A conversation with Medpin director Kathryn Saenz Duke
Medpin, or medicine for people in need, began in 1999 as a project of the Public Health Institute. During its eight-year tenure, Medpin worked with a broad group of California clinics, pharmacy schools, and health care foundations to get people appropriate medications in safety net settings. PostScript recently talked with Kathryn Saenz Duke, director of Medpin until it closed under funding challenges late last year. In the aftermath of the California showdown over health reform, PostScript asked Saenz Duke about what the defeat of universal coverage means for Californians who can’t afford their prescription drugs.
PS: What was your background before Medpin? How did you get interested in prescription drug access issues?
KSD: As a senior staffer on the California State Select Committee on AIDS in the 1980s, our committee worked with a broad spectrum of patients, advocates, and political groups to create new laws and policies, sometimes finding common ground and unexpected allies. After the Senate, I joined a University of California research team looking at managed care’s impact on safety net providers.
From there, I moved to the California Medical Association, where I met many doctors who felt caught between rapidly increasing direct-to-consumer drug advertising, formularies, and their relationship with patients. All those experiences brought me in 1999 to the project that became Medicine for People in Need (Medpin).
PS: Is there a short version of what Medpin was, and what happened to it?
KSD: Medpin’s first project was based on a cy pres litigation settlement in which all parties agreed to have an independent nonprofit organization distribute more than $170 million worth of diverse brand name drugs from 25 companies at no charge to recipients.
We worked with 150 California public hospitals and community clinics caring for uninsured people, designed and operated a new, award-winning drug order and distribution system, and helped safety net providers fill 2,600,000 one-month medication supplies for indigent patients who might otherwise not have received those medications.
Those were real achievements. But we were also committed to bringing longer term benefits to safety net clinics. We introduced many to the federal 340B discount program, promoted greater awareness and use of generic drugs, and helped the clinics better use drug companies’ patient assistance programs. We sponsored California’s law allowing expanded use of 340B with community pharmacies, and created new working relationships among California’s large county indigent care systems, nonprofit community clinics, and faculty from California’s seven pharmacy schools.
PS: Will the needs Medpin met be met by something/someone else, or is that still unclear?
KSD: When the decision was made to close Medpin due to funding challenges, we were pleased to look back at how much of our past work has ongoing impact, and to know that many of the other nonprofits we have partnered with continue their work.
But important work remains, and many of our former partners are facing their own funding difficulties.
PS: Is the pharmaceutical industry doing its part to help patients in need?
KSD: Medpin has always encouraged safety net providers to avoid confusing patient assistance programs with drug samples, which are part of drug companies’ marketing efforts. It’s interesting that Medicare Part D’s infusion of federal funds into prescription drug spending has brought greater scrutiny to the design of patient assistance programs and their impact on that federal spending.
This new legal attention is especially important for safety net providers, who feel pressure to accept much-needed financial help for many of their low-income patients, including from drug companies through patient assistance programs (and for some clinics, through drug samples). There is tension between using this short term help vs. moving toward evidence-based prescribing that may favor lower cost, generic drugs that aren’t “free,” but can offer better overall value.
PS: Is the government doing its part to help patients in need? Where’s the slack?
KSD: Two existing federal programs immediately come to mind as needing more government attention and support: Part D Low Income Subsidies, and “340B.” (The 340B program helps uninsured and Medicaid patients by requiring significant purchase discounts for their safety net providers).
With this being such an exciting election year, maybe there’s a chance that policy leaders can engage people to think broadly about what government should be doing to help all of us improve our health, and particularly those in most need.
PS: How did Medpin relate to pharmaceutical companies?
KSD: When I started with Medpin, I assumed we would eventually come together with PhRMA to identify and pursue some common interests, while agreeing to disagree on other matters.
But I soon realized that PhRMA didn’t need or want to work with us. It’s more comfortable for them to purchase communications, outreach, or other assistance than to develop a relationship with an independent nonprofit like Medpin.
Someone once commented to me that “Drug companies don’t understand and therefore don’t trust a nonprofit organization.” At first I scoffed at this, but later came to see it as an insight into our experience with them.
We did interact with a few individual drug companies. For instance, we gave several awards each year of the cy pres project to companies judged to have been most constructive in providing good products for uninsured patients.
After that project ended, a few drug companies—most notably Merck and AstraZeneca—responded to our invitation for dialogue about continuing some portion of the work we had done together. But these conversations did not progress, partly because Medpin decided to proceed only if a larger number of companies agreed to move ahead, and that never happened.
PS: Did Medpin work with patient advocacy groups? Considering that they are powerful consumer voices, but that some take funding from PhRMA members, what do you think their net effect has been on the conversation around prescribing and access?
KSD: Medpin’s focus has been on helping vulnerable patients by working with health care professionals in “safety net” settings. We have promoted evidence-based prescribing through drug monographs, guidelines, and other materials we’ve developed with two pharmacy schools and our statewide group of safety net pharmacists and physicians.
As for groups taking PhRMA funding, I believe that leaders from a number of “disease groups” are trying to think carefully about whether and how it’s possible to accept drug company funding while staying independent of pressure–however subtle or self-generated–to avoid ruffling their funders’ feathers. Do I think there could be more self-examination on this issue? Absolutely, yes.
PS: What does the defeat of California Health Reform mean for patients who can’t afford their prescription drugs and the community health clinics that serve them?
KSD: Watching California’s recent health care reform efforts has been déjà vu for those of us who followed this state’s earlier drama over drug pricing. We had several years of high-profile legislative efforts to address drug costs in California, followed by a confusing and expensive ($80 million) campaign in 2005 involving two drug discount program ballot initiatives.
After voters failed to approve either measure, our Governor and legislative leaders enacted the bipartisan California Discount Prescription Drug Program in early 2006, which blended elements from both initiatives. But that law failed to include any funding, and we’re waiting to see if anything comes from all the money and political negotiating invested these past years.
Uninsured people will continue to need care and help on their drug costs from safety net providers. There is some good news these days because a number of medications that used to be high priced are now available generically at much lower cost. The bad news is that effective pharmaceutical care must be set within larger medical care and health promotion activities, and our state and national leaders are still trying to patch together financing and delivery system for those activities.
Right now California’s public officials face a $16 billion budget deficit, so I don’t expect health reform here anytime soon.
A final thought: Just as pharmaceutical care should be only one part of effective medical care, so should medical spending and attention be put into a larger framework of topics not typically considered medical or health-related.
Recent writing by Michael Pollan, Steve Schroeder, Dick Jackson, and other thoughtful observers should move us all to pay more attention to our food, the built environment of our communities, tobacco use, and other factors whose combined power to help or hurt our health status is greater than the impact of medical care.
How ironic it would be if we in the U.S. achieve access to appropriate medication at affordable prices for everyone, but see growing numbers of people eating fast food, smoking cigarettes, and living in communities designed more for cars than humans. I think sometimes we need to step back and at least acknowledge this bigger picture of “health.”