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Evaluating an Urban Safety-Net Pharmacy
Financial Sustainability of the At-Cost Stock Medication Program at
St. Joseph's Neighborhood Center
***144***
Community Health Improvement Clerkship
September 29, 2006
Introduction
From the Medicare Part D benefit program to importing drugs from Canada, the
high cost of pharmaceuticals is in the news on an almost-daily basis. Many Americans
have trouble affording prescription medications but individuals without health insurance
are particularly hard-hit by high drug prices. Patients without prescription coverage and
limited ability to pay for pharmaceuticals have reduced access to medications, inhibiting
optimal treatment of acute and chronic medical conditions. This paper will address one
effort to improve uninsured patients’ access to medications.
St. Joseph’s Neighborhood Center (SJNC) is a non-profit community health
center located in the South Wedge area of Rochester. It is run by the Sisters of St.
Joseph, an order of Catholic nuns. The center provides uninsured (and some
underinsured) members of the community with services including medical visits (adult
medicine, pediatrics, women’s health, psychiatry and some specialty services),
counseling, dentistry, chiropractic, physical therapy, social services advocacy and
educational services including literacy and GED tutoring. It is a busy place and currently
hosts 10,000-11,000 medical and mental health visits alone per year. The center has
three full-time and eight part-time paid staff, and around 20 volunteer physicians, nurse
practitioners and other health care professionals provide medical services. Patients are
requested to pay a $5.00 donation for each visit to help cover overhead, and are asked to
pay for lab tests (at a discounted rate). Counseling is provided on a sliding-scale basis.
Services are otherwise free.
URWell Student Outreach is a project of University of Rochester medical
students to found a medical student-run clinic to serve the uninsured. In the planning
stages of the project it was decided to partner with St. Joseph’s Neighborhood Center and
expand their hours one evening a week rather than creating a new, independent clinic.1
This provides a link between the University and a community agency and allows for
sharing of resources including office space, equipment and supplies, pharmaceuticals
including samples, and a referral base of specialists. URWell had its first clinic night on
September 14, 2004. Currently, three teams of two medical students each see around 6-8
patients per night on Tuesday evenings, precepted by a volunteer physician.
As mentioned above, pharmaceutical access is one of many difficulties
encountered by individuals without health insurance. Several methods of obtaining less-
costly medications are used by the providers at St. Joseph’s (and consequently by
URWell). These include sample medications, drug company-run patient assistance
programs (PAP), and a partnership with Woodward Health Center, another health center
in Rochester. Woodward has a pharmacy that is subsidized by federal 340b funding to
provide prescriptions to the uninsured at reduced rates. The partnership allows SJNC
patients to get prescriptions filled there, taking advantage of the subsidy.
However, each of these options has limitations. Sample medications are provided
by drug companies to promote their new, brand-name pharmaceuticals; older medications
whose patents have expired are not generally obtainable in this fashion. Drug company
patient assistance programs are an excellent source of medications for patients who
qualify but the application process is lengthy. The partnership with Woodward Health
Center is a fantastic resource but requires patients to obtain transportation to another site
to fill their prescriptions, and medications there may still be expensive for some
individuals.
History of the stock medication program
To fill some of the gaps in the available pharmaceutical resources, St. Joseph’s
and URWell collaborated to start a stock medication program to expand uninsured
patients’ access to needed pharmaceuticals. In the fall and winter of 2004, Antoinette
Eng and I investigated the feasibility of starting a program to purchase commonly-used
generic medications in bulk and sell them at-cost to patients. The process of examining
the pharmaceutical resources available to St. Joseph’s and laying the foundation for the
stock medication program is detailed in Developing an Urban Safety-Net Pharmacy:
Formative Program Evaluation2 as well as Developing an Urban Safety-Net Pharmacy:
Implementation of Formative Program Evaluation.3 The start-up costs for the initial
medication purchase (around $1000) were paid for by URWell using funds from the
AAMC Caring for the Community Grant it had received. The program began offering
medications to patients in November 2005; a list of the medications included in the stock
program can be found in Table 1. Nicotine gum and nicotine patches were also
purchased in order to be included in the stock program. However, the prices for these
were never added to the list of available medications and consequently they have not
been used. It is important to note, though, that URWell runs a smoking cessation
program in conjunction with the New York State Smoker’s Quitline and the Fax-to-Quit
program. In addition to individual counseling, nicotine replacement patches from the
Quitline are provided to patients at no charge.
