Vincent Keane's Testimony Before Council of the District of Columbia-

Rx Drug Benefits for DC's Elderly

Introduction

Good morning Chairman Allen, and members of the Committee on Human Services.  My name is Vincent Keane, I am the CEO of Unity Health Care, Inc. (Unity).  Under our current contractual relationship with the D.C. Healthcare Alliance (The Alliance), Unity manages and staffs the pharmacies currently funded by the Alliance.  These sites are located at:

These sites provide pharmaceuticals for all eligible patients enrolled in The Alliance.  No patients other than Alliance patients are served through these pharmacies (i.e. no Medicaid or private insurance prescriptions are filled there.)  These pharmacies are intended to serve not only Alliance patients within the Unity primary care network, but also all Alliance patients who are served through the Non-profit Clinic Consortium (NPCC) Health Centers, private physicians, and those patients who are discharged from hospitals.  Again, I want to emphasize that Unity’s role in the pharmacy system is to manage and staff the pharmacies, for which we get an annual fee under the terms of our Alliance contract.  Unity does not determine eligibility, it does not establish the drug formulary, it does not purchase or pay for the medications.

DOH and The Pharmacy

The medications are purchased and paid for by the Department of Health (DOH) through an arrangement with the Department of Defense (DOD).  Unity’s pharmacists working in collaboration with DOH staff, stock the pharmacies with drugs that are pre-approved on the formulary established by a Pharmacy Committee working under the direction of DOH.  Unity has installed a computer system that provides connectivity between all sites, confirms eligibility once determined by The Alliance, and is capable of generating the necessary reports required by the Health Care Safety Net Administration (HCSNA).

Pharmacy Utilization

There is little doubt about the importance that quality pharmaceuticals play in the therapeutic process of all patients, but especially those in The Alliance, because many within this group are sicker than the population in general.  In the long run, it has been proven that early intervention with the proper medications can reduce more expensive use of hospitalizations and emergency rooms.  It is my personal belief, and that of all my medical staff, that increased access to quality medications improves health outcomes, enhances continuity of care, and ultimately reduces costs.  However, initial up front cost are high.  One of the most expensive drivers in health care today is the cost of pharmaceuticals, but like all prevention methods, whether it be in the area of crime or health care, we aren’t always able to see the long term benefit, in the short run.  As the HCSNA Annual Report indicates for the first year of services: “one of The Alliance’s primary goals is increasing prescription access to the uninsured.”  I am proud that we in Unity as a partner within The Alliance have achieved this in the first year of operation with roughly an 11% increase over previous utilization in the PBC system.  In the current year we anticipate utilization to be higher because we have added a pharmacy at Upper Cardozo Health Center to the system.  This site has only been operational since December 2002 and already we are seeing a much higher volume of patients and prescriptions dispensed than anticipated.

Pharmacy and the Elderly

The status of the elderly receiving medications under The Alliance has been inconsistent at best over the 18 month history of The Alliance.  There have been periods of uncertainty regarding enrollment and eligibility for Medicare recipients that has contributed significantly to “gaps in service” for this population.  Because of the manner in which The Alliance contract was structured by the Control Board, Medicare recipients were deemed ineligible for The Alliance because they were considered to be an insured class.  However, as we know, Medicare does not cover prescription drugs, and therefore Medicare recipients unable to pay for expensive medications, and in some cases requiring multiple prescriptions, are unable to access a very important therupeutic component for their health and welfare.  This problem was exacerbated by the fact the Medicare recipients prior to The Alliance, in the PBC system, were able to access these medications without any limitations on income.  The income criteria and the non-insurance status required for Alliance membership established by the Control Board, rules out Medicare recipients from access to pharmaceuticals.

However, through a series of Administrative decisions by DOH personnel, a group of Medicare recipients approximately 520, were allowed to receive “pharmacy benefits only” under The Alliance.  This number was drawn from the original list of PBC members who were Medicare recipients and who subsequently applied for and received membership in The Alliance.  It is not clear how many of the 520 individuals are actually accessing benefits, and the financial income of those 520 is unclear, some may be 100% of poverty and below, some could be 100% to 200% and some could be 200% and above.  Their determining characteristic is that all had previously received pharmacy benefits under the PBC.  It should be noted this is not the universe of Medicare recipients who received benefits under the PBC, that is closer to 1,500.  This current cadre of Medicare eligibles (about 520) are now eligible for medications under The Alliance program.  This number does not include the over 65 population whose income enables them to access medications because they are also Medicaid eligible.  It is estimated that the pharmacy costs for serving this “520 number” is roughly $400,000 per annum.  This number does not include those who have already become eligible for Medicare since The Alliance was initiated.

