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Anticipating the Future:Trends to Look for in Pharmacy
Krystalyn Weaver, PharmD
Director, Policy and State Relations
National Alliance of State Pharmacy Associations
About NASPA
The National Alliance of State Pharmacy Associations (NASPA), founded in 1927 as the National Council of State Pharmacy Association Executives, is dedicated to enhancing the success of state pharmacy associations in their efforts to advance the profession of pharmacy. NASPA’s membership is comprised of state pharmacy associations and over 70 other stakeholder organizations. NASPA promotes leadership, sharing, learning, and policy exchange among its members and pharmacy leaders nationwide.
Growing Pressures on the Business of Pharmacies
Growing Pressure…
•Decreasing margins
•MAC pricing
• Increasing costs of generics
• Increasing regulations
•More pressure to increase volume
•More complex drug therapy regimens
• Increased competition for jobs
…New Opportunities
•Value based payment
• Focus on quality and cost containment
•Complex medication regimens – reliance on pharmacist expertise
• Increasing recognition of pharmacists value
Getting to the Preferred Future
• Transformation of pharmacy practice• Collaborative Practice
• Public Health
• Education and training
• Enhanced role of technicians
• Focus on quality
•Remedying the business model
Transformation of Pharmacy Practice
Collaborative Practice
Collaborative Practice Agreements
•Creates formal relationship between pharmacists and physicians or other providers
•Defines certain patient care functions that a pharmacist can autonomously provide under specified situations and conditions
•Many are used to expand the depth and breadth of services the pharmacist can provide to patients and the healthcare team
Components of a CPA Authority
Statute/Regulations
• Define collaborative practice authority and restrictions• HIGHLY variable
Agreement
• Defined by collaborating practitioners• Defines the conditions of the relationship, delegation of authority/expansion of scope, defines the parties• Legal document
Protocol
• Defines the clinical parameters for the provision of care• Varying degrees of detail• May or may not be required by state laws/regulations
Existing Landscape
•Collaborative practice authority: 48 states• Proposed in AL and in the works in DE
• Pharmacist modification of therapy: 45 states
• Pharmacist initiation of therapy: 39 states
•Allow multiple pharmacists on one agreement: 25 states
•Many other parameters…
CPA Applications
•Chronic Disease Management• Anticoagulation
• Cardiovascular disease/hypertension
• Diabetes
• Others
•Acute Treatment
• Public Health
Transformation of Pharmacy Practice
Public Health
Point of Care Testing
•Rapid Diagnostic Testing• Influenza
• Strep
• Screening• HCV/HIV
• Lipids
• A1C
•Monitoring• Lipids
• A1C
• INR
Statewide Protocols
•Naloxone
• Immunizations
• Smoking Cessation
•Hormonal Contraceptives
• Travel Medications
Pharmacists & Naloxone
HI
AK
DCMOWV
MS
NH
NC
FL
KY
WA
SC
OH
CAMDDE
TN
MANYRI*
IL
CT
VT
NJ
MI*
ME
MNOR
ID
MT ND
SD
NV*UT
AZ NM
TX
WY
CO
NE*
OK
KS
IA
WI
IN
PA
VA
AR
AL GA
LA
Based on data collected by NASPA (updated June 2015)
Statewide naloxone protocol or prescriptive authority for pharmacists
Broad** collaborative practice provisions
* Broad collaborative practice provisions but need a separate agreement for each pharmacist
Pharmacists are authorized to dispense without a prescription
Statewide protocol or prescriptive authority bill proposed in 2015 session**Broad = Allow initiation of therapy, community pharmacists authorized to participate, no drug restrictions (may need to specify within the agreement), laws/regulations silent regarding the relationship between the prescriber and the patient
Education and Training
Residency Training
ASHP 2020 Vision for Residencies
•ASHP House of Delegates Resolution:
• To support the position that by the year 2020, the completion of an ASHP-accredited postgraduate-year-one residency should be a requirement for all new college of pharmacy graduates who will be providing direct patient care.