Medication Price Antibiotics ($5.00/course of treatment)
Albuterol MDI $10/unit Amoxicillin 250 mg chewable tablets
Amlodipine 5 mg $1.10/tablet Amoxicillin 500 mg capsules
Atenolol 50 mg $0.05/tablet Azithromycin 500 mg (STD treatment only)
Gemfibrozil 600 mg $0.15/tablet Ciprofloxacin 500 mg
Glipizide ER 5 mg $0.20/tablet Doxycycline 100 mg
HCTZ 25 mg $0.05/tablet Fluconazole 150 mg
Lisinopril 20 mg $0.15/tablet Metronidazole 500 mg
Lovastatin 20 mg $0.25/tablet Penicillin VK 250 mg
Metformin ER 500 mg $0.15/tablet Trimethoprim/sulfamethoxazole 160/800 mg
Metoprolol XL 50 mg $0.50/tablet
Naproxen 220 mg $0.05/tablet
Omeprazole 20 mg $0.60/tablet
Ranitidine 150 mg $0.10/tablet
TABLE 1. Stock medications carried by St. Joseph’s Neighborhood Center
For medications other than antibiotics, patients are charged on a per-tablet basis.
For example, hydrochlorothiazide is priced at $0.05 per 25 mg tablet, so a typical dose of
25 mg daily would cost $1.50 per month. Prices were set by rounding the per-tablet cost
of the medications up to the nearest five cents. This provides a buffer to ensure that
enough funds are taken in to purchase further medications; the intention is for the
program to be financially self-sustaining. Antibiotics are priced using a different scheme;
patients are charged at $5.00 for a course of treatment, whatever the provider deems that
to be. Azithromycin is restricted to the treatment of sexually transmitted infections due
to its cost, more than $9.00 per tablet, but patients are still charged the $5.00-per-course-
of-treatment rate. Patients are expected to pay for medications at the time of dispensing
but an exception is made for antibiotics: these may be given out if the patient is unable to
pay.
A record of each prescription dispensed through the program is made on a
preprinted carbonless form with space to record the date, patient’s name, name and
strength of the medication, directions for use, lot number and price. The top copy goes to
the patient as a record of what they received. The bottom copy is retained by the center
as a record of what has been dispensed, and so that in case of a recall patients with
medication from affected lots can be contacted.
The stock medication program is not intended to be patients’ “final destination”
for access to pharmaceuticals; instead, it is meant to be used as a bridge to patient
assistance programs or other long-term solutions. However, no official policies are in
place dictating how many refills a patient may obtain from the program.
There was initially some misunderstanding between SJNC staff and URWell
leadership about the payment model of the stock medication program. Another service
that SJNC offers is laboratory testing, and the Center has negotiated a contract with a
local lab company to provide services at the Medicaid rate. Patients are requested to pay
these costs but if they are unable to, the lab tests can still be performed. An account is
kept in the patient’s chart of owed lab fees and patients are asked whether they can pay
something toward these when they come in. Patients are not sent bills for these charges.
Historically, around 50% of lab charges are covered by patients in this manner. It was
the understanding of URWell that the stock medication program would operate under a
similar model. This was clarified in a May 2006 meeting, and the policy that patients
must pay for medications (except antibiotics) at the time of dispensing was implemented
by URWell at that time. In addition, SJNC staff began more carefully tracking whether
patients had paid for medications.
Objectives
The present study aims to evaluate the status of the stock medication program
both quantitatively and qualitatively. From a quantitative standpoint, the program’s
records will be reviewed to determine how it is being used and whether it is meeting its
goal of financial sustainability. Qualitatively, feedback will be sought from SJNC
providers on how the program is working for them and their patients.
Methods
Quantitative
Permission was obtained from St. Joseph’s Neighborhood Center executive
director Christine Wagner to examine records related to the stock medication program as
a form of internal review. All medication dispensation forms from the initiation of the
program in November 2005 through September 20, 2006 were reviewed and the date,
medication name, number of tablets and price charged were entered into a spreadsheet.
