Ling takes policy know-how to the clinic
Tina Ling, MPH, PharmD ’13
Fair Oaks Health Center, Redwood City
Ambulatory care clinical pharmacist
Beyond the PharmD: Year-long residency in ambulatory care at UC Davis Medical Center in Sacramento, California
Expertise: Ambulatory care
Tina on her role as an outpatient pharmacist: “Literally any issue relating to a drug, the clinic staff will come to me for help, whether it’s a cost issue, a drug interaction, or patients taking too many medications. One time a provider even asked me, ‘What’s that medication? It’s a white tablet with pink speckles on it.’”
From refugee to policy advocate and pharmacist
Tina Ling was born in a refugee camp in Thailand after her parents fled the genocide in Cambodia. Growing up in Southern California in an immigrant-rich community, she saw her parents and many of their neighbors struggle with their new country’s language, culture, and economics—including access to health care and health literacy.
As a result, she had a dual vision for her career: improving health care access for vulnerable populations and, ultimately, developing better public health policies. After earning a Master of Public Health degree, Ling became a policy advocate for the Asian Law Caucus, a San Francisco-based legal and civil rights organization serving low-income Asian Pacific American communities.
“In order to be effective at changing policy, you need to have a big-picture overview of how policies are made. I understood this from working at the Asian Law Caucus,” Ling says. “But I realized that you also need first-hand experience working at the ground level to really be an effective policy advocate.”
She decided that pursuing a doctor of pharmacy (PharmD) degree at UC San Francisco, with its clinical education, was her next step. “I feel there’s something unique that you gain through working directly with patients. With that first-hand knowledge, I can educate policymakers and speak from personal experience about actual issues in our community.”
Once at UCSF, she found a golden opportunity for deep-dive learning, via the School of Pharmacy’s Medicare Part D Outreach and Peer Educator Program. Through this elective course and volunteer program, she mastered the complexities of how insurance and drug coverage work and how to advise patients on drug assistance programs—all to help people access and afford their medications. That experience was “exactly what I needed to be successful in the career that I aspired to have,” says Ling.
A two-part program with one aim
Medicare Part D Outreach: Trained student pharmacists provide individual counseling to seniors in the community on how to choose the best Part D plan for their needs.
Peer Educator Program: After intensive training, student pharmacists provide presentations to health care providers and health professional students on drug-cost containment and assistance strategies.
The common goal: To help patients afford their prescribed medications.
What can a pharmacist do?
Ling was used to friends and the public associating pharmacists solely with retail settings, not knowing they also manage drug therapies in hospitals and outpatient clinics, where they often develop individualized medication plans for patients, and educate them about their prescribed drugs.
But in her year giving Peer Educator lectures to health care students and providers, she recalls: “It really hit home that our role as clinical pharmacists isn’t well understood. It was a stark first-hand reminder of how little other providers know about our role. After the presentation, we’d hear, ‘Wow—I didn’t realize the scope of services you can offer.’”
In addition, Ling often found other providers didn’t know how much medications actually cost. Peer educators might ask an audience about the price of a month supply of Advair Diskus, an inhaled prescription medication to treat asthma. “We’re not talking about an obscure cancer medication,” she notes. “We’re talking about something that people take daily to help with their breathing.”
Their provider audiences would guess “about $50,” says Ling. “In reality, it costs closer to $250 [per month] without insurance. We’d always get a reaction from that. It really sinks in for the providers when they learn the true cost of just one commonly prescribed medication.”
Indeed, she and her fellow volunteers’ many hours of Peer Educator lecture preparation paid off in question-and-answer sessions that were “a true dialogue between the professions” and also an early chance for the pharmacy students to apply their studies to real world situations.
Beyond the PharmD
After completing a year-long residency in ambulatory care at UC Davis Medical Center in Sacramento, Ling joined the staff of the Fair Oaks Health Center, an outpatient clinic of the San Mateo Medical Center, located in Redwood City, California.
She opted for outpatient care, she explains, because “In an ambulatory care setting you really have the opportunity to have that one-on-one interaction with the patient, to address what they need, what the issues and barriers are, and hopefully solutions.”
For example, Ling finds that there is typically some combination of three reasons why patients are unable to take their medications as prescribed by their physicians (i.e., non-adherence). “They can’t afford it—that’s a financial barrier. Or sometimes they don’t know what the medication is for and they don’t think it’s important, so they don’t take it—that’s a health literacy barrier. Or they don’t know how to take their medication because they can’t read the directions written in English—that’s a language access barrier.”
As the clinic’s first and sole pharmacist, Ling's day-to-day work runs a wide gamut from drug evaluations to insurance issues. “Literally any issue relating to a drug, the clinic staff will come to me for help,” she says, “whether it’s a cost issue, a drug interaction, or patients taking too many medications. One time a provider even asked me, ‘What’s that medication? It’s a white tablet with pink speckles on it.’”
