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 Associationskweaver@naspa.us

QUESTIONS?