To correlate this data with whether the medications had been paid for, the receipt books
for that time period were then examined. For each donation and payment the center
receives, a receipt is generated with the payer’s name and the category that the money
should fall into (medical/dental/chiropractic/physical therapy visit donation, counseling
fee, lab fee, stock medications, etc.). For selected instances where evidence of payment
could not be found, the census form (a tracking form generated for each visit to the
center) was looked up in an attempt to determine why payment had not been received,
and whether non-payment was occurring only from URWell patients or those of other
providers as well. Finally, invoices from the pharmacy that the medications are ordered
from were used to determine the prices the center is being charged. These data were all
combined in the spreadsheet and analyzed to determine the number of prescriptions
filled, the rates at which the different drugs are being prescribed, the number of
prescriptions not paid for (and the relationship of this to the policy clarification in May
2006), whether the prices being charged were greater or less than the cost of the
medications, and the overall financial balance of the program.
Qualitative
Informal key informant interviews were conducted with several SJNC providers
to determine how the program is working for them, and to solicit suggestions for
improvement and requests for new medications to be added to the program.
Results and Discussion
Quantitative
Usage statistics. In the first approximately 10½ months of the stock medication
program from November 2005 through September 20, 2006, 327 prescriptions were
filled, totaling almost 12,000 tablets. The most popular medications were
hydrochlorothiazide (67 prescriptions, 3395 tablets), atenolol (38 prescriptions, 2193
tablets), lisinopril (36 prescriptions, 1488 tablets), and metformin (33 prescriptions, 1575
tablets). At the other end of the spectrum, amlodipine, gemfibrozil and penicillin VK
have never yet been used, and metoprolol XL has only been prescribed twice. See Figure
1 for prescribing frequencies of all medications in the program.
80
70
Number of prescriptions
60
50
40
30
20
10
0
Naproxen
Lovastatin
HCTZ
Atenolol
Metronidazole
Metoprolol XL
Ranitidine
Albuterol
Metformin ER
Fluconazole
Ciprofloxacin
Omeprazole
Lisinopril
TMP/SMX
Doxycycline
Gemfibrozil
Amlodipine
Glipizide ER
Amoxicillin chewable
Azithromycin
Penicillin VK
Amoxicillin capsules
FIGURE 1. Frequency of prescriptions for all medications in the stock
program during its initial period of November 2005-September 2006.
In the case of amlodipine and metoprolol, high cost is the most likely reason they
have gone unused; amlodipine is being charged at $1.10/tablet and metoprolol at
$0.50/tablet. These prices are much higher than most others on the stock medication
formulary because they are only available as brand-name preparations. The gemfibrozil
and penicillin VK have not been used presumably because providers simply have not
found a need to prescribe them. Another issue is that the gemfibrozil expires in
September 2006 and will have to be discarded, representing a loss to the program.
Rates of Non-Payment. For 64 prescriptions (20% of the total), corresponding
receipts were unable to be found; i.e., it appeared that they had not been paid for. Of
these, 16 were for antibiotics and 48 for other medications. This was somewhat
surprising, since antibiotics are the medications allowed to be provided at no charge. An
additional 13 prescriptions were partially paid for. A significant caveat is that the lack of
a receipt does not necessarily indicate that the medication was not paid for, and these
figures should be viewed as approximate. This is illustrated by the fact that after the May
2006 policy clarification, SJNC staff began keeping closer track of the medication
dispensation slips and most have a note on them indicating whether they were paid.
Oddly, though, of the 103 prescriptions filled after May 23, 2006, five slips marked
“paid” had no associated receipt able to be found, either on the day of the prescription or
several days following. This suggests that unfortunately, examining the receipt books
may not be the most reliable way to determine whether payment has been received for a
medication. Overall, no receipt was found for 55 of 224 (25%) of prescriptions before
May 23, but only 9 of 103 (9%) of prescriptions filled after May 23. This demonstrates
the success of the efforts to ensure that medications are being paid for, but it is unknown
whether this tighter management may have inhibited some patients from receiving
needed drugs.
