ARRX - Fall 2019

Fourth Quarter 2019 Award-Winning Quarterly Publication of the Arkansas Pharmacists Association

Pharmacist Immunization Expansion Why Professional Dispensing Fees and NADAC in Community Pharmacy Matter

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2020 Community Pharmacy Scholarship Apply at phmic.com/scholarship • Apply October 1 - December 2, 2019 • Recipients selected will be awarded $2,500 each • Up to $50,000 awarded annually

Pharmacists Mutual Insurance Company 808 Highway 18 W | PO Box 370 | Algona, Iowa 50511 P. 800.247.5930 | F. 515.295.9306 | info@phmic.com

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APA Staff John Vinson, Pharm.D. Executive Vice President & CEO John@arrx.org Jordan Foster Director of Communications Jordan@arrx.org

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Susannah Fuquay Director of Membership & Meetings Susannah@arrx.org Celeste Reid Director of Administrative Services Celeste@arrx.org Emily Wilson, Pharm.D. Executive Fellow emily@arrx.org Debra Wolfe Director of Government Affairs Debra@arrx.org Office E-mail Address Support@arrx.org

Arkansas Pharmacists Association 417 South Victory Street Little Rock, AR 72201-2923 Phone 501-372-5250 Fax 501-372-0546 AR•Rx The Arkansas Pharmacist © (ISSN 0199-3763) is published quarterly by the Arkansas Pharmacists Association, Inc. It is distributed to members as a regular service paid for through allocation of membership dues ($5.00). Non-members subscription rate is $30.00 annually. Periodical rate postage paid at Little Rock, AR 72201. Current edition issue number 88. © 2019 Arkansas Pharmacists Association.

POSTMASTER: Send address changes to AR•Rx The Arkansas Pharmacist 417 South Victory Little Rock, AR 72201 Opinions and statements made by contributors, cartoonists or columnists do not necessarily reflect the attitude of the Association, nor is it responsible for them. All advertisements placed in this publication are subject to the approval of the APA Executive Committee. Visit us on the web at www.arrx.org.

CONTENTS

Publisher: John Vinson Editor: Jordan Foster Design: Gwen Canfield - Creative Instinct

4 From the President: Regional Meeting

Recap

5 Calendar of Events 2019-2020 8 FEATURE: Why Professional Dispensing

Fees and NADAC in Community Pharmacy Matter

14 Rx & the Law: A Pharmacist's Duty to

an Unknown Third Party

15 Safety Nets: Seldom Used Abbreviations 16 Member Spotlight: Greg Lance 17 New Drugs: FDA Modernization and

Innovation Has Intended Effect on Drug Approval Rate

18 FEATURE: Pharmacist Immunization

Expansion

22 UAMS: New Leadership, Familiar Face 24 Harding University: 2019 HUCOP

26 AAHP: Hindsight in 2020 27 AAHP 2019 Fall Seminar 29 Compounding Academy: Never Say

This Again!

29 APA Wins Coveted Communication

Award

30 2019 Arkansas Pharmacists

Association Regional Meetings

ADVERTISERS 2 Pharmacists Mutual 6 USPS Proof of Ownership 7 Retail Designs, Incorporated 7 Arkansas Pharmacy Support Group 13 Biotech Pharmacal 19 Law Offices of Darren O'Quinn 23 UAMS College of Pharmacy 23 EPIC 25 Pharmacy Quality Commitment Back Cover: Cardinal Health

Annual Report

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APA Board of Directors 2019- 2020 Officers President – Dean Watts, P.D., DeWItt President Elect – Kristen Riddle, Pharm.D., Greenbrier Vice President – Max Caldwell, P.D., Wynne Past President – Stephen Carroll, Pharm.D., Benton

Regional Representatives Region 1 Representatives - John Hall, Pharm.D., Fort Smith - Dylan Jones, Pharm.D., Fayetteville - Spencer Mabry, Pharm.D., Berryville Region 2 Representatives - Greta Ishmael, Pharm.D., Cherokee Village - Jett Jones, Pharm.D., Jonesboro Region 3 Representatives - Brandon Achor, Pharm.D., Sherwood - Brittany Sanders, Pharm.D., Little Rock - Lanita White, Pharm.D., Little Rock Region 4 Representative - Betsy Tuberville, Pharm.D., Camden Region 5 Representative - James Bethea, Pharm.D., Stuttgart At Large Representatives - Stacy Boeckmann, Pharm.D., Wynne - Rick Pennington, P.D., Lonoke Arkansas Association of Health-System Pharmacists Erin Beth Hays, Pharm.D., Pleasant Plains Academy of Compounding Pharmacists Andrew Mize, Pharm.D., Springdale Academy of Consulting Pharmacists Denise Robertson, Pharm.D., Little Rock

Ex-Officio APA Executive Vice President & CEO John Vinson, Pharm.D., Benton AR State Board of Pharmacy Representative John Kirtley, Pharm.D., Little Rock Board of Health Member Marsha Boss, P.D., Little Rock UAMS College of Pharmacy Representative (Dean) Cindy Stowe, Pharm.D., Little Rock Harding College of Pharmacy Representative (Dean) Jeff Mercer, Pharm.D., Searcy General Counsel Nate Steel, J.D., Little Rock Treasurer Richard Hanry, P.D., El Dorado UAMS COP Student Gabriella Nepomuceno, Little Rock

Harding COP Student Brittany Petty, Searcy 4

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FROM THE PRESIDENT

Regional Meeting Recap

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s I sit to open this Dean Watts, P.D. column, I can’t President help but think back over the last six weeks and reflect on our just-completed eleven regional meetings and tour of the state. On behalf of the APA staff and myself, I want to thank those that attended a regional meeting for your interest and participation. I have a renewed admiration for the APA staff due to the obvious thought and effort they put into conducting the business of the APA. Not only do they man the office and attend important meetings in Little Rock by day, but by night they will be set up and ready to host a regional meeting in Mountain Home or El Dorado. And in their spare time they might be accepting awards such as a Prism Award from the Public Relations Society of America! I tip my hat to each of them.

With the regional meetings behind me, I look forward to going back to Dean’s Pharmacies to participate in the fall rituals that we all welcome and, at the same time, dread.

The return of autumn weather and the illnesses that follow, immunizations and the threat of flu season, and Part D signup beginning with “Which plan is best for me?” Once again, we each have more on our plate than we can comfortably manage, and that is before we open the doors and let the customers in! With that said, I want to highlight a few items on each plate that were touched on in the regional meetings.

First, in the Part D space, we need a Part D plan we can recommend to our patients that fills the patient’s needs and is retail pharmacy friendly. Is IndyHealth a possible answer? Many of our colleagues have listened to IndyHealth’s vision of what a Part D plan should be and believe it could be a valid option.

If you have an interest in learning more about IndyHealth contact John Vinson or me for contact info.

Next, the AR BCBS/PrescribeWellness initiative to improve star ratings by tapping into retail pharmacy expertise deserves consideration. There is certainly a learning curve for most of us to participate, but if we can become proficient at pushing star rating metrics for this small subset of patients, then we can expand that push to a larger sample of patients in other Part D plans.

According to Sykes & Company P.A., a CPA firm representing a wide array of independent pharmacies, there is a definite increase in profitability of stores that are pushing metrics to 5-star levels, due to decreased DIR fees.

Last, but possibly most important, is the need to continue being the watchdog over PBM practices. My concern is regarding comments I heard in a meeting with the Insurance Commissioner and his staff. Those comments were basically “Why all the outrage? We saw the outrage in the legislative committee meetings, and we see laws passed but now we are not seeing the complaints from the field.”

We do not want to lose our momentum or our credibility after all the hard work that has been done. Let Margie Farmer at the commissioner’s office hear your stories. I truly believe they are eager to enforce the law, but it is up to us to provide specific complaints to be investigated.

Here in the Delta and Grand Prairie it is harvest season. The rituals of harvest season are characterized by an attitude of hard work - heads down, move ahead, work to exhaustion hard work.

Some days are golden and some days everything breaks down but complete the work because the payoff is in sight.

