Planning for Prescription Drugs during a Disaster: Perspectives from Patients, Physicians, Pharmacis

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Planning 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

• 2008 APHA Session 3321.0

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Introduction 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
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Introduction 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

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Introduction 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
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Introduction 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
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Study 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

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Methods

• 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

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Results

• 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

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Results

• 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.
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Results

• 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.

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Results

• 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.
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Results

• 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

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Results

• 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.
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Results

• 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)

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Results

• 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)
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Discussion

• 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

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Discussion

• 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

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Discussion

• 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)

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References

• 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).

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Thank you. Questions?kcarameli_at_ucla.edu

• 2008 APHA Session 3321.0