The increasing cost of prescription medication in the United States is well documented (Wechsler, 2000). The cost of medication is a hardship for anyone managing a chronic disease, but is an even larger burden for those who are financially vulnerable. Individuals who are not compliant with prescribed medication regimes are estimated to cost the United States between $13 and $15 billion annually (Mistry & Sorrentino, 1999). One of the major reasons individuals are not compliant is cost. Patients who are forced to choose between the purchase of food or medication are unable to follow the physician's treatment plan. Unaware of the cost of the medications they prescribe, many physicians place a financial hardship on their patients (Reichert, Simin, & Halm, 2000).
Social workers in health care settings daily encounter individuals unable to pay for prescription drugs, including patients with little or no insurance and those unable to afford deductibles and co-payments. The lack of insurance coverage for prescription drugs, combined with the increasing cost of drugs, has resulted in many individuals being unable to obtain good medical care. Moreover, failure to take medically necessary medications results in revolving-door admissions to hospitals and more office visits (Harjai, 2000). To address these issues the Social Services Department at the University of Missouri Health Care developed the Medication Assistance Program (MAP).
Before the development of MAP, the University of Missouri provided free medication to patients with financial hardships. In 1998 the university calculated pharmacy charges of $655,929 for necessary medications for which there was no reimbursement. In July 1998 the university hired a BSW social worker as a resource specialist and initiated a case management process to help lower these burdensome costs. The challenge was to find resources and help clients develop long-term strategies for medication management, following them in the hospital and in the community as appropriate.
Referrals to the resource specialist originate from the hospital, office walk-ins, pharmacies, and clinics. Records are maintained on each client. Referrals are carefully reviewed to identify services that have been provided in the past. The worker maintains a close relationship with the Division of Family Services to coordinate each client's history with the Medicaid program and to refer clients for assistance. Patients are managed in inpatient and outpatient care.
Four categories of patients are served by the MAP: (1) Medicaid patients with required spend-downs or co-payments; (2) patients with insurance who cannot meet deductibles; (3) patients who qualify for various programs but have not obtained them; and (4) patients with no insurance.
Medicaid, a federal-state partnership, was designed to ensure that all poor Americans have access to health care. However, the program has many gaps. Patients often become eligible for Medicaid benefits only after they "spend down" some of their income. If the resources and income of a poor individual in need of medical care are above the state-prescribed poverty level, the person must incur a designated amount of medical expenses to become eligible for Medicaid. The spend down is calculated quarterly. The spend-down amount and the number of months in a quarter are determined by the state Medicaid agency and differ among recipients (Shi & Singh, 2001).
A patient with a spend-down requirement is referred to the Division of Family Services (DFS). The resource specialist contacts the DFS to ensure that the patient has applied for Medicaid, determine the months of the spend-down quarter, and assess whether the spend-down amount can be met with medication charges. If the spend down can be met, then the resource specialist completes a Request for Medication Assistance form and sends a copy to the hospital outpatient pharmacy with the patient. …