This is pharmacy’s harvest season and hopefully our payoff is near. Let’s enter the season with the farmer’s attitude, hope and determination. Thank you for supporting the APA and the profession of Pharmacy. Here’s wishing you a happy and bountiful harvest. §

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2019-2020 Calendar of Events NOVEMBER ————————— November 7-10, 2019 American Society of Consultant Pharmacists Annual Meeting and Exhibition Gaylord Texan Resort Grapevine, TX

DECEMBER ————————— December 6, 2019 APA Board Meeting APA Hosto Center Little Rock, AR

December 8-12, 2019 American Society of Health-System Pharmacists Midyear Clinical Meeting Las Vegas, NV December 15, 2019* Last Chance CE APA Hosto Center Little Rock, AR

FEBRUARY 2020 —————— February 28, 2020 CE at the Races Oaklawn Gaming and Racing Hot Springs, AR

MARCH —————————— March 6, 2020 UAMS P3 Pinning Ceremony Main Campus Little Rock, AR

March 7, 2020 APhA Travel Vaccine Certification APA Hosto Center Little Rock, AR March 9, 2020 UAMS P3 Pinning Ceremony Northwest AR Campus Fayetteville, AR

APRIL ———————————

April 16, 2020* Arkansas Pharmacy Foundation Golf Tournament

MAY ——————————— May 1, 2020 Harding P3 Pinning Ceremony Harding Campus Searcy, AR

May 8, 2020 Harding Class of 2020 Meeting Searcy, AR May 9, 2020 Harding College of Pharmacy Commencement Searcy, AR May 15, 2020 UAMS Class of 2020 Meeting Little Rock, AR May 16, 2020 UAMS College of Pharmacy Commencement Little Rock, AR

JUNE ——————————— June 6-10, 2020 American society of Health-System Pharmacists Summer Meeting Seattle, WA

AUGUST —————————— August 6-7, 2020* APA Board Retreat

SEPTEMBER ————————

Late August – September 2020 APA Regional Meetings Around the State

OCTOBER ————————— October 8-9, 2020* AAHP Fall Seminar

October 17-20, 2020 National Community Pharmacists Association Annual Convention Nashville, TN October 29, 2020* APA Golden CPE Hosto Center Little Rock, AR

NOVEMBER ———————— November 12-15, 2020 American Society of Consultant Pharmacists Annual Meeting and Exhibition Gaylord Palms Resort Kissimmee, FL * denotes dates subject to change

June 10, 2020 APA Board Meeting Doubletree by Hilton Little Rock, AR June 11-13, 2020 APA 138th Annual Convention Doubletree by Hilton Little Rock, AR

AAHP Board

Arkansas State Board of Pharmacy

Executive Director.............Susan Newton, Pharm.D., Russellville President.....................Erin Beth Hays, Pharm.D., Pleasant Plains President-Elect................Kimberly Young, Pharm.D., Little Rock Immediate Past President.........David Fortner, Pharm.D., Rogers Treasurer...........................Kendrea Jones, Pharm.D., Little Rock Secretary.................................Melissa Shipp, Pharm.D., Searcy Board Member at Large...........Joy Brock, Pharm.D., Little Rock Board Member at Large........Chad Krebs, Pharm.D., Little Rock Board Member at Large.......Amber Powell, Pharm.D., Little Rock Technician Representative....BeeLinda Temple, CPhT, Pine Bluff

President.......................................Debbie Mack, P.D., Bentonville

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Vice President/Secretary.........Lenora Newsome, P.D., Smackover

Member..........................................Steve Bryant, P.D., Batesville Member................................Lynn Crouse, Pharm.D., Lake Village

Member..........................................Brian Jolly, Pharm.D., Beebe

Member..........................Rebecca Mitchell, Pharm.D., Greenbrier Public Member........................................Carol Rader, Fort Smith Public Member............................................Amy Fore, Fort Smith

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*Once per year, APA is required to publish a Statement of Ownership and file it with the United States Postal Service.

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Why Professional Dispensing Fees and NADAC in Community Pharmacy Matter

By John Vinson, Pharm.D.

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he Centers for Medicare & Medicaid Services (CMS) issued a 658-page final rule, Medicaid Program; Covered Outpatient Drugs (CMS-2345-FC; taking effect on April 1, 2016. This rule required state Medicaid Fee for Service pharmacy plans to change to a pharmacy cost-based actual acquisition cost reimbursement for drugs plus an objective average professional dispensing fee. The state of Arkansas studied the average cost for professional dispensing fees in Arkansas pharmacies through a national accounting firm, Myers and Stauffer and published a 64-page report in June of 2016 with the results. These results were used to build a state plan amendment that would later be approved at the state level and federally by CMS. The state also chose to submit an ingredient cost reimbursement that mostly uses National Average Drug Acquisition Cost (NADAC) but may also utilize a state actual acquisition cost calculation (SAAC), wholesale acquisition cost (WAC), or ACA federal upper limit (FUL) especially when a NADAC doesn’t exist. A NADAC value often does not exist for immunizations, medications used for rare conditions, or for most over the counter products.

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To calculate NADAC, CMS randomly surveys a few thousand of the 67,000+ pharmacies in the United States once monthly and hundreds of independent and chain pharmacies around the nation voluntarily respond with invoice pricing data from their wholesaler. The publicly available online NADAC pricing files are updated with this information on a weekly basis for pricing changes identified.

NADAC website: https://www.medicaid.gov/medicaid/ prescription-drugs/pharmacy-pricing

The Model

The Arkansas state professional dispensing fee data revealed objective data that supported a CMS and state approved $9 for non-preferred brand and $10.50 professional dispensing fee for generic and preferred brand drugs (approximately 87% of the dispensed medications). According to CMS, reasonable expenses related to a pharmacist’s time that fall under the category of pharmacy costs for the professional dispensing fee include, but are not limited to:

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• Patient counseling • Carrying out drug use reviews and preferred drug list review activities • Measuring or mixing the covered outpatient drug and filling the container • Looking up information about a patient’s health plan coverage • Physically giving the Medicaid beneficiary their completed prescription • Packaging (bottles, labels, ink) • Operational expenses associated with facility and equipment maintenance necessary to the pharmacy’s operation (computers, building, insurance, licensure, regulatory compliance expenses, etc.)

This approved methodology was launched on April 1, 2017 in Arkansas Fee for Service Medicaid. This contracting methodology has become known in the industry as the NADAC-Plus contracting model. The model has produced pricing stability, transparency and financial savings for taxpayers in Arkansas Medicaid. The methodology is objective for generic drug dispensing in community pharmacies as it rewards low cost drug use and patient care associated with face to face interactions. The exact version adopted by Arkansas Medicaid is not fair for pharmacies that see a high proportion of patients that require brand name medications including COPD, asthma, HIV, cancer, blood dyscrasias, genetic disorders and autoimmune disorders. The data in Arkansas demonstrated the cost of dispensing for high dollar “specialty drugs” ranged from $96 to $269 and as high as $415 for clotting factors. We will continue to advocate for tweaks in the program in the future to address these known issues, especially when the Arkansas market is not reflected in NADAC surveys.

Pros and Cons

NADAC Plus pricing and market variations have potential to provide transparent stable pricing for the community pharmacy market in the private sector as well. On September 4, 2019, a pharmacy benefit manager Capital Rx, an emerging company founded in 2017, made national news by announcing the launch of the Clearinghouse Model, a NADAC based pricing model that aims at eliminating secrecy from prescription drug pricing to free up expensive administrative burden away from negotiating complicated, opaque pricing deals to tackling pharmaceutical care management. Capital Rx says their model will be offered to employers and will be a radical departure from traditional pharmacy benefit manager contracting models. The new model according to Capital Rx will reflect transparent, consistent costs for all prescription drugs, eliminate spread pricing, and these costs will be the same for all customers.

However, this increase in transparency with published NADAC can create serious threats to eliminate competition

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The NADAC-Plus contracting model has produced pricing stability, transparency and financial savings for taxpayers in Arkansas Medicaid.

when PBMs use traditional contracting with MAC lists and spread pricing, especially small independent pharmacy providers and small chain pharmacies who have very little collective negotiation leverage. Less competition leads to less consumer choice and eventually higher prices. For example, there was an article out of Ohio in the Columbus Dispatch in early September 2019 where the pharmacy benefit manager drastically raised the reimbursement on PBM defined specialty drugs in the managed care Medicaid program, with many of these drugs being filled in their own mail order pharmacies.

