Published: October 12, 2008 01:02 am      

Dispensing medication

Free clinics concerned about new rules

FAIRMONT — Currently, patients who receive care at Milan Puskar Health Right in Morgantown can be seen by a doctor and go home with a prescription to treat whatever illness brought them there, whether it be an acute sickness like a sinus infection that requires an antibiotic or a chronic condition such as diabetes.

Although the clinic does not have a pharmacist, the doctor who sees the patient — who must be uninsured and low income — can prescribe and dispense the medication.

“If they are our patient and they come in and the prescription is written by our provider who is on site, then the prescription would go over to the med room and the pharmacy technicians would fill the order as written by the provider, and the patient would get it right away,” said Laura Jones, executive director of Milan Puskar Health Right.

“If there are questions, they are referred back to the provider who wrote the prescription to them.”

Whether this will continue to be the case after the 2009 state legislative session remains to be seen. Last year, legislators decided that medication dispension at the state’s 10 free health clinics would be put under the auspices of the West Virginia Board of Pharmacy.

That means that once board of pharmacy officials finish writing rules and regulations governing medication dispensing at pharmacies, upon passage by the state Legislature, free clinic workers then have to abide by those rules.

The first draft would not have allowed pharmacy technicians — someone who is trained to fill prescriptions but who cannot answer patient questions — to operate without a pharmacist working. At Milan Puskar Health Right, pharmacy technicians currently work 52 hours each week to fill prescriptions.

Clinic officials balked; as free clinics, they rely greatly on volunteer support, and getting full-time pharmacists would not be covered in the budget.

After a meeting in Charleston that included legislators in addition to free clinic staff, board of pharmacy officials changed the rules to allow a medical provider to oversee the pharmacy technicians.

“It still presents a problem, because it’s not realistic in our system for the prescribing provider to be seeing patients and also supervising and overseeing technicians,” Jones said. “They have to be in the pharmacy — that’s what they are saying now. The prescribing provider has to be in the pharmacy and we would have to find a volunteer or someone else to be in the pharmacy the whole time the pharmacy technicians are there.”

Clinic officials also maintain that their health-care providers would be covered by state Board of Medicine guidelines which allow them to dispense medications.

“The board of medicine’s attorney said they don’t have the authority to usurp the physicians’ ability to dispense medicine,” said Jim Harris, executive director of Health Access Inc., a free clinic in Clarksburg. “We are still working out the details of what that will look like.”

David Potters, the executive director of the board of pharmacy, agrees that to be true in part, but said that does not represent the full story.

While the board of medicine does allow a dispensing physician to dispense medication to their own patients, and at free clinics, to patients they have not seen, “if a physician is dispensing to a patient that’s not their own, that would be the practice of pharmacy,” Potters said.

That then would fall under the jurisdiction of the board of pharmacy, he said.

In general, Potters believes there needs to be more oversight at the free clinic pharmacies.

“On paper and in practice, we have to have more control and supervision for some of them,” Potters said. “Some of them are already operating with great oversight; Wheeling (Wheeling Health Right) has a full-time pharmacist on staff. Others were operating with no licensed pharmacists. They were not necessarily checking the prescriptions that were being filled nor checked by a physician.”

These rules would not require a pharmacy to be open full time so therefore, a pharmacist or prescribing provider would not have to spend a 40-hour week overseeing the dispensing of medication. Instead, it could be open just eight hours a month.

“The pharmacist in charge (PIC) must be there eight hours per month, which could be two hours per week or they could do it all in one day in an eight-hour shift,” Potters said.

This scenario also concerns Jones and some of her colleagues, however, because they believe that their patients — who sometimes have to take time off work or travel a great distance for a free clinic appointment — should go home with whatever medications they need.

“We have someone who drives here from Tucker County,” Jones said. “We just got a referral from Lewis County. They drive from Lewis County and they are seen by our provider. If we don’t have someone who can dispense medication to them, they are not likely to come back anytime soon to pick those up.”

Milan Puskar Health Right also has patients from as far away as Barbour and Randolph counties as well as the eastern end of Wetzel County and all over Preston County, “practically in Maryland,” Jones said.

