A representative of at least 15 D.C. pharmacies dispensing prescription drugs for low income people with HIV and AIDS and the director of the city’s Department of Health gave conflicting views this week on whether patients’ ability to refill their prescriptions for life-saving AIDS drugs will be disrupted beginning July 1.
A decision by DOH to terminate its contract with the local pharmacy chain Care Pharmacies that has administered the city’s AIDS Drug Assistance Program, or ADAP, was expected to prompt an as yet undetermined number of pharmacies to discontinue serving ADAP patients, potentially preventing the patients from obtaining the drugs when their current prescriptions run out, according to pharmacist Michael Kim, owner of Grubbs Pharmacy.
“This is going to be an absolute disaster,” said pharmacist Tamara Foreman, a member of the D.C. Board of Pharmacies, an independent entity that advises the city on pharmacy related matters.
“The patients are not being notified,” said Foreman, who also serves on the board of a non-profit organization that advocates on behalf of pharmacy patients. “They are being told to anticipate a gap in service, but they’re not being told where to go if their pharmacy stops filling their prescription.”
Dr. Mohammad Akhter, director of the DOH, and Dr. Gregory Pappas, director of DOH’s HIV/AIDS, Hepatitis, Sexually Transmitted Disease, and Tuberculosis Administration (HAHSTA), strongly dispute that assessment. Both told the Blade that no ADAP patients will be adversely impacted by the pharmacy related changes DOH is putting in place.
“We are providing the patients with a 60-day supply of drugs during the transition period,” Akhter told the Blade on Wednesday at a news conference on the release of the city’s 2011 Annual Report on its efforts to combat HIV/AIDS.
“I can tell you that no patients will be harmed in any way,” said Akhter.
He said DOH recently decided to postpone for one month the implementation of the revamped ADAP pharmacy program.
But he and Pappas declined to disclose how many pharmacies involved in the existing ADAP program operated by Care Pharmacies and how many others have opted to join the revised program to be operated directly by DOH.
Some AIDS activists, including Patricia Hawkins, a former Whitman-Walker Health official and member of the D.C.-area HIV Planning Council, have expressed concern that patients’ ability to refill their ADAP prescriptions could be jeopardized if too few pharmacies agree to be part of the new DOH pharmacy network.
Kim said Grubbs planned to stop serving ADAP patients beginning July 1, when the new city-administered program was originally scheduled to go into effect. Kim couldn’t be immediately reached to determine whether Grubbs would continue filling ADAP prescriptions for another month following DOH’s decision to postpone the new program.
Kim indicated in an earlier interview that DOH might postpone implementation of the new program, but said DOH had not informed Care Pharmacies that it planned to do so.
He and others familiar with the ADAP program said they were told by the city that a list of the participating pharmacies in the new program would be released on June 15.
The city didn’t release such a list on that date, prompting pharmacists and activists to fear that too few pharmacies would join the new system to adequately serve ADAP patients in need of prescriptions.
Kim said Grubbs, which is believed to have processed the largest number of ADAP prescriptions in D.C. over the past decade, isn’t signing up for the city’s revamped program because the DOH has cut in half its reimbursement payment for ADAP drug prescriptions and plans to keep the lower payment in place for the next five years.
He said the lower payment makes it too costly for Grubb and other pharmacies to process ADAP prescriptions. He acknowledged that Care Pharmacies currently collects the reimbursement for the prescriptions from the city, takes a cut to cover its own administrative costs and disburses the remaining amount of about $7 per prescription to the other pharmacies in the current program. The city was expected to dispense the reimbursement directly to each pharmacy under the new system.
ADAP, a joint federal-state program, was created under the Ryan White AIDS Care Act in the early 1990s as a means of providing life-saving AIDS drugs to low-income patients as well as symptom-free people with HIV who don’t have private health insurance coverage and can’t afford to pay for the drugs.
Many of the HIV medications, such as anti-retroviral drugs, cost between $1,000 to as much as $2,000 for a one-month prescription, AIDS advocacy groups familiar with ADAP have said.
A staffer with the city’s AIDS administration, who isn’t authorized to speak to the media, said DOH chose to set up its own network of local pharmacies to process ADAP drug prescriptions rather than renew Care Pharmacies’ contract to “expand the options” for patients.
The staffer said DOH wanted to bring in more pharmacies and different types of pharmacies, including those providing mail order services, into the ADAP network beyond the 24 that have been participating under the Care Pharmacies network.