The publicly available NADAC pricing lists also allow PBMs to see the purchase price at an individual drug level and potentially use this sensitive pricing information to squeeze out their competition with below cost reimbursement in traditional PBM contracts. The dominant PBMs compete with small and large pharmacy provider practices because they own large mail order pharmacies, specialty mail order pharmacies and the largest brick and mortar retail pharmacy network in America. Arkansas pharmacists have seen this abuse of size and access to sensitive NADAC pricing data happen in 2018 and 2019 with commonplace below cost reimbursement both on individual claims and aggregate level reductions in reimbursement with aggressive generic effective rates and brand effective rates for commercial and

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2019 Highlights – ACT 994 • Prohibition on payment on any claim below NADAC or below WAC when no NADAC is published • It also allows pharmacies to accept payment rates below this if that is their usual and customary charge, thus allowing for competition for lower prices.

• Prohibition on effective rate contracts (generic effective rates, brand effective rates). Aggregate level reimbursement through “effective rates” cannot be used to reduce overall reimbursement, thus circumventing the requirement to pay above the national average pricing floor of NADAC on individual claims in state regulated plans.

• Prohibition on spread pricing in state regulated plans.

managed care Medicaid plans as well as unsustainable DIR fee financial claw backs in Medicare D plans.

loopholes in previous MAC appeal law of 2015 (ACT 900) and the PBM licensure law of 2018 (ACT 1 and 3).

Small grocery, chain and independent pharmacies have very little negotiation ability for fair contracting, even when they participate in contracting through a pharmacy services administrative organization (PSAO). PSAOs like Epic, Elevate and HealthMart Atlas may represent thousands of pharmacies, but they are handcuffed by the United States antitrust laws and can only negotiate through a messenger model rather than true collective negotiation in the way a large vertically integrated PBM / PBM owned pharmacy / health plan can negotiate. The playing field is stacked against providers, especially small businesses and small providers, by the federal government. The pharmacies in a PSAO are not allowed to discuss pricing together behind closed doors and are not allowed to stick together as one if the negotiations in the messenger model go south. In other words, if the PSAO does not sign the terms offered by the PBM, the PBM can bypass the PSAO and sign any of the individual pharmacies represented by the PSAO that it wants to individually and leave out those it wants to leave out.

The original draft bill, prior to being amended at the request of the legislature, also had provisions for a higher pricing floor for high cost drugs greater than $600 per month and mandatory dispensing fees no less than those approved by the state Medicaid program ($10.50 for preferred brand and generic drugs). These provisions would have leveled the playing field, to ensure local access to Arkansas pharmacists, but the insurance carriers used fear mongering about consumer insurance premium increases to lobby against fair policy. The reality is that it will not add costs or raise premiums if health plans and PBMs would pay an objective payment with NADAC plus to include a fair and objective dispensing fee. In fact, Arkansas and West Virginia have seen greater than $50 million dollars and $59 million dollars in savings per year to taxpayers by using a NADAC Plus model in Medicaid programs. Instead, the health insurance plans and PBMs prefer an opaque complex model with arbitrary proprietary MAC lists and arbitrary dispensing fees that generate greater profit for them.

2019 Highlights - ACT 994

ACT 994 went into effect on July 24, 2019. The insurance commissioner and his team will also be updating Rule 118 for more clarification on implementation of ACT994. The legislation is groundbreaking and pharmacists and their PSAOs need to monitor contracts, contract amendments and financial data on a monthly basis to see if market conditions are improving or eroding. One specific concern is that without the required dispensing fees, some PBMs and health plans may cut all reimbursement to exactly NADAC with no dispensing fee. APA and state legislators want to know if you are seeing this happen. This is not an acceptable payment methodology and I would consider this retaliatory in nature rather than in the best interest of patient care. A pharmacist or pharmacy cannot safely operate and

(see box above) In the 2019 legislature, Senator Kim Hammer and colleagues passed new state legislation that applies to PASSE insurance companies, Arkansas Works plans, state funded health plans, and private fully insured commercial insurance. The state is not currently enforcing state law in Medicare D plans, federal employee plans, and employer sponsored self-insured plans because of recent unfavorable rulings in federal court for pharmacy benefit managers regulation as it applies to federal plans and large employers who may have employees in multiple states. The new Arkansas legislation, SB520, became Act 994 of 2019 after being signed into law by Governor Hutchinson. To address the unfair playing field discussed above, the new law closed

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NADAC IN COMMUNITY PHARMACY

Trade Practices Act under the Arkansas Attorney General.

Congress is starting to understand what is going on in Medicare D and managed care Medicaid as a rip off to taxpayers and providers. provide sound patient care at NADAC plus a zero or fifty cent dispensing fee. There must be enough “Plus” in the NADACplus model in a combination of markup on the ingredient cost and/or the dispensing fee for safe and effective operations.

Keep in mind, that the Arkansas 2015, 2018 and 2019 PBM laws also include a provision that pharmacy benefits manager or representative of a pharmacy benefits manager shall not reimburse a pharmacy or pharmacist in the state an amount less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate for providing the same pharmacist services. ACT 994 of 2019 requires pharmacy benefits managers to report to the Insurance Commissioner on a quarterly basis for each healthcare insurer the individual and aggregate amount a pharmacy benefits manager paid for pharmacist services itemized by pharmacy, by product, and by goods and services. I will be

An encouraging piece of news is that United States Congress is starting to understand what is going on in Medicare D and managed care Medicaid as a rip off to taxpayers and providers...The fires are spreading from one state to the next, putting pressure on federal policymakers to act. Grass roots matters. advocating for the insurance commissioner and attorney general to monitor this information to ensure that pharmacy benefit managers are not paying their own pharmacies higher rates than they are competing pharmacies, especially if we have example where PBMs and health plans are paying pharmacies rates that we all know are not sustainable (NADAC plus a zero dispensing fee). Paying your own PBM pharmacy higher rates now violates both PBM licensure Act under the Arkansas Insurance Commissioner and the Deceptive

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An encouraging piece of news is that United States Congress is starting to understand what is going on in Medicare D and managed care Medicaid as a rip off to taxpayers and providers. They are listening and learning from states like Arkansas, Iowa, Oregon, Georgia, Ohio, Kentucky, New York, Louisiana, West Virginia, Pennsylvania, Illinois and others.

The fires are spreading from one state to the next, putting pressure on federal policymakers to act. Grass roots matters.

Senator Grassley (Iowa) and Senator Wyden (Oregon) introduced bipartisan language for Medicaid managed care programs (the PASSEs in Arkansas) that would require a pricing floor to Arkansas pharmacists similar to the original Arkansas 520 draft. In managed care Medicaid programs, it would prohibit spread pricing, require objective predictable reimbursement for dispending fees and drug ingredient cost to pharmacies, and require PBMs to act as claims processors for administration of the benefits. Their language in the Chairman’s Mark, the Prescription Drug Pricing Reduction Act of 2019, had an initial score of $100 billion in savings to taxpayers and patients from the Congressional Budget Office (CBO).

Section 206. Improving Transparency and Preventing the Use of Abusive Spread Pricing and Related Practices in Medicaid

• This provision would amend the Social Security Act (SSA) Section 1927(e) to require pass-through pricing for CODs in Medicaid including under managed care.

• It would require payment for pharmacy management services to be limited to ingredient cost and a professional dispensing fee that is not less than the professional dispensing fee that the State plan or waiver would pay (NADAC plus $10.50 or $9 for most drugs in Arkansas), passed through in their entirety to the pharmacy that dispenses the drug, and made in a manner that is consistent with Section 1902(a)(30)(A) and sections 447.512, 447.514, and 447.518 of title 42, Code of Federal Regulations.

• It would require payment to the pharmacy benefit manager (PBM) for administrative services to be limited to a reasonable administrative fee and require that the entity or PBM make available to the State, and the HHS Secretary upon request, all costs and payments related to CODs and accompanying administrative services.

• It would make any form of spread pricing unallowable for purposes of claiming Federal matching payments under Medicaid.

In the United States House, H.R.1034, the Phair Pricing Act of 2019, introduced by Congressman Collins of Georgia, has additional encouraging language for Medicare D reform.