Further analysis of non-payment. A few instances of non-payment were
investigated further in an attempt to clarify the reasons for the non-payment. When each
visit at St. Joseph’s is scheduled, a census form containing the patient’s name, contact
information, appointment scheduling information and reason for the appointment is filled
out. This form is attached to the front of the patient’s chart and has space for the provider
to write information about follow-up visits and spaces to enter lab fees, counseling fees,
and other charges. The patient then brings this form to the front desk to check out. A
revision of this form was made in November 2005 to add a space for the provider to enter
stock medication fees (interestingly, the old revision of the form was still in use as late as
April 2006). These forms are kept after the visit is completed and were located for a
small, non-random sample of fourteen cases where stock medications were not paid for
(see Table 2). Of the fourteen, in three cases no pharmacy fee was noted on the census
Notation Number of patients
No note of fee on census form 3 (1 URWell, 2 daytime)
Fee noted on census form 10 (4 URWell, 6 daytime)
Fee noted on census form + 1 (daytime)
noted as “paid”
Total 14
TABLE 2. Notation of pharmacy fees on selected census forms
form. This suggests that the non-payment may have been because the provider forgot to
note the charges, and so the front desk did not know to collect these funds. Two of these
were URWell patients and one was a “daytime” patient. In ten of the fourteen cases, the
fee was noted on the form, suggesting that the non-payment may have been due to the
patient telling the front desk they were unable to pay, payment was made but a receipt
was not filled out, the patient paid many days later and so the receipt was in the book
much later than the date of the visit, or similar circumstances. Of these ten cases, four
were URWell patients and six were daytime. The remaining case had “$1.50 – paid”
written on the census form, yet no receipt had been found. As above where money was
noted to be paid on one form but no receipt is apparent, this suggests the possibility of
money being received without a receipt being recorded. However, having spent some
time at the front desk, staff there (both daytime and URWell) are quite fastidious about
recording monies received. It remains mysterious why this gap is occurring in some
cases. A larger study of these census forms was not able to be undertaken due to the
amount of time it would have taken to find all of the forms involved in non-payment, as
they are not well organized (recall that there are 10-11,000 visits per year at SJNC, and
each visit generates a form). Nevertheless, the few that were studied suggest that
providers are doing a relatively good job of noting pharmaceutical fees and that non-
payment (or lack of evidence of payment) is most often occurring at the front desk. They
also indicate that non-payment was associated with both daytime and URWell patients.
Timing of payment. Of the 263 prescriptions that were paid for, in 26 cases the
money was received one or more days after the date of the prescription. It is unknown
how many of these were instances where the provider dispensed the medication and they
and/or front desk staff took an IOU on later payment, and in how many the medications
were left at the front desk for the patient to pick up and pay for at a later date. It does
suggest, though, that having patients return to the center can be effective in some cases.
Mis-assignment of monies received. Front desk staff are instructed to record a
receipt for all money received, and to note on the receipt which category the funds should
be assigned to. If a patient has $3.00 in lab charges, $2.00 in pharmaceutical fees and
wishes to make a $5.00 visit donation, these should be broken down as such on the
receipt. In 24 instances during the study period, funds that should have been noted on the
receipt as stock medication fees were mistakenly assigned to the medical visit donation or
in a few cases, to lab costs. This makes it difficult for SJNC to adequately assess how
much money is received in payment for stock medications. For the financial analysis
below, in instances where funds were supposed to have been recorded as pharmaceutical
fees but were assigned to medical visit donation, the prescription was counted as “paid,”
in the theory that the money was received by St. Joseph’s, just mis-accounted. There
were also three instances where the patient paid both a stock medication fee and a
donation, but the total amount was all assigned to pharmaceuticals.
Shift of funds from one budget department to another. It was noted during the
analysis of the receipt books that if patients had pharmaceutical fees, they very often
reduced their requested $5.00 visit donation accordingly. For instance, if a patient had a
$5.00 pharmacy fee a visit donation was frequently not given, and if a patient had a $3.00
pharmacy fee, $2.00 would be given as a visit donation. It is possible that the addition of
the stock medication program may actually reduce the amount of money received in
donations from patients, used to help fund general overhead. The same phenomenon was
already occurring with lab fees prior to the advent of the stock medication program. The
number of visit donations made is large compared to the number of pharmaceutical
and/or lab charges, though, so most likely it does not represent a significant reduction to
the general budget. It may be interesting to study further, however.
Stock medication costs. All available invoices for stock medications were
examined, and some surprising results were found. Table 3 shows the average prices
calculated for all medications in the stock program, and some have been expanded to
demonstrate differences in price when different quantities of medications are ordered.
