Anyone who has flipped through a newspaper recently knows that the escalating cost of prescription drugs is an issue of national concern, especially as such drugs become an increasingly significant element of medical care. The problem that higher medication prices pose for the uninsured - whose ranks numbered 41.2 million Americans in 2001, according to the U.S. Census Bureau - is obvious. Even patients who have health insurance that covers other needed services may shoulder all or most of the burden of buying their outpatient prescription medications. When a patient with a limited income must choose between buying groceries or filling a prescription, the prescription is likely to go unfilled.

Do you know how many of your patients can't afford to comply with their treatment regimen? These patients aren't going to walk into your office wearing sandwich boards that proclaim their financial situation. The most effective way to find out who can't afford their medications is to take the time to ask.

KEY POINTS

Patient assistance programs are a valuable resource for low-income patients, and some physicians have found ways to make them easier to use. Some states and communities have programs that offer free prescription drugs to eligible patients or that help patients fill out applications for assistance programs. Drug discount cards can be helpful to patients who can afford to pay part of their prescription costs.

Mary Jo Welker, MD, chair of clinical family medicine and associate dean for primary care at the Ohio State University Department of Family Medicine in Columbus, says, "When I see patients, I review their medication list with them every time, and for each drug I ask 'Are you taking this?'" If she discovers that the patient isn't taking a particular medication, or isn't taking it as prescribed, Welker can follow up to determine whether the medication's price is at the heart of the compliance problem.

Paul H. Hunter, MD, a family physician with Covenant Medical Group in South Milwaukee, Wis., takes a slightly different approach to identifying patients who can't afford to fill their prescriptions. He suggests that physicians and staff members keep three Ps in mind: Polite, Private and Persistent.

Polite. Show sensitivity to your patient's feelings about disclosing his or her financial status. Rather than asking the patient "Can you afford this medication?" Hunter suggests using a technique he learned from the staff of the Kansas City (Mo.) Free Health Clinic. "A much better way to ask the question is, 'Are you going to have any problem filling this prescription today?'" says Hunter. Not only does this question open the door for the patient to tell you that he or she can't afford the medication, it can also spark a dialogue about other issues that may affect the patient's compliance.

More than 75 drug companies offer patient assistance programs.

Private. Assure the patient that any financial information he or she shares with you and your staff will be kept confidential.

Persistent. If a patient tells you that he or she can't afford to fill a prescription, ask follow-up questions to find out more about the patient's particular situation. From the information you glean, you'll learn whether you can help, and if you can, what forms of assistance would be most appropriate.

Unfortunately, there's no panacea that will perfectly meet the needs of every low-income patient in every situation. However, if you and your staff become familiar with existing prescription assistance options available to low-income patients, you can be a valuable resource and increase the likelihood that these patients will get the care they need.

Patient assistance programs

Through patient assistance programs (PAPs), many pharmaceutical companies offer limited quantities of free or low-cost medications to patients who either don't qualify for or aren't adequately aided by other forms of assistance. According to data compiled by Volunteers in Health Care, a national resource center on caring for the uninsured that is funded by the Robert Wood Johnson Foundation, more than 75 drug companies offer PAPs. Some companies have a separate PAP for each drug or class of drugs they make available.

Companies do not necessarily make all of their self-administered prescription drugs available through their PAPs, although more than 800 medications are currently offered. Among these are approximately 53 percent of the top 200 medications prescribed in 1999.¹ The Pharmaceutical Research and Manufacturers of America (PhRMA) reports that in 2001, the PAPs of its member companies distributed prescription medications with a wholesale value of about $1.5 billion to more than 3.5 million patients.

Just as no two snowflakes are alike, there is seemingly infinite variety when it comes to PAPs and their requirements, and they tend to change or be discontinued frequently and without warning. It's beyond the scope of this article to discuss the details of specific programs, but the following are some general characteristics:

"Limit your assistance to just a couple of different drugs instead of dealing with the paperwork of ordering every drug."

Application access. Some programs make their applications available only through the health care provider, while others can be accessed by the patient or a patient advocate online or by calling a toll-free number.

Application process. Enrollment may be allowed over the phone, but in most cases, an application must be submitted to the PAP via fax or mail. Some programs accept photocopied application forms while others require an original. The application may request information such as the patient's health and drug insurance coverage and financial status. A PAP may also require documentation (e.g., W-2 forms, tax returns, bank statements) to verify the patient's financial information.

Eligibility. Eligibility requirements, such as income limitations, vary from one company's program to another. Not all PAPs require that participating patients be uninsured. For example, certain PAPs may help insured patients who have exceeded the limits of their drug benefit, and most will assist Medicare beneficiaries who don't have supplemental drug coverage. However, some programs deny assistance to applicants who are eligible for drug benefits from a public assistance program (including state and local programs), regardless of whether the patient is enrolled for such coverage or not.