Med list education, alterations, and prior authorization
“Doctors will come to me and say, ‘I just saw this patient. Their medication list is just a mess. I’m not sure what they’re taking. Can you talk with them and educate them?’”
Sometimes, Ling finds, “when reviewing medications with a patient—that’s when I can make recommendations to the doctor and say, for example: ‘Patient reports diarrhea and this drug is known to cause it, so I think this other medication would be more appropriate.’ Or, ‘based on more recent studies, this class of blood pressure medication is not as effective as this other class. I recommend switching, with close follow up.’”
Ling’s role also entails making a compelling case for prior authorization—insurance plan approval for a drug not routinely covered by its formulary, often because it’s pricier. “I can look through the labs [test results] and the patient’s clinical chart and say, ‘This patient has tried and failed these different medications, and this is why this particular medication is needed for this particular patient at this time.’”
Tools for helping patients
The Peer Educator program “really provided me with some tools,” says Ling. “Before being a Peer Educator, I had no idea about Medicare drug coverage, patient assistance programs, or co-payment assistance—all those things were so complicated. Learning about them, and later becoming an expert, really helped me in terms of actually practicing in the field.”
And she finds ample opportunities to use those tools in her practice. Fair Oaks Health Center serves a mostly low-income population that is commonly enrolled with Medi-Cal (state Medicaid). Non-adherence to prescribed drug regimens due to financial issues “happens frequently with our patient population,” Ling explains.
In one case, she recalls, a patient had been taking three diabetes medications, but his blood sugar levels were still not well controlled. An endocrinologist recommended, based on the lab test results, that the patient should be prescribed a newer, less commonly used drug called Invokana.
Initially, prescription coverage was rejected, as was an application for prior authorization by the patient’s insurance plan, a public plan for low-income residents of San Mateo County. Plan rules called for patients to first try insulin, “a relatively cheap drug” that is covered, says Ling.
“The doctor said, ‘My hands are tied. I’ll prescribe the insulin, knowing that it’s not the most effective drug for this patient,’” Ling recalls. But she took on the case and found the patient qualified for the drug manufacturer’s Patient Assistance Program, a tool covered in the Peer Educator presentation, so he was able to get Invokana free of charge for a year.
Addressing medication adherence across disciplines
Based on her experience working directly with patients, Ling determined that language access was a significant barrier to medication adherence for patients at Fair Oaks Health Center, most of whom are limited-English speakers and often can’t read English directions on medication bottles.
This language barrier may lead to patients taking their medications incorrectly. Ling remembers a patient reporting that she was taking her once-daily thyroid medications three times a day. The patient had confused the thyroid medication with her pain medication.
To address the problem, Ling takes a multidisciplinary approach that includes educating providers about new laws and resources to improve medication adherence. For example, in 2016, a new law took effect that requires California pharmacies to provide medication directions in one of five languages, including Spanish—the predominant language spoken among Fair Oaks Health Center patients. Ling educates providers on how to request language-appropriate labeling on prescriptions they write for limited-English language patients, so retail pharmacies can provide this crucial information in a way the patient can understand.
Just as in the Peer Educator lectures, Ling seeks to impart helpful knowledge while at the same time presenting her profession’s go-to expertise: “It’s great for other providers to know about resources to help patients with their medications and to have their team access those resources,” she says. “But when clinics do have access to a clinical pharmacist, we can be that expert.”
Part of our series
The Part D learning experience—10 years on
10 years ago, a distinctive program was created by UCSF School of Pharmacy students and faculty members to help low-income seniors afford their prescribed medications through the federal Medicare Part D drug benefit and to teach health care provider peers how to navigate the benefit with their patients.
We spoke to UCSF PharmD alumni who participated in this program to find out if the lessons learned have carried over to their careers.
|Mon Mar 13||Thinking it through in pharmacy school, the UCSF way|
|Wed Mar 15||Drysdale sees team-based patient care as essential|
|Fri Mar 17||Pong Dahl tackles medication and affordability challenges|
|Tue Mar 21||
Ling takes policy know-how to the clinic
|Thu Mar 23||Frear solves medication problems at the systems level|
About the School: The UCSF School of Pharmacy is a premier graduate-level academic organization dedicated to improving health through precise therapeutics. It succeeds through innovative research, by educating PharmD health professional and PhD science students, and by caring for the therapeutics needs of patients while exploring innovative new models of patient care. The School was founded in 1872 as the first pharmacy school west of the Mississippi River. It is an integral part of UC San Francisco, a leading university dedicated to promoting health worldwide.