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2006 Model Practice Application (Public)
Application Name: 2006 Model Practice Application (Public) : Baltimore City Health Department : Medicare Part D Surveillance and Response Initiative
Applicant Name: Dr. Oxiris Barbot, MD
Medicare Part D Surveillance and Response Initiative
Baltimore City Health Department
The goal of this project is to ensure access to essential medications for residents in Baltimore City during the transition to Medicare Part D, the new drug benefit in Medicare. On January 1, approximately 28,000 residents of Baltimore City lost comprehensive drug coverage through the Maryland Medicaid program or state pharmacy assistance and gained Part D coverage. And, as many as 77,000 other Baltimore City seniors on Medicare could voluntarily switch to the new program.
To accomplish this goal, program staff designed a strategy in advance that directly targeted the 98 pharmacies in Baltimore City. Beginning on January 1, 2006 the program educated pharmacists, provided 24-hour access to assistance and funding, and linked patients as having problems into case management.
The goals of this project are to:
- Provide education and 24-hour support to pharmacists,
- Facilitate referrals to case management for residents having problems with Part D,
- Establish safety net financing to ensure access to essential medications,
- Advocate for city residents mistreated by Medicare Part D drug plans,; and
- Monitor the impact of Part D implementation on public health.
In accomplishing these goals, the program has been able to ensure that city residents do not leave the pharmacy without essential medications because of problems with the implementation of Medicare Part D.
Responsiveness and Innovation
The Medicare Part D Surveillance and Response Initiative was designed to protect vulnerable Baltimore City residents from losing access to essential medications during the transition to Medicare Part D. The importance of this issue was identified in advance based on warnings from expert agencies and collaboration with pharmacies and the Commission on Aging.
In December, the Government Accountability Office identified three potential problems that low-income individuals might experience during the process of switching drug coverage from Medicaid to Medicare on January 1, 2006 – they might be dropped from coverage because of inaccurate data-sharing between state and federal agencies; they might be dropped from coverage if only recently eligible for the benefit; they might have difficulty obtaining certain drugs or service from their customary pharmacy.
The approach to this issue was uniquely proactive and supportive. Unlike other areas that appeared taken by surprise whethe program to provide education to pharmacists to make the new program work for patients, rather than simply extend state financing of medications.
The result was a program that was effective and not especially costly. The program was described by experts at the Kaiser Family Foundation and elsewhere as the only proactive Medicare Part D surveillance and response program in the country.
Agency Community Roles
The Medicare Part D Surveillance and Response Initiative has at core an innovative collaboration between the Health Department, Baltimore City pharmacies, and the City Commission on Aging and Retirement Education. The project developed out of a series of planning meetings with pharmacies in December 2005. What developed was a clear template for how to avert problems with Medicare Part D. Here’s how the initiative looks to a city pharmacist and patient:
The pharmacist sees a patient who cannot obtain needed medication through Medicare Part D. He or she calls 311, our city’s 24-hour emergency support line, to report the problem. The city operator transfers the call immediately to a cell phone held by a Health Department pharmacy project officer on call. The pharmacy officer first gives advice about how the problem might be solved through the Medicare Part D system. If this advice does not work, the officer can also authorize payment for medications when there is no other option for the Baltimore city resident. The Health Department then enters the information into a database, where it is seen by case managers from the Aging Commission. The case managers contact the patient within 72 hours to ensure that Part D problems are resolved.
Costs and Expenditures
- Website: $800
- Telephones and electronic fax: $595
- Printing: $200
- Support for pharmacy visits: $120
- Contracts for two caseworkers: $40,000
- Health department staff salary: $66,000
BCHD designed the initiative in close collaboration with city pharmacies and with Baltimore City’s Commission on Aging and Retirement Education (CARE). Under this initiative, Baltimore City completed the following start up tasks:
- Task 1: Establish a 24-hour surveillance program based in pharmacies to identify problems experienced by city residents with Medicare Part D. Timeframe: Beginning in the first two weeks of December 2005 -- BCHD began jointly planning this initiative with the heads of chain pharmacies, independent pharmacies, and the Maryland Pharmacy Association. BCHD also reached out to individual pharmacists through their central offices and individually, via media, website, fax, email, and face to face visits to 75% of city pharmacies. BCHD established a hotline and backup message system through the city’s non-emergency call center. BCHD also reached out to the public through the media.
