Post-Katrina lessons inspire reforms

NEW ORLEANS —Two years following the heroic effort that was coordinated by members of retail pharmacy, wholesalers, pharmaceutical distributors and the Centers for Medicare & Medicaid Services to re-establish a pharmaceutical distribution system shattered by Hurricane Katrina, the industry has laid the cornerstone to a set of new pharmaceutical distribution protocols that easily can be put into play in the wake of a future disaster.

At the heart of the plan, an emergency electronic warehouse of patient data combined with an established blueprint for reimbursement that the industry has pieced together, applying lessons learned from the stopgap prescription drug database, KatrinaHealth.org, created in the aftermath of Katrina.

“One of the things we learned from Katrina is there is a greater industry need for a very formal, defined process where pharmacies responding to an emergency can process prescriptions for patients who have been evacuated or are without their medication regardless of the type of disaster,” said Mike Simko, manager of pharmacy clinical services at Walgreens. With as many patients as Katrina displaced, pharmacies were asked to replace lost medications. However, if the pharmacy could not produce a medical record, it was difficult to replace those medicines without a medication history to authenticate the prescription, Simko said.

Addressing access and authentication, ICERx.org, a prescription drug database warehouse consisting of an aggregation of retail pharmacy prescription files, went live in June. “Since Katrina, SureScripts has worked with the major pharmacies … in conjunction with the National Association of Chain Drug Stores and the National Community Pharmacists Association in building an infrastructure that allows for the capturing of dispensed drug information from the pharmacies,”Rick Ratliff, chief operating officer for SureScripts, told Drug Store News. The resulting database, the master patient index, allows users to match records across different pharmacy databases in case of an emergency.

That way, if a displaced patient patronizes the pharmacies of both a Walgreens and a Rite Aid, the health care professional serving that patient has access to a more complete pharmaceutical record.

In addition to pharmacies, prescription information also is gathered from pharmacy benefit managers and state Medicaid programs. During a state of emergency, licensed health care professionals who have registered on ICERx.org can access that information database containing prescription histories of a patient from the affected area.

The ICERx.org portal is actually a market-driven solution that’s part of SureScripts’ medication history service, a service that doctors signed with SureScripts now can access in 12 states, Ratliff said. While the medication history service is being rolled out on a market-by-market basis—an additional 27 states are expected to go live with the service this year—SureScripts has agreements with retail pharmacy in place that would enable ICERx.org capabilities within 48 hours in the event of an emergency.

“As an example, we’ve rolled out our Rx History Service in Florida, [but] we haven’t rolled it out in Louisiana,” Ratliff explained. “We’re going through a process in rolling out a service, but if there is an emergency, we have an agreement to break that process and zero in to make sure we have the data available for the affected area.”

A third lesson borne out of the Katrina experience revolved around proper—and timely—reimbursement. Following Katrina, there were concerns regarding who would reimburse pharmacies for prescriptions dispensed, and how much that reimbursement would be. At the time, pharmacists dispensed those medicines in good faith, without any guarantee of reimbursement. Many pharmacy retailers were paid extremely late—if at all.

“Many claims went unpaid or there was confusion as to who was actually going to pay the pharmacy,” Simko recalled, prompting significant delays in reimbursement. Having an established reimbursement protocol, combined with the patient history index at ICERx.org, also should help reduce fraud and abuse, he said.

NACDS and the National Council for Prescription Drug Programs have been working toward developing standards and processes to be able to bill for services in an orderly fashion since Katrina.

Hopes are high that the reimbursement question has been addressed with the recent introduction of the Emergency Prescription Assistant Program. Spearheaded by CMS, the new resource utilizes existing pharmaceutical supply chain infrastructure as the distribution mechanism for future emergency responses. Like any other third-party insurance, the Emergency Prescription Assistant Program provides pharmacists with specific instructions on how to handle prescriptions for victims of disasters of national significance, how to bill these claims for reimbursement and how much they can expect in reimbursement.

“In the event of a disaster of national significance, the Federal Emergency Management Administration will identify individuals or groups of individuals who may be eligible for the EPAP and that information will be communicated to pharmacies through Argus [Health],” explained Larry Kocot, senior advisor to the administrator at CMS. “Upon activation of the EPAP system, disaster victims may present at any network pharmacy to fill a prescription written for a covered medication to treat an acute condition, to replace maintenance drugs that the individual may have lost in the emergency or to obtain certain covered [durable medical equipment]. Pharmacies will be required to check for existing coverage at the point of sale prior to billing the EPAP,” he added.

Wholesalers also have taken precautions in preparation of an emergency, as well, not only to make sure that in-demand medicines are readily avail-able—metronidazole for the treatment of tetanus, insulin and intravenous solutions were in greatest demand following Hurricane Katrina—but also that the supply chain feeding those medicines into emergency areas remains intact.

“Even prior to Katrina, we’ve had a [business continuity plan] for our network…in place,” said Don Walker, senior vice president of distribution operations at McKesson. “Post Katrina, one of the single largest [lessons] was—what is your plan when your infrastructure totally crumbles?” he said. Most continuity plans prior to Katrina had contingency plans in place, he noted, but Katrina took out communications, road infrastructure and power.

“We’ve gone back and revamped our plans,” he said, increasing satellite communication capability among distribution centers and such customers as hospitals, for example. “The biggest challenge we had was customers were fundamentally unable to say ‘I need this,’ because they couldn’t get a message out.”

As another example, Cardinal Health has up to three backup locations for each distribution center, systems in place to track the movement of their private fleet and access to an emergency stockpile of fuel.