Growth in Residencies
2010 2011 2012 2013 20140
500
1000
1500
2000
2500
3000
3500
4000
4500
MatchesPositionsApplicants
Slow Growth in Residency Sites
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
02000400060008000
100001200014000160001800020000
PositionsApplicants
Training Programs
•Certificate Training Programs• Delivering Medication Therapy Management Services
• Pharmacy-Based Cardiovascular Disease Risk Management
• Pharmacy-Based Immunization Delivery
• The Pharmacist and Patient-Centered Diabetes Care
• Point of Care Testing
•Advanced Training Programs• Pharmacy-Based Travel Health Services
• ADAPT Patient Care Skills Development
• Advanced Preceptor Training
Board Certification
• Board of Pharmacy Specialties• Ambulatory Care Pharmacy
• Critical Care Pharmacy
• Nuclear Pharmacy
• Nutrition Support Pharmacy
• Oncology Pharmacy
• Pediatric Pharmacy
• Pharmacotherapy
• Psychiatric Pharmacy
• Continuous growth – number of BPS certified pharmacists has approximately doubled every five years
Enhanced Role of Technicians
Increased Education for Technicians
• 2020: Required completion of ASHP-accredited pharmacy technician education program • New applicants only
• Potential opportunities• More advanced workforce
• Workload shift
• Potential challenges• Workforce challenges
• Compensation
• Availability of education sites
Shifted Focus of PTCB Exam
Assisting the Pharmacist in
Serving Patients; 66%
Maintaining Med-ication and In-ventory Control Systems; 22%
Participating in the Administration and
Management of Pharmacy Practice;
12%
Source: Pharmacy Technician Certification Board
Shifted Focus of PTCB Exam
Source: Pharmacy Technician Certification Board
Pharmacology for Technicians;
13.75%
Pharmacy Law and Regulations, 12.5%
Sterile and Non-sterile Compound-
ing, 8.75%Medication Safety,
12.5%
Pharmacy Quality As-surance, 7.5%
Medication Order Entry and Fill
Process, 17.5%
Pharmacy Inven-tory Management;
8.75%
Pharmacy Billing and Reim-
bursement; 8.75%
Pharmacy Information Systems Usage and Appli-
cation; 10.00%
New PTCE Blueprint
•Driven by results of job analysis
•Reflects evolution of technician responsibilities
• Increased specificity for knowledge domains
•Revising the PTCE • Blueprint and item mapping
• Gap analysis and new item development
• Standard Setting
Focus on Quality
Changing Payment System
• Transition away from fee for service
•Need to demonstrate outcomes and value to payers
• Pharmacy Quality Alliance• Focus on adherence measures potential to change the
game in network creation and contracting
• Pay for performance (P4P)• Inland Empire Health Plan
IEHP P4P Program
• Partnering with Pharmacy Quality Solutions• Using the EQuIPP platform
• Seven measures • PDC: diabetes, hypertension, statins
• Diabetes care: appropriate treatment of hypertension (ACE-I/ARB)
• Asthma: absence of controller therapy
• Safety: use of high-risk meds in the elderly
• Generic dispensing rate (least weighted measure)
• **Other measures to be included in phases 2 and 3
•Meet or exceed benchmarks bonus payment to community pharmacy
Remedying the Business Model
Why Provider Status?
Promote consumer access and coverage for
pharmacists’ patient care services.
-Tom Menighan
The Patient Access to Pharmacists’ Care Coalition (PAPCC)
• Publically announced early March 2014
•Currently more than 29 organizations and growing
•Representing patients, pharmacists, and pharmacies, as well as other interested stakeholders
www.pharmacistscare.org
PAPCC – H.R. 592 and S. 314Scope of Proposal
• Pharmacists – State-licensed pharmacists with a B.S. Pharm. or Pharm. D. degree who may have additional training and certificates depending on state laws
• Services – Services authorized under state pharmacy scope of practice laws
• Patients – Services provided in/ for Medically Underserved Areas (MUA), Medically Underserved Populations (MUP), or Health Professional Shortage Areas (HPSA)
• Reimbursement – Consistent with Medicare reimbursement for other non-physician practitioners, pharmacist services would typically be reimbursed at 85% of the physician fee schedule
PAPCC - H.R. 592 and S. 314
Are only a limited number of
pharmacists eligible under the
federal bill?
A Closer Look at New York
Where We Stand & Next Steps
• Both NY Senators and 10 Representatives are cosponsoring – THANK them!
