HealthRight Rx — The Sigmond Papers

HealthRight Rx

Increasing Access to Prescription Medications

through Patient Assistance Programs

Jarone Lee

April 2003

A Community Based Masters Project presented to the faculty of Drexel

University, School of Public Health in partial fulfillment of the

requirement for the degree of Master of Public Health.

AWKNOWLEDGMENTS

CBMP Committee:

Linnette Black

Robert M. Sigmond

Special Thanks to:

Raymond Lum

Dennis Gallagher

Lauren Goldstein

Donna Brian

Bernice Clark

Friends and Family

TABLE OF CONTENTS

LIST OF TABLES Page iv

ABSTRACT Page v

INTRODUCTION/SPECIFIC AIMS Page 1

BACKGROUND AND SIGNIFICANCE Page 3

DESIGN AND METHODS (WORKPLAN) Page 13

RESULTS Page 17

DISCUSSION Page 34

CONCLUSIONS AND RECOMMENDATIONS Page 39

LIST OF REFERENCES Page 43

APPENDIX A: Abbreviations Page 46

APPENDIX B: Description of RxAssist Plus Page 47

APPENDIX C: HealthRight Rx Materials Common to All Pilot Sites Page 49

APPENDIX D: Pilot Materials for Temple Health Connection Page 53

APPENDIX E: Pilot Materials for Eleventh Street Page 61

LIST OF TABLES

TABLE A: Development Timeline for HealthRight Rx Page 16

TABLE B: Programs Contacted for the Development of Page 18

HealthRight Rx

TABLE C: How HR Providers Offer Medications to the Page 25

Uninsured and Under-insured

TABLE D: Expansion Timeline for HealthRight Rx Page 30

ABSTRACT

HealthRight Rx: Increasing Access to Prescription Medications through Patient Assistance Programs

Jarone Lee, Student

Robert M. Sigmond, CBMP Chair

Objective: Access to prescription drugs is a major health care policy issue facing the United States. With few long-term national solutions on the horizon for the uninsured and the non-Medicare under-insured, many Americans must look increasingly to state and community-level solutions for access to prescription drugs. This Community Based Masters Project (CBMP) outlines an initiative and poses a set of related policy recommendations that address this problem. The initiative and policy recommendations are aimed at systematically assisting Philadelphias safety-net providers to take better advantage of the pharmaceutical industrys programs that offer free prescription medications to disadvantaged individuals Patient Assistance Programs (PAPs). The project was developed for HealthRight, Inc., a federally funded community agency comprised of North Philadelphias safety-net providers.

Methods: This project involved three steps: (1) Assessing potential challenges and solutions by examining current literature, initiatives in other communities, and the current landscape of Philadelphias safety-net providers; (2) Designing a program based on this assessment for a multi-provider environment, in which qualified patients can be systematically enrolled in PAPs; and (3) Planning and successfully implementing a pilot program at two sites.

Results: Through negotiations between HealthRight and health care providers, a program for enrolling patients in the PAPs, called HealthRight Rx, was created and successfully tested at two pilot sites. The process was built to be as patient and provider friendly as possible. After a month and a half of piloting, HealthRight Rx has assisted 19 patients with 53 separate PAP applications.

Conclusions: HealthRight Rx represents an effective approach to accessing PAP drugs that can be readily replicated throughout the Philadelphia area and beyond. Furthermore, the success of the pilot projects demonstrate that even during a period of limited resources, there are real opportunities and resources available for collaboration between community-based organizations and committed health care providers to provide for disadvantaged populations.

INTRODUCTION/SPECIFIC AIMS

According to the Kaiser Family Foundation, approximately 25% of the United States (US) population has no insurance coverage for prescription drugs (Kaiser Family Foundation, 2001). Of this 25%, a little over half are uninsured, with the rest under-insured (Kaiser Family Foundation, 2001; US Census Bureau, 2002). With few long-term solutions on the horizon for providing prescription drug coverage to the uninsured and the non-Medicare under-insured, these figures are expected to rise. To address this growing need for prescription drug access, most pharmaceutical companies have Patient Assistance Programs (PAPs) that offer free prescription medications to the disadvantaged (PhRMA, 2003b). Unfortunately, because of the time-commitment required to enroll patients into PAPs, health care providers in Philadelphia make little to no use of them. Many patients are left to find their own means for obtaining medications.

HealthRight (HR), a non-profit organization comprised of North Philadelphias safety-net providers, aimed to increase use of PAPs among its provider network to treat chronically-ill patients. Based on this goal, the following three steps were carried out for this Community Based Masters Project (CBMP):

Examination of existing models and programs across the nation aimed at increasing access to prescription pharmaceuticals for the indigent, with an emphasis on PAPs;
Design a program based on the information gathered;
Plan and implement a pilot project at two sites to work systematically with PAPs.

BACKGROUND AND SIGNIFICANCE

Access to Prescription Medications: A National Problem

The number of prescription drugs dispensed in the United States nearly doubled from 1.8 billion to 3.0 billion between 1992 and 2000 (Kaiser Family Foundation, 2001). Overall, the average retail price of a prescription drug rose at a greater rate than general inflation, from $22.06 in 1990 to $45.79 in 2000 (Kaiser Family Foundation, 2001). As the use and the cost of drugs rose, health plans have shifted drug costs to the insured consumer by raising premiums and/or copays. Confronting these higher insurance costs, many consumers will either be forced to join health plans with little to no prescription drug coverage or drop their health insurance coverage completely.

This growing population of uninsured and under-insured are charged retail prices for their drugs without the deep discounts that are made available by drug manufacturers to health insurers, pharmacy benefit managers, and large volume drug purchasers. Ultimately, the uninsured will find themselves paying the highest retail prices for prescription medications, in turn forcing them often to limit or forego use of prescription drug treatments.

Barring any major national solution, many Americans will have to rely increasingly on safety-net providers for medications. These safety-net providers in turn depend heavily on drug samples (Richardson, 2003; Volunteers in Health Care, 2001). Unfortunately, the limited supply of drug samples only offers an effective short-term solution.

In addition to drug samples, a few community-based health care centers have sufficient financial resources to offer their uninsured and under-insured patients comprehensive access to medications. This method involves dispensing medications to the patient at a reduced price or free of charge. The health care centers absorb a majority of the costs. To help reduce the burden of this cost, there are two drug-discounting options that can be explored:

(1) Bulk Purchasing Programs (BPPs): Bulk Purchasing Programs (BPPs) are programs created to offer discounted drug pricing to eligible parties. Currently, there is one federal BPP that sets a ceiling-price on drugs sold to eligible safety-net providers. This particular program was established by section 340B of the Public Health Service Act (PHS) and then amended by section 602 of the Veterans Health Care Act (Office of Pharmacy Affairs, 2002). As a result, this program has collected a myriad of names 340B, 602, PHS, discount, and ceiling pricing (Office of Pharmacy Affairs, 2002).

(2) Private Negotiations: Another method to assist community-based health care providers with their prescription drug costs is through direct negotiations with drug distributors and manufacturers. Some drug distributors (especially local private pharmacies) are willing to enter into agreements to better serve the disadvantaged. One good example is the Middlesex (Connecticut) Community Access Program (MCAP). MCAP, as a not-for-profit clinic serving the uninsured, has a strong relationship with a nearby private pharmacy. Through collaboration and a strong philanthropic commitment to providing for the underserved, this pharmacy provides free and inexpensive medications to its uninsured population.

In addition to negotiating with drug distributors, providers can also enter into agreements with drug manufacturers. Similar to MCAPs collaboration with a local pharmacy, the West Virginia Health Right (WVHR) has successfully contracted with a local drug distributor. The agreement provides WVHR with pricing similar to, and at times better than those offered by 340B.

Unfortunately, even with drug discounts there is a real risk that health centers will not be able to sustain the financial burden of paying for medications much longer.