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The increase in transparency with NADAC has serious risk and threats to eliminate competition, especially small independent pharmacy providers and small chains pharmacies who have very little collective negotiation leverage.

This bill has been co-sponsored by all four Arkansas House members, Congressman Westerman, Crawford, Womack and Hill. It includes language for pricing fairness in Medicare D with language that says “In no case may a negotiated price for a covered part D drug furnished by a pharmacy be less than such pharmacy’s cost of purchasing and dispensing such drug and providing such other services associated with furnishing such drug.” It also includes DIR reform and quality measure reform. The devil is in the details of how this would be implemented, but there is already a model for a metric for determining the cost of dispensing cost and purchase cost of drugs in CMS within Medicaid programs. Survey data should be used in Medicare D to determine fair dispensing fees, and MAC pricing should either be eliminated or not be more aggressive than NADAC. Back in Arkansas, community pharmacists need to continue to advocate to their computer software vendors to include data on NADAC pricing to be displayed at the point of dispensing. They also should update reporting features to allow standardized business reports for below NADAC pricing specific to BIN, Group and PCN. Arkansas pharmacists need to continue to educate state and federal legislators on how your business operations function and what services you offer that improve patient care in local communities that depend on both a fair product reimbursement and dispensing fee. We also highly encourage you to file complaints with the insurance commissioner when our state laws are violated, and patient care is threatened and harmed. The laws become irrelevant and pointless if not utilized effectively and enforced.

APA has produced easy to use forms listed at www.arrx.org to file complaints and identify which plans are most likely state regulated. We encourage you to print these, become familiar with them and use them.

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Payment for pharmacist services as providers remains important but can quickly become irrelevant in community settings if there is not a stable predictable model for reimbursement for product and dispensing. 75% of our Arkansas graduates practice in community settings, and they have face to face access to patients as many as 35 times a year with incredible potential to improve patient outcomes for diseases like diabetes, heart disease, and COPD. These community practitioners cannot realize their potential without continued access to these patient lives.

Without dispensing, these patients are not visiting community pharmacies practices. The same thing is true in hospitals, without dispensing, the clinical programs are not as robust and the talent pool of high-quality pharmacists is less.

Eroding anticompetitive payment models that commoditize the drug product, threaten to eliminate community positions with a future of mail order only option for most maintenance and specialty prescriptions effectively destroying local relationships with pharmacist providers. APA will continue to fight against these pressures from accountants, benefit consultants and businessmen who do not understand or care about the healthcare delivery by the local providers and the healthcare received by patients. Often, they focus on the commodity of the drug or a kickback received from someone else in the supply chain, rather than the quality patient care delivered. We will also continue to support the efforts of our state Attorney General and Legislative Audit in their investigations of PBM practices in Arkansas over the last decade. We look forward to a brighter tomorrow for patient care to thrive in more stable markets for pharmacist healthcare providers in Arkansas based community settings.

Our patients, especially those fragile chronically ill patient populations with limited health literacy and limited family support systems, deserve our best. §

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A Pharmacist's Duty to an Unknown Third Party This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and the Arkansas Pharmacists Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

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recent court decision in Michigan re-examined an issue first discussed in this column about ten years ago. In the Sanchez case from Nevada in 2009, the patient, driving while under the influence of prescription medications, hit two men, killing one. The survivor and the decedent's family sued a number of parties, including eight pharmacies, for the injuries and wrongful death. The Nevada court cited Common Law principles that a person has no duty to control another's dangerous conduct, or to warn others of that dangerous conduct absent a special relationship and foreseeable harm.

The court decided that there was no special relationship because the plaintiffs in that case were unidentifiable prior to the accident.

The Michigan decision dealt with a very similar situation. In this case, a patient's car crossed the centerline and collided with another car, killing two women and injuring another. The patient had received a number of prescriptions for controlled substances, including fentanyl patches, over the previous two years. On the day of the accident, the patient received a prescription for fentanyl patches. Upon leaving the pharmacy, he put a patch in his mouth and chewed it presumably in an attempt to bypass the time-release mechanism.

The decedents' families and the survivor filed suit against both the prescriber and the pharmacy alleging that a special relationship existed between the patient and the pharmacy and that it was foreseeable that the patient would drive while intoxicated. The pharmacy filed a motion for Summary Judgment stating that no such relationship existed and that it was not foreseeable that the patient would misuse the patch.

The trial court disagreed with the pharmacy’s position and denied their motion.

The pharmacy appealed the ruling to the Michigan Court of Appeals. The Court of Appeals reviewed a line of pharmacy cases in Michigan dating back to 1980. The existing rule in Michigan is that a pharmacist does not have a duty to warn a patient of possible adverse events when dispensing a drug pursuant to a facially valid prescription. Based on these cases, the Court concluded, ". . . it would be illogical to impose such a duty on the pharmacist with respect to a third party." The Court also concluded that the pharmacy had no duty to monitor the patient's use of fentanyl.

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In a somewhat unusual circumstance, one judge filed a concurring opinion in which he agreed with the conclusion, but urged the Michigan Supreme Court to take up the case because he believed that Michigan case law was based on an incorrect interpretation of the law. He reviewed legislation and regulations from which he concluded that a pharmacist does have a duty to warn of possible adverse events and to monitor the patient's use of medications. The first of these was the Federal regulation under the Controlled Substances Act that created a pharmacist's corresponding responsibility to consider the validity of an order for a controlled substance.

The conclusion was that the Michigan case law stating that a pharmacist has no legal duty to monitor the prescribing of controlled substances was at odds with Federal law. The judge also cited Michigan laws and regulations supporting the conclusion that pharmacists have a broader duty than the current case law outlines.

The judge urged the Michigan Supreme Court to take up the case because the Court of Appeals did not have the authority to overturn Michigan case law. However, in April 2019, the Supreme Court declined to hear the appeal and the Court of Appeals ruling stands.

While some states' case law still follows the concept of the Learned Intermediary (i.e., the pharmacist has no duty to warn the patient because of the involvement of the prescriber who is the Learned Intermediary). The concurring opinion in this case gives us a glimpse of where the law is likely to go. As pharmacists continue to expand the array of services that they can provide to patients and technological advances place more information into their hands, it seems unlikely that pharmacists will be able to continue to rely on the defense of filling a facially valid prescription. While this may not extend to a duty to unknown third parties, pharmacists should be prepared for future courts to impose a duty to warn patients of possible adverse events and to monitor their medication usage. § ________________________________________________________________ © Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, Risk Management & Compliance at Pharmacists Mutual Insurance Company.

This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.

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THE ARKANSAS PHARMACIST

11/5/19 9:43 AM

UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES COLLEGE OF PHARMACY

Melanie Reinhardt, Pharm.D. Eddie Dunn, Pharm.D.

Seldom Used Abbreviations This issue of Safety Nets illustrates the potential hazards associated with poorly handwritten prescriptions. Thank you for your continued support of this column.

A pharmacy technician received the original, handwritten prescription illustrated in Figure One. The prescription was written by a veterinarian for a dog diagnosed with Type 1 Diabetes. The technician entered the information into the computer as Novolin N, 100 units/mL, quantity 10 ml, with directions of "Give 16 units four times a day." The order was then transferred from the input queue to the pharmacist verification queue in the computer. The pharmacist immediately questioned the "four times daily" dosing interval and telephoned the veterinarian for clarification. The veterinarian said he had prescribed Novolin N at a dosing interval of once daily. He explained he had written the prescription abbreviation "s.i.d." not "q.i.d." The pharmacist stated she had never heard of "s.i.d." The veterinarian said "s.i.d." means once daily and apologized for using this seldom used abbreviation. After this, the prescription was correctly filled and the dog's owner appropriately counseled.

This prescription is unique in that the prescriber wrote the abbreviation "s.i.d." which stands for "semel in die" or "once per day." Its use is particularly hazardous because "s.i.d." is virtually unknown outside of veterinary medicine. Its persistence in veterinary medicine is puzzling, given its use in medical practice has disappeared.

Figure 1

The pharmacist and technician in this case were unfamiliar with "s.i.d." and initially interpreted the abbreviation as the more familiar "q.i.d." or four times daily. In fact, at first glance, the abbreviation more closely resembles "q.i.d." than "s.i.d.". If this initial interpretation had gone undetected, the Novolin N vial would have left the pharmacy with a label instructing the owner to administer a four-fold overdose. People trust the information contained on their medication labels. This could have resulted in the dog's owner questioning her understanding of the veterinarian's verbal instructions provided during the dog's examination.