Average Price
Medication Charged to SJNC
Albuterol MDI $16.96/unit
Amlodipine 5 mg $1.02/tablet
Amoxicillin 250 mg chewable tablets $0.13/tablet
Amoxicillin 500 mg capsules $0.05/tablet
Atenolol 50 mg $0.08/tablet
purchased in quantity of 1000 $0.02/tablet
purchased in quantity of 300 $0.47/tablet
Azithromycin 500 mg $9.41/tablet
Ciprofloxacin 500 mg (prior to recent order) $0.15/tablet
most recent order, 7/28/06 $2.96/tablet
Doxycycline 100 mg $0.09/tablet
Fluconazole 150 mg $0.69/tablet
purchased in quantity of 24 $0.58/tablet
purchased in quantity of 12 $0.92/tablet
Gemfibrozil 600 mg $0.13/tablet
Glipizide ER 5 mg $0.13/tablet
purchased in quantity of 500 $0.17/tablet
purchased in quantity of 200 $0.02/tablet
HCTZ 25 mg $0.02/tablet
Lisinopril 20 mg $0.04/tablet
purchased in quantity of 500 $0.03/tablet
purchased in quantity of 100 $0.09/tablet
Lovastatin 20 mg $0.14/tablet
Metformin ER 500 mg $0.05/tablet
purchased in quantity of 1000 $0.03/tablet
purchased in quantity of 200 $0.09/tablet
Metoprolol XL 50 mg $0.43/tablet
Metronidazole 500 mg $0.11/tablet
Naproxen 220 mg $0.04/tablet
Omeprazole 20 mg $0.40/tablet
purchased in quantity of 200 $0.30/tablet
purchased in quantity of 60 $1.09/tablet
Penicillin VK 250 mg $0.02/tablet
Ranitidine 150 mg $0.02/tablet
Trimethoprim/sulfamethoxazole 160/800 mg $0.05/tablet
TABLE 3. Prices charged to St. Joseph’s Neighborhood Center by
MetCareRx Pharmacy for stock medications
Atenolol is the most striking example of this; it cost only 2 cents/tablet when ordered in
quantities of 1000 but jumped to 47 cents/tablet when a smaller bottle of 300 was
ordered. This caused the average price of atenolol to be $0.08/tablet, more than the stock
medication program is charging patients (0.05/tablet). Similar but less extreme discounts
were evident when fluconazole, lisinopril, metformin and omeprazole were purchased in
larger quantities. Glipizide presented a confusing picture, with a higher price per tablet
charged when a larger quantity was ordered. But for several medications, the benefits of
ordering in larger quantities are clear, and the most popular medications are used enough
that ordering bottles of 1000 is easily justifiable.
The most surprising feature of the pharmacy invoices was the July 28 order for
ciprofloxacin where $591.49 was charged for 200 tablets, or $2.96/tablet! The order was
examined more closely and it appears that “Cipro” was ordered as a brand-name drug
rather than “ciprofloxacin,” the generic. However, the ciprofloxacin in the stock
medication cabinet is all generic and it does not appear that any brand-name Cipro was
received anyway. The pharmacy where the medications are purchased (MetCareRx) will
be contacted to request a refund of the difference in price.
Another problem involved the pricing of albuterol metered-dose inhalers. The
initial price quoted was around $9.00/unit, so the price for patients was set at $10/unit.
The initial order for albuterol was for only one inhaler, and $9.05 was charged for it as
expected. However, the next order was for 10 units and $178 was charged. This put the
average price for albuterol at $16.98/unit, and the program is taking a loss on every
inhaler provided. For the past two orders of medications, though, albuterol has been
ordered but not been received. There is a national shortage of some brands of albuterol
MDIs related to their conversion to CFC-free propellants.4 SJNC’s stock medication
program has been out of albuterol for several months. Patients are being given
prescriptions to fill at local pharmacies (which evidently do have stock), and the inhalers
there do not cost much more than we were charging. SJNC providers miss having the
convenience of being able to give patients an inhaler at their visit, though, and it is hoped
that albuterol MDIs will again become available through MetCareRx soon.
Financial balance of the program. The average prices in Table 3 were used to
calculate the actual cost of each of the 327 prescriptions filled during the study period.
