1 Transforming Patient Care Paramount Issues and Opportunities in Pharmacy PracticeRHODE ISALND SOCIETY OF HEALTH SYSTEM PHARMACITS 2013 RISHP 9th Annual Future of Pharmacy Showcase Saturday, November 2, 2013 Paul W. Abramowitz, Pharm.D., Sc.D. (Hon), FASHP Chief Executive Officer

2 Disclosure InformationSPEAKER: Paul W. Abramowitz, Pharm.D., FASHP, Chief Executive Officer American Society of Health-System Pharmacists TITLE: “Transforming Patient Care: Paramount Issues and Opportunities In Pharmacy Practice” MEETING: Rhode Island Society of Health System Pharmacists 2013 RISHP 9th Annual Future of Pharmacy Showcase Saturday, November 2, 2013 I have no relevant financial relationships to disclose.

3 The Accountable Care OrganizationObjectives Discuss future pharmacy practice models and new methods of care delivery to improve outcomes of care Describe a focus on the full continuum of medication therapy to eliminate silos of care Practice Model Change New Methods of Care Discuss the ACO Model and ways in which pharmacists should participate The Accountable Care Organization Connecting All Aspects of the Medication-Use Continuum

4 Objectives Obtaining Provider Status for PharmacistsIdentify opportunities and ways pharmacists should educate the public, patients, and payors to enlist their support for availability of pharmacy care Enhancing the Public’s Understanding of the Vital Role of the Pharmacist in their Care Describe the importance and process for pharmacists to obtain provider status at the Federal, State and Local levels Obtaining Provider Status for Pharmacists Yes, It is Important! Explain how the evolution of CDTM to broaden pharmacist prescribing privileges will improve the delivery of health care Pharmacist Interdependent Prescribing Optimizing Patient Outcomes

5 Practice Model Change New Methods of Care

6 Practice Model Change - New Methods of CareWhat is a Practice Model? Defines important types and levels of patient care services Allows for: Application of best practices Standardization of care Judgment of pharmacist and individual patient needs 6

7 Practice Model Change - New Methods of CareWhat is an Optimal Practice Model? Incorporates roles of pharmacists, technicians, and other support personnel into the provision of interprofessional care Encompasses patient care activities that span across all sites of care Optimizes technology and information systems to enhance care 7

8 Practice Model Change - New Methods of CareImperatives for Practice Model Change Our Patients Medication use and its outcomes are far from optimal in the U.S. Admissions and readmissions to hospitals due to medication therapy are too high Provision of primary care and management of chronic disease is inadequate to meet global needs Wellness and prevention do not receive adequate attention 8

9 Practice Model Change - New Methods of CareImperatives for Practice Model Change Health System Spending National Health Expenditure,$2.8 trillion in 2012, $8,952 per person, and 17.9% of GDP - projected to be 19.6% by 20211 Estimated waste in the healthcare system = $765 BILLION annually2 The Affordable Care Act (ACA) attempts to address these problems ACOs are designed to reward appropriate care utilization and ultimately capitate payment but need the full participation of pharmacists 9

10 Practice Model Change - New Methods of CareImperatives for Practice Model Change, “The Elevator Speech” Pharmacists are the: Most accessible healthcare professionals Specifically and intensively educated and trained in drug therapy Maximizing pharmacists integration into health care teams will improve: Quality Safety Patient Satisfaction Financial Performance 10

11 Practice Model Change - New Methods of CareThe Patient Hospitals & Health Systems Clinics Home Care Long-Term Care Specialty Pharmacy Community Pharmacies Urgent Care Insurers Current Silos that Exist in the Pharmacy Practice Continuum Lack of effective transition of care mechanisms Less than optimal division of responsibilities 11

12 Practice Model Change - New Methods of CarePrinciples for Practice Model Redesign3 Health care will become increasingly inter-professional, team-based Medication preparation, distribution, & dispensing should be more centralized & automated Vast majority of pharmacists’ time must be spent providing direct patient care in all settings We need a well-trained technician workforce to provide more complex medication-use roles Increased definition & standard-ization of pharmacy direct care services offered for all patients is necessary