The plan currently underway is to transfer this population over the next four (4) month period to a D.C. Pharmaceutical Resource Center (DCPRC), whereby they will be enrolled in a patient assistance program, and thus allow them to access free medications for chronic illnesses, from major drug companies who offer such programs.  The DCPRC is sponsored by DOH under a grant from Community Voices, in collaboration with the D.C. Primary Care Association (DCPCA), and will be operated by the Archdiocesan Health Care Network of Catholic Charities (AHCN).  I want to take this opportunity to compliment all the individuals and agencies involved in helping bring the DCPRC into existence, and I believe that it is one step in the right direction to address the critical needs of seniors on Medicare who lack pharmacy benefits.  The transition period from Alliance to DCPRC will address such issues as:

·        Income levels

·        Continuity of patient care

·        Adequate access to medications during the transition period, i.e. 60/90 day coverage until the DCPRC system takes over

The concept of the DCPRC is not new, many physicians and community clinics have been utilizing patient assistance programs on behalf of their patients for years.  What is different, is that the laborious paperwork and administrative screening process, along with knowing the eligibility requirements for each drug company will be conducted at one central location by the staff of AHCN.  The DCPRC will address some of the needs of our seniors.

However, I must also add a caveat here, I do not believe that a DCPRC type program is a substitute for a system of care required to address a large population who lack access to pharmaceuticals.  The DCPRC can serve as an excellent pilot program, and the targeted number is currently 600 patients.  However, last year alone in the Unity network, we served over 2,200 Medicare only patients, of which 1,300 were at former PBC sites.  Many of these patients were between 100%-200% of poverty, and even those above 200% would be heavily burdened to have to pay for the multiple medications that they require for their illnesses. 

I believe that the DCPRC will be most successful if it is not perceived as “the system of care” for the pharmaceutical needs of our seniors, but if it is a supplement to a system of care that guarantees care for our most vulnerable seniors.

Provision of prescription drugs for Medicare patients is a national problem.  The current Federal Budget for F.Y. 2004 attempts to address this issue.  But I must add it is very limited and the only way that patients could access this benefit is through enrolment in a Medicare Managed Care Program, and to date the experience of seniors with Medicare Managed Care has been poor at best.  I do not believe we will see any significant relief to this problem on the Federal level.

The DCPRC, and similar patient assistance programs are a supplement but I don’t believe they are a solution.  There are risks with the PRC type programs including:

·        Possibility of disruption in patient care

·        Lack of access to all necessary drugs for seniors with an emphasis on chronic care drugs only

·        The “fickleness” of the drug companies in withdrawing certain drugs from their patient assistance programs once a market and a patient/physician loyalty has been developed toward that drug.

·        The high volume of patients who need such medications could not be served by a PRC system that has limited staff and limited resources.

·        I am concerned about the sustainability of the PRC beyond December 2003 when funding runs out even though I know that DCPCA will work hard to secure ongoing funds.

Absence, a strong federal commitment to this issue, and given that The Alliance contract at least is implicit that “Medicare recipients” should not receive any benefits under The Alliance, I strongly recommend that you, Ms. Allen through your Committee on Human Services insure the inclusion of targeted resources in the F.Y. 2004 budget to address this problem.  We in the non-profit community will continue to seek every means possible to secure medications for this vulnerable population which given the current state of the economy will increase as more and more Medicare patients come onto the rolls.  But without resources our efforts are patchwork at best.

The single biggest complaint that I have heard from Unity providers and pharmacists over the past 18 months of The Alliance operation has been the inconsistency and inadequacy of access to medications for the Medicare population.  I am here today as much to advocate for my staff that feel their patients are being compromised through lack of such medications.  They are excited about the possibilities of the DCPRC, but they too would like to see an additional system of care, adequately funded to address this issue.