Childrens Defense Fund

1
Childrens Defense Fund

• From Card To Care
• Houston/Harris County
• Covering Kids and Families
• Access Initiative

2
Covering Kids and Families Access Initiative

• Funded by Robert Wood Johnson Foundation,
  administered by Center for Health Care Strategies
• Houston one of 17 national pilot sites
• Purpose to identify and remove access barriers
  for CHIP/Medicaid recipients

3
Phase OneResearch with Families

• 11 focus groups, with neighborhood partners,
  reached 112 parents of children on CHIP/Medicaid
• Face to face interviews 48 parents with 108
  children on CHIP/Medicaid
• Surveys of 37 pharmacists, 8 providers
• Analysis conducted by UT School of Public Health
  at Houston

4
(No Transcript)
5
FindingsPrescription Coverage and Costs

• Parents in all communities had problems filling
  prescriptions through CHIP and Medicaid.
• Often parents were told that medications were
  not covered by Medicaid, including
  antibiotics, OTC medications, asthma/allergy
  medications, diaper rash cream, durable medical
  equipment.
• As a result, parents paid out of pocket for
  prescriptions 20 - 100 for medications, up to
  80 for asthma equipment, 60 to 100 for asthma
  medications.

6
Other problems--prescriptions

• 3 prescription limit for adults is spilling over
  to children - childrens prescriptions should be
  unlimited.
• Parents wait 3-4 hours to 3 days and go to
  several pharmacies to get prescriptions filled.

7
Specific examples

• Three prescription limit Parent was given three
  prescriptions for her daughter but told that she
  had to wait for an additional prescription for
  her daughters head-aches until the next month.
• Parent has to wait 23-42 days for insulin for
  diabetic son, or must pay out of pocket, because
  child needs insulin every 28 days.
• Pharmacist wrote not covered in red letters on
  the prescription so that the parent could not get
  the prescription filled at another pharmacy.
• Parent told to choose between vaccinating their
  child or filling a prescription for the childs
  illness because Medicaid would not cover both.
• Child was given enough asthma medication
  (abuterol) for half a month (17 doses). Parent
  was told that Medicaid will only cover 1
  prescription every 30 days, and paid 30 for
  second prescription.

8
CHIP Cost-Sharing Cap

• Parents that had reached CHIP cost-sharing cap
  were still being charged for doctor
  visits/prescriptions and didnt receive 0 co-pay
  cards.

9
Access to Primary Care

• Parents did not have access to clinics after
  hours or on weekends. Most ER visits due to
  asthma attacks or fever.
• Parents not aware of 24 hour nurse call lines
  available through Medicaid.
• Long-wait times at doctors offices 1 ½ to 5
  hours with an appointment, up to 6 hours without
  an appointment. Parents miss ½ day of work due
  to long waits.

10
Other issues

• Being assigned to providers/plans without parents
  knowledge.
• Costly dental and vision services for CHIP
  parents, and paying out of pocket (100 - 200)
  for broken or misplaced eyeglasses under
  Medicaid.
• Treatment by provider/staff.
• Lack of interpreter services.
• Lack of awareness about Medicaid Transportation
  Program.

11
Pharmacist Surveys

• Main barrier in filling prescription drug
  requires prior authorization (PA)
• Lack of awareness about new preferred drug list
  and PA requirements.
• Lack of understanding of federal requirement to
  give out 72 hour supply of a non-preferred drug
  in cases of emergency. How to define emergency?
• Difficulty in reaching Vendor Drug Program during
  evenings and weekends. Busy call-lines on
  weekdays.

12
Provider Concerns

• Major barrier also formularies, preferred drug
  lists, getting prescriptions filled.
• Other barrier lengthy wait-time for specialty
  care. Limited pediatric specialists available,
  paperwork complicated, certain health plans lack
  specialty care and will not allow clients to go
  out of network.