Perhaps somewhat ironically, the prescribing situation at the state’s free clinics became an issue last winter when legislators passed the law that created West Virginia Rx. The program, which was up and running in the spring, helps uninsured patients get medications for free through a mail-order, central-fill pharmacy operated at West Virginia Health Right in Charleston, another one of the state’s free clinics.

“What occurs is that there is no oversight by the board of pharmacy,” said Sen. Roman Prezioso, D-Marion and chair of the state Senate’s Health and Human Resources Committee. “In every state, anytime drugs were given to free clinics, there was oversight by the boards of pharmacy. That was not the case in West Virginia.”

Other states have a variety of rules and regulations that govern free clinic prescriptions. Some are stricter than West Virginia’s; others are similar to the way the Mountain State’s free clinics currently operate.

“It’s different in each state,” said Nicole Lamoureux, the executive director of the National Association of Free Clinics, headquartered in Alexandria, Va. “That’s the first thing we need to understand. Each state has different regulations and different ways on how they do things.

“Some states have volunteers and some states have pharmacists on site. It depends on what each state’s regulation is.”

Free clinic officials also assert that rural areas will have more trouble than urban ones following rules that require extra staffing because of a dearth of pharmacists — especially those who might be willing to volunteer time.

“It’s not just about money” to pay pharmacists, Lamoureux said. “It’s also about time, especially in more rural areas. If someone can’t get there to help you, there is a whole set of patients who can’t get the medications they need.”

Lamoureux has written to the West Virginia Board of Pharmacy on behalf of the state’s free clinics, she noted.

“We expressed that other states have dealt with issues in various ways, and all have managed to balance the need for safety and treatment of the poor,” Lamoureux said. “We’ve asked that a collaborative partnership be worked out. We are concerned about the working poor accessing their costly medication if not through the West Virginia free health-care system.”

In fact, some states have rules stricter than what West Virginia currently operates under. Some free clinic patients in those states utilize the $4 prescription program offered by some pharmacies, including Wal-Mart and CVS.

However, while that sounds like a potentially useful option, Jones does not want to rely on it.

“We have patients who can’t afford $4 medications,” Jones said. “They might be on 12 different medications and maybe four of them are $4 medications, so that’s $16.”

Even clinics with pharmacists expressed concerns about the rules. Pat White, executive director of West Virginia Health Right in Charleston, which has a pharmacist about 80 percent of the time the clinic operates, noted that if rural clinics close, that means more patients for her facility.

“If those rural clinics close, we’re in deep trouble,” she said. “We can’t handle the physical plant volume for the rest of the state, let alone there’s the access issue for the patients.”

The state’s 10 free health clinics see about 50,000 actual patients a year multiple times and hand out nearly half a million prescriptions, Jones said. Not all clinics prescribe medications to their patients. The Susan Dew Hoff Memorial Clinic in West Milford, for instance, does not.

“Once we give a patient a prescription, it’s up to them to get it filled,” said Sister Mary Rebecca Fidler, the clinic’s executive director. “If they can’t afford to pay it, we call the pharmacy and tell them to send us a bill.”

At Milan Puskar Health Right, most of the prescription medicines — $1.3 million worth last year — are generics donated by Mylan Pharmaceuticals, hence the clinic’s name. The budget would not be able to cover all the medications prescribed.

“We’re talking about the need for a healthy workforce,” Jones said. “A lot of folks are working for small businesses or employers that don’t offer insurance or working part-time so they don’t get insurance. They are still low-income even though they might be working two jobs.”

For now, Jones and her colleagues are waiting to see what happens. On Monday, the board of pharmacy will address the issue during its regular monthly meeting that clinic officials can attend.

Potters expects a couple more meetings back and forth after that, “and we believe we’ll be able to agree upon modifications to make the product even better,” Potters said.

Then the rules will go to the legislative session, where lawmakers will take up the bill.

“We’re still involved in the process,” Prezioso said. “In the next session, we’ll be looking at those regulations to see what occurs. We have the option to reject them, amend them or do what we need to do to make them work.”

E-mail Mary Wade Burnside at mwburnside@timeswv.com.