning.   I'm not in so much pain.'   Those are the big rewards.”

“I've seen my patients health improve because they're able to keep their medications and their sanity as well,” says Dr. Wolken,   “It's a month to month type of thing for them, so they really struggle...Now we can bridge that gap...and it's something really concrete, something we can offer that's outside of everything else and it works.   My patients have been able to take their medications, and that's the bottom line.”