These costs were then compared with the money received in payment. Overall, if the
overcharge involving ciprofloxacin discussed above is ignored, for the study period of
November 2005-September 20, 2006 the program had a net positive balance of $254. If
the ciprofloxacin is included, the balance is $50, still net positive. Comparing the
financial balance of antibiotics with non-antibiotics (if the ciprofloxacin is again
ignored), antibiotics had a $194 net positive balance, and non-antibiotics had a $60 net
positive balance. One thing that this analysis does not take into account is $183 spent on
medications such as amlodipine, gemfibrozil and penicillin that are not being used and
whose initial outlay, therefore, may be hard to recoup. It is possible that the amlodipine
may be able to be returned. At least, however, these are a one-time expense to be
absorbed. To avoid this situation in the future, though, any new additions to the stock
program should be considered carefully to determine whether they will be affordable, and
whether they will actually be used.
Qualitative
Key informant interviews revealed that providers were universally enthusiastic
about the program. Many cited its convenience as a major asset; if patients walk out the
door with medications in hand, they are potentially much more likely to take them than if
they have to take the extra step of filling a prescription at a pharmacy.
Elly Weinstein, pediatric nurse practitioner noted that it has been nice to have
chewable amoxicillin tablets and doxycycline available. She has on occasion paid for
medications (particularly albuterol) from her own pocket for her patients if parents are
unable to pay. She would like to see inhaled steroids such as fluticasone for use as an
asthma controller added to the program, as these are not reliably available as samples.
Sue Groth, women’s health nurse practitioner said that the program has been
working well for her. She would like to have oral contraceptives added, since the
samples the center has are often different brands from one week or month to the next.
She likes the fact that fluconazole is available for treating vaginal yeast infections but
would also like to have topical treatments such as miconazole or clotrimazole available,
as that is sometimes more appropriate for patients than oral treatment. She would also
like to see acyclovir or valacyclovir added to the program for the treatment of herpes
simplex.
Rita d’Aoust, adult nurse practitioner, expressed how grateful she was that
URWell was able to provide start-up funds for the stock program. She did not have any
specific suggestions or requests but articulated frustration at the high price of calcium
channel blockers (CCBs) in general. She noted that by the time she considers placing a
patient on a CCB, he or she is already on multiple medications, indicating the treatment-
resistance of their hypertension. However, taking the next step and prescribing a CCB is
difficult due to their high cost.
Dr. Warren Glazer, an internist, Dr. Leon Zoghlin, a family practice
physican, and Charlotte Torres, a family nurse practitioner, all expressed that they
were glad to have the program, particularly for its convenience. None had specific
suggestions or requests, indicating that general adult pharmaceutical needs
(antihypertensives and oral diabetes medications, primarily) are adequately covered by
the program.
Recommendations
Based on both the quantitative and qualitative results of this study, a number of
recommendations can be made to St. Joseph’s for ways to improve the stock medication
program and ensure its financial sustainability. These recommendations provide
numerous opportunities for further partnership between SJNC and University of
Rochester medical students, and several could become future CHIC projects.
1. Addition of new medications to the stock program. Key informant
interviews identified inhaled steroids, oral contraceptives, topical yeast infection
treatments and acyclovir/valacyclovir as desired additions to the program. URWell
students could collaborate with staff at SJNC to investigate the feasibility of adding these.
The cost that will be charged to patients will need to be carefully examined; as
demonstrated with amlodipine, a cost-prohibitive medication will not be used and its
initial expense will be difficult to recoup. In addition to those possible new medications,
other calcium channel blockers are available in generic form, and these could be
investigated for possible addition to the program if their cost profile is more favorable.
The start-up costs of purchasing new medications for the program will be able to be paid
by URWell as there are funds specifically allocated for pharmaceuticals in this year’s
budget.
2. Removal of some medications from the stock program. Amlodipine, and
gemfibrozil have not been used at all and should not be reordered. It should be
investigated whether the amlodipine can be returned to the pharmacy for refund or credit
to recoup its $92 cost. If this is not possible, it could perhaps be discounted so that at
least it gets used and not simply thrown away when it expires. The penicillin VK has
never been used either, but could be kept around in case it is needed (perhaps there were
no cases of streptococcal pharyngitis seen in the past 10 months, but there may be in the
future). However, it should probably not be reordered when it expires. The metoprolol is
also only available as brand-name Toprol XL (and thus expensive, and is being charged
to patients at $0.50/tablet). It has only been used a couple of times and atenolol, another
beta-blocker, is available for only $0.05/tablet. The metoprolol should likewise probably
be dropped from the program.