Another Option for Safety-net Providers: Patient Assistance Programs

Another cost-effective option that safety-net providers can explore is to tap into Patient Assistance Programs (PAPs). PAPs are programs created by the pharmaceutical industry that offer low-income individuals time-limited supplies of needed prescription medications for free.^,

The first program was created in 1978 by Stuart Pharmaceuticals for their breast cancer treatment drug, Nolvadex (AstraZeneca, 2003a; Kunsio, 2003). At that time, Nolvadex had just become available on the market and, as a result, was expensive and not covered by most health plans (AstraZeneca, 2003b; Kunsio, 2003). Responding to physicians advocating for patients who could not afford Nolvadex, Stuart Pharmaceuticals created a program that offered Nolvadex for free to low-income individuals (AstraZeneca, 2003a; Kunsio, 2003). Following this success, many physicians and patient advocates began lobbying other pharmaceutical companies to create similar programs (Bell, 2003; Kunsio, 2003). With the creation of more programs, there followed a culture shift in the pharmaceutical industry towards philanthropic care. PAPs not only provided tax-deductions for the drug companies though their respective foundations, but also built better relationships with many physicians and communities (Bell, 2003; Kunsio, 2003). As a result, there currently are over 130 pharmaceutical company programs offering over 862 different medications through PAPs (Needy Meds, 2003; PAPrx, 2001; PhRMA, 2003a).

Each PAP is independently operated by the pharmaceutical companys foundation (e.g. AstraZeneca Foundation) which, because of anti-trust laws, is not allowed to have a direct connection with the business unit or other programs (Bell, 2003; Kunsio, 2003). As a result, the application process and eligibility requirements vary greatly depending on the PAP, making enrolling patients in these programs very work intensive. Furthermore, PAPs generally provide only a 90 day supply of medications, so patients requiring long-term supplies must continually reapply. Because most safety-net providers do not have the staff and time available to devote to working systematically with these programs, they make only sporadic use of them. Yet, by enrolling qualified patients into PAPs, many providers can move away from depending on drug samples. Some providers may also be able to reduce the financial burden incurred from directly purchasing medications for their disadvantaged patients, especially the chronically-ill.

Based on these advantages, the national use of PAPs rose steadily from 1.1 million patients serviced in 1997 to 3.5 million patients serviced in 2001 (PhRMA, 2003b). However, 3.5 million represents only a small fraction of patients who are in need and eligible for these programs. As is the case nationally, many of Philadelphias safety-net providers currently make little to no use of PAPs. Though under-utilized, PAPs represent an invaluable resource for both individual patients and health care providers, and thus present a unique opportunity for expanded use in Philadelphia.

Philadelphia Environment: Patient Assistance Programs

In 1977, Philadelphias only public hospital (Philadelphia General Hospital PGH) closed and left Philadelphias indigent population in the care of eight city-run municipal health centers (District Health Centers DHCs), not-for-profit community-based health centers (e.g. Federally Qualified Health Centers), and area hospitals (City of Philadelphia, 2003). The fallout of PGHs closure resulted in the DHCs and not-for-profit health centers providing the bulk of primary care services to the indigent, with specialty service referrals to area hospitals.

Interestingly, a side-effect of this new system was that the DHCs and the financially-able community-based health centers not-for-profit federally-qualified health centers (FQHCs) became the primary dispensaries of medications to Philadelphias disadvantaged. This resulted because of some important changes made in the health care delivery environment during the 1980s and 1990s: (1) the cost-conscious use of managed care to shift the focus of health care services from in-patient to out-patient primary care (e.g. physician gatekeepers); (2) the steady increase in the number of uninsured and under-insured; (3) the progressive use and reliance on prescription drugs for patient care; and (4) the steady rise in drug costs (Lee and Estes, 2001; Stevens, 1989; Starr, 1982).

Currently, the DHCs dispense approximately 560,000 prescriptions, which cost the City approximately $10 million annually (Benson, 2002). In an attempt to reduce this financial burden, the DHCs and some not-for-profit FQHCs have begun exploring various methods to cut their prescription drug expenditures e.g. BPPs, Private Negotiations, and PAPs. Some safety net providers have already enrolled in or begun enrolling in the 340B drug purchasing program, while others entered into agreements with local pharmacies to receive discounted drug pricing.

Some Centers also use PAPs, but in these Centers few eligible patients are enrolled and only for a few medications. Yet, by increasing enrollment of qualified patients into PAPs, these Centers will be able to provide needed medications to their disadvantaged patients. Furthermore, the DHCs and some not-for-profit FQHCs can reduce the financial burden incurred from directly purchasing medications for patients who are qualified for PAPs. As a result, there is a need to create a centralized program that Philadelphias safety-net providers can use to systematically enroll patients into, and thus take full advantage of, PAPs.

HealthRight, Inc. and Patient Assistance Programs

HealthRight (HR) is a federally-funded 501(c)3 organization structured as a consortium of Philadelphias safety-net providers, established to design and implement a model system of health care for the chronically-ill uninsured in North Philadelphia. By assisting HRs network of safety-net providers gain access to free and low-cost medications through the PAPs, HR will ultimately improve the quality of care rendered, improve access to medications, and reduce the financial burden of providing care to the uninsured.

HRs consortium is comprised of DHCs, not-for-profit FQHCs, hospitals, and nurse-managed primary centers. Currently, the following providers have made commitments to HRs goals:

District Health Centers Community Health Center 5, Community Health Center 6, and Strawberry Mansion;

Federally Qualified Health Centers Fairmount Primary Care Center, Maria del los Santos Health Center, Hunting Park Health Center, Broad Street Health Center, Quality Community Health, Covenant House, and Hope Clinic;

Hospital Systems Albert Einstein Medical Center, Temple University Health System, and North Philadelphia Health System;

Nurse-Managed Primary Care Centers La Salle Nursing Center, Association de Puertoriquenos en Marcha (APM) Community Nursing Center, Temple Health Connection (THC), and Eleventh Street Family Health Services of Drexel University (Eleventh Street).

Grants from the federal governments Community Access Program (CAP) are the primary source of funding for HR. CAP grants are awarded by the federal government to communities that are actively designing and implementing more coordinated, efficient, and cost-effective health care systems for the uninsured (Health Resources and Services Administration, 2002). The CAP grant provides only limited funds for direct services to patients. Nevertheless, the network of providers assists HR enrollees with access to the following services (Health Federation of Philadelphia, 2000):

assistance with gaining access to the health insurance market (public and private programs);
designation of a medical home for primary care;
access to hospital-based specialty services;
access to acute care services;
access to mental/behavioral health (psychiatric, substance abuse, and counseling); and
care-coordination/management (social services, coordination of referrals and services, and compliance support).

HRs service area is Central North Philadelphia within the following contiguous zip codes 19120, 19121, 19122, 19123, 19125, 19126, 19130, 19132, 19133, 19134, 19140, 19141, and 19144. The adult population of this target service area is 229,851, or 27% of the Citys adult population (Health Federation of Philadelphia, 2000; Health Strategies & Solutions, 2002). The target population is uninsured adults between the ages of 19 and 64, diagnosed with diabetes (ICD 250-250.9), chronic respiratory (ICD 460-519) or cardiovascular disease (ICD 390-459) an estimated 12,000 persons (Health Federation of Philadelphia, 2000; Health Strategies & Solutions, 2002). It is the poorest section of the City, with the highest proportion of unemployed, uninsured and chronically ill persons, and is home to most of the citys immigrant and refugee populations (Health Federation of Philadelphia, 2000). Within this community, 61,600 reported having high blood pressure, 23,215 reported having asthma, and 15,630 reported having diabetes (Health Federation of Philadelphia, 2000). Overall, 28,000 adults reported being uninsured, of which 17,300 (62%) had incomes below 150% of the federal poverty level (Health Strategies & Solutions, 2002).

As is the case nationally, the majority of the uninsured are employed 44% claiming full-time and 18% part-time employment (Health Federation of Philadelphia, 2000; Health Strategies & Solutions, 2002). However, many of these adults have low paying jobs that do not offer health insurance or affordable alternatives. In recent years, there has been a significant increase in the number of area businesses that do not insure their workers. Based on a 2000 survey of 228 small-business employers in North Philadelphia, none of the firms provided health insurance to all of their employees, with a staggering 75% not offering coverage at all (Health Federation of Philadelphia, 2000; Health Strategies & Solutions, 2002). High cost was the primary reason cited (Health Federation of Philadelphia, 2000; Health Strategies & Solutions, 2002). Through HR providing better coordination of care, health promotion activities, and access to a full continuum of care, the chronically-ill members of this population should be able to better control their health needs and reduce the financial burden on the providers. Ultimately, HR hopes to implement its program across all of Philadelphia.

