Title: Planning for Prescription Drugs during a Disaster: Perspectives from Patients, Physicians, Pharmacis
1Planning for Prescription Drugs during a
Disaster Perspectives from Patients, Physicians,
Pharmacists, and Insurers
Kelley Carameli, MS, CHES, UCLA School of Public
Health Deborah C. Glik, ScD, UCLA School of
Public Health David P. Eisenman, MD, MSHS, UCLA
Division of General Internal Medicine and Health
Services Research Joy Blevins, MS, MPH, Los
Angeles County, Emergency Preparedness and
Response Program Brian dAngona, MD, MPH
2Introduction Background
- Over the Past Decade
- 6 in 10 Americans have at least one chronic
medical condition - 77-97 of Americans with chronic illness use a
prescription medication - Chronic illness accounts for 50 of all U.S.
healthcare expenditures - 3 out of every 4 health dollars spent on
prescription drugs
Anderson Horvath, 2004 Machlin, Cohen,
Beauregard, 2008
3Introduction Background
- U.S. Drug Delivery System
- A complex, interdependent system of
- Policy benefits
- Refill time frames
- Formularies
- Co-payments
- 3rd party benefits managers
- Just-in-time delivery practices
- Burden of work on patient, physician,
pharmacist
4Introduction Background
- Prescription Drugs Disaster
- Following Hurricane Katrina, most recovery
shelter evacuees required chronic illness drug
replacement - 68 in Texas 80 in Michigan
- Disaster responders have recently responded to
the prescription drug delivery systems
vulnerability - 2005 Hurr. Katrina Emergency Rx History
established - 2008 Hurr. Ike, Gustav Centers for Medicare and
Medicaid activated Emergency Prescription
Assistance Program
Hayes, 2008 Jhung et al., 2007 Irvin Atas,
2007 McCloskey, 2007
5Introduction Background
- Household Prescription Drug Stockpiles
- U.S. household medication behaviors disaster
- 50 keep a 3-day supply of their prescription
drugs at home - 38 of persons with chronic medical conditions
keep less than a weeks supply of
medications - Personal stock guidelines inconsistent (3, 14,
30-day) - The vulnerable are disproportionately affected by
chronic illness and disaster extra stocks may be
difficult
APHA, 2007 Cutter, 2003 Murphy et al., in press
6Study Purpose
- To examine disaster-related prescription drug
availability and accessibility in Los Angeles
County for individuals with a chronic medical
illness - We reviewed insurance pharmacy benefits
of major insurers in Los Angeles
County - We interviewed patients, physicians, insurers,
pharmacists, and government regulators - The goal was to understand and recommend options
for strengthening disaster management plans at
personal, local, and organizational levels
7Methods
- Mixed methods design (January-June 2007)
- Evidence of Coverage policy review (n9 policies)
- Focus group interviews patients caregivers
(n158) - Key informant interviews physicians (8),
pharmacy executives (10), government agencies
(3), and insurance executives (n9) - Semi-structured interview guides developed from
Reutzel (1998) and Donabedian (1980) frameworks - Interviews transcribed verbatim and analyzed
(ATLAS.ti) for common domains of content
8Results
- Insurance Pharmacy Benefits
- All insurers provided minimum 30-day drug-units
- 30-day retail or in-network pharmacy single
co-payment - 60-100 day mail-order (8 policies), retail (3
policies) - Prescription refill policies
- 30-day refill after 70-75 of use 1 week left
- 60-100 days refill after 60-70 of use 3-4 weeks
left - Two insurers had written vacation or
replacement policies
9Results
- Patients Caregivers
- Patient focus group overview
- Groups included elderly (4), adults (5), parents
of children with chronic illness (5) English
Spanish focus groups - 34 private insurance 23 public 31 uninsured
- Patients who were less-acculturated, had fewer
resources, and lacked health insurance had more
difficulty acquiring routine medications
Between the two simple steps of the refill and
the insurance approval, something is going to go
wrong. You can bet on it.
10Results
- Patients Caregivers (cont.)
- Although patients were motivated to have
extra medication for routine and
disaster purposes - Most had not considered adding meds to disaster
kit - Some felt they could do without, others
transferred prescriptions to national pharmacies,
few made pre-emptive lists of household
medication needs - Barriers to extra supplies restrictive insurance
policies, poor patient-physician communication,
multiple meds.
11Results
- Physicians
- 30-day dispensing unit is harmful to stable
patients - Easier for patients to run out (vs. 60-100 day
unit) - 30-day set by insurers to contain costs, minimize
risk - Physician recommendations patient preparedness
- Print electronic record as a medication history
- Provide 60- to 90-day prescription for stable
patients - Create clinician protocols to guide disaster
discussion for chronic medication patients
itd be great if there were some kind of
protocol or Im able to write on the
prescription This supply is for disaster
preparedness.