13 Practice Model Change - New Methods of CarePrinciples for Practice Model Redesign3 Every patient should receive a comprehen-sive pharmaco-therapy plan Expect the public to insist on additional requirements for credentialing & privileging of pharmacists in general & specialty practices More and more pharmacists will be practicing in clinics Collaborative practice will evolve to include greater pharmacist responsibility for prescribing as part of coordinated health care teams in all settings Primary care and adherence must receive a much greater emphasis by pharmacists

14 Practice Model Change - New Methods of CareChange How We Think about Providing Care as Pharmacists Not Just Acute Care (Hospitals) or Ambulatory Care (Community and Clinics), But PATIENT CARE! Accessibility of Care and Remote Care ASHP’s vision is that medication use will be optimal, safe, and effective for all people all of the time.

15 Practice Model Change - New Methods of CareChange How We Think about Providing Care as Pharmacists Inter and Intraprofessional Care Interprofessional Care4 - the provision of comprehensive health services to patients by multiple caregivers working collaboratively to deliver quality care within and across settings Intraprofessional Care – team of providers from the same profession working together to deliver care in and across different settings We have focused on INTERprofessional but INTRAprofessional also requires attention!

16 Practice Model Change - New Methods of CarePharmacy Care – Every Patient in Every Site of Care Medication therapy services should include3: Complete medication history & reconciliation Development of comprehensive, multidisciplinary, accessible and transferable pharmacotherapy plan Ongoing medication assessment for appropriateness Application of best practices Adherence assessment and improvement Target patients that require enhanced or specialty pharmacy care Primary and preventative care Chronic disease management Manage transitions of care

17 Practice Model Change - New Methods of CareIMPROVING HEALTH – OPTIMIZING OUTCOMES “Expanded pharmacy practice models in collaboration with the physician or as part of a health team improve patient and health system outcomes and optimize primary care access and delivery.” -- Dr. Regina M. Benjamin, U.S. Surgeon General (Ret)5 In response to the U.S. Public Health Service’s report: Improving Patient and Health System Outcomes through Advanced Pharmacy Practice: A Report to the Surgeon General 2011, by Rear Admiral Scott F. Giberson, Acting Deputy Surgeon General, USPHS

18 Practice Model Change - New Methods of CareHospital Care Pharmacists provide clinical services to all inpatients at levels based on individual needs Design drug therapy from basic to complex therapeutic regimens Monitor for planned outcomes & adjust therapy Prevent adverse drug events Reduce unnecessary drug use Medication safety should permeate every aspect of care Manage transitions of care and collaborate with the patient’s pharmacists in other settings Ensure cost effectiveness

19 Practice Model Change - New Methods of CareHospital Care ASHP 2012 National Survey – Monitoring and Patient Education6 Pharmacists continue to improve medication use in hospitals through: Patient monitoring and education Safety initiatives Collaborative practices With other health care professionals Results Monitoring of patients increased from 20.3% in 2000 to 46.5% in 2012 Therapeutic drug monitoring programs exist in 80% of hospitals Pharmacists routinely perform discharge counseling in 24.7% of hospitals Technology Usage in Hospitals: Computerized prescriber order entry % Barcode-assisted medication administration % Smart pumps – 77.0%

20 Practice Model Change - New Methods of CareAmbulatory Clinics Many more pharmacists will be working on interprofessional teams in ambulatory clinics: Pharmacists can be embedded in clinics and/or staff, pharmacist directed clinics Clinic and patient selection based on specified patient parameters with follow-up based on pharmacotherapy plan Clinic time should be allocated between physician, pharmacist and nurse based on patient medication therapy needs, and will require a redesign of processes Electronic health records, technicians, and automation can facilitate Results: Enhanced outcomes Reduced costs of care Improved clinic throughput and accessibility of care

21 Practice Model Change - New Methods of CareCommunity Pharmacies Many examples of patient centered new care models, including: Medication therapy management services Therapeutic drug monitoring programs Chronic disease management Primary care and wellness programs Collaborative drug therapy management Patient assistance programs Vaccinations Walgreens new care model in their pharmacies But these and others need to become the norm!