Cost. Many PAPs offer assistance at no charge; however, some do require patients to submit a co-payment or pay shipping charges to receive their medication.

Response time. The time from application to delivery typically ranges from seven days to six weeks, depending on the program. Submitting an application that is incomplete or includes erroneous information will obviously delay the response.

Delivery of medication. Most PAPs deliver medication to the patient's physician, but some will send it directly to the patient. Other PAPs will issue a card or voucher that the patient can exchange for his or her medication at a participating pharmacy.

Amount of medication. PAPs only provide a limited supply of medication in response to each application. Patients may be able to receive up to a 180-day supply of the requested medication; however, some programs only provide a 30-day supply.

Refills. Many PAPs require the patient to submit a new application in order to receive a refill of their prescription.

Re-enrollment. Patients may be required to re-enroll in the PAP periodically.

For comprehensive, up-to-date information on individual PAPs, the Web sites listed in the box on page 55 are your best bet. These sites also tell you how to contact a particular pharmaceutical company's PAP directly.

Making PAPs more manageable

If you're just starting out with PAPs in your practice, navigating the twists and turns of the process can quickly become overwhelming, even if you're extremely motivated. Most are designed to require the participation of the physician and his or her staff at several stages of the process. At the very least, your signature will be required. It's also possible that you'll be required to write the prescription, determine whether that drug is offered through a PAP, verify the patient's eligibility, obtain an original application form from the drug company, fill out significant portions of a lengthy application, get the patient to fill out his or her portion and provide any necessary documentation, mail the form, receive delivery of the medication, dispense it to the patient properly, and then start the whole process over again when the patient's 30-day supply is gone.

So how can you keep PAPs from being a P-A-I-N? Concentrate your efforts to do the most good with the resources you have and retain your sanity too, suggests Hunter. Rather than trying to access every drug for every patient, develop a limited PAP drug formulary. For example, says Hunter, "Look at what you're seeing most in your practice. If, like most family doctors these days, you're taking care of a lot of patients with diabetes or hypertension, pick a few medications that you frequently prescribe."

Eric Schneider, PharmD, the director of pharmacotherapy for Greenwood Family Medicine Residency, echoes Hunter's point, saying, "Some drugs are just easier to obtain from PAPs than others, so you can limit your assistance to just a couple of different drugs instead of dealing with the paperwork of ordering every drug."

In some areas, local organizations will help eligible patients fill out the necessary paperwork for PAPs.

Become familiar with the process for requesting these few medications (or assign this responsibility to a staff member) and focus your efforts on streamlining that process instead of constantly starting from scratch. Diane Orlov, a nurse practitioner in the Department of Family Medicine at Ohio State University who handles much of the legwork when patients need to apply to a PAP, says, "When a patient needs to request a medication that's frequently prescribed, like Lipitor, I already have a pre-made file that I can go right to. I've got the applications in there, and everything's pretty much ready to go."

A similar approach is getting to know the PAP (or PAPs) of one pharmaceutical company very well. "Try out a company's PAP for one patient, and if it seems totally difficult to use, then try a different one," Hunter advises. "Get to know one or two companies and then expand from there." Hunter wrote an online resource titled Patient Assistance Programs (PAPs): A Primer for Family Physicians (available online at http://home.wi.rr.com/phunter1/PAPprimer.html) that lists a sampling of PAPs that, in his experience, are convenient for family physicians to access.

Once you've determined which drugs will be part of your practice's PAP formulary or picked a specific company's program to try, give some thought to who in your office will oversee the process. Because filling out PAP paperwork is not the most cost-effective use of a physician's time, a member of the support staff should handle these responsibilities, Schneider says. However, freeing up paid staff time may not be feasible for practices that are already swamped.

In some areas, local organizations will help eligible patients fill out the necessary paperwork for PAPs. Welker says, "We have a program that was put together by the Columbus (Ohio) Medical Association Foundation for patients over age 65. It's called Prescriptions for Care. Physicians can call their offices and they will take care of filling out all the PAP paperwork for the patients and work with the patients. The physician still has to write the prescription and sign the forms, and the physician still has to receive the medication and give it to the patient, but at least they get help with the paperwork."

It's worth the time to find out if such a program exists in your community. If not, you might consider creating a volunteer position in your practice for someone to come in once a week or a few times a month to assist patients in applying for PAPs and deal with the administrative responsibilities.

The effort to access prescription drugs from a PAP is a partnership between you and your patient, so don't take all the responsibility on yourself. Think of your role as providing information and guidance to empower your patient to do his or her part. The patient handout on page 59 points patients in the right direction to find more information on PAPs. Richard J. Sagall, MD, one of the co-founders of NeedyMeds, notes, "On our Web site [www.needymeds.com], we strongly encourage patients to complete everything they can on a PAP application form before they take it to the physician."