Fortunately for the dog's owner (and the dog!) the error was detected during verification. The pharmacist took time to question the "four times daily" dosing interval rather than mindlessly verifying the order in a robotic fashion. It is important that pharmacists treat each order as a unique entity, instead W W W. A R R X . O R G

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of "just one more" or "a problem" that will interrupt workflow.

This case also illustrates the hazards associated with prescription abbreviations, especially archaic ones like "s.i.d.". If the veterinarian had simply written "Give 16 units once daily", the order would have been crystal clear. In the interest of patient safety, words should be completely written - never abbreviated. § STUDENT SPOTLIGHT

Overcoming Anxiety With Supplements: A Mom’s Perspective - Hannah Cooper

“Mom, my tummy hurts.” How many times have parents heard this from our children? Usually we attribute this to the child not wanting to comply with what we’ve asked of them. In fact, this statement could be masking what is going in inside them. Anxiety in children is often misdiagnosed due to their “symptoms” manifesting in ways that are different to adult anxiety.

Symptoms of anxiety in children may manifest as stomachaches, headaches, and excessive crying.

As a mother of a child with anxiety, I wanted to explore alternative therapies to treat his anxiety instead of relying on a prescription medication. There is now evidence suggesting that vitamin and mineral deficiencies may play a role in both childhood and adult anxiety. Many diets are poor in micro-nutrients such as magnesium, B-complex vitamins, folic acid, and vitamin D. My son would often complain of stomachaches and began to cry in situations that previously did not affect him. After two months of mineral supplementation, I began to see a noticeable decrease in his anxiety. He no longer complains about his stomach hurting and is thriving in school. I encourage any parent who is struggling with a child with anxiety to explore starting a supplement routine.

References: https://www.heysigmund.com/resilience-anxiety-and-nutrition/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2959081/

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MEMBER SPOTLIGHT

Greg Lance, Pharm.D. Practice Setting: Clinical Pharmacist, Encompass Health Rehabilitation Hospital of Jonesboro

Pharmacy school and graduation year: University of Arkansas for Medical Sciences Class of 2015

Years in business/years teaching: 3 and a half years Favorite part of the job and why: Because our pharmacy

has a great working relationship with the providers of our facility, most changes to a patient’s regimen is simply a text message or phone call away. Also, through hospital protocols, we can adjust most drug doses and frequencies according to a patient’s renal function.

Least favorite part of the job and why: While I do get to do

some discharge counseling for our patients, I must admit that I am a community pharmacist at heart. Most of the patients I see are only here one time. I enjoyed seeing my “regulars” when I was in the community setting.

What do you think will be the biggest challenges for pharmacists in the next 5 years?

Our state is very fortunate to have such an active Association who work extremely hard fighting for us. I have several friends who own small community pharmacies, and I worry that PBMs and associated DIR fees will make it hard to have a sustainable business model for them, and the rest of the community pharmacy world.

Oddest request from a patient/customer: I’ve been pretty

lucky and haven’t had a lot of crazy things happen to me in my short career. However, when I first started out as a clerk in the summer of 2007, an older lady came into the pharmacy and got her medication. I told her the amount she owed, which was a little less than five dollars. She had really bad rheumatoid

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arthritis and said she couldn’t get her money out of her pocket.

She asked me to please get the money out of her right pocket for her. Being 19 and afraid to get fired, I complied. The $5 bill was soaked with sweat. If that’s the worst thing that happens to me, I’ll have a good career.

Recent books read: I have read the Game of Thrones books and also Ready Player One recently. I am now starting on The Seven Figure Pharmacist.

Favorite activities/hobbies: Although I am not very good at it, there is something wonderful about hitting the golf course and getting a good round in. It’s a wonderful escape from the real world, and it’s something a person can enjoy throughout their entire life.

Ideal dinner guests: I always have admiration for people

who have the courage to stand up for what is right. If I were to choose just one, it would probably be Abraham Lincoln. There are very few people who have helped shape our wonderful country in a more positive way.

If not a pharmacist then…: If I were not a pharmacist, I

would have tried to be a biology professor at a college or possibly a high school football coach. I enjoy being a positive influence in our younger generation’s lives.

Why should a pharmacist in Arkansas be an active member of the Arkansas Pharmacists Association? While our state

is only a small percentage of the country, our Association is one of the strongest. It has been a constant advocate for not only expanding practice abilities, but also for protecting our livelihood. §

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THE ARKANSAS PHARMACIST

11/5/19 9:43 AM

FDA Modernization and Innovation has Intended Effect on Drug Approval Rate

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here was a time when the FDA approved on average only 20 drugs per year and most of them during the 4th quarter or the month of December. With enactment of the FDA Modernization Act of 1997, the FDA Amendments Act of 2007, and the FDA Safety and Innovation Act of 2012, there has been a consistent steepening of the new drug approval curve. During this past quarter, 15 new drugs or biologics were approved, so the rapid pace of new drug approval continues. And, not to be overlooked, there were several drugs that received approval for significant new indications which is beyond the scope of this column.

Inrebic™ (fedratinib) was granted priority review as a kinase inhibitor with orphan drug status for intermediate-2 or highrisk primary or secondary myelofibrosis.

Oncology:

Rozlytrek™ (entrectinib) received priority review as the third oncologic drug approved for cancer treatment based on a common biomarker rather than body location of a tumor. It is approved for both the genetic defect NTRK gene fusion, and ROS1 (+) non-small cell lung cancer. Nubeqa™ (darolutamide) received expedited approval as an oral During this past quarter, treatment for non-metastatic castrationInfectious Disease: resistant prostate cancer. Xpovio™ 15 new drugs or biologics Three antiinfectives received (selinexor), an oral nuclear export were approved, so the accelerated priority review this inhibitor, was granted accelerated rapid pace of new drug quarter as qualified infectious disease approval for relapse/refractory multiple products under the Generating myeloma under certain conditions. approval continues.

Antibiotic Incentives Now initiative.

Turalio™ (pexidartinib), another Xenleta™ (lefamulin) is a pleuromutilin kinase inhibitor, received orphan drug antibacterial with IV/PO formulations and breakthrough therapy designations indicated to treat community-acquired bacterial pneumonia. for treatment of the rare tenosynovial giant cell joint tumor.

Pretomanid received orphan drug status and became only Polivy™ (polatuzumab vedotin-piiq) received priority the second drug approved under the limited population review, breakthrough therapy, and orphan drug designations pathway for antibacterial/antifungal drugs, and is indicated as the first chemoimmunotherapy for relapsed/refractory to treat multi-drug-resistant tuberculosis. Recarbrio™ B-cell lymphoma. (imipenem, cilastatin, relebactam) which includes a new beta-lactamase inhibitor was approved for gram (-) UTI and New Dosage Forms: intra-abdominal infections.

Significant new dosage forms approved this quarter include: Baqsimi™ (glucagon, nasal powder) for severe Chronic Care: hypoglycemia; Gvoke HypoPen™ (glucagon, prefilled Nourianz™ (istradefylline), a selective adenosine A2A autoinjector) for severe hypoglycemia; Thiola® EC (tiopronin, receptor antagonist, was approved as add-on therapy to enteric-coated delayed-release) for cystinuria; Xembify™ carbidopa/levodopa for Parkinson’s patients experiencing (20% immune globulin) for primary immunodeficiencies; “off” episodes. Rinvoq™ (upadacitinib) is an oral JAK Drizalma Sprinkle™ (duloxetine, delayed-release sprinkle) inhibitor for treating moderate-to-severe rheumatoid arthritis. for all approved indications; Katerzia™ (amlodipine, oral Accrufer™ (ferric maltol) is an oral non-salt formulation suspension) for all approved indications; Myxredlin (human of ferric iron for the treatment of iron deficiency anemia. insulin, short-acting) as the first ready-to-use insulin for Vyleesi™ (bremelanotide) is a first-in-class melanocortin IV infusion; Nayzilam® (midazolam, nasal spray) for 4 receptor agonist designed for self-administration with intermittent episodes of frequent seizure activity; Ruzurgi an autoinjector and indicated for hypoactive sexual desire (amifampridine, tablets) for Lambert-Eaton myasthenic disorder in premenopausal females. Wakix® (pitolisant), also syndrome; and Slynd® (mifampridine, tablets) as a progestinfirst-in-class as a selective histamine 3-receptor antagonist/ only oral contraceptive. § inverse agonist, is a non-controlled substance indicated to treat excessive narcolepsy-related daytime sleepiness.

