Pharmacy Practice News - February 2007 Student Pharmacists Tutor Patients on New Drug Benefit By Jan Greene Recognizing that clinical pharmacists are an untapped resource for helping seniors understand their drug benefits under Medicare Part D, California's pharmacy schools are training their students to educate and advocate for patients around the state. The Partners in D program, started by faculty at the University of California, San Francisco (UCSF), School of Pharmacy, began as a pilot project in 2004 to help students understand the new and important law, explained Tim Cutler, PharmD, an assistant clinical professor of pharmacy at UCSF and a practicing pharmacist in Sacramento. Both students and professors foresaw that clinical pharmacists not only would have to understand the new program themselves, but also would need to explain the options to their patients. They started a pilot program that offered training for students in the community pharmacy program at UCSF, and added a health policy course taught by Helene Lipton, PhD, a health policy specialist at the school. The students in her course also set up a peer-to-peer program to educate medical and nursing students on campus about Medicare Part D. "It's a good way for us to improve the interdisciplinary relationship between pharmacists and other medical professionals," Dr. Cutler said. In a third prong of the pilot program, trained students provided outreach to seniors through both group presentations and one-on-one counseling. "We had students in community pharmacies go and talk to people who were having trouble" with Part D, Dr. Cutler said. "They worked with providers, insurance and Medicare to improve their use of the benefit." Concerns Over "Donut Hole" A Focus of Counseling Meanwhile, throughout California and the nation, it was becoming clear that patients needed a lot of help choosing from among the dozens of options they faced, and that there was confusion about the so-called donut hole-the gap in coverage when a patient must spend between $2,250 and $5,100. For patients who are dual-eligible for Medicare and Medicaid, the coverage gap doesn't apply. But there are low-income patients who aren't in Medicaid who do face the gap and are particularly vulnerable to the loss of coverage. Medicare's own consumer advisers were overwhelmed by the task of educating such beneficiaries, as were other consumer advice services, such as the all-volunteer Health Insurance Counseling and Advocacy Program, Dr. Cutler said. The stakes are high when it comes to helping patients navigate their way through the donut hole. A 2006 study by researchers at Kaiser Permanente of Northern California looked at almost 200,000 people ages 65 and older enrolled in Medicare+Choice plans during 2003. It found that those with $1,000 caps on drug benefits had worse clinical outcomes than those of a comparison group whose drug needs were fully covered. Patients who had to shell out for drugs once their benefits were exhausted had higher death rates and more hospitalizations. (For counseling tips on helping patients steer clear of trouble when they hit the Medicare Part D donut hole, see sidebar.) The sheer number of Medicare Part D plans poses another challenge for plan consumers and counselors. Seniors in California, for example, must choose from among as many as 71 different plans, depending on their county. A total of 2.8 million Medicare beneficiaries are enrolled in Part D, although it appears that another 700,000 who are disproportionately low-income have no source of drug coverage, according to a September 2006 study by the California HealthCare Foundation. Dr. Lipton and UCSF professor Marilyn Stebbins, PharmD, sought grant funding to expand the pilot program to the six other pharmacy schools in California. They eventually received $3.7 million from the Amgen Foundation to expand and run the Partners in D program for three and a half years, with Drs. Lipton and Stebbins as principal investigators. The grant program is focused on using pharmacy students to reach underserved elderly Californians in particular. Because that population includes many people who speak languages other than English, the students' diverse backgrounds and language skills allow them to relate well to the seniors who need help, Dr. Cutler said. The initial confusion among seniors trying to decide which plan to choose has receded, he noted, but there will be a continuing need for counseling and support, particularly for those who are eligible for both Medicare and Medicaid and can switch plans on a monthly basis. The plans themselves sometimes change from year to year, such as one that dropped its coverage of the donut hole and increased its price by $30 in the second year of the program. "Once you're in a [Medicare Part D] plan, the story doesn't end there; the plan landscape changes each year," Dr. Cutler said. "So there is a continuing need for counseling." Partners in D has trained about 400 students at