3. Smart ordering. As discussed above, ordering in larger quantities is more
cost-effective for most medications. Recommendations include ordering no fewer than
1000 tablets of hydrochlorothiazide, atenolol, or metformin and no fewer than 500 tablets
of lisinopril, 200 of omeprazole, or 24 of fluconazole. It is hard to know what to
recommend regarding ordering of glipizide, where significantly more per tablet was
charged when a larger quantity was ordered. Perhaps consultation with the pharmacy
will clarify the reason for this. In addition, careful attention should be paid to ordering
medications by generic rather than brand names to avoid another incident like the
ciprofloxacin one. A sheet has been provided to Katherine McCormick, the SJNC
administrative assistant responsible for ordering the medications, that lists the generic
names and correct spellings of all medications in the program. The suggested minimum
order amounts will be added to it.
4. Consideration of price changes. As can be seen by comparing Tables 1 and
3, in several instances the per-tablet price we are charging is more than five cents above
the price we are paying for the medication. Lisinopril is priced for patients at
$0.15/tablet, but only costs the program $0.04/tablet. Metformin is also priced at
$0.15/tablet, but costs an average of $0.05/tablet and only $0.03/tablet when purchased in
large quantities. Lovastatin is priced at $0.25/tablet but costs $0.15/tablet, and
omeprazole is priced at $0.60/tablet but costs $0.40/tablet ($0.30/tablet when purchased
in large quantities). Some of these prices could be reduced, thus expanding access to
patients with minimal funds, while still maintaining the financial sustainability of the
program.
5. Nicotine gum and nicotine patches. Nicotine gum and patches were ordered
as part of the stock medication program and also in conjunction with the development of
URWell’s smoking cessation program. The nicotine gum would be a valuable addition to
the stock medications. The only barrier to using it is that it is not known how much was
paid for it, and thus how much patients should be charged. This can be easily rectified
with a call to the pharmacy it was ordered from. There is also a large quantity of patches
that were ordered, but these have not been used because patients are able to get free
nicotine patches from the New York State Smokers’ Quitline. It appears that they were
purchased, but some URWell students thought that they had come from the Quitline.
This should be investigated further, and if they were purchased, perhaps some can be
returned. This would be a good project for URWell staff to pursue, since the gum and
patches were ordered at the request of the URWell smoking cessation program.
6. Albuterol. This has not been available for several months due to national
shortages. When it can be ordered again, investigation should be undertaken into its cost.
The $17.75/inhaler price most recently charged to us is significantly greater than the
initial order at $9.00 each, and the program has been losing money on them. Albuterol
inhalers were identified as a significant need, particularly by pediatric nurse practitioner
Elly Weinstein, and it would be nice to be able to stock them. Perhaps if they are going
to be more expensive they will just have to be subsidized by other medications.
7. Exceptions to the “must pay at the time of dispensing” rule. Currently, the
stated policy is that patients must pay for medications at the time of dispensing and the
charges can only be waived in the case of antibiotics. However, during the period after
May 23 when the policy was clarified there were a few slips that said “fee waived per
Nicole” (the office manager), or “didn’t pay per Leon” (Dr. Zoghlin, one of the volunteer
providers). It will probably be difficult to come up with a specific policy for when non-
antibiotic pharmaceutical fees can be waived due to patient need, but may be a good thing
to look into. So far the stock medication program has done well even with a 25%
nonpayment rate, but if some prices are lowered as suggested, the “profit margin” will
become much tighter.
8. Consideration of encouraging patients to bring money to appointments.
Many of the uninsured patients we see also lack access to financial institutions. A
significant number likely do not have a checking account and rely on cash to carry out
many transactions. Patients are notified of the requested $5.00 visit donation when they
make appointments, but if lab or pharmacy fees are generated as part of the visit, many
times patients cannot pay simply because they do not have money with them. Perhaps it
would be worthwhile to request that patients bring a small amount of extra money, if they
have it, to their appointments in case lab or pharmacy fees are incurred. This has the
potential to reduce return trips to the center to pick up medications that could not be paid
for, etc.