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11/5/19 9:43 AM

Pharmacist Immunization Expansion

By Emily Wilson, Pharm.D. and John Vinson, Pharm.D.

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THE ARKANSAS PHARMACIST

11/5/19 9:43 AM

P H A R M A C I S T I M M U N I Z AT I O N E X PA N S I O N

A

new immunization law (HB1278 / Act 652 sponsored by Representatives Jimmy Gazaway and Robin Lundstrum) was passed in Arkansas giving pharmacists authority to order and administer vaccines under a general written protocol for ages 7 – 17 years of age. In addition to scope of practice expansion, Act 652 also includes a requirement for written parental or legal guardian consent for patients under 18 years of age.

The Arkansas Pharmacists Association (APA) has updated our immunization protocol with the Arkansas Department of Health (ADH) and consent form to reflect the new legislative updates of Act 652. APA’s immunization protocol is now newly updated to include ages 7 – 17 years of age and parental consent now incorporated into the universal screening and consent form. The newly updated immunization protocol and consent form are member-only benefits available to our Arkansas Pharmacists Association members.

As a reminder, the use of the APA/ADH immunization protocol signed by Dr. Jennifer Dillaha, Medical Director of Immunizations at ADH, is reserved for pharmacists who have not been able to find a local physician to collaborate and sign a local general protocol. It is considered best practice to establish a local relationship and utilize a generalized immunization protocol signed by a local provider.

This relationship may lead to additional opportunities to collaborate for other disease states and programs in your community with this collaborating physician.

APA’s immunization protocol is now newly updated to include ages 7 – 17 years of age and parental consent now incorporated into the universal screening and consent form. The newly updated immunization protocol and consent form are member-only benefits available to our Arkansas Pharmacists Association members. well-child visits with their child’s pediatrician, affirms trust and credibility with patients while building rapport with local pediatric providers.

Potential Barriers in Care

Three-fourths of Arkansas children are insured by either ARKids A or ARKids B. This means that 75 percent of pediatric patients (≥7 years of age) have insurance that will not pay for pharmacistadministered vaccines in community pharmacies, unless the pharmacy participates in VFC or SCHIP vaccine program in collaboration with the Arkansas Department of Health and Arkansas Medicaid.

With Act 652 comes new opportunities to provide care for our pediatric patients while opening doors to build interprofessional rapport.

Pushback

The pediatric community voiced concern over Act 652 fearing that parents would be less motivated to bring their children to annual well-child visits with a pediatrician now that pediatric patients (≥7 years of age) can receive pharmacistadministered immunizations in the community setting. This is a reasonable concern of the pediatric community as the American Academy of Pediatrics (AAP) recommends wellchild visits with a pediatrician annually.

Physicians also have quality programs, like Arkansas Medicaid PCMH, where Performance-Based Incentive Payments (PBIP) can be negatively impacted when children don’t come in for yearly well-child visits – this is both a financial hit to the physician’s practice and poor patient care.

As pharmacists in the community setting, we are wellpositioned to educate parents on the importance of annual well-child visits with a pediatric primary care provider.

Communicating knowledge of AAP recommendations to parents of pediatric patients, along with encouraging annual

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P H A R M A C I S T I M M U N I Z AT I O N E X PA N S I O N

ARKids A (Medicaid) – children receive vaccine through federal Vaccines for Children (VFC);

VFC vaccine can only be used for ARKids A. Vaccines for Children (VFC) allows Medicaid-eligible children (<19 years of age) free access to childhood immunizations. The Arkansas Department of Health (ADH) oversees VFC in Arkansas.

Per cdc.gov, the Vaccines For Children (VFC) program is a federally funded program that provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay. CDC buys vaccines at a discount and distributes them to grantees – such as state health departments and certain local and territorial public health agencies – which in turn distribute them at no charge to those private physicians’ offices and public health clinics registered as VFC providers.

ARKids B – children receive vaccine through State Children’s

Health Insurance Program (SCHIP); ARKids B is Arkansas’s main SCHIP-funded program, currently covering around 6,000 children of state employees. State Children’s Health Insurance Program (SCHIP) provides coverage to children of state employees with qualifying household incomes.

Only VFC and SCHIP providers are able to bill ARKids A and ARKids B for vaccine administration.

The reality of Act 652 scope of practice expansion is that 75% of the pediatric patients pharmacists now have the authority to immunize under protocol are covered by insurance that most community pharmacies are unable to bill, unless the pharmacy enrolls and participates in Vaccines for Children and State Children’s Health Insurance Program (SCHIP). There is a hand full of pharmacies who are piloting participation in these programs, although the management and participation are complex and financially challenging. (refer to “Pro-Tips” below for actionable items)

Our Role

Scope of practice expansion means greater opportunity for pharmacists to reach more patients and positively impact the health of Arkansans. Community pharmacists remain the most accessible medical professionals – nearly all Americans (~94%) live within 5 miles of a community pharmacy – and see patients more regularly than any other healthcare provider.

Community pharmacists have long served as first-line triage for patients in the community setting, recommending overthe-counter products for self-care, offering counsel and health screenings, and referring patients from the community setting to primary care providers, urgent care clinics, and

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emergency departments. We are uniquely skilled to care for patients where they are, and expertly trained to delegate care when needed.

Becoming aware of potential barriers in patient care help us provide better care following new legislative changes.

Inquiring about well-child visits and immunization status builds rapport between both patients and providers.

The more educated we are as individuals, the stronger we become as a profession. Staying up to date on recent legislative changes and seeking to understand its implications in areas of healthcare transcending pharmacy help solidify the role of pharmacy in healthcare: indispensable. §

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POST THIS SHEET FOR REFERENCE

Pro Tips

Pharmacist Immunization Expansion • Review and update your generalized protocol to allow routine and catch up vaccines for children and teenagers age seven (7) years old and older.

• Meningitis, Tetanus/Diphtheria and Pertussis (Tdap), Human papillomavirus (HPV) , are all

routine vaccines in teenagers where pharmacists can especially make a positive impact • Meningitis (ACYW-135) and Tdap are required vaccines in Arkansas for school and pharmacists may be able to help close care gaps in a timely manner at the beginning of each school year for those children who are overdue and their primary care provider may not have open office visit slots to accommodate all of the needed well child visits. School requirements for meningococcal and Tdap: • one or two doses of Meningococcal vaccine with one dose for 7th grade and a second dose of Meningococcal vaccine at age 16 years (as of September 1st each year). However, if the first dose of Meningococcal vaccine is administered at age 16 years or older, no second dose is required; or if not vaccinated prior to age 16 years, one dose is required.

• one dose of Tdap for ages 11 years (as of September 1st each year) and older

• HPV vaccine is not required for school entry;

however, HPV causes cancer and Arkansas has one of the lowest HPV vaccination rates in the country for both males and females.

• Arkansas pediatricians during the 2019 legislative session communicated to the Arkansas Pharmacists Association that pharmacist administered HPV vaccination is the biggest collaboration need for improving population health and saving lives.

• It is also often a challenge that the first dose of HPV vaccine is given during a physician or primary care office visit and the child is not

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brought back in a timely manner to complete the 2 or 3 dose series (depending on patient age). Arkansas pharmacists can help close these care gaps to prevent HPV cancer and save lives.

• Update your vaccine screening form to include

parental or legal guardian consent for children age 7 to 17.

• Update your vaccine screening form to include

a question about the date of their last primary care provider office visit and well child exam for children.

• Proactively refer children to their pediatrician or other primary care provider if their last well child visit has not occurred in the last calendar year. Team based care will be appreciated by your pediatrician colleagues and your patients will receive higher quality care.

• If a child under age 19 is uninsured or health care

is financed or covered by a Medicaid program the child may be eligible for vaccine coverage through Vaccines for Children or State Children’s Health Insurance Program (SCHIP).

• All local county health departments participate and offer vaccines through these programs.