12Results
- Pharmacies Government
- Prescription dispensing practices guided by
- Professional standards (state/federal
regulations ethics) - Finances (drug inventory counseling paperwork)
- 30-day dispensing unit is an impediment for
patient reserves - Retailers willing to dispense 90-day units
- Pharmacies encourage patients to build personal
reserve - Concerns about patient reserves additional
co-pay, rotating stocks, time to educate patients
13Results
- Pharmacies Government (cont.)
- Disaster preparedness plans for pharmacies
- National chains able to pool resources less
susceptible to inventory or delivery barriers
than smaller stores - Pharmacists concerned about reimbursement during
disaster ethical code to dispense emergency
supply - Pharmacists wanted a policy like the Robert T.
Stafford Act for pharmacy care liability and
reimbursement
Back during the Northridge earthquake, I know
that many pharmacists, especially independents,
all went into the pharmacieswith their door open
for patients to comethis is part of their
professional responsibility.
14Results
- Insurers
- Prescription medication practices guided by
- Professional standards (state or federal
regulations) - Finances (reimbursement policies, drug inventory)
- Insurers preferred members to refill on-time
and not run out of medications - Reluctant to support a specific prescription
disaster supply policy - Encouraged members to build own disaster
reserves by refilling early - Encouraged use of mail-order (currently 10 use)
15Results
- Insurers (cont.)
- Disaster preparedness plans for insurers
- Internal business continuity plans
- Mass refill overrides
- Reconstruct medication profiles
- Insurers believed that pharmacists would assume
the leading role in replacing disaster
medications - Lacked inter-industry, mutual-aid partnerships
Collaborative relationships are important
delivery of pharmaceutical services would need
the cooperation of participating pharmacist,
retailers and manufacturers, as well as
government agencies. (Non-profit insurer)
16Discussion
- Recommendation 1
- Refine existing policies and develop new ones to
maximize patients ability to build and maintain
prescription medication reserves - Chronically-ill patients should maintain
sufficient personal stocks general agreement
14-30 days for stable pts. - 30-day dispensing units are an obstacle to this
goal - Alternative ways to build medication reserves
- Educate patients about insurers vacation
policies - Encourage mail-order services
- Approve higher retail dispensing units early
refill reminders
17Discussion
- Recommendation 2
- Train physicians, pharmacists, and insurers to
speak with each other and their patients about
disaster planning, and building and maintaining
prescription medication reserves - Provide timely print/web educational materials,
training resources, and industry guidelines to
insurers, physicians, and pharmacists - Trained professionals can better inform patients
18Discussion
- Recommendation 3
- Encourage greater two-way communication,
partnership, and disaster drill exercise between
industry stakeholders and local, State, and
federal govt. - Collective action is needed during disaster
- Few had external mutual aid plans with other
stakeholders - Include stakeholders in routine disaster
exercises - Encourage participation in profession-based
disaster teams - Medical staff Disaster Medical Assistance Team
(DMAT) - Pharmacists Pharmacy Emergency Response Team
(PERT) - Businesses Business Executives for National
Security (BENS) - Patients Citizen Corps/Civilian Emergency
Response Team (CERT)
19References
- G. Anderson and J. Horvath, The Growing Burden
of Chronic Disease in America, Public Health
Reports 119, no. 3 (2004) 263-270. - S. Machlin, J.W. Cohen, and K. Beauregard,
Health Care Expenses for Adults with Chronic
Conditions, 2005, Statistical Brief no. 203, May
2008 - H.B. Hayes, CMS activates emergency system to
fill evacuees prescriptions, September 15, 2008,
http//www.govhealthit.com/online/news/350561-1.ht
ml (accessed 22 September 2008). - M.A. Jhung et al., Chronic Disease and
Disasters Medication Demands of Hurricane
Katrina Evacuees, American Journal of Preventive
Medicine 33, no. 3 (2007) 207-210. - C.B. Irvin and J.G. Atas, Management of Evacuee
Surge from a Disaster Area Solutions to Avoid
Non-Emergent Emergency Department Visits,
Prehospital and Disaster Medicine 22, no. 3
(2007) 220-223. - P. McCloskey, Pharmacies launch emergency
RxHistory service, April 24, 2007,
http//www.govhealthit.com/online/news/102547-1.ht
ml (accessed 22 September 2008). - American Public Health Association, Addressing
the Unique Needs of Individuals with Chronic
Health Conditions, April 2007,
http//www.nphw.org/2007/pg_newsltr_friday.html
(accessed 5 July 2007). - S.L. Cutter et al., Social Vulnerability and
Environmental Hazards, Social Science Quarterly
84, no. 2 (2003) 242-261. - S.T. Murphy et al., Predictors of Emergency
Preparedness and Compliance, Disaster Medicine
and Public Health Preparedness (in press). - T.J. Reutzel, Outpatient Drug Insurance A
Framework to Guide Literature Review, Research,
and Teaching, American Journal of Pharmaceutical
Education 62 (1998) 1-11. - A. Donabedian, The Definition of Quality and
Approaches to its Assessment (Ann Arbor, MI
Health Administration Press, 1980).
20Thank you. Questions?kcarameli_at_ucla.edu