The PRICE clinic for low-income elderly: a managed care model for implementing pharmacist-directed services

The Medicare Modernization Act of 2003 calls for medication therapy management programs (MTMPs) to control anticipated growth in drug use and expenditures. In 2006, prescription drug plan sponsors, including health plans, pharmacy benefit managers, and other entities, will be required to offer MTMP services performed by pharmacists or other health professionals. The Pharmacist Review to Increase Cost Effectiveness (PRICE) Clinic in Sacramento, California, is a pharmacist-directed, multidisciplinary model that is adaptable to providing MTMP services in a managed care setting. The PRICE Clinic serves a 3-fold mission: (1) to help low-income elderly patients decrease out-of-pocket (OOP) drug expenses; (2) to ensure that patients receive clinically appropriate, cost-effective drug regimens; and (3) to improve access to needed medications. The objectives of this study were to characterize and document the number and type of PRICE clinic interventions; measure changes in generic drug use; document savings in OOP drug costs; and measure patient access to drugs that had been, or would have been, discontinued because of cost.

A noncontrolled retrospective PRICE Clinic database review was conducted for the 520 patients seen in the PRICE Clinic in calendar year 2002. Study participants were low-income elderly with multiple chronic diseases, multiple medications, and high drug costs. For each patient, researchers documented the number and type of interventions performed by pharmacists and the drug class involved in each intervention. Changes in generic drug use and OOP costs were assessed by a preanalysis and postanalysis of selected outcome variables and a comparison of results with comparable patient populations in large state and national databases. Self-report was used to examine whether patients had discontinued medications because of cost, and the PRICE Clinic database analysis examined whether interventions enabled patients to resume previously discontinued medications.

PRICE clinic conducted 1,297 interventions among the 520 study patients in 2002, an average of 2.5 interventions per patient. The most common drug classes involved in interventions were lipid-lowering drugs, angiotensin-converting enzyme inhibitors, and asthma and allergy drugs. Generic drug use increased from 51% before PRICE clinic interventions to 56% afterward, a relative increase of 9.8% and more than 30% higher relative to the benchmark value. OOP medication expenditures decreased 68%, from dollar 185 to dollar 60 per patient per month, or dollar 1,500 per patient per year. A total of 215 patients (41%) reported that they had or would soon discontinue drugs because of cost; 186 (87%) of these patients were able to continue or resume the drug as the result of PRICE Clinic interventions. The most common interventions were pharmaceutical industry-sponsored patient assistance programs, generic substitution, and therapeutic interchange.

Results from this pilot study indicate the benefits of providing pharmacist-directed services to the population targeted by MTMP services, which encompasses Medicare beneficiaries with multiple chronic diseases, multiple drugs, and high drug costs. By providing pharmacist consultation at the point of care to ensure appropriate drug use, decrease OOP expenditures, and improve access to needed drugs, the PRICE Clinic is a possible model for further development in the implementation of MTMP services.