APA staff and Rachel Odom (VFC coordinator) at the Arkansas Department of Health may be able to assist pharmacists to learn more about participation in VFC or SCHIP if interested.

Contact Information Rachel Odom, VFC Coordinator Email: rachel.odom@arkansas.gov Phone: (501) 661-2170 Referral to a local county health department or a primary care provider who participates in VFC and SCHIP may be needed.

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UAMS SCHOOL OF PHARMACY

New Leadership, Familiar Face Cindy D. Stowe, Pharm.D. Dean

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he’s back! My first day back as the UAMS COP dean was July 29, 2019. In 2014, I was given the opportunity to be dean at Sullivan University College of Pharmacy and Health Sciences and reconnect with my Kentucky roots. And now, I am back at the UAMS COP with a stronger commitment than ever to advance the mission and vision of the COP and contribute in a meaningful way to help shape the profession that I love. I was drawn back to Arkansas for many reasons but one that is clear to me is the pharmacy profession in this State. The pharmacy profession in Arkansas is strong, passionate, and purposeful in its commitment and leadership. To be a part of this group is an honor, and I look forward to helping solve difficult challenges and pushing the boundaries of what we see for the pharmacy profession.

One of my first responsibilities as dean was to participate in welcoming the PharmD Class of 2023. Within weeks, I hit the road to reconnect with friends of the College and profession by speaking at the 2019 APA Regional Meeting circuit. Additionally, I’ve spent my first days as dean getting to know the staff, faculty, and students of the College and listening to their goals, passions for the profession, and their concerns. As all of you know, when you take on a new role there is always a transitional period. To me, this period is a balancing act between the things that need to be addressed immediately and the long-term planning necessary to make tomorrow better for all of our stakeholders.

The pharmacy profession in Arkansas is strong, passionate, and purposeful in its commitment and leadership. To be a part of this group is an honor.

I have appreciated the questions and comments that I have received while at the APA Regional Meetings. The questions have focused broadly on class size (admissions) and workforce development (curriculum). The Class of 2023 is 75 students strong. These students met the review process and embody the knowledge, skills, attitudes, and behaviors that will shape the future of pharmacy practice into the second half of the twenty-first century. It is amazing to think about the impact these student pharmacists will have over the course of their careers. Another somewhat connected point raised at the APA Regional Meetings was the cost of pharmacy education and the total debt load of graduates that includes tuition and fees (pre-pharmacy and pharmacy)

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and living expenses. In the 2019 UAMS COP salary survey (109 of 110 graduates participating), 88% of those surveyed have student loans with an average of $157,753 (range $20,000-$280,000). The total cost for tuition and fees at the UAMS COP for 2019-2020 is $88,604. Of those colleges/ schools within 350 miles, we have the second to lowest instate tuition and fees (range $76,668-$138,744).

Now more than ever, student pharmacists entering our profession need to be agents of change.

Now more than ever, student pharmacists entering our profession need to be agents of change. These student pharmacists must be innovative, entrepreneurial, and risk tolerant. The focus of the curriculum must be designed to help educate these student pharmacists to meet these challenges. The UAMS COP faculty have started a curricular transformation process that is focused on meeting this need more effectively. A big change in the educational process will focus on ‘how’ the curriculum is delivered in the context of the information age and the pressure to solve problems in environments of greater complexity and uncertainty.

The UAMS COP has always had a strong working relationship with the profession through the APA and the Board of Pharmacy. As dean, I plan to continue to work collaboratively to enhance the profession. We value your input and I look forward to finding new and creative ways to gather your feedback. As the College embarks on initiatives such as strategic planning and curricular transformation, we will consistently engage with the pharmacy community to inform decision making. I am thrilled to be back in Arkansas at a college of pharmacy that I love. I look forward to working with you to advance the profession and as we continue to move the College forward as a national leader in the education of pharmacists and scientists. § References 1. University of Arkansas for Medical Sciences College of Pharmacy 2019 Salary Survey.

2. American Association of Colleges of Pharmacy 2019-2020 Tuition & Fees at U.S. Colleges and Schools of Pharmacy. https://public. tableau.com/profile/aacpdata#!/vizhome/2019-20TuitionFees/ TuitionandFeesDashboard Last accessed 2019September29.

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HARDING UNIVERSIT Y REPORT

2019 HUCOP Annual Report

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reetings from all of us at Harding University College of Pharmacy (HUCOP)! Fall is definitely my favorite time of year as we welcome new and returning students to campus. It’s also a time when we are privileged to visit with many of our friends throughout the state during the APA Regional Meetings. This year’s meeting format allowed us to share a HUCOP report and answer questions from attendees concerning our program and pharmacy education in general. The following is a recap of some information that we were able to share at the various meetings throughout Arkansas: Jeff Mercer, Pharm.D. Dean

We were delighted to welcome our twelfth class of pharmacy students this year – the class of 2023! This class of 40 students hail from ten different states and three foreign countries. They are a diverse group of individuals that were chosen based on an overall assessment of academic quality indicators and fit for the mission of our program. Following a week-long orientation to Harding and our Searcy community, they are now a close-knit cohort that we feel certain will successfully meet our rigorous academic and service-based requirements along their journey towards becoming pharmacists. We are excited for this new group of students and hope you get the opportunity to meet them soon.

Speaking of admissions, if you know of a student who wants to become a great pharmacist, send them our way! Our admissions cycle for the next academic year (2020-21) has already begun. We are taking applications and scheduling interviews on a rolling basis. Our admissions criteria are selective and holistic with a goal of attracting outstanding students with a mission-centered mindset that desire to serve others through the noble profession of pharmacy. We offer a competitive tuition that is less than similar private schools, and scholarship opportunities are available for both financial need and high academic performance. You can find out more about our admissions process, including information about Open House events and our Early Assurance Program by visiting our website or giving us a call.

By far, the most exciting news that we have to share with you concerns accreditation. In June of this year, the College received notification from the Accreditation Council for Pharmacy Education (ACPE) that our accreditation status was continued through July of 2026! Around that same time, Harding University received word from the Higher Learning Commission that our University accreditation was affirmed until 2025. Both of these achievements are the result of intensive work by our faculty and staff and serves as

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validation of our commitment to quality education at Harding University.

Many of the questions that we received during the Regional Meetings involved the direction of pharmacy education.

Times have certainly changed as pharmacists continue to accept more clinical responsibility for patient care. As the marketplace changes, we are teaching and training students in contemporary and team-based pharmacy practice models so they are prepared to take on new roles and responsibilities.

We are already seeing success as our graduates enter advanced practice both in traditional community and hospital settings as well as new and diverse practice opportunities like ambulatory care, consultant, regulatory, and healthsystem specialties, among others. We continue to see some graduates settling in rural settings and/or seeking pharmacy ownership as a career. While the overall practice profile and location opportunities have changed of recent, a pharmacy degree is still of great value as evidenced by more than 95% of our graduates employed in pharmacy settings at one-year following graduation.

A pharmacy degree is still of great value as evidenced by more than 95% of our graduates employed in pharmacy settings at one-year following graduation.

In closing, I would like to express our gratitude to all of you who serve as preceptors, mentors, advocates and encouragers to our students. You are so important in providing a wellrounded education for our students. We simply could not do what we do without you!

That’s a bit about what’s going on at Harding University College of Pharmacy. If you have any questions or interest in our program, please visit us at www.harding.edu or give us a call at 501-279-5528. §

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ARKANSAS ACADEMY OF HEALTH-SYSTEM PHARMACISTS

Hindsight in 2020

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arly October the Arkansas Association of Health System Pharmacists (AAHP) put on a Erin Beth Hays, Pharm.D. AAHP President wonderful fall seminar with the theme “2020 Vision.” With about 200 pharmacists, technicians, and students in attendance, we gathered for continuing education, networking, and celebrations. We opened up the seminar with a presentation from Arkansas’s own Nicki Hilliard, Immediate Past Present of APhA, as she provided an update on provider status at the national level and the obstacles we will have to overcome to get there. The continuing education programming continued throughout the two days bringing us new ideas clinically and operationally.

So how exactly can looking back help us move forward?

1. Looking back brings perspective and provides clarity.

When we reflect on something we can dig into the why’s of how something came about. How did we get here?

