Pong Dahl tackles medication and affordability challenges

Krystal Pong Dahl, PharmD ’11

Pong Dahl

Krystal Pong Dahl, PharmD

Krystal Pong Dahl, PharmD ’11

John Muir Physician Network (Part of John Muir Health), Walnut Creek
Supervisor for Ambulatory Care Pharmacy Services

Beyond the PharmD: Pharmacy residency at San Francisco Veterans Affairs Medical Center

Expertise: Ambulatory care

Krystal on her UCSF mentors: “It broke down some barriers for me—being mentored by innovative leaders encourages us to take on challenges.”

A big shift in perspective

“Insurance and law and policy weren’t initially exciting to me,” Krystal Pong Dahl readily concedes. “It’s not what I was initially drawn to in pharmacy.”

In fact, what had thrilled her as an undergraduate biochemistry major taking her first pharmacology class was discovering “how this little pill works in the body,” she recalls.

“I thought ‘Wow, if other people understood this, they would potentially see their medications differently,’” she says. “And then when I learned that pharmacists teach people about medications—that really sparked me.”

But getting involved in the School of Pharmacy’s Medicare Part D Outreach and Peer Educator program at UC San Francisco radically altered her perspective.

“You realize that if you don’t understand the insurance benefit, your patient’s not going to be able to get or afford their medications,” she says. “At that point, it doesn’t matter how great their regimen is or if you dose-adjust it appropriately. That’s when I wanted to learn more about it and then spread the message to other providers so they can help advocate for their patients, too.”

Navigating benefits and polishing presentations

Indeed, Pong Dahl soon discovered that navigating the Medicare Part D drug benefit could be nearly as complex as medication management, given its annual changes in plan formularies, coverage gaps, and under-applied low-income subsidies.

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.

During Peer Educator lectures and Medicare Part D outreach work, she found, “Here you have these providers with so much higher education, and they still struggle to understand this complicated benefit that’s constantly changing. And then, for the patients, it’s just so unrealistic to expect them to understand it as well, but it dramatically affects them.”

In addition to being immersed in Part D details and jargon as a peer educator, Pong Dahl recalls her faculty mentors helping to imbue her interdisciplinary presentations with a confidence born of expert preparation.

“Helene [Lipton, PhD] and Marilyn [Stebbins, PharmD] spent so much time and energy helping us to perfect our presentations,” she says. Lipton even kept a running tally of how often Pong Dahl was unconsciously using “so” as a filler word when introducing her slides.

Thus, while Pong Dahl came to UCSF with public speaking experience and even had the chops to emcee events like the annual tongue-in-cheek Mr. Pharmacy competition, the program took her skills to a whole new level.

When tackling the program’s rarefied speaking opportunities, such as addressing grand rounds at Zuckerberg San Francisco General Hospital—“a more high-stakes presentation than Mr. Pharmacy,” she laughs—the inevitable nervousness in addressing a roomful of experienced providers was balanced by “knowing the content and envisioning what questions they would have.”

Beyond the PharmD

After earning her PharmD, Pong Dahl completed a year-long residency at the San Francisco Veterans Affairs Medical Center, focusing her elective rotations in ambulatory care. She is now the supervisor for ambulatory care pharmacy services for the John Muir Physician Network (part of John Muir Health), which includes more than 1,000 primary and specialty care physicians in the East Bay.

As a testament to her exemplary work, she received the 2016 New Practitioner Achievement Award from the California Society of Health-System Pharmacists (CSHP), the largest state pharmacist association.

In her job at John Muir, Pong Dahl is working to develop outpatient clinics including one providing comprehensive medication management—complete reviews of patients’ medication lists for appropriateness, dosing, and potential interactions, as well as explaining the drugs to patients—precisely the patient education prospect that drew her to pharmacy to begin with.

Overseeing a sea change

She also started and is working to expand an anticoagulation clinic at a time when therapies prescribed to prevent blood clots are undergoing a sea change.