- Task 2: Create an electronic follow-up database to ensure that residents identified by pharmacists with problems would be contacted by caseworkers from the city’s Commission on Aging and Retirement Education. Timeframe: First two weeks of December 2005 – Health Department technology staff collaborated with Commission on Aging staff to create a shared, secure database for all reports.
- Task 3: Provide for immediate intervention to prevent Baltimore’s poorest and most vulnerable residents from forgoing essential medications during the transition, including the establishment of a $50,000 reserve fund for medications. Timeframe: Third week of December 2005 – BCHD identified $50,000 in its general funds pool and cleared its use for medication payments with the City’s Board of Estimates.
- Task 4: Advocate for city residents with Medicare drug plans that failed to meet expectations on coverage. Timeframe: Beginning in January 2006, BCHD has written 20 letters to health plans that have violated the rules of Medicare Part D. All of the plans have responded and fixed the problems that were identified.
- Task 5: Build upon its existing biosurveillance system to monitor for changes in Emergency Department use among seniors. Timeframe: Last week in December 2005—Monitoring for hyperglycemia among seniors in a large city Emergency Department was established.
The goal of BCHD's effort was not to support a federal insurance program indefinitely. Rather, the goal was to respond to the temporary challenge of a difficult transition period. As a result, sustainability has a different meaning for this project than it might for others. What BCHD would like to sustain is not 24-hour support for Medicare Part D, as this may not always be necessary. Instead, BCHD would like to sustain is (1) a close relationship with city pharmacies, essential partners in public health; (2) the capacity to quickly develop a response to an imminent public health threat; and (3) an understanding in the community that the Health Department can respond to unusual challenges to public health.
The overwhelmingly positive response of area pharmacies to the program sets the stage for this sustainability. Pharmacists have testified before the state legislature that this program is a model for the country. One told a National Public Radio reporter in a story broadcast on January 13th, “We have one number to call,” he says, and pharmacists can “fax the information, we can phone the information, we can e-mail the information to the Baltimore city health department and know they're going to get on it right away.” The Los Angeles Times profiled the program as an excellent local solution to a national problem in “Baltimore Goes on Alert for Drug Benefit Status” on December 21st. Heads of Maryland pharmacy chains, the Mayor of Baltimore City, and Maryland Senators and Congressmen are quoted on the program's website – www.baltimorecitymedicare.org -- in support of the program as a national model.
Within the Health Department, staff are using this effort as a model for preparedness. Each division is identifying areas where we can coordinate with community partners to respond quickly to an emerging need. BCHD will continue to coordinate with pharmacists, use our emergency call center, and partners at the Commission on Aging. The next project will likely relate to access to flu vaccine during the annual flu season.
Outcome Process Evaluation
Goal: Provide 24-hour support to pharmacists, to fund case management for residents having problems with Medicare part D, and to establish safety net financing to ensure access to essential medications.
Objective: To establish 24-hour support to pharmacists:
- Performance measures: Provided immediate transfer of pharmacist call from 311 call center to on-call health department staff.
- Data collection: 311 operator automatically enters into 311 CitiTrack database the time of call and time of transfer to health department staff.
- Outcome (short-term):Between the 311 operator and the email backup system, on call staff have received handled 100% of calls. We are also conducting a follow-up survey of pharmacies with the University of Maryland to determine what helped and hindered our communications with them.
Objective: To identify and resolve problems with Medicare Part D:
- Performance measures: Insured residents receive the prescriptions they need.
- Data collection: Pharmacists faxed or called in reports of residents experiencing problems with Part D – reports included resident name, contact info, plan info, and medications.
- Outcome (long-term): All residents receive follow-up from CARE. In 76 cases pharmacists receive direct assistance in solving the Part D problem, and in 45 cases the health department paid for medications. Of the 131 reports in the database, 120 are considered closed and resolved. The remaining 11 open cases are in process – caseworkers are still trying to reach the patient or are still working on the issue reported.
Objective: To facilitate case management for residents having problems with Medicare Part D:
- Performance measures: Connected patients for case management within 72 hours of report received.
- Data collection: Health department and CARE staff share a database of cases received through the Part D project. Database automatically tracks time of entries and updates made to reports.
- Outcome (short-term): Caseworkers are now able to outreach all cases within the 72 hour window.