22 Practice Model Change - New Methods of CareTransitions of Care Translates into One Medication-Use System Across All Settings HOSPITAL PATIENT Community Pharmacist Hospital Pharmacist Clinic Pharmacist Managed Care Pharmacist Long-Term Care Pharmacist CLINIC COMMUNITY

23 Practice Model Change - New Methods of CareOur Technician Workforce State laws evolving: 42 states regulate technicians; 16 require certification Need uniform laws for completion of accredited training program as prerequisite for technician licensure (ASHP Policy, June 2012) Community pharmacies with ASHP-accredited programs: Walgreens (nationwide) Rite Aid (nationwide) CVS (only in South Carolina)

24 Practice Model Change - New Methods of CareOur Technician Workforce7 New Pharmacy Technician Certification Board (PTCB) Certification and Recertification Standards: 2015 Will require all 20 recertification CE hours to be pharmacy technician-specific 2020 Candidates must successfully complete an ASHP-accredited education program

25 The Accountable Care OrganizationConnecting All Aspects of the Medication-Use Continuum

27 The Accountable Care OrganizationConnecting All Aspects of the Medication-Use Continuum Understanding ACOs9 Performance Requirements – 33 Measures of Quality in 4 Domains Patient/caregiver experience (7 measures) Care coordination/patient safety (6 measures) Preventive health (8 measures) At-risk populations (12 measures): Diabetes (6 measures) Hypertension (1 measure) Ischemic Vascular Disease (2 measures) Heart Failure (1 measure) Coronary Artery Disease (2 measures)

28 The Accountable Care OrganizationConnecting All Aspects of the Medication-Use Continuum Understanding ACOs10 Pay for performance will be phased in over the ACO’s first agreement period as follows (as of June 2013): Year 1: Pay for reporting applies to all 33 measures Year 2: Pay for performance applies to 25 measures; pay for reporting applies to 8 measures Year 3: Pay for performance applies to 32 measures; pay for reporting applies to 1 measure - a survey measure of functional status

29 The Accountable Care OrganizationConnecting All Aspects of the Medication-Use Continuum11

30 The Accountable Care OrganizationConnecting All Aspects of the Medication-Use Continuum ASHP ACO Task Force12 13 individuals with administrative and clinical experience with ACOs in various health care settings Purpose: To explore how pharmacy can improve medication use in the ACO model Goals: Improve medication outcomes in and across all sites of care Reduce admissions and readmissions Improve clinical processes of care Enhance patient experience Reduce cost of care

31 The Accountable Care OrganizationConnecting All Aspects of the Medication-Use Continuum ASHP ACO Task Force12 Recommendations: Pharmacists need to more fully participate in ACO care design and provision Identify and focus on high-risk patients and communicate across the health care continuum Measure quality and financial impact of pharmacist on the ACO

32 The Accountable Care OrganizationConnecting All Aspects of the Medication-Use Continuum ASHP ACO Task Force12 Recommendations: Redesign pharmacy services – “System of Care” Model Deploy appropriate pharmacy resources across multiple settings Allocate budgets based on: Incorporate automation and technology to improve efficiency, accuracy, and convenience of patient care services Disease Interventions Required Treatment

33 The Accountable Care OrganizationConnecting All Aspects of the Medication-Use Continuum New Trends and Developments13 ACO Pioneers – Mixed Reviews Some Success Gross savings: $87.6 million in 2012 Improved quality and performance for Medicare patients in 15 quality measures For 670,000 Medicare beneficiaries in Pioneer ACOs, spending grew by only 0.3% vs 0.8% in conventional Medicare Not so Successful 9 of 32 Pioneers will be leaving ACO program 13 Pioneers had shared Medicare savings 2 Pioneers owe Medicare program $4 million