DESIGN AND METHODS (WORKPLAN)

Overview

This project designed and planned a pilot HealthRight Rx, a program that encourages and assists HRs providers to work systematically with PAPs.

Target Population

The program was designed for HRs target population as described previously.

Methods

HealthRight Rx was created in a succession of stages: (1) reviewed background literature; (2) researched current best practices of other programs; (3) determined what is being done by HRs providers; (4) developed a range of options that HRs providers can use based on what was learned; (5) planned and assisted with the implementation of pilot projects; and (6) prepared a plan for expanding the pilot project to all HR provider sites, and ultimately citywide.

Stage (1): Background literature review involved conducting a review of programs across the nation that are designed to increase prescription drug access for the indigent. The review was not limited to programs using PAPs, but also examined programs that used BPPs (e.g. 340B) and those that had private agreements with drug distributors.

Stage (2): Using the list of programs gathered, we (my HR colleague, Lauren Goldstein and I) then examined the current best practices of these programs. This stage required identifying programs that worked specifically with PAPs. Many programs were created and designed to work with specific health care provider groups or populations e.g. hospital systems or diabetics respectively. Undoubtedly, we learned much from these programs. However, we wanted to design a program that can be used in a multi-provider setting, so we identified and sought out third-party type programs with expansive provider networks. HRs access to other CAP grantees played an invaluable role during this stage.

Stage (3): Concurrently carried out with Stage 2, in this stage we determined how HRs providers are providing medications to their uninsured and underinsured populations. We created a database containing information on the use of PAPs, 340B, and private agreements with drug distributors.

Stage (4): Next, we developed a range of options based on what was learned in the previous stages. Based on this information, we formulated different options for how the HR providers can better use PAPs. The options ranged from having most of the workload centralized at HR to most of the workload shifted to the providers. We also selected one HR provider that would be the best site for the pilot project.

Stage (5): With a variety of options formulated and a site chosen, we then began planning a pilot project. We worked with the administrators and health care providers to develop a flow-process for how best to enroll their patients in PAPs. The pilot helped us iron out many important details, thereby providing guidelines that will be useful for expanding to other HR sites. Because of the time-constraints of this project, we were only able to assist with the implementation of two pilots.

Stages (6): The last phase of this project was to develop a plan for expanding the pilot to all the HRs providers and eventually city-wide.

Timeline

Table A shows the timeline for the development of HealthRight Rx.

RESULTS

Background Research/Other Programs

After an initial literature and environment review, we identified 28 communities that were in some stage of developing a pharmaceutical access program. These communities were found through two resources: (1) HRSAs Field Office and (2) Health Research and Educational Trust (HRET) listserv.

HRSAs Field Office: Because of HRs CAP grantee status, we received much needed assistance from Philadelphias HRSA field office. Dennis Gallagher, the HRSA program officer for HealthRights CAP grant, was especially helpful. Mr. Gallagher was able to put us in contact with other regional CAP grantees that were working with PAPs.

HRET listserv: An email, requesting information from other programs, was sent to the American Hospital Associations HRET listserv. The HRET listserv put us in contact with many people who were part of functional programs that used PAPs to provide medications to the indigent. Table B lists the programs contacted for the development of HealthRight Rx.

From conversations with staffs of the programs in Table B, the following obstacles were identified for setting up a PAP processing system in a multi-provider setting similar to HRs:

Complex Application Handling The most prominent obstacle that all the programs in Table B encountered was their inability to find an efficient method for completing the application forms for individual patients. This is a unique problem for programs that are off-site from the provider (e.g. HR). Off-site programs had to find the most efficient method of gaining signatures, income verification materials (e.g. tax returns and W2s), original prescriptions, and other needed materials from the prescriber and patient. This required good patient and provider education, as well as strong working relationships with the providers. Off-site programs identified two major bottleneck points: (1) provider-level bottleneck and (2) patient-level bottleneck.

Provider-level bottleneck At minimum, all the applications require the providers original signature and license information. With very busy schedules, the provider can often neglect, lose, or misplace the applications. As a result, many programs have experienced delays in submitting the applications. The most common remedy for this problem is to continually remind the prescriber with a call or a visit until the application is completed. More often than not, programs only get involved with filling out the applications and do not follow up with the provider.
Patient-level bottleneck Similar to the provider-level bottleneck, all the applications require at least the patients original signature. Many of the applications require extensive financial information and proof of income (e.g. tax-returns and W2s). At some point, all this information must be gathered and included with an application. However, this bottleneck is not as big of a problem as the provider-level bottleneck. This is because most programs that assist with PAPs have processes that are patient-initiated. As a result, the patients are adamant about completing the applications and produce the needed documents quickly.

One solution that some programs have used to overcome these bottlenecks is to gain power-of-attorneys from the patient and/or prescriber. By allowing for an authorized signature by a third party, this eliminates the hassle of gaining signatures so that PAPs can be completed without a face-to-face visit with the patient and/or prescriber.

Changing Application Forms, Eligibility Requirements, and Programs Changing application forms, eligibility requirements, and programs are a major problem. Changes take place for many reasons drug company mergers, funding changes, application form updates, etc. Unfortunately, in general the drug companies do little to notify the beneficiaries and applicants of PAPs regarding changes. There are many anecdotal stories of patients waiting for medications, only to find out months later that their application was rejected due a change in the form.

Fortunately, there are computer databases available to help keep up with the changes. Some databases charge a nominal fee for each application accessed, while others are available for free. The two commonly used free databases are: (1) RxAssist and (2) Needy Meds. RxAssist is available through Volunteers in Health Care, a not-for-profit organization committed to providing for the uninsured (Volunteers in Health Care, 2003a). However, RxAssist is relatively new and as a result is not as comprehensive as some of the commercial databases. Needy Meds is a website-based database containing most of the current medications and applications. Needy Meds is regularly updated and is available to anyone with access to the internet (http://www.needymeds.com). Many not-for-profit programs across the nation concurrently use RxAssist and Need Meds to help their patients. Generally, drugs and PAPs that RxAssist lacks can be found on Needy Meds and visa versa.

Reapplication Process Similar to the wide variation in the PAP application processes, there is also great variation in the reapplication process. Some programs require the patient to resubmit income verification annually, while others require resubmission every few months. One program also has break periods in the medication allotment. The medications are offered in "3 month on and 1 year off" intervals. Most programs address this issue by setting up a database to track when patients need to reapply.

Delay of Initial Supply of Medications Another major problem identified is the two to three month delay before the first round of medications is received. This is especially problematic for patients in need of life-sustaining medications. As a result, many other programs have made emergency funds or emergency supplies of medications available to patients during this gap period.

Distribution of Medications Once a patient is enrolled in a PAP, the medications have to be delivered and distributed. In most cases, distributing the drugs becomes the responsibility of the provider site. As a result, the provider has to be committed to handling, tracking, and distributing the medications. Depending on the provider, this could require a big time-commitment. Small clinics and practices can handle the medications similar to drug samples, except that each drug received must go to one specific patient. These smaller sites also know the patients well and should have little problems distributing and tracking the medications. Larger clinics with an in-house pharmacy will also have less difficulty because they should already have systems to handle the new medications. Medium-sized clinics without an in-house pharmacy will have the hardest time adjusting to this extra burden. Medium-sized clinics are big enough to see a large population of patients eligible for the PAPs, but too small to have the extra staff required to handle the drugs. Many of HRs provider sites fall in this group. As a result, distributing drugs will become a greater issue as HealthRight Rx expands beyond the initial pilots.

In addition to these process issues, a few unique considerations that were brought up by some of the programs:

Provider Prescribing Habits Enrolling individuals in the PAPs will require some safety net provider sites to add brand-name medications to their formularies. For example, patients with hypertension, who had previously received generic medications through the health centers charity efforts, can now receive a continuous supply of brand-name medications through one of the PAPs. This saves the patient and the health center money, but will also change the providers prescribing habits. So instead of prescribing a clinically equivalent generic, the provider will prescribe the brand-name drug, counteracting the cost-conscious behavior of prescribing cheaper generics over expensive brand-names.

Privacy of Patient Information Because PAP applications require confidential patient information, many programs transfer patient information electronically (fax, email, and/or internet) to complete the applications. With the privacy standards from the Health Insurance Portability and Accountability Act (HIPAA) regulations coming into effect on April 14, 2003, measures have to be taken to ensure privacy of patient information. Programs have raised this issue not as a major problem, but instead as something to take into consideration.