HAVE YOU REVIEWED YOUR PRESCRIBING HABITS LATELY?

One relatively easy way to help your low-income patients is to evaluate your current prescribing practices. Here are two habits you may want to foster: Be cost-conscious Without even realizing it, you may be in the habit of prescribing certain drugs to treat certain conditions, regardless of cost. The next time you reach for your prescription pad, simply ask yourself, "Is there a less expensive way to treat this problem that will work as well for this patient?" Obviously you don't want to provide inferior care just to save your patient a few bucks. Rather, be attuned to opportunities to provide the same excellent care for less, whether by substituting a generic formulation for a brand-name drug, reconsidering the dosing frequency or, for patients with limited prescription coverage, taking a few extra minutes to find out which drugs are covered on the patient's formulary and prescribing accordingly. Use drug samples appropriately When a patient can't afford to fill his or her prescription, you may be tempted to look to your practice's supply of drug samples for help. However, this tactic doesn't solve the problem; it only puts it off to be faced another day. You can't count on having samples of every medication you might need to prescribe for a low-income patient, and sampling isn't practical for the ongoing treatment of chronic diseases. Used appropriately, drug samples can help you help your patients avoid spending more than they need to. Starting a patient off on a sample of the medication for a brief trial period avoids unnecessary expense if the patient finds the drug's side effects are intolerable or if the drug doesn't offer the desired therapeutic benefit. The same idea applies when you're trying out several comparable medications to determine which one works best for the patient. Samples may also come in handy as a stopgap when a patient is waiting to get a supply of low-cost or free medicine. However, keep in mind that giving samples to your low-income patients may actually exacerbate their needs in the long run. Welker points out, "Samples are usually the newest drugs, which can mean that they're the most expensive drugs. For example, when you're starting a patient who doesn't have a lot of money on a blood pressure pill, you probably don't want to give them a brand new, really expensive drug. If possible, you probably want to start with one that's cheaper."

Schneider saw this philosophy in action at the University of Arkansas family practice residency. "We developed a packet of information for patients that let them know what they needed to provide for us before we would help them with the application process," Schneider says. "The big piece was proof of income, just so we could be comfortable that they met income requirements. Basically, until they filled out the questionnaire and provided that baseline information, we didn't do anything for them. The idea wasn't to be punitive about it, but we wanted them to do their part." You may find that patients who take an active role in applying for assistance through a PAP are more invested in complying with their treatment regimen.

State and local programs

Does your state or community offer a program to help low-income and indigent patients overcome barriers to accessing prescription medications? If so, what are the eligibility requirements? If you don't know the answers to these questions, chances are good that your patients don't either. By doing a little detective work to determine whether medication assistance programs exist in your area, you can avoid having your practice shoulder the full burden of helping your low-income patients get their prescription drugs.

Unfortunately, not every state or community has a prescription assistance program available, but those that do can provide invaluable support to family physicians. Before you refer any of your patients to a program in your area, find out more about the services they provide. For example, the program may have a limited formulary of free prescription drugs. Some programs may require the physician to fill out a referral form before a patient can receive assistance. Others require the patient to fill out an application form, so you might consider having some of these forms available in your office to hand out to eligible patients. You might also consider creating a brief patient handout that lists the programs in your area, their contact information, what services they provide and who is eligible.

