Public health response: Maryland department leveraged partnerships
to help
restore access to pharmacy services after Baltimore's unrest

The recent unrest in Baltimore City required rapid response to multiple issues from the health and social services safety net in Maryland. In the week since the protests began, the Department of Health and Mental Hygiene (DHMH) has been working closely with our state and local partners to identify the key public health impacts. DHMH has worked with our state partners in Medicaid and the Baltimore City Health Department to address the issues quickly, in a client-centric manner that aligns with our mission to improve the overall health of Marylanders. In particular, the closure of multiple pharmacies in the city meant an “all-hands on deck” approach to ensuring city residents’ continued access to needed medications.
 
DHMH’s unique organizational structure provides for a continuum of care; this enabled the state to rapidly respond to pharmacy closures. In the health department, representatives for Medicaid and Public Health literally sit right next to one another, an important organizational nuance that has facilitated daily collaboration on the issues impacting city residents. Baltimore City has the highest Medicaid enrollment in Maryland, with 43 percent of the city’s residents enrolled. As the largest payer of health services, Medicaid plays a role in assuring access to care and services in a crisis that cannot be overstated.
 
Pharmacy services for chronic and acute disease management are critically important. A Medicaid recipient may be dependent on multiple, and at times costly, medications to manage these conditions.
 
The day after the April 27, 2015 disruptions and fires, reports of pharmacy closures came to the Department from multiple sources, including pharmacies, the media, and our contracted Medicaid Managed Care Organizations. A quick rubric was needed in order to respond to the needs of the city residents. While not all was done in rapid fire succession, we used both our existing Continuity of Operations Plan as well as national resources to guide our efforts to reach the impacted population.
 
 
Tracking pharmacy closures

The disruptions caused the closure of up to 15 pharmacies in high-need communities in Baltimore. These pharmacies were within a three-mile radius. We realized a quick protocol would be needed to respond to the needs of the residents of Baltimore City. So, our first step was to work with pharmacy providers and regulators to create a centralized tracking system on pharmacy closures.
 
In parallel, DHMH Secretary Van Mitchell exercised his public health authority to ask pharmacies to provide the department with daily status updates on their operations. This list has been updated and shared daily with the State’s emergency management system, the Baltimore City Health Department, hospitals, managed care organizations, other health care outlets and local media outlets.
 
 
Leveraging the ubiquitous cell phone to spread the word
 
While coordination at the state level was crucial, on-the-ground efforts also were essential to assure that medications were getting into the hands of the vulnerable city residents who needed them. A great means of facilitating this has been contacting residents by cell phone. We know that cell phone access is pervasive across all demographic categories of race, gender, age and income. A recent study from the Kaiser Family Foundation found that 86 percent of adults with annual incomes below $30,000 and 83 percent of adults with less than a high school education owned a cell phone as of May 2013. One of Maryland’s contracted MCOs, Riverside Health, immediately identified members who lived in the affected areas or who had prescriptions filled at closed pharmacies, and sent them text messages that directed them to alternative pharmacies that could meet their immediate needs.
 
 
Utilizing chain pharmacy providers as partners 
 
Individuals using a chain pharmacy were able to pick up their prescriptions at other locations because of shared systems. When individuals called a chain pharmacy, their call was routed to the closest chain. Patients who did not pick up their prescriptions were contacted via text or phone call and referred to their next-closest location; for individuals with maintenance drugs, mail order was utilized when necessary. Transferring patients at independent pharmacies was more challenging. The department collaborated with the Maryland Pharmacists Association to determine the number of independent pharmacies impacted by the disruptions in Baltimore City.
 
 
Using payers as partners
 
In addition to text messaging their members, MCOs immediately relaxed their prior-authorization requirements for refills, and the state made certain that chain pharmacies were able to transfer prescriptions to other locations. Pharmacy claims data populated by the Maryland Medicaid Pharmacy Program also was heavily utilized to conduct outreach. Medicaid pharmacy claims for closed pharmacy locations for both MCO and Medicaid fee-for-service was used to conduct outreach to individuals to make sure they had other arrangements. Some MCOs arranged for delivery and mail order.
 
 
Reaching people by going door-to-door
 
The Baltimore City Health Department organized pharmacy access issues through their 3-1-1 phone portal. From there, the Baltimore City Health Department team took on care through a case-by-case basis, arranging for prescription transfers, transportation and medication delivery.
 
 
Where are we now?
 
Baltimore City is in the recovery stage. As of today, eight pharmacies have reopened -- leaving seven still currently closed. Efforts continue to be coordinated to ensure continuity of care and to relieve the burden to pharmacy access. This event illustrated the importance of strong linkages within DHMH and with our partners on the local and state levels. 
 
 
[Editor's note: If you would like to volunteer to help Baltimore rebuild or you would like to donate to organizations helping that rebuilding process, please visit www.marylandunites.org -- CG]