Quality of Care Enrolling individuals in the PAPs could result in uninsured patients receiving a perceived higher level of medical care than the insured, or others who could not qualify for PAPs. For example, the PAPs allow for uninsured patients to receive drugs like celecoxib for arthritis, while their insured counterparts receive ibuprofen for the same conditions. This perceived inequality could create an ethical dilemma for those working at increasing equity in healthcare.

HealthRights Providers

Table C shows what HRs providers are currently doing about providing medications to their uninsured and under-insured patients. HRs providers were asked about five different options: (1) use of drug samples (DS); (2) use of PAPs (PAP); (3) participation in bulk replenishment PAPs (BRP); (4) agreements with drug distributors through private negotiations (PN); and (5) participation in 340B (340B).

Hospitals  Officials at both the North Philadelphia Health System (NPHS) and Temple University Health System (TUHS) stated that they tap into PAPs when possible. In addition, officials at Albert Einstein Healthcare Network (AEHN) and TUHS said that uninsured and under-insured patients upon discharge are given short supplies (3 days and 7 days worth respectively) of drugs and a referral to a DHC. We were not able to find out if TUHS had private agreements with local pharmacies for their uninsured and under-insured patients.

Non-Hospital Providers Many of the other HR provider sites report use of PAPs. However, they all report that they have no formal process for using the PAPs. As a result, there is only limited and sporadic use. An administrator at Delaware Valley Community Health (DVCH) stated that it has social workers that help patients apply for PAPs. However, the social worker only helps with the PAPs when time permits. In addition, the centers that assist patients with PAPs only assist with a few programs. For example, staff at Spectrum Health Services (SHS) only helps patients apply for the GlaxoSmithKline Beecham and Merck PAPs.

Piloting HealthRight Rx

The HealthRight Rx pilot began at two provider sites on February 25, 2003: (1) Temple Health Connection and (2) Eleventh Street Family Health Services of Drexel University (Eleventh Street).

Pilot Site 1: Temple Health Connection (THC)

Contact: Dr. Donna L. Brian, Director

Address: 1035 West Berks Street, Philadelphia, PA 19122

Phone: 215.765.6690

Fax: 215.765.7694

THC is a small nurse-run primary care center located in the heart of North Philadelphia. It has served approximately 500 patients, with an estimated 20-30 patients that could benefit from PAPs. The staff at THC is very dedicated to their community and patients and their administrative director, Dr. Donna Brian, was very accessible and interested. As a result, THC became the first pilot site.

Through discussions with Dr. Brian, we developed a process for HealthRight Rx and distributed the work involving use of PAPs according to the needs of THC. Currently, THC identifies a patient in need of HealthRight Rx and faxes the patients phone number and list of medication to HRs main office. We decided that using a sticker was the best method for helping the THC staff identify that a patient was getting medications through HealthRight Rx. The sticker was tailored to THCs patient medication form. Appendix D includes a copy of the stickers created and how they look on THCs patient medication form.

Once a patient is identified by THC, HR staff will then call to fill out the enrollment application form for HealthRight Rx (Refer to Appendix C). The enrollment application contains the most commonly asked questions on PAP applications. Based on the information on the common application form, HR staff will check the availability and eligibility of the patient for the drugs needed. Using RxAssist, applications for a patient are printed out and filled out as completely as possible. A coversheet is then generated with specific instructions on what THC staff and the patient must do to complete the application (example in Appendix C). The filled-in applications and coversheet are then hand-delivered to THC. The THC staff will complete the applications, mail them off, and subsequently dispense the medications. Refer to Appendix D for the specific details about the agreed upon process.

In order for the patient to receive a continuous supply of drugs, the patient needs to resubmit application materials every few months. As a result, another major component of HealthRight Rx is to track the dates a patient needs to resubmit the PAP applications. For this pilot, we are tracking the dates both on paper and electronically. Refer to Appendix C for the paper form used to track the reapplication dates. Electronic tracking is done through RxAssist. Since RxAssist stores the patients medication information in Microsoft Access format, we can easily regenerate reports listing when a patient needs to reapply.

Pilot Site 2: Eleventh Street Family Health Services of Drexel University

(Eleventh Street)

Contact: Bernice L. Clark, Family Nurse Practitioner

Address: 850 West 11^th Street, Philadelphia, PA 19123

Phone: 215.769.1100

Fax: 215.769.1119

Similar to THC, Eleventh Street is a small nurse-run primary care center located in North Philadelphia that sees approximately 400 patients. The clinical staff consists of only 1.5 certified nurse practitioners, 1 registered nurse, 2 medical assistances, and 1 mental health professional. The staff at Eleventh Street was very accessible and interested. As a result Eleventh Street became the second pilot site.

The process for piloting HealthRight Rx at Eleventh Street is similar to THCs process. Please refer to Appendix E for specific details.

HealthRight Rx Pilot Results

As of the beginning of April 2003, HealthRight Rx has assisted 19 patients with 53 separate PAP applications. On March 11, 2003, the first patient received medication through HealthRight Rxs assistance.

Expansion of HealthRight Rx:

A plan was created to expand HealthRight Rx beyond the two initial pilot sites.

Expansion will be done in three phases as shown in Table D: (1) Staff Recruitment; (2) HR-Wide Expansion; and (3) City-Wide Expansion.

Staff Recruitment The first phase involves recruiting a full-time director/manager and some volunteers and/or part-time staff for the program. The director will have the responsibility of not only working with the patients, but also the responsibility of exploring future directions for HealthRight Rx. This will involve building strong relationships with HRs providers and other organizations and agencies. Furthermore, the director will have to work with HRs Executive Director and Board of Directors to ensure the financial and administrative sustainability of the program.

In addition to hiring a director, recruiting volunteers and/or part-time staff for doing most of the patient work is integral to the sustainability of HealthRight Rx. Since working with the patients requires minimal technical skills, much of the patient duties can be done by part-time and volunteer staff. This will allow the director to concentrate on expanding and improving the program.

HR-Wide Expansion The second phase involves enrolling patients into HealthRight Rx from new HR provider sites. After many of the kinks with the process are worked out at the two pilot sites, HealthRight Rx should expand to the Hope Clinic. The Hope Clinic is slightly bigger than THC and Eleventh Street and as a result will generate a greater volume of patients. This will allow the staff of HealthRight Rx to get acclimated to working with a greater volume before expanding to the bigger multi-clinic sites. Starting a pilot with the Hope Clinic should take no more than one month.

Next, HealthRight Rx should consider expanding to Delaware Valley Community Healths (DVCH) two sites. Because DVCH is bigger and more complex than THC, Eleventh Street, and Hope Clinic, we estimate that it will take three months to work smoothly with DVCHs two clinics. Many lessons will be learned about working with multi-provider clinics from the DVCH pilot. Ultimately, this will make expanding to the other multi-clinic sites in HR simpler.

After DVCH, Hunting Park should be considered as the next expansion site because of its affiliation with Greater Philadelphia Health Action (GPHA). GPHA is one of the largest health care provider networks in Philadelphia. As a result, if HealthRight Rx is expected to expand city-wide, it would be beneficial to consider expanding to Hunting Park sooner, as opposed to later. This will make working with GPHAs other sites much easier in the future. Currently, Hunting Park is the only GPHA site within HRs geographic boundaries. However, as both HRs program and HealthRight Rx expand, many of GPHAs sites are expected to become part of HRs provider network.

At this point, HealthRight Rx will have enrolled a large number of patients. As a result, the director should consider recruiting more staff. Then, HealthRight Rx can expand to the rest of HRs provider network: the City of Philadelphias DHCs, APM Community Nursing Center; Covenant House Health Services; La Salle Neighborhood Nursing Center; and any new centers recruited to HRs network.

City-Wide Expansion Next, enrolling patients from non-HR clinics should be considered. In addition, there are many other points-of-entry that should be considered for patients into HealthRight Rx. For example, the Pennsylvania Health Law Project (PHLP) works with many patients who are in need of PAP assistance. As a result, HealthRight Rx should look into working the PHLP and other numerous community-based organizations in Philadelphia.