9. Policy on number of refills. As mentioned above, there is no current policy
on the exact number of times a patient may use the stock program for a given medication,
just a guideline that patients should be steered toward more long-term solutions since St.
Joseph’s is not a pharmacy. One significant sticking point is that Bristol-Myers Squibb,
which manufactures the Glucophage brand of metformin, has dropped it from its patient
assistance program. Patients who are already receiving PAP Glucophage from Bristol
can continue to do so, but no new patients may sign up. There are other manufacturers of
metformin that may offer PAPs but it is likely that the stock medication program will be
called upon to fill a more long-term need for some patients taking metformin. The
program is most likely capable of handling this need without problems, but SJNC (and
URWell) may need to clarify the goals of the program in this area.
10. Development of new receipt books. The current receipt books being used
are generic ones from an office supply store. They serve the purpose but SJNC would
benefit from custom receipt books that allow for easy recording of the proper allocation
of monies received. They would need retain some of the features of the current books,
such as 2-part forms so that patients can take one copy of the receipt and the center can
retain the other, and the retention of the bottom copies in the book so that they don’t get
lost. But a custom form where receptionists can easily enter the amount of visit
donations, lab fees, pharmaceutical fees, etc. would make tracking the financial status of
the stock medication program easier. URWell students could collaborate with SJNC on
designing a new book, and URWell may be able to provide funds towards printing.
11. Sustainability of this analysis. The financial analysis provided in this paper
was time-consuming to generate. In a completely separate project, a database has been
developed to gather the information for all of the census forms generated. Perhaps more
information on whether stock medications are paid for could be integrated into that
database, allowing easier, faster analysis of the program. In addition, monitoring
pharmacy invoices could become one of the duties of the URWell steering committee
member responsible for pharmaceuticals. That person could add new invoices to the
database begun for this study, and continue to monitor the prices SJNC is being charged.
Errors such as the overcharge for ciprofloxacin could be caught early and corrected.
Conclusions
The stock medication program at St. Joseph’s Neighborhood Center is providing a
valuable service and filling a needed gap in pharmaceutical access for uninsured patients,
providing over 1000 tablets per month at an extremely low cost. It is achieving its goal
of breaking even financially, and the prospect for its long-term financial sustainability is
excellent.
Personal Impact
This project was an extension of the work I have been doing with URWell for
much of my time in medical school; during my second year I was the steering committee
member responsible for pharmaceutical matters. This whole experience has opened my
eyes to the often strange world of the pharmaceutical and pharmacy industry. I will be
going into anesthesiology, a field that does not deal with the type of pharmaceutical
access dealt with in this paper, but which nonetheless obviously has a very high usage of
specialized medications. One issue in anesthesiology that interests me is the relative
costs of inhaled anesthesics. Isoflurane is a very inexpensive anesthetic, while
sevoflurane, depending on hospital contracts, costs many times more. There is debate,
however, whether based on the characteristics of sevoflurane (patients wake up faster,
thus potentially leading to faster OR turnover times and greater productivity) it truly is
more expensive when considered from a systems standpoint. This kind of issue
fascinates me and I look forward to learning more about topics like this, in order to
provide the most cost-effective (yet highest-quality) care possible – which, hopefully,
will translate to improved healthcare access.
References
1. Camenga, Deepa. Understanding the Uninsured in Rochester and Nationwide: The
Purpose, Progress and Practicalities of URWell, the Free Clinic Founded and
Operated by Medical Students at the University of Rochester. University of
Rochester Community Health Improvement Clerkship, 27 Aug. 2004.
2. Eng, Antionette. Developing an Urban Safety-Net Pharmacy: A Formative Program
Evaluation. Final paper for University of Rochester Community Health
Improvement Clerkship, 27 Aug. 2004.
3. 18. Developing an Urban Safety-Net Pharmacy: Implementation of Formative
Program Evaluation. Final paper for University of Rochester Community Health
Improvement Clerkship, 24 Sept. 2004.
4. US Food and Drug Administration: Drug Shortages. Current Drug Shortages.
http://www.fda.gov/cder/drug/shortages/#Current
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