Effects of Changes in Patient Cost Sharing and Drug Sample Policies on Prescription Drug Costs and Utilization in a Safety-Net-Provider Setting

Jared T. Lurk; Douglas J. Dejong; T. Mark Woods; Maureen E. Knell; Cathryn A. Carroll


Am J Health Syst Pharm. 2004;61(3) 

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The project was conducted in a single location at the Saint Luke's Hospital Multi-Specialty Clinic in Kansas City, Missouri. This clinic is one of the four clinics responsible for the care of the Medicaid, uninsured, and underinsured population in the health system. It provides primary care through the internal medicine service full-time five days a week and offers, at a minimum, weekly ambulatory care services, including cardiology, anticoagulation, surgery, gastroenterology, pulmonology, endocrinology, orthopedic, psychiatry, and ophthalmology services. The clinic is part of the medical education programs of the University of Missouri—Kansas City but is financed by the hospital rather than the university and receives no city, state, or federal funding. All patients in the clinic are financially screened and required to apply for Medicaid if they are seeking assistance. If a patient is denied by Medicaid and other assistance programs, the clinic patient may enter a special low-income program supported through the hospital. While financial considerations play a part in the operation of the clinic, the clinic's focus is to provide quality care while maintaining cost-effectiveness.

Since the study began in 1999, the medical personnel, clinic schedules, specialty services provided, and number of physicians participating in the clinic have varied on the basis of patient need, financial restructuring of the clinic, and availability of physician faculty. In general, the clinic was staffed weekly by 1 or 2 full-time faculty physicians, 2 to 4 part-time faculty physicians, approximately 20 medical residents, and 20 medical students. Each specialty ambulatory care service provided at the clinic typically involved 1 faculty physician and 0 to 4 residents or fellows providing half-day services on a weekly basis during the study.

The clinic also functions as an experiential rotation site for students from the University of Missouri— Kansas City School of Pharmacy and School of Medicine. A faculty member from the pharmacy school has provided services to the clinic since 1997. During the study, two or three pharmacy students participated in services approximately 10 months out of each year. Also beginning in 1999, two pharmacy practice residents completed longitudinal ambulatory care rotations through weekly service to the clinic. Since 2000, the number of pharmacy residents in the clinic increased to four per year. Pharmaceutical services included direct patient care through collaboration with the medical residents and faculty physicians, patient education, anticoagulation and lipid disease management clinics, referred consultations for drug therapy, and drug information. In addition, pharmacy students, pharmacy residents, and pharmacy faculty participated in quality improvement, drug utilization, and cost-containment projects and clinic staff education for such projects. Pharmaceutical services were provided each day of the week to the medicine clinic throughout most of the evaluation period.

The clinic's low-income program was initiated at the inception of the teaching clinic at Saint Luke's Hospital in the early 1980s. Over the years, the program became very expensive to manage as the clinic and the prescription drug program grew. Other problems identified included no standardization of patient qualifications for the prescription drug program, rapidly rising administrative costs, and drug-use-control and regulatory problems. Some of these problems were believed to be associated with prescription drug samples.

A plan to improve the clinic and its prescription drug program took shape. A number of interventions were applied to help manage the growth. The development of patient qualification criteria to receive the prescription drug program's benefit, the expansion of utilizing pharmaceutical companies' patient assistance programs, and the institution of copayments ($5 generic, $10 brand) were initial actions taken to help address the problems. During the evaluation period, the patient copayment amounts were increased to $7.50 for generics and $15 for brand-name drugs. An additional intervention was the removal of pharmaceutical manufacturers' prescription drug samples. Prior to this intervention, pharmaceutical company representatives supplied the clinic liberally with drug samples. The availability of these drug samples created significant drug-use-control problems, including poor documentation of distribution, potential diversion, and regulatory concerns involving requirements set forth by the Joint Commission on Accreditation of Healthcare Organizations. There was also a strong belief among some members of the clinic and hospital staff that drug samples encouraged less than optimal selection of drug therapy and encouraged the use of expensive brand-name drugs when less expensive generic or multisource medications were appropriate. Starter packs (14-day supplies) of commonly prescribed generic medications were placed in the clinic to provide prescribers with enough medication to initiate therapy for a patient without making the patient pay for a full course of drug therapy immediately.


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