DISCUSSION

Summary of Results

Designing and implementing HealthRight Rx took approximately eight months, with the last two months dedicated to planning the pilot. Two small nurse-run clinics began piloting HealthRight Rx on February 25, 2003 THC and Eleventh Street. These were effective pilot sites because they conform to three major criteria. First, they both provided for a small and consistent patient population. This ensured that we were not overwhelmed by the number of patients. Second, both clinics had small staffs comprised of dedicated administrators and clinicians, where many of the clinicians doubled as administrators. This made it very easy to not only plan the pilot, but also communicate and fix problems that arose during the pilot. Third, both THC and Eleventh Street already had experience with PAPs, making for a smooth transition to piloting HealthRight Rx.

On March 11, 2003, the first set of medications was received by a patient enrolled in HealthRight Rx. As of the beginning of April, HealthRight Rx had assisted 19 patients with 53 separate PAP applications. The success of HealthRight Rx shows that even during a period of limited resources, there are real opportunities for community-based organizations and committed health care providers to provide for the disadvantaged if there is willing, meaningful, and carefully planned collaboration aimed at achieving that goal. As with prescription drugs, there may be many opportunities with other products and services available for the disadvantaged, which the busy and over-worked staffs of safety-net organizations do not have the time and/or skill to access.

Unique Characteristics of HealthRight Rx

Developing and implementing HealthRight Rx within HRs provider network and Philadelphias health care environment presented some unique obstacles. Unlike most programs in other cities, HR consists of many different types of health care providers. Some of the providers are small clinics serving a small patient population on an ongoing basis, while others are major institutions rendering care to a huge populace. As a result, HealthRight Rx had to be designed to handle variations in organizational structures, personalities, and cultures. We accounted for this by planning for a wide range of possible setups. For example, at some of the clinics, we would need to have a HR representative onsite to see the patients, while at other sites, we could deliver the completed PAP applications and follow-up every so often.

Funding Streams for HealthRight Rx

For HealthRight Rx to be sustainable, new and continual funding sources have to be identified and pursued. During the course of this project, we applied for a grant with the Philadelphia Foundation. As of the writing of this paper, the Philadelphia Foundation is still reviewing our grant application. Because of the recent attention to the uninsured and prescription drugs, there should be many grant opportunities available for programs like HealthRight Rx. Furthermore, once the program is better developed, additional funding sources should be available.

Expanding to Delaware Valley Community Health (DVCH)

Expanding HealthRight Rx to all HR providers should take a little over a year. The next major hurdle will be starting a pilot at Delaware Valley Community Health. DVCH was selected because it has only two clinics within HRs network, as compared to the City of Philadelphia with three and Quality Community Health Care (QCHC) with four sites. Spectrum Health Services (SHS) also has two sites affiliated with HR, but unlike DVCH, SHSs main site is not part of HRs network. Not having SHSs main site within HRs network would make SHS a difficult site in which to set up a pilot. As a result, DVCH seems to be the best site for the staff of HealthRight Rx to learn how to work with multi-clinic providers.

Also, DVCH would be the next logical site because HealthRight Rx offers an ideal fit to their use of 340B pricing for purchasing discounted drugs. This is because HealthRight Rx would enable DVCH to purchase drugs for their Medicaid patients through 340B, while enrolling their uninsured and under-insured patients in PAPs with HealthRight Rxs assistance. Thus, DVCH will not only realize the financial gains from their Medicaid patients through 340B pricing, but also reduce the financial burden of providing medications to their uninsured and under-insured patients.

Piloting at DVCH will take much time and effort because DVCH has two different clinic locations and a more complex administrative structure than THC, Eleventh Street, and Hope Clinic. Many issues that did not arise with the other pilot sites will become more prominent here. For example, there will be a greater need to have an explicitly defined process in place. Also, communicating issues and changing protocols will take longer to implement at DVCH than at the smaller one-clinic sites. However, once the DVCH pilot is up and running, expanding to the other multi-site providers will be simpler.

Expanding to the City of Philadelphia

Currently, the City of Philadelphia is pursuing external contracts for enrolling their patients into PAPs. Because the outcome of these negotiations is currently unknown, expanding to the City of Philadelphias DHCs was moved back on the timeline. Depending on what results, there might only be a limited role for HealthRight Rx in the DHCs. However, if the Citys negotiations fall through then the director for HealthRight Rx should consider expanding to the DHCs sooner.

Future Potential of HealthRight Rx

In addition to those served at the HR provider sites, there are many other populations of patients that can benefit from HealthRight Rx. In particular, attention could be directed at the large adult Medicaid population that does not have prescription drug coverage. The Pennsylvania Department of Public Welfare, and in particular the Philadelphia County Assistance Office, would be critical partners in expanding the reach of PAPs to this very vulnerable population.

Assuming that HealthRight Rx has successfully expanded city-wide, the director of HealthRight Rx should consider bringing HealthRight Rx to the attention of the legislators and public officials in Harrisburg. Following the examples of Florida and Hawaii, where the state governments have begun funding programs that assist qualified state residents with PAPs, HealthRight Rx could act as a focal point for such an initiative in Pennsylvania.

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CONCLUSIONS AND RECOMMENDATIONS

Access to prescription medications is a crucial issue currently facing the United States health care system. This problem affects not only the uninsured, but many of the insured as well. With few comprehensive solutions on the horizon, many Americans must look increasingly to community-based solutions for prescription drug access. In an attempt to address this need, HR designed and implemented HealthRight Rx to assist Philadelphias safety-net providers to take better advantage of PAPs. HealthRight Rx represents an effective approach to accessing PAP drugs that can be readily replicated throughout the Philadelphia area and beyond.

Based on the success and future potential of HealthRight Rx, the following health policy recommendations were developed with respect to sustainability and expansion of the program:

HealthRight Rx Sustainability
Recommendation #1: Maintain HealthRight Rx as an Internal Priority for HR

Until another solution arises to provide drug coverage to the uninsured and under-insured in Philadelphia, there is a great need for HealthRight Rxs services. Recognizing this fact, HR should make the sustainability and expansion of HealthRight Rx a priority.

Recommendation #2: Recruit a Full-time Director/Manager

Recruiting a full-time director/manager will greatly increase the sustainability of HealthRight Rx. The director must focus not only on improving patient care, but also on planning the future direction of the program.

Recommendation #3: Recruit Part-time and Volunteer Staff

In addition to recruiting a director for HealthRight Rx, efforts should be put into recruiting part-time and volunteer staff that will help with the work with patients. Since filling out PAP applications requires only a minimal skill level, much of the duties with patients can be done by part-time and volunteer staff. Ultimately, this will allow the director more free time to plan and develop the long-term strategy of the program.

Recommendation #4: Look for External Funding Sources

For HealthRight Rx to be sustainable, new and continual funding sources have to be identified and pursued. Because of the recent attention to the uninsured and prescription drugs, there should be many grant opportunities available for programs like HealthRight Rx. Furthermore, once the program is better developed additional funding sources should be easier to secure.

HealthRight Rx Expansion
Recommendation #5: Expand Incrementally

HealthRight Rx should expand slowly and incrementally. Currently, HealthRight Rx is only piloting at two small sites. The next pilot site should be similar to THC and Eleventh Street, but with a higher volume of patients. This will enable HealthRight Rxs staff to work with a larger patient load. Only after this third pilot is running smoothly should HealthRight Rx consider expanding to the HRs multi-clinic sites.

Recommendation #6: Expand Across the Commonwealth of Pennsylvania

Once HealthRight Rx is established in Philadelphia, many other communities across Pennsylvania can benefit from HealthRight Rxs experiences and services. Following the examples of Florida and Hawaii, where the state governments have begun funding programs that assist qualified state residents with PAPs, HealthRight Rx could act as a focal point for such an initiative in Pennsylvania.

Health Policy Implications
Final Recommendation: Look to Community-Based Solutions for Health Care Reform

The success of HealthRight Rx and similar programs across the nation demonstrates that even during a period of limited resources, there are real opportunities and resources available for collaboration between community-based organizations and committed health care providers to provide for disadvantaged populations. Therefore, future efforts and policy directions should look towards community-based solutions as a vehicle for health care reform.

LIST OF REFERENCES

AstraZeneca Pharmaceuticals (2003a) Patient Assistance Program - Description. AstraZeneca US Website. http://www.astrazeneca-us.com/drugassist/pap.asp

AstraZeneca Pharmaceuticals (2003b) AstraZeneca History 1970 to 1979. AstraZeneca US Website. http://www.astrazeneca-us.com/about/history70s.asp

Bell, G. A. (2003) Telephone Conversation with George A. Bell, Manager of Patient Assistance Programs for GlaxoSmithKline. GlaxoSmithKline. February 10, 2003.