34 The Accountable Care OrganizationConnecting All Aspects of the Medication-Use Continuum New Trends and Developments14 Hospital-Owned Insurance Plans: Lower premiums; collected directly from patient Eliminate health insurance companies – “middlemen” Providers limited to particular health-system 18% of hospitals currently own health insurance companies 28% of hospitals expect to launch insurance plans within 5 years New health plans may soon be offered on the Affordable Care Act’s health insurance exchanges Example: University of Pittsburgh Medical Center Tiny start-up to now dominant health plan in western PA Cost savings: Medical services costs have increased 2% annually compared to % annually around the country Own and sell proprietary software to assist other hospital-run plans to run health plan (such as phone operators to handle claims)

35 Enhancing the Public’s Understanding of the Vital Role of the Pharmacist in their Care

36 Enhancing the Public’s Understanding of the Vital Role of the Pharmacist in their CarePatients need increased understanding of what pharmacists provide to improve medication outcomes, decrease adverse drug events, enhance safety and control the cost of their care With this understanding, they will insist on access to the full services of pharmacists from employers and payors Simultaneously, we should make the case to private and public payors that pharmacists will: Decrease health care costs Greatly expand access to care Improve patient satisfaction

37 Enhancing the Public’s Understanding of the Vital Role of the Pharmacist in their CareNational publically reported quality measures and initiatives should expand and: Include additional metrics related to optimal medication use Include measuring patient’s understanding of their medication therapy Track appropriate monitoring and follow-up for important medication therapies Comprehensive pharmacy services should be included in the CMS Value Based purchasing program

38 Enhancing the Public’s Understanding of the Vital Role of the Pharmacist in their CarePharmacists are the most accessible health care professionals and should be utilized as such to play a much larger role in primary care and the management of chronic disease Educate all patients on admissions

39 Obtaining Provider Status A Fundamental Issue for Pharmacists

40 Provider Status – A Fundamental Issue for PharmacistsWhy is it Important for the Pharmacists? Absence reduces visibility  Implies secondary role  Impedes care provision Extensive documentation of need and improvement in outcomes, cost, and access when pharmacists provide clinical services Pharmacists practicing in clinics and expansion of services offered in community pharmacies will require financial support Fundamental issue for full professionalization

41 Provider Status – A Fundamental Issuefor Pharmacists Why is it Important for Pharmacists? (cont.) Need pharmacists to provide primary care and manage chronic disease Also opportunities for new care models Pharmacists have and can: Improve outcomes of care Enhance medication safety Reduce costs of care Expand access to care HOWEVER, they are constrained from universally doing so as incentives are inappropriately aligned to provide the necessary workforce

42 Provider Status – A Fundamental Issuefor Pharmacists Implications for Pharmacists Regarding the Patient Protection and Affordable Care Act Roll-out15 By million people will gain access to medical care 17,000 Primary Care Physicians are currently needed; another 40,000 more by 2025 to care for aging population Pharmacists represent 3rd highest number of licensed health care providers (approx. 300,000) Acknowledging pharmacists as non-physician providers in Social Security Act will allow licensed pharmacists to: Work collaboratively with physicians and other providers Optimize medication therapy in patients Deliver best patient-centered care

43 Provider Status – A Fundamental Issuefor Pharmacists Elements of Strategy and Process The Provider Status Coalition Coalition of Pharmacy Organizations Actions: Draft vision, core principles – agree on who are providers and what is provided Obtain independent review of evidence of pharmacists’ value Enlist support of Broader Coalition also including non-pharmacy health care organizations, providers, payors, patients and public Work simultaneously at national, state and local levels

44 Provider Status – A Fundamental Issuefor Pharmacists Elements of Strategy and Process (cont.) Actions: Federal Ask -- Amending the Social Security Act to Recognize Pharmacists—Preliminary Considerations Pharmacists listed as providers in Medicare Part B with a list of specified covered services (SSA Section 1861) Additional pharmacists’ services could later be approved by the HHS Secretary Pharmacists also listed as providers in ACOs (SSA Section 1899) Obtain mock CBO scores (i.e., estimated cost to the federal budget) Possibly modify Federal Ask based on CBO scores