UCSF, who have counseled a total of about 2,700 seniors and providers in the past two academic years. The program is monitoring its effectiveness with measurements of seniors' knowledge before and after their counseling sessions, but outcomes data are not yet available. The Student's Perspective For the students, the focus on insurance coverage is a unique but vital introduction to the wider medication issues their future patients will face. "For me, it hit home how important it is for us, becoming professional healthcare providers, to understand every aspect of healthcare, not just what each drug does," said David Smith, a third-year UCSF student who has participated in Partners in D. "You start to understand the whole gamut of what a patient has to go through and how hard it is for them." The students took their laptops and wireless Internet access with them to visit patients' homes and senior centers to counsel mostly low-income people about their Part D options. They would inventory the patient's medications and help him or her choose the best drug coverage plan, using their training and Medicare's web-based tool that compares plans. "Most seniors we have dealt with are not terribly familiar with [the Web site] and have trouble navigating it," said Tony Chung, another third-year student. They also helped identify lower-cost generic options and recommended that patients ask their doctors about switching. "It was nice because we could attach a dollar number to that drug" and the specific savings that were possible, Mr. Chung added. Dr. Cutler expects the program to continue beyond the time the grant funding runs out, given the importance of the topic. "We feel like this project could go on and on," he said. Tips for Not Falling Through the Donut Hole Once a Medicare beneficiary has chosen a Part D plan, the next big issue is the so-called donut hole-the coverage gap during which a senior must spend between $2,250 and $5,100 on prescription medications in a year. People whose total drug bill pushes them into that coverage gap are looking at paying full freight for their prescriptions up to a certain point. Those who counsel seniors-including the pharmacy students in the Partners in D program of the University of California, San Francisco-seek out ways to help people through the coverage gap, and there are some options for patients to manage the costs and possibly avoid hitting the gap altogether. For instance, the Centers for Medicare & Medicaid Services suggests the following: " Work with a doctor to identify generic or lower-cost brand-name drugs that are equally effective. " Keep using the Medicare drug plan card during the gap to get the drug plan's discounted rates. " Explore drug assistance programs sponsored by states, charities and pharmaceutical manufacturers. " Look for state pharmaceutical assistance programs. " Medicare beneficiaries with limited incomes and resources can qualify for extra help through the Social Security Administration. Let Them Take OTCs There's also the option of avoiding prescription medications altogether, as a brochure put out by Procter & Gamble points out. An increasing number of over-the-counter (OTC) alternatives are available for major ailments, the brochure notes, including the company's Prilosec OTC (omeprazole) for frequent heartburn and Pepto-Bismol (bismuth subsalicylate) for diarrhea and indigestion, as well as Claritin (loratadine, Schering Plough) for allergies. OTC medications are paid for out of pocket and do not count toward the Part D tallies, so they might be best used to avoid reaching the gap to begin with, the press release suggests. Patient care advocates are less enthusiastic, however, about telling patients to take OTC medications when their prescription drug coverage runs out. "Patients needing OTC medications are not who typically call us; rather, those with debilitating, potentially life-threatening illnesses call in, looking for help," said Deane Beebe, public affairs director for the Medicare Rights Center, a New York-based consumer group. "When they're nearing the donut hole, these patients are literally in a panic, wondering how they are going to continue to afford their medications." The Medicare Rights Center offers a number of potential solutions, such as information on lower-cost generic drugs, patient assistance programs and charitable organizations that offer partial Part D relief. "The problem is that these measures only work for specific groups of patients; they're not for everyone," Ms. Beebe stressed. "Too often, there is no solution to surviving the coverage gap other than to borrow money, go into debt or go without prescribed drugs. Until we have a universal, more complete drug benefit in this country, many people with limited funds and serious illness will continue to suffer." Pharmacists seeking information on patient assistance programs and other resources can visit the Medicare Rights Center's Web site at http://www.medicarerights.org/