CAREAssist Turns to Mail Order to Reduce Deficit

July 7, 2010 -- As the state deficit spirals out of control, a program that provides medications to HIV positive patients is the latest to take a hit. With a $2.1 million budget hole looming, at least a portion of that money could be saved if people are willing to receive their prescription medication in the mail, rather than going to a pharmacy.

 

But it won’t be an easy road ahead with community advocates and legislators expressing caution.  

 

It’s critical not to frighten people into thinking they might lose their life-saving drugs by sending a clear message that mail order is strictly voluntary, said Rep. Val Hoyle (D-West Eugene). “Otherwise it will end up costing us more in the long run with people ending up in the emergency room.”

 

On July 1, a bid proposal hit the streets, seeking a vendor to coordinate this mail order option for the CAREAssist program. The deadline is Sept. 1, with the program expected to begin in November.

 

Oregon isn’t breaking new ground, said Tom Burns, director of pharmacy programs for the Oregon Health Authority. Half the states in the country offer a mail order option, giving them the ability to purchase drugs at a deep discount.  

 

“Mail order will be an option but not the primary way to deliver drugs,” Burns said. “We realize that a lot of people don’t have a secure address or mail delivery to their home. No one will be mandated to use it.”

The state also intends to contract with a network of pharmacies that do a high volume of CAREAssist business, paying them a set fee for such prescriptions, Burns said. An on-line claims adjudication process will be developed to verify eligibility.  

 

The bid proposal even goes one step further – calling for a medication therapy and management utilization program -- to make certain people receive the correct medication, stay on those drugs and are able to get refills.

 

The state will purchase all the pharmaceuticals through the 340B Drug Pricing Program, which is housed in the federal Health Resources and Services Administration, and realize savings through higher rebates, which will increase from 18 to 28 percent. That agency, which administers the Ryan White grants for HIV/AIDS treatment support, explored ways that a direct purchase of 73 of the most common used drugs by the program could increase rebates by about $2 million.  

 

“We want to reduce our costs by using 340B pricing and taking possession of the drugs,” Burns added. “Independent pharmacies that provide very good and very strong utilization management who know their clients personally will be invited to participate and awarded contracts.”

 

Unless the state takes action by introducing a mail order option, it might be forced to curtail the number of people eligible for the CAREAssist program. “That’s the last thing we want to do,” Burns said. “It was clear to us we weren’t going to be able to sustain growth in this program without finding some savings.”

 

It’s critical that people have access to their medications, said BJ Cavanor, public policy coordinator with Cascade AIDS Project. “We’re trying to work out the best outcome for everyone and understand the need to save money and curb costs.”

 

This is a very fragile and mentally challenged population, added Hoyle, who also directs the 100 Percent Access Coalition in Lane County focused on finding affordable, quality and appropriate healthcare. “A number of people on HIV medications are living in crisis and may be drug addicted. They do very well with a high level of care coordination. The pharmacy is often their patient-centered medical home.”

 

Rep. Jim Thompson (R-Dallas) has concerns about the potential of a bidding war among pharmacies, which could potentially lead to lower quality services. “Pretty soon people will find themselves at each other’s throats, and the whole quality of the program will be gone over cost,” he said. “We can’t jeopardize the pharmacy component even if it costs us more to do it.”

 

People working in community pharmacies question the efficacy of using mail order for such a vulnerable population. For example, patients receive a 90-day supply, which cuts down on the dispensing fee, but when their therapy changes midway through, and they’re given a different drug, that medication goes to waste.

 

“Even the federal government is trying to shift the 90 day supply back to 30 days for Medicare recipients because CMS realizes there’s a waste issue,” said Shelley Bailey, pharmacy manager at Central Drugs in downtown Portland, which serves many patients who don’t have a strong support network. “There’s a massive amount of impact on cost when medications are wasted.”

 

Community-based pharmacies also provide compliance packaging at no additional cost, which isn’t often available by mail order, she said. By having such a disposable package, patients can simply punch out the doses, take the medication and discard the package later.

 

“Mail order doesn’t do this in a specialized way,” she said. ”The assumption is that mail order is cheaper, yet we’re not seeing any outcomes that it’s cheaper. The agency is making an incorrect assumption that mail order will save money.”

 

Currently between 6,000 and 7,000 Oregonians live with HIV infection, and 300 new cases are diagnosed every year. Of those, 2,300 low-income people receive comprehensive services through the CAREAssist program such a housing assistance, case management and pharmaceutical drug services. In the past two years, there’s been a 35 percent increase in clients.

 

It costs $4.1 million for prescription drugs for that population and $10.5 million annually for their health insurance, which includes the cost of premiums and medical services. Paying for insurance is the way CAREAssist assures its clients have access to prescription drugs, Burns said.   

 

CAREAssist works with 338 pharmacies, including 14 pharmacies at Kaiser, whose clients will not be affected by the changes. About 90,000 prescriptions a year are provided to these clients.   

 

FOR MORE INFORMATION

 

To review a copy of the bid proposal regarding CAREAssist, click here,