• Others to work on:
Senate: 27 cosponsorsHouse: 179 cosponsors
Dist. Representative
Dist. Representative
Dist
Representative
1 Zeldin 10 Nadler 17 Lowey
2 King 11 Donovan 18 Maloney
3 Israel 12 Maloney 19 Gibson
4 Rice 14 Crowley 24 Katko
5 Meeks 15 Serrano 27 Collins
7 Velazquez 16 Engel
Provider Status at the State Level
The 3 Components and Current Landscape
State vs. Federal Landscape
State• Designation not
usually associated with payment
• Scope of practice defined in state statute
• Incremental changes, year by year
• No one solution fits every state
Federal• Designation in Social
Security Act would likely lead to payment for service
• Scope of practice not defined
• All “asks” are a heavy lift, difficult to go back year after year
• Generally unified goal
Common Goal:Patient Access to Pharmacists’ Patient
Care Services
Achieving Patient Access
Provider Designation
Optimization of
Pharmacy Practice Act
Payment for Service
Patient Access to Pharmacists’ Patient
Care Services
A Focus on Payment for Services at the State
Level
State Provided Medical Benefits
• State Employees and/or State Medicaid programs
• Some states have found success in implementing an MTM or other pharmacy service benefit into one of these state funded programs
•Could be done with or without recognition as a provider in that state
• Example: Minnesota
Mandate for Private Insurers
•Addition of a provision within the insurance code could attempt to require that a service that is provided by pharmacists (such as MTM or other services) be covered
• Example: Washington State
Working with Private Insurers (no legislative action)
• There is nothing stopping private insurers from covering any service they find valuable
•Have to be prepared to demonstrate value and have plan for how the service will be able to be delivered
• Examples: Ohio (covered later in detail), Tennessee
•Some kind of Payment31
•Some Medicaid Service17• Medicaid MTM12
•State Employee MTM6
Payment for Services
2015 Payment Legislation
Connecticut• HB 6157; Introduced 1.22.15• Adds MTM as a covered benefit in Medicaid
North Dakota• SB 2320; Introduced 1.20.15• Adds MTM as a covered benefit in Medicaid
Oregon• SB 558• Requires that a health benefit plan cover pharmacists’
consultation services under certain conditions
Passed!
2015 Payment Legislation
Hawaii• HB 614• Requires coverage of lab tests ordered by pharmacists
Montana• HB 455; LC 134• Adds comprehensive medication management as a
covered benefit in Medicaid
Tennessee• SJR 104• Resolution to encourage TennCare to cover MTM for
Medicaid recipients
Where are we now?
Existing Opportunities
• Part D MTM
• Vaccinations
• Cash services• Screenings, medication reviews
•Medicaid• Pharmaceutical Care Management, Diabetes Education
• Contract with local employers• Disease management, screenings, vaccine clinics
•Medicare Annual Wellness Visits
• Incident-to billing
Around the U.S.: MinnesotaMinnesota Medicaid
• Patients• Outpatients taking three or more meds to treat or prevent at
least one chronic condition (who are not Med D eligible)
•Medication Therapy Management Services• Providers are paid based on the defined level of care provided
(1-5) based on the complexity of the encounter
• Must use an electronic documentation system
• SB 825 – removes the three medication requirement• Cited as a net savings to the Governor’s proposed budget
based on previous results
Around the US: Washington State
• Substitute Senate Bill 5213 (2014)
• Effective January 1, 2015
•Requires payment that incentivizes pharmacists and other qualified providers to provide comprehensive medication management services in health homes for Medicaid managed care patients with multiple chronic conditions
• “Less about a turf battle, more about care”• Worked collaboratively with physicians to advocate and pass
the bill
Around the U.S.: Ohio
• Services Covered• Caresource, Ohio’s largest Medicaid managed care
organization opted to cover MTM services for all covered lives
• Implemented similar to Part D MTM
• Patients in need of services are identified
• Needed interventions can also be identified at the point of care
• First Year Outcomes• 106,239 MTM services delivered
• Return on investment: $4.40:$1, as reported by Caresource
• Drug savings: $1.35:$1
Where are we going?
Post Provider Status
•Billable services• Diabetes self-management training
• Screenings
• Smoking cessation counseling
• Wellness visits
• Disease management
•Billing Codes• Current Procedural Terminology (CPT)
• G-codes
• Chronic Care Management Codes
• Transitional Care Management Codes
Post Provider Status
•New Opportunities• Collaboration with other practitioners
• Help them with their quality metrics!
• Contract with ACOs and Medical Homes
• Pay for performance
• Assist hospitals with transitions of care and reducing readmissions
• Find out what the needs are in your area:
• http://khn.org/news/medicare-readmissions-penalties-2015/
• Others??
Practical Considerations
• Pharmacy Design: Privacy considerations, equipment investments (screenings, etc)
• Education: Certificate training programs, billing (Medicare Learning Network – MLN Connects®)
• Technology: Information technology, interoperability
•Quality: Be ready to be measured on patient outcomes
The association is watching for these needs and working on them in advance
What Can You Do?
Advocate
Support
Learn
So many other issues to watch for!
• Telemedicine/telepharmacy
• Pharmacogenomics/ personalized medicine
•Rise in specialty pharmacy
• Increases in automation
• “Printing” drugs
•Move toward integrated care delivery
•Greater roles in public health
Krystalyn WeaverDirector, Policy and State RelationsNational Alliance of State Pharmacy [email protected]
QUESTIONS?