13
SolutionsPhase Two

• Prescriptions/Pharmacy Consumer education on
  Vendor Drug Program
• CHIP Cost-Sharing Cap Develop clear procedures
  on what happens when parents meet cap and improve
  tracking materials for families

14
Vendor Drug Program

• Vendor Drug Program administers outpatient drug
  benefit for Medicaid, and, effective March 1,
  2002, for CHIP.
• VDP created new prior authorization requirement
  for Medicaid drugs, February, 2004, will soon do
  so for CHIP.

15
Issues with VDP

• Lack of training on giving out 72 hour supply of
  non-preferred drugs in cases of emergency.
  Result parents have to go back to the ER to get
  medications.
• Difficulty of getting through on busy call-lines
  and nights/weekends.
• Little consumer education on preferred drug
  list/prior authorization. HHSC guidance HHSC
  is not notifying parents directly about changes
  because of concerns about unduly alarming parents
  about potential changes to their medications.

16
StrategiesVendor Drug Program

• Work with HHSC to develop consumer education
  materials on preferred drug list, PA.
• Inform families that 3 prescription drug limit
  applies only to Medicaid adults, not to children.
• Work with HHSC to train providers/pharmacists on
  VDP, preferred drug list, prior authorization
  process.
• Create clear guidance on 72 hour emergency supply
  provision.
• Create on-line system for creating prior
  authorization and expand hours of call-line.

17
StrategiesCost-Sharing Cap

• Develop clear procedures on what happens when
  parents reach cap and investigate why current
  procedures are not working.
• Work with HHSC to automate cap through health
  plans, providers or proposed universal benefits
  cards.
• Develop pilot project in Houston/Harris County to
  improve and simplify cost-sharing tracking
  materials for families.
• Train health plans, pharmacists, providers and
  peer educators about CHIP cost-sharing process.

18
Action Steps

• Partnering with City of Houston Chief Pharmacist.
• March 17 Pharmacist Training on CHIP Vendor Drug
  Program sponsored by the Houston Association of
  Pharmacists.
• Training for healthcare providers on VDP held on
  July 21 sponsored by Texas Medical Association.
• Developed educational materials on VDP for
  pharmacists, providers and consumers.

19
Impact

• 160 pharmacists and providers trained!
• Pharmacist training 92 of participants said
  that the workshop would be helpful to their work
  with CHIP/Medicaid recipients, and 100 found the
  workshop worthwhile.
• Provider training 93.4 of respondents said
  that the program would be helpful to their work
  with CHIP and Medicaid recipients.

20
Impact

• Incorporated CKF-AI strategies into the work of
  Texas Childrens Health Plan.
• Held a town hall meeting for 160 plus staff to
  present CKF-AI findings.
• Met with leadership team to incorporate CKF
  strategies into TCHPs daily work with families.
• TCHP added a question on pharmacy to its regular
  member surveys.
• Developed an educational series on the
  CHIP/Medicaid Vendor Drug Program for
  pharmacists, providers and consumers, in English
  and in Spanish.

21

• Partners
• Research
• University of Texas School of Public Health
  (Houston)
• University of Texas Prevention Research Center
• Healthcare Providers
• City of Houston Health Department, Harris County
  Hospital District and Health Department
• Health Plans Amerigroup, Texas Childrens
  Health Plan and Hospital, UTMB Choice One
• Maximus, Medicaid enrollment broker
• Gateway to Care Community Access Collaborative
• CHIP Outreach Organizations Harris County
  Public Health Environmental Services, Families
  Under Urban Social Attack, St. Luke's Episcopal
  Health Charities.
• Pediatricians, Ben Taub General Hospital
• Peer Educators/Community Partners in Targeted
  Neighborhoods
• Community Doula Program, ProSalud, Families Under
  Urban Social Attack
• Navigators of the Gateway to Care Community
  Access Collaborative
• Neighborhood Centers, Inc. Head Start Program

22
Childrens Defense Fund

• Contact
• Barbara Best
• Texas Executive Director
• Childrens Defense Fund
• 4500 Bissonnet, Suite 260
• Bellaire, Texas 77401
• 713.664.4080 (voice)
• 713.664.1975 (FAX)
• bbest_at_childrensdefense.org
• www.cdftexas.org