The second article is by Mitzi McGinnis, PharmD and Sheila L. Kasten, PharmD. And highlights pharmacy resources available to medically indigent persons.  Understanding these resources is critical for case managers who work with clients for whom affordability of health care is an important problem.

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Literacy and Effective Client Engagement in Health Care

By Mary Craymer R.N., Ambulatory Nurse Case Manager

Breton Health Center/ Funded by West Michigan Consortium

Communication is the foundation for improved health care in the 21st century.   As America becomes more technologically advanced, patient self-care expectations rise exponentially.  As little as 15 years ago, patients were hospitalized three to four days for cholycystectomy and monitored under the watchful eye of trained staff.  Today this procedure is a same day surgery and the patient and family are expected to properly prepare for surgery, understand and monitor for signs and symptoms of post-op complications, and report significant events.

Physicians, nurses, patient educators, and pharmacists provide patients with a mass of information, oral and written.  Everyone carefully documents the breath and depth of instructional materials provided.  If a patient does not follow the instructions he or she may be labeled as non-compliant, difficult to work with, or other cliché.  Startling as it may seem for modern America, 50% of the population have difficulty with reading comprehension, and/or computing skills. 

The AMA Foundation reported at a March 2000 national conference that poor health literacy skills cost the U.S. health system $73 billion annually.  The 1992 National Adult Literacy Survey, which defines literacy as using printed and written information to function in society, found that 21% of Americans are functionally illiterate (read at or below 5th grade) and 27% are marginally literate (have difficulty with reading comprehension and/or computational skills).

Patients with low literacy are frequently ashamed and hide it.  A 1997 study of patients in two public hospitals found that those with inadequate literacy skills were five times more likely to misinterpret their prescriptions than patients with adequate reading skills, and they averaged two more doctor visits per year than those with marginal or adequate skills.

A 1996 study of patients with reading difficulties discovered that 67% of them had never told their spouse and 19% had never told anyone about their reading problem.  Low health literacy is found among all ethnic groups, with the greatest prevalence found among native-born whites.  Low health literacy is particularly common among the older persons (65 to 70% of adults aged 60 and older have inadequate or marginal literacy skills) and those with low-income (about 45% of all functionally illiterate adults live in poverty).

Reuters Health Report, February 1999, reports one out of three U.S. Medicare recipients lack the literacy skills necessary to understand and follow their physicians instructions.  Investigators conducted in-person interviews to determine the health literacy of 3,260 Medicare recipients enrolled in a large managed care organization.  Thirty-three point nine percent (33.9%) of English-speaking and 53.9% of Spanish-speaking respondents were found to have either marginal or inadequate health literacy.  Twenty-three percent (23%) did not understand how to interpret a blood glucose range. 

Dr. Mark V. Williams, FACP, associate professor of medicine at Emory University in Atlanta states, Patients with inadequate literacy skills run a 52% greater risk on being hospitalized.  Doctors run a higher risk of being sued by patients who do not understand medical terms and instructions.

§ 26% could not read their appointment slips.

§ 47% could not understand written directions to take medicine on an empty stomach. 

§ 60% did not understand the standard consent form (June 1999 ACP-ASIM Observer, American College of Physician-American Society of Internal Medicine).

These figures mean that 48% of the patient population cannot read printed materials distributed by pharmaceutical firms for physician use in educating patients.  Patients cannot read the drug printout literature distributed when obtaining a prescription.

The Journal of the American Medical Association reported in July 2002 on a study by UCSF researchers.  The study followed 408 patients with adult-onset diabetes, excluding those who had dementia or were non-English speaking.  Thirty-six percent with inadequate health literacy, as opposed to 19% of patients with adequate health literacy, had diabetic retinopathy.  Only 20% of patients with inadequate health literacy had optimal blood sugar control as opposed to 33% of those with greater health literacy.  Other diabetic complications were similarly related to health literacy.

These patients did not fit a stereotyped illiterate, marginally adjusted profile.  The majority was or had been meaningfully employed, had families, functioned well in their own social circle, and owned their own homes.

As stewards of Americas health care dollars and quality patient care, case managers have a unique opportunity to take action in addressing the needs of this population until such time when literacy is addressed by our nations educational system.  Identification of health literacy level and development of educational materials and communication style to meet individual patient needs does impact patient outcomes and ability to implement physician plan of care.

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Assistance Programs for the Pharmaceutically Indigent

by Mitzi M. McGinnis, PharmD and Sheila L. Kasten, PharmD

As healthcare professionals we have to deal with the financial burden that increasing prices of prescription medications place on the consumer.  In the United States there are more than 40 million people who do not have health insurance.  This creates a growing need for assistance for patients who cannot afford their medications.  Over the past few years, more people have become uninsured or underinsured leaving them with no way to obtain their necessary medications.  Pharmaceutically indigent has been used to describe patients who cannot afford the medications that they require.  Helping indigent patients find assistance can be very difficult, but very beneficial to the patient.  Healthcare personnel should be aware of the assistance available at national, state, and community levels.  Patient assistance programs provide free medications to patients who meet certain criteria.  In 2001, more than 3.5 million patients utilized these programs, up from 1.1 million in 1997.  During 2001, there were 10 million prescriptions filled by patient assistance programs with a value of about $1.5 billion, up from $2 million in 1997.  The importance of this is emphasized by the fact that cost of prescription medication is the fastest rising area in health care. 

Most pharmaceutical companies have a patient assistance program that will provide patients with free medication if they meet the financial and demographic criteria.  Each company has its own application process and set of requirements.  Most companies provide 90-day supplies of medication to qualifying persons.  A few companies will even allow a 6-month supply depending on the medication.  Currently there are 75 companies that offer assistance with over 130 programs available within these companies.  Over 800 medications are offered which include 53% of the top 200 prescribed medications available.

Some organizations have designed their patient assistance program information to be more user friendly for the medical community.  These include Volunteers in Healthcare-RxAssist (www.rxassist.org), Pharmaceutical Research and Manufacturers of America (www.phrma.org), Medicare (www.medicare.gov/prescription/home.asp), RxHope (www.rxhope.com), and NeedyMeds (www.needymeds.com), among others.  Volunteers in Healthcare has a free program that manages a patient list and fills out the application forms for use by clinics that handle a large number of patient assistance cases.  The other listed sites will not fill out the forms, but they will direct the user to them.  Medicare provides details on the programs, but it does not give access to the forms.  RxHope is an internet-based applicant management service and offers some programs that support electronic submission of applications.  Applications can be printed from this site, but they are not filled out when printed.  Healthcare personnel or patients can access this site.  Each patient creates his/her own sign-in and can search the requirements and print off applications.

Challenges of running an indigent drug program include keeping track of the detailed financial information about applicants, providing proof of no insurance, and dealing with changes in the pharmaceutical companies application forms.

 There are organizations that provide assistance to applicants whose physicians do not provide this support.  These organizations charge a fee per application.  The fee is refundable if the patient is not accepted by at least one assistance program.  This process requires the patient to be more actively involved in their medications to manage the paperwork.  When applicants receive the completed paperwork, they should submit their applications using copies so that they do not need to pay again when refills are required.  The Medicine Program, The Patient Assistance Network, and We Care Medical Mall all offer this service. 

Some programs target the Medicare population.  These programs are offered directly from the manufacturers and either offer medications at a discounted cost or for a specific co-pay.  Patients that have Medicare with no prescription coverage and meet the financial requirements qualify.  Some programs offer better discounts than others and the patient can benefit from shopping around.