RESOURCES FOR PHYSICIANS

State and local programs Visit www.rxassist.org to find a quick-reference chart that lists drug assistance programs by state. The downloadable chart (www.rxassist.org/pdfs/state_programs.pdf) notes the population served by each program (some only provide assistance to elderly or disabled patients), as well as contact information. This Web site was developed by Volunteers in Health Care (VIH). Visit the Medicare Web site at www.medicare.gov/prescription/home.asp to locate information on public and private programs that offer discounted or free medication, as well as Medicare health plans that include prescription coverage. By entering your ZIP code, you can search a database to identify any drug assistance programs in your area. The site provides a basic description of each program, including general eligibility requirements, covered services and contact information. Community health centers may offer prescription assistance to low-income patients. To locate a center in your area, contact the Health Resources and Services Administration at 888-ASK-HRSA (888-275-4772). Local Area Agencies on Aging may be able to assist patients who are 65 or older and can't afford their medications. To find an agency near you, contact the Eldercare Locator at 800-677-1116 or online at www.eldercare.gov. Discount cards Certain pharmaceutical companies offer drug discount cards to qualified Medicare recipients. Each of the phone numbers listed below is set up to take calls from patients. GlaxoSmithKline Orange Card: 888-672-6436. Eli Lilly and Company's LillyAnswers Card: 877-795-4559 or www.lillyanswers.com. Novartis Care Card: 866-974-2273 or www.careplan.novartis.com. Pfizer for Living Share Card: 800-717-6005 or www.pfizerforliving.com. TogetherRx Card, a joint drug discount card that offers savings on selected medications offered by Abbott Laboratories, AstraZeneca, Aventis Pharmaceuticals, Bristol-Myers Squibb Company, GlaxoSmithKline, Janssen Pharmaceutica Products, Ortho-McNeil Pharmaceutical, and Novartis: 800-865-7211 or www.together-rx.com. Patient assistance programs RxAssist (www.rxassist.org): This site is sponsored by Volunteers in Health Care, a nonprofit, national resource center funded by the Robert Wood Johnson Foundation that provides assistance to programs serving the uninsured. RxAssist is a comprehensive, searchable database that allows you to search for information by company, brand name, generic name or therapeutic drug class. Detailed program information and application forms are available, as well as information on other strategies for accessing free and low-cost medications. NeedyMeds (www.needymeds.com): This site was founded by a social worker and a family physician in 1997. NeedyMeds allows you to search for information by program or drug name. It includes detailed program information, forms, news and other useful tools. NeedyMeds also offers a printed manual for purchase. Pharmaceutical Research and Manufacturers of America (PhRMA) (www.phrma.org): This site includes a directory of PAPs offered by participating PhRMA members. The directory includes links to application forms and information on program operations. RxHope (www.rxhope.com): RxHope is a privately held company that has received funding from several sources, including PhRMA. This site includes detailed PAP information and application forms. RxHope is unique because a small number of companies allow physicians to submit PAP applications electronically through this site. The Association of Clinicians for the Underserved (ACU) offers a booklet titled Handbook 4: Pharmaceutical Assistance Programs that explains how PAPs work. The booklet costs $5 for nonmembers. Visit their Web site at www.clinicians.org/opa/booklets/opabookdex.asp for more information. Volunteers in Health Care is creating a practical, how-to guide for using PAPs that will be available in January of 2003. For more information about this product and other VIH resources on pharmaceutical access, visit www.volunteersinhealthcare.org or call 877-844-8442. Other resources Visit www.rxassist.org/pdfs/rx_pt_packet.pdf to download a free patient information packet listing a variety of resources for obtaining free and low-cost medications.

Drug discount cards

Certain pharmaceutical companies offer drug discount cards that may be an option for patients who can afford to pay a portion of their medication costs. Income limits differ from one program to another, but all require that applicants be Medicare enrollees who have no other form of prescription drug coverage and are not eligible for any state-funded drug benefit plan. At participating pharmacies, a drug discount card may entitle the patient to a discount (typically 20 percent to 40 percent) on the purchase price of a medication or entitle the patient to pay a flat rate (typically $12 to $15) per 30-day prescription. For an at-a-glance comparison of the drug discount card programs, visit the NeedyMeds Web site (www.needymeds.com/discountcomp.html).

Although drug discount card programs may represent good intentions to help low-income populations, be aware of their limitations. Hunter notes, "These programs cover a small group of patients who are just above the poverty level. A lot of Medicare patients aren't going to qualify." Welker points out that even for patients who do qualify, the savings offered may not be enough. "If truly indigent patients have a number of prescriptions and they have to pay a $15 co-pay for each, they may still have to decide which prescriptions they're going to fill each month because they only have so much money to spend. Even making that small co-payment is going to be a burden for them," she says. Hunter agrees, "When you're talking about patients who have prescriptions that total $300 to $500 each month, well, 20 percent is 20 percent, and that will help. But it's still not anything near the level of help they need."

Even offering assistance on a small scale can yield benefits for them and you.

Why bother?

Helping low-income patients access the prescription drugs they need can be a complicated and frustrating endeavor. The last thing you need in your practice is added hassle, so why bother? First of all, remember that identifying your low-income patients and helping them access needed prescription drugs doesn't have to be an all-or-nothing effort. Even offering assistance on a small scale can yield benefits for them and you. For one thing, you can add value to your practice. "It's a patient service that will help you retain and satisfy your patients and attract new patients," says Hunter.

Finally, think about this effort as an extension of your mission as a family physician. Sagall comments, "The question that I would pose to someone who asks 'Why bother?' is what good do your diagnostics and treatment do if the person can't afford the medications? If someone has hypertension and can't afford their anti-hypertensives, everything you say is worthless. Yes, there are also lifestyle issues, but if patients can't afford their medication, you're doing them no good."

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1. Chisholm MA, DiPiro JT. Pharmaceutical manufacturer assistance programs. Arch Intern Med. 2002;162:780-784.

Send comments to fpmedit@aafp.org.

Karen Montemayor is a senior project editor with the American Academy of Family Physicians. Conflicts of interest: none reported. The author would like to acknowledge the contributions of Stephanie Geller, EdM, to the list of resources that accompanies this article. Geller is the research director of Volunteers in Health Care, Pawtucket, R.I.

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