What was needed to make this happen? If it developed into a positive outcome then we can incorporate the answers to these questions to achieve another positive outcome. If it’s a negative outcome we are reflecting on, we can discover what to avoid in the future.

2. Looking back builds respect for the profession and recognizes how much it has grown. Our profession has grown over the decades both in numbers and in our professional practice. We have more pharmacists in the A conference centered on “2020 Vision” was perfect for nation that ever before. The profession has grown by over finishing out 2019 and pushing into the new decade.

20% in the last 10 years with over 314,000 pharmacists However as much as we all want 20/20 vision for our futures, nationwide and over 420,000 pharmacy technicians. we all know that the future is not always predictable and With these numbers have come more avenues for that hindsight is 20/20. What are some things we have pharmacists to serve their patients. These pathways have learned from the past that can included dispensing, clinical help us in the future? Some initiatives, immunizations, things I have learned in my short compounding, managing tenure as a pharmacist include In the last 10 years... chronic disease states, the importance of technology, teaching the future of the working together in groups for growth in the pharmacy profession pharmacy profession, a common goal, and building managing various as-pects relationships. pharmacists of the healthcare arena and the list can go on and on.

Technology has become a driving pharmacy technicians Our role has expanded from force in pharmacy and the dispensing a product to healthcare world. It has been a providing quality care to our progression first with electronic patients whether it’s through pharmacy profile systems and education, protocols, developing and embracing automated dispensing machines. Then along came the electronic medical record and patient safety initiatives with technology, and again the list can go on and on. bedside medication verification and smart IV pumps. We have also seen e-prescribing and the importance of software 3. Looking back aids future learning and assists in planning like the prescription drug monitoring program. Many of for the future. What do we need to know more about? us would not function in our day to day jobs without the Where do we want to go based on where we have been? technology we have at our fingertips.

What relationships do we need to build to be successful?

20% 314,000 420,000

Also looking back we can see how powerful we can be in groups. The most recent example being the change pharmacists made at the state level through the PBM legislation. No single pharmacist by themselves could have made that happen. Showing how important our organizational work can be.

Lastly relationship building is important to project us forward in our profession. The networking we do helps us in our professional lives as we share ideas and communicate to each other opportunities. It also helps us as we work interprofessionally with other healthcare workers to achieve the ultimate goal of caring for our patients.

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To forecast the future, we must first read the signs of the season’s pasts. Let’s learn together going forward not forgetting about what we have done in the past.

I want to personally thank the fall seminar committee for putting on a great conference. Thank you for your hard work and dedication to making it a memorable event. Congratulations to all the AAHP awards winners and poster winners that were recognized at the awards banquet. We appreciate your hard work moving the profession forward. Also congratulations the Harding University College of Pharmacy team for winning the Student Jeopardy competition. We look forward to seeing everyone again next year at the 54th Annual Fall Seminar. §

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AAHP 2019 Fall Seminar

AAHP Fall Seminar Keynote Speaker – Dr. Nicki Hilliard

Manager of the Year – Chad Krebs Manager of the Year – Chad Krebs

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AAHP 2019 Fall Seminar

Mark and Brenda Riley

Clinician of the Year - Laura Parr

Residency Preceptor the Year - Meagan Doyle

Congratulations to All Our AAHP 2019 Fall Seminar Award Winners! *Not Pictured: Staff Pharmacist of the Year Virginia Porter New Practitioner of the Year - Todd Weaver

Student of the Year - Maggie Thannisch

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Technician of the Year- Kimberly Wyatt

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COMPOUNDING ACADEMY REPORT

Never Say This Again!

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here is a phrase used in business, in our personal lives, in churches, basically anywhere where two or more people are making a decision. It’s used flippantly. It seems innocuous. But it is one of the most damaging phrases you can utter. It has the power to stop a business in its tracks and turns potential into inertia.

Andrew Mize, Pharm.D. Compounding Academy President

What is this terrible phrase that can wreak such havoc on our businesses? What sentence could have such a negative impact that even our bottom line takes a hit?

“That’s how we’ve always done it.”

This simple phrase that I’m sure we’ve all said before, (Me: [With hand raised] “Guilty”) doesn’t seem so bad on its surface. I mean, things have been good, and if things have been good, we should keep doing what we’ve done before, right? Umm…no.

If there’s one thing that these USP Guideline changes have told us, it’s that we must change, adapt, and develop our practices into a safer, more responsible model. The Guidelines and those charged with enforcing them require it of us.

We can discuss the merits of arguments such as overreach, limiting patient access, and lack of scientific data supporting some of these changes. Those are important discussions to have and I’m ready to have them. We however, cannot throw, what my parents called a hissy fit, and demand things stay as they are. This approach will not lead to any improvements for our stores, our team, or our patients.

The approach I would encourage you to use instead, involves having a mindset of ‘continual improvement.’ Identify holes in your processes, in your training, in your compounding technique. Identify pain points for patients and the prescribers who frequent your business. Ask your team what areas need attention. Work to fill these holes by making changes in whatever area merits it.

A great place to start would be to perform an Assessment of Risk for USP <800>, if you haven’t already completed one.

Also do a self-inspection using the Board of Pharmacy’s inspection form. Go through the applicable chapters of USP and grade your store on each section.

As we all know, the practice of compounding has been under a tremendous amount of scrutiny since the NECC debacle in 2012. However, instead of complaining about the tower of guidelines sitting on your desk (guilty again), approach the problem from the perspective that you can make your practice better.

Continual improvement isn’t just a one and done type of thing. The goal is to never be satisfied with how things are – to always want to make them better. By doing this our patients will receive better care. Our teams will be more engaged and committed to the mission. My guess is, your bottom line will also begin to show continual improvement.

When we stop growing, we start dying. When we get satisfied that things are ‘good enough,’ we fall into a rut, where we resist change. We resist exerting effort to improve. And we fall into the trap of uttering that phrase,that we must never say again. §

Arkansas Pharmacists Association Wins Coveted Communication Award

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he Arkansas Pharmacists Association took home a Prism Award from the Public Relations Society of America in September at the annual PRSA Awards ceremony. APA Director of Communications Jordan Foster accepted the award in the Crisis Communication category for the organization's efforts to mobilize APA membership, engage patients, educate the public, and involve local media during the PBM reimbursement crisis of early 2018. The efforts of Foster, former APA CEO Scott Pace, current APA CEO John Vinson, and the rest of the APA staff in carrying out the communications campaign ultimately led Governor Hutchinson to call a special legislative session where a law was passed requiring PBMs to be regulated in the state of Arkansas. The successful efforts of the staff and members also established Arkansas as a national leader in the pharmacy world. A special thank you to all APA members, patients, legislators, and friends of pharmacy who were part of the efforts to fight back against the PBMs in 2018 and beyond.

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2019 Arkansas Pharmacists Association REGIONAL MEETINGS The Arkansas Pharmacists Association held its 2019 Regional Meetings in 11 cities across the state during the months of August, September, and October. Members were able to engage with state pharmacy leaders, get updates from the colleges of pharmacy, APA, and the State Board, and enjoy camaraderie and fellowship with fellow pharmacists in the area. 2019 Regional Meetings were a departure from previous years with new cities added (El Dorado, McGehee, and Pine Bluff), a new format that encouraged audience participation through questions and answers, and a visit to the newly renovated press box event space in the Johnny Allison Tower at ASUâ&#x20AC;&#x2122;s football stadium. APA member participation is integral to the success of the association. Thank you to all who attended!

Harding University, Searcy

Searcy

Little Rock The new format for 2019 featured a panel comprised of representatives from the colleges of pharmacy, the state board, and APA.

Little Rock

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Little Rock

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Little Rock

Springdale

APA wishes to thank our Regional Meeting Sponsors: AmerisourceBergen, Ashford Advisers, Cardinal Health, Centennial Bank, Harding College of Pharmacy, Indy Health Solutions, McKesson, Smith Drug, and UAMS College of Pharmacy.

Jonesboro attendees were able to check out the newly renovated press box at ASUâ&#x20AC;&#x2122;s stadium

State Board Executive Director John Kirtley discusses the new NARCANsas phone app Centennial Bank hosted a pre-meeting reception in their suite at Johnny Allison Tower.

Pine Bluff

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Jonesboro

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