Until recent years, such clinics were pretty much synonymous with instructing patients, monitoring blood levels, and adjusting oral doses of warfarin (brand name Coumadin). This can be complex, since the blood thinner has a narrow range of safe and effective doses, which can be readily affected by diet, concurrent illnesses, and interactions with other drugs.

But Pong Dahl’s 2014 arrival at John Muir followed the addition of several new oral clot-preventing drugs. Generally, they’re deemed easier to manage than warfarin: simpler dosing, no food interactions, and no routine blood monitoring.

Still, the newer drugs, collectively dubbed Target-Specific Oral Anticoagulants (TSOACs), have their own issues. “One of [the drugs], if a patient’s renal function is too good, then they can’t be on it because there’s an increased risk of stroke,” says Pong Dahl.

She is developing criteria to help network physicians decide whether their patients are good candidates for the TSOACs and the appropriate dosing, based on aspects such as interactions with other drugs and kidney function. She also helps patients transition to the new drugs.

Conscious of both clots and costs

Pong Dahl’s Peer Educator-polished presentation skills are routinely put to work in her collaborative workplace. She has presented on the TSOACs at John Muir Health’s outpatient grand rounds and has routine presentations to the quality and care management committees—all audiences comprised of physicians and nurses.

And while her roles are primarily clinical in nature, her UCSF pharmacy training continues to infuse her work with concerns about drug insurance coverage, affordability, and access.

For example, in overseeing patients who are transitioning from warfarin to the newer anticoagulants, she’s mindful of their higher cost—potentially about $300 a month versus just a few dollars for warfarin—which may affect a patient’s ability to adhere to their regimen. And since the newer drugs’ effects are more short-lived, a missed dose could compromise their protection against clots.

Helping a patient transition from warfarin to a newer anticoagulant, Pong Dahl recalls following up by phone to ask, “‘Were you able to pick up the prescription? Was the co-pay within an affordable amount for you?’ I didn’t feel comfortable closing that case until I knew they could pay for it long term, because I figure if they ran out of samples then went to the pharmacy and were told a price they couldn’t afford, they would just stop and not have any [clot-preventing] coverage.”

“I also start thinking, ‘Even if it is covered, what will it contribute toward their total drug cost for the year? [This is a concern due to Medicare Part D’s coverage gap, the so-called "donut hole."] “Because they’re on this other medication that’s also expensive,” she explains. “It’s a consideration I may not have appreciated had I not been involved with the Peer Educator program.”

Ultimately, as part of a generation of pharmacists addressing health system needs in newly expanded roles, Pong Dahl feels one of the Part D and Peer Educator program’s strengths is exposure to its innovative mentors. “Just being able to work with Helene and Marilyn had an effect on me, because it showed me that change can happen,” she says.

Marilyn Stebbins, PharmD, for example, has regularly innovated in outpatient care, including a clinic at a Sacramento medical group focused on reducing elderly patients’ out-of-pocket drug costs. So when Pong Dahl was given the opportunity to develop new ambulatory programs at John Muir, she called Stebbins: “Marilyn answered my questions and helped me envision success. It broke down some barriers for me—being mentored by innovative leaders encourages us to take on challenges.”

In this two-minute clip, Pong Dahl reveals what knowledge she uses daily as a supervisor for ambulatory care pharmacy services.


The Part D learning experience—10 years on

In 2007, 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.

Thu Mar 23, 2017 Frear solves medication problems at the systems level
Tue Mar 21, 2017 Ling takes policy know-how to the clinic
Fri Mar 17, 2017 This page:
Pong Dahl tackles medication and affordability challenges
Wed Mar 15, 2017 Drysdale sees team-based patient care as essential
Mon Mar 13, 2017 Thinking it through in pharmacy school, the UCSF way

About the School: The UCSF School of Pharmacy aims to solve the most pressing health care problems and strives to ensure that each patient receives the safest, most effective treatments. Our discoveries seed the development of novel therapies, and our researchers consistently lead the nation in NIH funding. The School’s doctor of pharmacy (PharmD) degree program, with its unique emphasis on scientific thinking, prepares students to be critical thinkers and leaders in their field.