Benson, C. (2002) City-run health clinics confronting a bitter pill. Philadelphia Inquirer. November 20^th: Local and Regional Section.

City of Philadelphia. (2003) Hospitals: The Closing of Philadelphia General Hospital. City of Philadelphia Department of Public Health Website. http://www.phila.gov/health/history/parts/part_5.htm

Health Federation of Philadelphia. (2000) Community Access Program HealthRight Grant Proposal. Human Resources and Services Administration.

Health Resources and Services Administration. (2002) The Community Access Program. US Department of Health and Human Services. http://bphc.hrsa.gov/CAP/

Health Strategies & Solutions. (2002) Business Plan. Health Strategies & Solutions, Inc. August 2002.

Institute of Medicine. (2000) Americas Health Care Safety-Net: Intact but Endangered. Institute of Medicine.

Institute of Medicine. (2002) Care Without Coverage: Too Little Too Late. Institute of Medicine.

Kaiser Family Foundation. (2001) Prescription Drug Trends: A Chartbook Update. Kaiser Family Foundation. November 2001.

Kunsio, L. (2003) Telephone Conversation with Lorrie Kunsio, Customer Service Representative for Express Scripts, Inc. Express Scripts, Inc. January 31, 2003.

Lee, P. R. and Estes, C. L. (2001) The Nations Health: 6^th Edition. Jones and Bartlett Publishing.

National Association of Community Health Centers (2000) Handbook of PHS Drug Pricing Program Policy Guidances and Technical Assistance Information. National Association of Community Health Centers.

Needy Meds (2003) Drug List Updated 1/6/2003. Needy Meds, Inc. http://www.needymeds.com/

Office of Pharmacy Affairs (2002b) How to enroll in 340B? US Department of Health and Human Services. http://bphc.hrsa.gov/opa/howto.htm

PAPrx (2001) PAPrx Features. PAPrx Website. http://www.paprx.com/features.html

Pfizer (2003) Access to Medicines: Sharing the Care. Pfizer. http://www.pfizer.com/subsites/philanthropy/access/sharing.care.index.html

PhRMA (2003a) Patient Assistance Programs. Pharmaceutical Research and Manufacturers of America. http://www.phrma.org/pap/

PhRMA (2003b) Patient Assistance Programs. Pharmaceutical Research and Manufacturers of America. http://www.phrma.org/pap/more.cfm

Philadelphia Health Management Corporation (2002) Community Health at the Cross Roads: Local Health Trends from PHMCs Southeastern Pennsylvania Household Health Survey, 1990 to 2000. Philadelphia Health Management Corporation.

Richardson, K (2003) Pharmaceutical Assistance Programs: In Basic Language. Association of Clinicians for the Underserved. Unpublished.

Silow-Carrow, S., Anthony, S. R., Seltman, P. A. and Meyer, J. A. (2001) Community-based Health Plans for the Uninsured: Expanding Access, Enhancing Dignity. W.K. Kellog Foundation.

Starr, P. (1982) The Social Transformation of American Medicine. Basic Books, Inc.

Stevens, R. (1989) In Sickness and in Wealth. Basic Books, Inc.

US Census Bureau (2002) Website News Releases. United States Department of Commerce. http://www.census.gov

Volunteers in Health Care (2001) Pharmaceutical Primer: Starting a Pharmaceutical Access Program. Volunteers in Health Care.

Volunteers in Health Care (2003a) About Volunteers in Health Care. Volunteers in Health Care Website. http://www.volunteersinhealthcare.org/aboutvih.htm

Volunteers in Health Care (2003b) Volunteers in Health Care Patient Tracking Information. Volunteers in Health Care Website. http://www.volunteersinhealthcare.org/softinfo.htm

APPENDICES

APPENDIX A

Abbreviations

ABBREVIATIONS

340B  Ceiling Drug Pricing Program for Qualified Safety-net Providers

AEHN  Albert Einstein Healthcare Network

AHA American Hospital Association

APM Association de Puertoriquenos en Marcha

BPP Bulk Purchasing Programs

BRP Bulk Replenishment Programs

CAP Community Access Program

CBMP  Community Based Masters Project

DHC District Health Center

DHHS United States Department of Health and Human Services

DS Drug Sample

DVCH Delaware Valley Community Health, Inc.

Eleventh Street Eleventh Street Family Health Services

FQHC Federally Qualified Health Center

GPHA  Greater Philadelphia Health Action, Inc.

HIPAA  Health Insurance Portability and Accountability Act

HR HealthRight, Inc.

HRET Health Research and Educational Trust

HRSA Health Resources and Services Administration

Hunting Park  Hunting Park Health Center

MCAP Middlesex Community Access Program

NPHS  North Philadelphia Health Services

PAP Patient Assistance Program

PGH Philadelphia General Hospital

PHLP  Pennsylvania Health Law Project

PHMC Philadelphia Health Management Corporation

PHS Public Health Service Act

PN Private Negotiations

PhRMA Pharmaceutical Research and Manufacturers of America

QCHC  Quality Community Health Care, Inc.

SHS Spectrum Health Services

THC Temple Health Connection

TUHS Temple University Health System

US  United States

WVHR West Virginia Health Right

APPENDIX B

Description of RxAssist Plus

RXASSIST PLUS

Volunteers in Health Care Patient Tracking Software Information

(Volunteers in Health Care, 2003b)

Volunteers in Health Care created the RxAssist Plus Patient and Medication Tracking Software to meet the needs of organizations helping low-income uninsured and underserved patients apply for medications through the pharmaceutical manufacturers patient assistance programs.

RxAssist Plus allows you to:

Store and track information on patients, visits, and providers

Easily add, delete, and search for patients
Enter household income information and calculate how a households income compares to the Federal Poverty Level
Run detailed reports on the demographic characteristics of all patients seen
Connect to the RxAssist website (www.rxassist.org) to locate information on patient assistance programs and then download forms which are automatically filled out using previously entered information on patients and prescribers
Track the status of applications to patient assistance programs
Track medications dispensed to patients
Run reports on the characteristics of clients you assist in applying to the pharmaceutical companies patient assistance programs
Run reports to assist in tracking the process of applying to pharmaceutical company patient assistance programs, including reminders about applying for a refill, alerts about outstanding applications, etc.
Run reports on the proportion of applications to patient assistance programs companies approved and average delivery times
Produce mailing labels for pharmaceutical company patient assistance programs and for the patients you help access these programs

Version 3.0 adds new features, including:

7 Simplified installation and upgrade procedures

7 Improved download speed to allow users to download applications to patient assistance programs in less time than previous versions

7 New security features, including a system of passwords and user names and an auto-logoff feature (in accordance with the HIPAA regulations)

7 A new audit feature to allow organizations to track changes made to the database by patient name or user name (in accordance with the HIPAA regulations)

7 Several new reports to allow users to track patient diagnoses, prescriptions dispensed, and other important actions more completely

In order to use RxAssist Plus, your computer must meet the following specifications:

Microsoft Windows 95, 98, 2000, NT, ME, or XP

Microsoft Office 97, 2000, or XP with graphics filters installed

100 MB Hard Disk Space

32 MB RAM

250 MHz Pentium Processor or Higher

CD-ROM drive

Internet access

RxAssist Plus is available to any non-profit organization, governmental agency, or practicing clinician serving uninsured patients. Our software is designed for organizations that have limited budgets for software, and we are committed to keeping the price of our software within reach of small budget organizations. Version 3.0 will cost $200 which includes access to technical support by telephone and email. We will be releasing an updated version on an annual basis and will charge for each new version.

If you have additional questions about RxAssist Plus, please contact Volunteers in Health Care at (877) 844-8442. We also invite you to visit our website, www.volunteersinhealthcare.org, to learn about our other services and products designed for organizations serving the uninsured and underserved.