45 Provider Status – A Fundamental Issuefor Pharmacists Elements of Strategy and Process (cont.) Effective marketing materials Identify “high profile” leaders, key congressional supporters, and other advocates Educate pharmacists and other providers State and grassroots campaigns Individual pharmacy practitioners State pharmacy societies and associations Marshall support of Colleges of Pharmacy, including pharmacy students to assist Public education using social media Multi-year strategy; achieving provider status will not be easy

46 Provider Status – A Fundamental Issuefor Pharmacists Major Strides Have Already Been Achieved – National Efforts Oct 2011: Centers for Medicare & Medicaid Services (CMS) – Changed Conditions of Hospital Participation16 Recognized Pharmacists as a “Non-Physician” Providers Hospitals can now recognize pharmacists as providers through credentialing/privileging process ADVOCATE!

47 Provider Status – A Fundamental Issuefor Pharmacists Major Strides Have Already Been Achieved – State Efforts17 October 2013: California Governor signed into law pharmacist provider status bill (SB 493). Law allows pharmacists to: Create “advanced practice pharmacist” category Perform patient assessments Initiate, adjust or discontinue drug therapy Participate in the evaluation and management of diseases and health conditions in collaboration with other health care providers Order and interpret drug therapy-related tests Refer patients to other health care providers Independently initiate and administer vaccines ADVOCATE!

48 Provider Status – A Fundamental Issuefor Pharmacists Major Strides Have Already Been Achieved – State Efforts (cont.) Feb 2013: U.S. Attorney General, Washington State, Opinion Letter18 Acknowledged pharmacists as health care providers under Washington’s law, “every category of provider” RCW Pharmacists can provide services or care for conditions included in basic health plan services and should be compensated for their services These services are within the scope of pharmacists’ practice ADVOCATE!

49 Provider Status – A Fundamental Issuefor Pharmacists Major Strides Have Already Been Achieved – State Efforts (cont.) Advanced Practice - Clinical Designation19 Common Job Title Pharmacy Clinician Clinical Pharmacy Practitioner Current States: North Carolina New Mexico California ADVOCATE!

50 Pharmacist Interdependent Prescribing Optimizing Patient Outcomes

51 Pharmacist Interdependent Prescribing Optimizing Patient OutcomesInterdependent Prescribing – Evolution of Collaborative Drug Therapy Management (CDTM) Changing Delivery of Care Model as it Relates to Prescribing20 Current model: Vertical Dependent Pharmacist and physician, working together with other members of the health care team, and forming a strategic partnership to optimize patient outcomes with medications. Proposed model: Horizontal Interdependent

52 Pharmacist Interdependent PrescribingMakes initial diagnosis Treats and monitors patient PHYSICIAN Based on physician diagnosis, selects & designs drug therapy regimen Writes prescription or medication orders *PHARMACIST Reviews and monitors patient’s drug therapy for efficacy and adverse events PHYSICIAN / PHARAMACIST / NURSE Changes medication orders, consulting with physician and nurse as needed PHARMACIST Optimizing Patient Outcomes Proposed Horizontal Model20 *In specific patients and specific situations previously determined by both the physician and the pharmacist OUTCOME: Improved outcomes and reduced costs. Better utilization of physician, nurse and pharmacist’s time.

53 Pharmacist Interdependent Prescribing Optimizing Patient OutcomesExisting International Models U.K.21: Supplemental prescribing Independent prescribing in area of pharmacist’s expertise Canada – Effective October 2012, Ontario22: Initiate therapy for smoking cessation Renew and adapt prescriptions Administer injections or inhalation (for education and demonstration) Administer the flu vaccine Quebec allowing pharmacists to prescribe medications that do not require a diagnosis, i.e.23: Antimalaria medications for travelers Australia: Currently in development National prescribing competencies Scope of practice

54 Putting it All TogetherFinal Thoughts Putting it All Together We need to educate the public as to the role of the pharmacist in patient care. Pharmacists in different sites of care must work together to provide the full spectrum of care. We need an increased emphasis on care basics, such as adherence, design of affordable drug therapies, elimination of unnecessary drug use, chronic disease management, wellness and primary care.