Kim, who serves on the Care Pharmacies board of directors, said that in addition to about 24 pharmacies that are part of the Care Pharmacies franchise, several unaffiliated pharmacies were part of Care’s ADAP network. Among them was Whitman-Walker Health, the city’s largest private AIDS services provider, which has its own in-house pharmacy. Others included the AIDS Healthcare Foundation, a worldwide AIDS care provider that has an in-house pharmacy in its D.C. office; and Safeway supermarket stores, which also have in-house pharmacies.
Foreman said the non-profit group CMS Health Initiative, with which she is affiliated, has provided quality control training and supervision under a city contract to ensure that D.C. pharmacies dispensing ADAP drugs meet the city’s requirements under the ADAP program operated by Care Pharmacies.
She said that in order to be approved by the city to dispense ADAP drugs, a pharmacy is required to provide patient counseling and a series of other patient-related services, including checks to make sure patients remain compliant with their drug regimen and don’t drop out of the program, placing their health at risk. She said all pharmacies in the program must provide free delivery service to patients.
Foreman and Kim also noted that under rules established by the D.C. DOH, pharmacies participating in the city’s ADAP program are reimbursed under a drug “replenishment” system. The system, which saved money for the city, requires the pharmacies to pay wholesale pharmaceutical supplies the first month’s prescription for all new patients. The city then replenishes the pharmacies with supplies of drugs for all subsequent prescriptions.
Kim said the system requires a pharmacy to pay out of pocket for the first prescription, which could come to between $1,000 and $2,000. He said he now fears that the expected fewer number of pharmacies that join the city’s in-house network will be hit by dozens of patients dropped from the pharmacies like Grubb’s, that choose not to join the new network.
“They could be facing an initial payment of $40,000 in a single month,” Kim said. “Many of them just can’t absorb that. They are small, independent pharmacies.”
One city government source, speaking on condition of anonymity, said Care Pharmacy and its representatives were exaggerating the potential harm the changes will have on patients because the city has ended what the source called a “sweetheart deal” for Care Pharmacies.
Kim disputes claims by sources from the DOH that the new city-operated network will include improved services and options over and above the Care Pharmacies contract.
“Basically, in my opinion, it’s all about money,” he said. “They feel that they are paying too much for the ADAP program. If you look at their program, they just took the current program that’s being run by Care Pharmacies and then they put it out and stamped it with their name and they cut the reimbursement in half. And that’s it,” he said.
“So if they say they’ve improved the program somewhat that’s a flat out lie because they haven’t done anything to the program except cut the reimbursement in half.
He said the current per-prescription reimbursement to Care Pharmacies is $20.50. DOH has invited pharmacies to apply to be accepted into the new program for a reimbursement of $10.50, he said.
“I can tell you that $10.50 was the rate that was given to us about 10 years ago,” Kim said. “It just doesn’t cover the costs.”
Whitman-Walker and AIDS Healthcare Foundation are among the local pharmacy providers that have signed up to be part of the new city ADAP network, representatives of the two organizations said.
Jerame Zelner, regional director of AIDS Healthcare Foundation’s pharmacies, said AHF is “very concerned” that many ADAP patients in D.C. will be unable to refill their prescriptions if a large number of local pharmacies that once participated in the program don’t join the new city network.
“We are taking steps to step in and help,” he said, noting that AHF, with a multi-million dollar budget, has the financial cushion to absorb the cost of a first month’s supply of drugs that other smaller pharmacies may not have.
AIDS Healthcare Foundation’s offices and pharmacy are located at 2141 K St., N.W., Suite 606. Zelner said that AHA, like all pharmacies participating in the current and soon-to-be started ADAP pharmacy network, provides fill delivery services for prescription drugs.
Hawkins of the HIV Planning Council said the Council is also concerned about patients not being able to fill prescriptions during the transition into the new program.
“No one from the city has told us how many pharmacies are dropping out and how many will be joining the new system,” she said. She said the Planning Council would be taking up the issue at an executive committee meeting on June 21.
Don Blanchon, Whitman-Walker’s executive director, said he doesn’t believe patients will suffer under the new system and said Whitman-Walker looks forward to its participation in the new program.
According to Blanchon, a decision during the past few years by the city to transfer many of its ADAP patients to the city’s Medicaid program has significantly decreased the number of remaining ADAP patients.
“There are currently around 500 ADAP patients and Whitman-Walker has 400 of them,” he said.
He said he doesn’t think city pharmacies should have a problem dispensing prescription drugs to the remaining 100.