APPENDIX C

HealthRight Rx Materials Common to All Pilot Sites

Prescription Drug Assistance Program
Enrollment Application

Date: ___/___/_____

Section I: Patient Information

Patients Name: _____________________________

Apt. #: ___________ PO Box: __________

Address ___________________________________

City: __________________ State: ___ Zip: ______

Phone Number: _____________________________

Date of Birth: ____ / ____ / _____

Social Security Number: ______ - _____ - _______

¨ Male ¨ Female

¨ Single ¨ Married ¨ Divorced ¨ Widowed

¨ Separated

Number of persons dependent on income: ________

Race: _____________________________________

Are you a U.S. citizen? _______________________

Section II: Patient Medical Information

Medical Condition(s): _________________________________________________________________________

Medications Needed (Include Dosages and Frequency): ______________________________________________

___________________________________________________________________________________________

Allergies to Medicines: ________________________________________________________________________

Physician Name: __________________________________________ Phone Number: _____________________

Physicians Address _________________________________ City: ____________ State: ____ Zip: __________

Health Insurance Information

Primary Insurance Company: ___________________________________________ Policy #: ________________

Secondary Insurance Company: _________________________________________ Policy #: ________________

Do you have prescription coverage? ¨ Yes ¨ No

If YES, what is the cap amount? _______________ Have you reached the cap? ¨ Yes ¨ No

Do you have a drug discount card? ¨ Yes ¨ No If YES, what company? ______________________

Do you have Medicaid? ¨ Yes ¨ No

Do you have Medicare? ¨ Yes ¨ No Number: ___________________________

Are you eligible for veterans benefits or workers compensation? ¨ Yes ¨ No

Patient Medical Expenses

	MONTHLY EXPENSE
Prescription Costs	$ _______
Prescription Coverage Fees	$ _______
Doctor/Provider Fees	$ _______
Lab Fees	$ _______
Other Medical Expenses	$ _______

Section III: Patient Income and Assets

GROSS MONTHLY INCOME:			ASSETS:	TOTAL $ VALUE	MONTHLY INTEREST/EARNINGS FROM ASSETS
	PATIENT	SPOUSE/OTHER	ASSETS:	TOTAL $ VALUE	MONTHLY INTEREST/EARNINGS FROM ASSETS
Salary/Wages	$ _______	$ _______	Stocks/Bonds	$ _______	$ _______
Pension	$ _______	$ _______	CDs	$ _______	$ _______
Social Security	$ _______	$ _______	Savings Account	$ _______	$ _______
SSI (Supp. Income)	$ _______	$ _______	Checking Account	$ _______	$ _______
Disability	$ _______	$ _______	IRA	$ _______	$ _______
Unemployment	$ _______	$ _______	Annuities	$ _______	$ _______
Alimony/Child Support	$ _______	$ _______	Other (specify):	$ _______	$ _______

TOTAL:	$ _______	$ _______	TOTAL:	$ _______	$ _______

HealthRight Employee Name: ____________________________

Initial Date Information Entered into RxAssist: ___/___/______

Last Updated: 2/2/2003

Prescription Drug Assistance Program

HealthRight Rx Coversheet

NAME: Example

DOB: --/--/----

DATE: --/--/----

NOTE: All Signatures Must Be Originals (No Copies or Stamps)

DRUG #1 Prempro (0.625/2.5 mg) QD

Novartis

Need Prescriber to Check Appropriate Specialty Box
Need Prescribers Signature and Date
Need Prescribers State License Number
Need Patients Signature and Date
Need Prescriber to Fill out "SECTION 3: PRODUCT INFORMATION"

Sig (three-month supply)

Mail in attached envelope to Wyeth

DRUG #2 Synthroid 300mcg QD

KingKare Pharmaceuticals

Need Prescriber s Professional Designation
Need Prescribers State License #

Need Prescribers DEA #

Need Patients Signature and Date
Need Prescriber to Fill Out "PRESCRIPTION INFORMATION" Section

Strength
Sig
Prescribers Signature
Date

Enclose the following items in the attached envelope:

Completed Application
Financial Verification (Pension, W2)

DRUG #3 Glucophage 500mg QD

Bristol-Myers Squibb Patient Assistance Foundation, Inc.

Need Patients Signature and Date
Need Prescribers Signature and Date at Bottom
Fax completed application to 1-800-736-1611

Prescription Drug Assistance Program

Medication Tracking Form

PATIENT NAME: ________________________________

SSN: ____-____-______

DOB: ___/___/_____

**CROSS OUT FOR STOPPED AND UNAVAILABLE DRUGS**

MEDICATION	PROGRAM	DOSAGE/ FREQUENCY	DATE DELIVERED PROVIDER	REORDER DATE 1	REORDER DATE 2	REORDER DATE 3	DATE STOPPED

APPENDIX D

Pilot Materials for Temple Health Connection

HealthRightR_x Pilot

PILOT SITE: Temple Health Connection

UPDATED: 4/8/2003

General Information
Temple Health Connection

Address: 1035 West Berks Street, Philadelphia, PA 19122

Ph: 215.765.6690

Fax: 215.765.7694

Operating Hours:

Mondays, Tuesdays, and Thursdays: 9am to 5pm

Wednesdays: 9am to 6pm

Fridays: 9am to 1pm (Staff available to 5pm)

Saturdays and Sundays: Closed

HealthRight, Inc.

Address: 714 Market Street, 5^th Floor Suite 597, Philadelphia, PA 19106

Ph: 215.413.8591

Fax: 215.413.8589

Operating Hours:

Mondays through Fridays: 9am to 5pm

Saturdays and Sundays: Closed

Abbreviations

Initial Application form HealthRights initial application form

HR HealthRight, Inc.

Medication List form A list of medications from a patients chart.

PAP Patient Assistance Program

THC Temple Health Connection

Instructions for Enrolling a New Patient into HealthRight Rx

THC staff initiates HealthRight Rx by identifying a patient who is a good candidate. The patient should fit into the following criteria:

uninsured or does not have prescription drug insurance coverage;
unable to pay for needed prescription drugs; and
requires a long-term supply of maintenance medications

Once a patient is identified, THC staff will affix a HR sticker to the patients medication list form found in the patients medical chart. The sticker will act as a future reminder that this patient is receiving prescription medications through HealthRight Rx.
THC staff will write the patients phone number in the space provided on the sticker and notify the patient that a HR representative will be contacting them about obtaining free medications. Please double-check the patients phone number because it is the sole method for HR to contact the patient.
THC staff will fax the medication list form with the affixed HR sticker and patients phone number to HRs main office (HR Fax #: 215.413.8589).
HR staff will then call the patient. HR staff will first educate the patient about HealthRight Rx and Patient Assistance Programs (PAPs). Next, HR staff will complete HRs initial application with the patient over the phone to determine the patients eligibility for PAPs. The initial application requires the following information (NOTE: It is very important to collect all the items on the initial application):

basic demographics and contact information;
medical conditions;
health insurance coverage;
health care expenses; and
complete financial information (assets and income).

From the information on the initial application, HR staff will check the eligibility of the patient for each medication on their THC medication list.
If patient is unable to receive any medication on their list through PAPs, HR staff will call THC to inform them. THC can then consider whether the patient is able to receive the medication through an alternative source or THC can consider changing the medication to one available through the PAPs (THC Phone #: 215.765.6690).
For medications that the patient is able to receive through PAPs, HR staff will complete the application.
HR staff will generate a cover sheet to inform THC staff of what they must do to complete the application (e.g. obtain signatures and extra documentation).
HR staff will then hand-deliver completed applications and cover sheet to THC every Tuesday.
HR staff will date and photocopy the application for the patients HR file.
After THC receives the applications, THC staff will follow the instructions on the cover sheet regarding signatures and supporting documents.
THC staff will then mail the completed applications to the corresponding pharmaceutical companies.
Once the medications are received, THC staff will distribute them to the patient.
HR staff will start the reapplication process after the first 60 days, and then every 90 days thereafter, unless HR receives other instructions from THC to stop or change the patients medications.