55 Putting it All TogetherFinal Thoughts Putting it All Together There should be an increased pharmacy presence in clinics, medical homes, ACOs, etc. Our models of practice must change significantly to achieve the above. Staying focused on what is right for the patient will always be our best strategy.

56 When I grow up, I want a pharmacist on my healthcare team!

57 Post - Questions 1. Pharmacists will become essential members of all health care teams because: The complexity of medication therapy requires a drug therapy expert if appropriate care outcomes are to be achieved and maintained Pharmacists have the education and training to maximize patient outcomes and control health costs Pharmacists are the most accessible health care practitioner All of the above

58 Post - Questions For pharmacists to obtain provider status and to practice at the highest level, which of the following advocacy efforts will it require: a) Strong and cohesive national coalitions of pharmacy associations, patient and consumer groups, and other healthcare organizations b) Grassroots efforts from individual pharmacy practitioners and affiliated societies c) Both d) None of the above

59 Post - Questions Advancing pharmacist interdependent prescribing ultimately helps to: a) Optimize and improve patient outcomes b) Reduce patient and healthcare costs c) More effectively maximize the use of all health care team members d) All of the above

60 References Keehan S, Cuckler G, Sisko A, Madison A, et al. National health expenditure projections: Modest annual growth until coverage expands and economic growth accelerates. Health Affairs, June 2012, Retrieved July 8, 2013 at l IOM, 2012, Best Care at Lower Cost. Abramowitz P. The evolution and metamorphosis of the pharmacy practice models. Am J Health-Sys Pharm. 2009; 66: MoHLTC. Inter-professional care: A blueprint for action in Ontario. August 20, 2007. Benjamin R. Letter to Scott Giberson, Chief Professional Officer, Pharmacy, U.S. Assistant Surgeon General. Dec. 14, 2011. Pedersen C, Schneider P, Scheckelhoff D. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education – Am J Health-Sys Pharm. 2013; 70: PR Newswire. Pharmacy Technician Certification Board announces certification program changes. Retrieved on August 21, 2013 at

61 References Calman N. Hauser D. Chokshi D. Lost to follow-up: The health goals of accountable care. Arch Intern Med. 2012; 172(7): CMS. Guide to quality measurement for Accountable Care Organizations starting in 2012: Agreement period, performance year, and reporting period. Retrieved on March 22, 2013 at Office of Clinical Standards & Quality. CMS. Accountable Care Organization 2012 Program Analysis Retrieved on August 21, 2013 at Muthlestein D. Continued growth of public and private ACOs. Health Affairs, ASHP Report. Report of the 2012 ASHP Task Force on Accountable Care Organizations. Am J Health-Sys Pharm. 2013;70:66-76.

62 References Gold J. 9 Pioneer ACOs Jump Ship After First Year. Kaiser Health News. Retrieved July 22, 2013 at Kliff A. Is this the end of health insurers? Washington Post. Retrieved July 8, 2013 at MacKinnon GE. Recognizing pharmacists as healthcare providers – a solution for the Patient Protection and Affordable Care Act roll-out. Formulary Journal. 2013, September. 48: Dept. of HHS. CMS. Medicare and Medicaid Programs; Reform of hospital and critical access hospital conditions of participation. Federal Register (205): , Retrieved on February 5, 2013 at https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/downloads/CMS3244P.pdf California provider status bill becomes law. Retrieved on October 5, 2013 at

63 References Community Pharmacy Foundation. Retrieved on February 6, 2013 at Murawski M, Villa K, et al. Advanced-practice pharmacists: Practice characteristics and reimbursement of pharmacists certified for collaborative clinical practice in New Mexico and North Carolina. Am J Health-Sys Pharm. 2011; 68: e47-e56. Abramowitz P, Shane R, et al. Pharmacists interdependent prescribing: A new model for optimizing patient outcomes. Am J Health-Sys Pharm. 2012;69: Department of Health. Pharmacist independent prescribing FAQ Ontario College of Pharmacists. Understanding your pharmacist’s expanded role. Retrieved September 5, 2013 at Legislative change in Quebec gives pharmacists expanded authorities. Can Pharm J. 2012;145:7.