Instructions for Adding and Stopping Medications (Includes Dosage Changes) for Patients Enrolled in HealthRight Rx

If a patient is enrolled in HealthRight Rx (has sticker on the medication list form) and needs a change in medications (addition, discontinuation, or dosage change), THC staff will update the medication list and fax it to HR (HR Fax #: 215.413.8589).
From the information on the initial application, HR staff will check the eligibility of the patient for each medication on their THC medication list.
If patient is unable to receive any medication on their list through PAPs, HR staff will call THC to inform them. THC can then consider whether the patient is able to receive the medication through an alternative source or THC can consider changing the medication to one available through the PAPs (THC Phone #: 215.765.6690).
For medications that the patient is able to receive through PAPs, HR staff will complete the application.
HR staff will generate a cover sheet to inform THC staff of what they must do to complete the application (e.g. obtain signatures and extra documentation).
HR staff will then hand-deliver completed applications and cover sheet to THC every Tuesday.
HR staff will date and photocopy the application for the patients HR file.
After THC receives the applications, THC staff will follow the instructions on the cover sheet regarding signatures and supporting documents.
THC staff will then mail the completed applications to the corresponding pharmaceutical companies.
Once the medications are received, THC staff will distribute them to the patient.
HR staff will start the reapplication process after the first 60 days, and then every 90 days thereafter, unless HR receives other instructions from THC to stop or change the patients medications.

Instructions for Reapplying to the Patient Assistance Programs

HR staff will start the reapplication process every 90 days unless HR receives other instructions from THC to stop or change the patients medications.
From the information on the initial application, HR staff will recheck the eligibility of the patient for each medication on their THC medication list.
If patient is unable to receive any medication on their list through PAPs, HR staff will call THC to inform them. THC can then consider whether the patient is able to receive the medication through an alternative source or THC can consider changing the medication to one available through the PAPs (THC Phone #: 215.765.6690).
For medications that the patient is able to receive through PAPs, HR staff will complete the application.
HR staff will generate a cover sheet to inform THC staff of what they must do to complete the application (e.g. obtain signatures and extra documentation).
HR staff will then hand-deliver completed applications and cover sheet to THC every Tuesday.
HR staff will date and photocopy the application for the patients HR file.
After THC receives the applications, THC staff will follow the instructions on the cover sheet regarding signatures and supporting documents.
THC staff will then mail the completed applications to the corresponding pharmaceutical companies.
Once the medications are received, THC staff will distribute them to the patient.
HR staff will check with the patient annually to record any changes on the patients HR initial application form.

HEALTHRIGHT RX STICKERS

FOR

TEMPLE HEALTH CONNECTION

Example of a sheet of stickers Page 59

Example of stickers on a THC patient medication form Page 60

HealthRight Rx Stickers for Temple Health Connection

This patient receives prescription medications through

HealthRight. When any changes are made to the medications, fax this sheet to (215) 413-8589.

Phone: (215) 413-8591

PATIENT PHONE: _______________________

This patient receives prescription medications through

HealthRight. When any changes are made to the medications, fax this sheet to (215) 413-8589.

Phone: (215) 413-8591

PATIENT PHONE: _______________________

This patient receives prescription medications through

HealthRight. When any changes are made to the medications, fax this sheet to (215) 413-8589.

Phone: (215) 413-8591

PATIENT PHONE: _______________________

<<EXTERNAL INSERT>>

THC FORM AND HR STICKER

APPENDIX E

Pilot Materials for Eleventh Street

HealthRightR_x Pilot

PILOT SITE: Eleventh Street

UPDATED: 4/15/2003

General Information
Eleventh Street Family Health Services of Drexel University

Address: 850 West 11^th Street, Philadelphia, PA 19123

Ph: 215.769.1100

Fax: 215.769.1119

HealthRight, Inc.

Address: 714 Market Street, 5^th Floor Suite 597, Philadelphia, PA 19106

Ph: 215.413.8591

Fax: 215.413.8589

Abbreviations

Initial Application form HealthRights initial application form

HR HealthRight, Inc.

Medication List form A list of medications from a patients chart.

PAP Patient Assistance Program

Eleventh Street Eleventh Street Family Health Services

Instructions for Enrolling a New Patient into HealthRight Rx

Eleventh Street staff initiates HealthRight Rx by identifying a patient who is a good candidate. The patient should fit into the following criteria:

uninsured or does not have prescription drug insurance coverage;
unable to pay for needed prescription drugs; and
requires a long-term supply of maintenance medications

Once a patient is identified, Eleventh Street staff will refer the patient to the onsite HR representative.
The HR representative will first educate the patient about HealthRight Rx and Patient Assistance Programs (PAPs). Next, HR staff will complete HRs initial application with the patient in person. The initial application requires the following information (NOTE: It is very important to collect all the items on the initial application):

basic demographics and contact information;
medical conditions;
health insurance coverage;
health care expenses; and
complete financial information (assets and income).

HR staff will affix a HR sticker to the patients medication list form found in the patients medical chart. The sticker will act as a future reminder that this patient is receiving prescription medications through HealthRight Rx.
From the information on the initial application, HR staff at the main office will check the eligibility of the patient for each medication on their Eleventh Street medication list.
If patient is unable to receive any medication on their list through PAPs, HR staff will notify the staff at Eleventh Street. Eleventh Street can then consider whether the patient is able to receive the medication through an alternative source or Eleventh Street can consider changing the medication to one available through the PAPs (Eleventh Street Phone #: 215.769.1100).
For medications that the patient is able to receive through PAPs, HR staff will complete the application.
HR staff will generate a cover sheet indicating what the onsite HR representative must do to complete the application (e.g. obtain signatures and extra documentation).
HR staff will then call the patient to set up an appointment with the patient at Eleventh Street. At this time, HR staff will also inform the patient what income verification materials they need to bring to the appointment.
At the appointment, the onsite HR representative will complete the PAP applications.
HR staff will date and photocopy the application for the patients HR file.
HR staff will then mail the completed applications to the corresponding pharmaceutical companies.
Once the medications are received, Eleventh Street staff will distribute them to the patient.
HR staff will start the reapplication process after the first 60 days, and then every 90 days thereafter, unless HR receives other instructions from Eleventh Street to stop or change the patients medications.

Instructions for Adding and Stopping Medications (Includes Dosage Changes) for Patients Enrolled in HealthRight Rx

If a patient is enrolled in HealthRight Rx (has sticker on the medication list form) and needs a change in medications (addition, discontinuation, or dosage change), Eleventh Street staff will update the medication list and fax it to HR (HR Fax #: 215.413.8589).
From the information on the initial application, HR staff will check the eligibility of the patient for each medication on their Eleventh Street medication list.
If patient is unable to receive any medication on their list through PAPs, HR staff will call Eleventh Street to inform them. Eleventh Street can then consider whether the patient is able to receive the medication through an alternative source or Eleventh Street can consider changing the medication to one available through the PAPs (Eleventh Street Phone #: 215.769.1100).
For medications that the patient is able to receive through PAPs, HR staff will complete the application.
HR staff will generate a cover sheet indicating what the onsite HR representative must do to complete the application (e.g. obtain signatures and extra documentation).
HR staff will then call the patient to set up an appointment with the patient at Eleventh Street. At this time, HR staff will also inform the patient what income verification materials they need to bring to the appointment.
At the appointment, the onsite HR representative will complete the PAP applications.
HR staff will date and photocopy the application for the patients HR file.
HR staff will then mail the completed applications to the corresponding pharmaceutical companies.
Once the medications are received, Eleventh Street staff will distribute them to the patient.
HR staff will start the reapplication process after the first 60 days, and then every 90 days thereafter, unless HR receives other instructions from Eleventh Street to stop or change the patients medications.

Instructions for Reapplying to the Patient Assistance Programs

HR staff will start the reapplication process every 90 days unless HR receives other instructions from Eleventh Street to stop or change the patients medications.
From the information on the initial application, HR staff will recheck the eligibility of the patient for each medication on their Eleventh Street medication list.
If patient is unable to receive any medication on their list through PAPs, HR staff will call Eleventh Street to inform them. Eleventh Street can then consider whether the patient is able to receive the medication through an alternative source or Eleventh Street can consider changing the medication to one available through the PAPs (Eleventh Street Phone #: 215.769.1100).
For medications that the patient is able to receive through PAPs, HR staff will complete the application.
HR staff will generate a cover sheet indicating what the onsite HR representative must do to complete the application (e.g. obtain signatures and extra documentation).
HR staff will then call the patient to set up an appointment with the patient at Eleventh Street. At this time, HR staff will also inform the patient what income verification materials they need to bring to the appointment.
At the appointment, the onsite HR representative will complete the PAP applications.
HR staff will date and photocopy the application for the patients HR file.
HR staff will then mail the completed applications to the corresponding pharmaceutical companies.
Once the medications are received, Eleventh Street staff will distribute them to the patient.
HR staff will check with the patient annually to record any changes on the patients HR initial application form.