IPA Journal - Apr/May/Jun 2019 by Iowa Pharmacy Association

A Peer-Reviewed Journal | Vol. LXXV, No. 2 | APR.MAY.JUN 2019

AN UPDATE ON OPIOID PRESCRIBING PATTERNS INSIDE: Annual Meeting Preview Peer Review Recaps: Legislative Day & Expo

TABLE OF CONTENTS 8515 Douglas Avenue, Suite 16, Des Moines, IA 50322 Phone: 515.270.0713 Fax: 515.270.2979 Email: ipa@iarx.org | www.iarx.org

PUBLICATION STAFF David Schaaf, Managing Editor Kate Gainer, PharmD Anthony Pudlo, PharmD, MBA, BCACP Laura Miller Casey Ficek, JD Matthew Pitlick, PharmD, BCPS

COVER STORY An Update on Opioid Prescribing Patterns pg. 20

How have measures to reduce the amount of opioids prescribed affected inappropriate opioid medication use?

OFFICERS CHAIRMAN Craig Logemann, RPh, BCACP, CDE - Ankeny PRESIDENT Cheryl Clarke, EdD, RPh, FAPhA - Waukee PRESIDENT-ELECT Connie Connolly, RPh, BCACP - DeWitt TREASURER Tim Becker, RPh, FACP - Mason City SPEAKER OF THE HOUSE Jim Hoehns, PharmD, FCCP, BCPS - Cedar Falls VICE SPEAKER OF THE HOUSE Ashley Dohrn, PharmD, BCGP - Le Claire

TRUSTEES REGION 1 Sharon Cashman, RPh - Waverly REGION 2 Jim Mennen, RPh - Coralville REGION 3 Sally Haack, PharmD, BCPS - Urbandale REGION 4 Carol Anderson, PharmD - Mason City AT LARGE Bill Baker, BS Pharm - Iowa City Craig Clark, RPh - Cedar Rapids Deanna McDanel, PharmD, BCPS, BCACP - Coralville Heather Ourth, PharmD, BCPS, BCGP - Ackworth HONORARY PRESIDENT John Rovers, PharmD, MIPH - Des Moines PHARMACY TECHNICIAN Jessica Burge, CPhT - Des Moines STUDENT PHARMACISTS Bridget Tunink - Drake University Austin Miller - University of Iowa The Journal of the Iowa Pharmacy Association is a peer reviewed publication. Authors are encouraged to submit manuscripts to be considered for publication in the Journal. For author guidelines, see www.iarx.org. “The Journal of the Iowa Pharmacy Association” (ISSN 1525-7894) publishes 4 issues per year: January/ February/March issue; April/May/June issue; July/August/ September issue; and October/November/December issue by the Iowa Pharmacy Association, 8515 Douglas Avenue, Suite 16, Des Moines, Iowa 50322. Periodicals postage paid at Des Moines, Iowa and additional mailing offices. POSTMASTER: Send address changes to: The Journal of the Iowa Pharmacy Association, 8515 Douglas Ave., Suite 16, Des Moines, IA 50322. Published quarterly, The Journal is distributed to members as a regular membership service paid for through allocation of membership dues. Subscription rates are $100 per year, single copies are $30. Printed by ColorFx; Graphic design done by the Iowa Pharmacy Association.

IPA Annual Meeting Preview everything new in this year’s Thursday-Friday agenda pg. 12

Peer Review: Using Medicare Claims to Identify a Population at High Risk for Adverse Drug Events and Hospital Use for Quality Improvement pg. 28

FEATURES

2019 Board of Trustees Election Results . . . . . . . . . . . . . . . . . . . 9 2019 Annual Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Student Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 COVER STORY: An Update on Opioid Prescribing Patterns 20 Midwest Pharmacy Expo Recap . . . . . . . . . . . . . . . . . . . . . . . . . 24 CPESN Iowa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Peer Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Legislative Day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Capitol Screenings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

IN EVERY ISSUE

President’s Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 CEO’s Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Health Care Hot Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Iowa Pharmacy News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Practice Advancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Public Affairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Technician Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 IPA Foundation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Members Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 IPA in Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Calendar of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Pharmacy Time Capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Mission Statement

The Iowa Pharmacy Association empowers the pharmacy profession to improve health outcomes. APR.MAY.JUN 2019 |

PRESIDENT’S PAGE

STORIES, AUTHENTICITY, FAMILY, RISK, SAND: DON’T MISS IT! Cheryl Clarke, EdD, RPh, FAPhA Waukee IPA President

rofessional meetings provide the opportunity to learn, network, dream, commiserate, celebrate, and honor, just to name a few. This article shares a few observations and reflections from my recent attendance at the 2019 American Pharmacists Association (APhA) Annual Meeting in Seattle.

Stories Iowa continued its long history of strong leadership at the national level. Brad Tice, former Iowa pharmacist leader, was inducted as APhA President. Brad previously served as IPA Speaker of the House, IPA Board Trustee, Drake University College of Pharmacy faculty member, and Leadership Pharmacy participant. Brad’s inaugural address focused on the power of storytelling. While encouraging APhA and state pharmacy association membership, he commented there is strength in numbers and in diversity. I immediately thought of IPA as we prepare to celebrate the 20th year of unification. I am thankful for those leaders who envisioned capitalizing on

| The Journal of the Iowa Pharmacy Association

“I am thankful for those leaders who envisioned capitalizing on our similarities while growing through our diversity in order to exponentially increase the strength of Iowa pharmacy.” our similarities while growing through our diversity in order to exponentially increase the strength of Iowa pharmacy. Those who led the unification process recently met in preparation for the celebration at the upcoming IPA Annual Meeting. It was such a pleasure to listen as they shared their amazing stories of persistence and self-sacrifice.

Authenticity It is remarkable that Iowa’s Presidential leadership was also evident at the student level as Kelli Jo Welter, Drake University College of Pharmacy and Health Sciences P3 student pharmacist, was installed as President of the APhA – Academy of Student Pharmacists. Kelli Jo encouraged her peers to be fearlessly authentic by embracing their personal uniqueness. Again, I thought of the IPA unification, when our leaders acted courageously to be authentic Iowans, true to our values by joining together to support our profession.

Family Iowa’s leadership was also notable in APhA’s advocacy efforts. As APhA PAC Board of Governors

Chairman, Iowa pharmacist Steve Firman presided over the APhA PAC Reception’s award ceremony. Michael Harvey, Drake University College of Pharmacy and Health Sciences P4 student pharmacist, was honored with the APhA Good Government Student Pharmacist of the Year award. When his award was announced, instead of walking immediately to the stage, Michael turned around and hugged his parents (and made several of us cry!) This action recognized that awards are rarely individual recognitions but are cultivated by the foundation of a supportive personal and professional family. Other pharmacy family members who were honored at the meeting, such as Jeanine Abrons as APhA-APPM Fellow and Bill Doucette as recipient of the APhAAPRS Clinical Research Paper Award, would undoubtedly agree.

Risk Progress requires risk. This was the theme advanced by Craig Hostetler, Brad Tice’s mentor, when Craig and Brad spoke to student pharmacists at the APhA-ASP Student Award Ceremony. We have several Iowans who are willing to embrace risk by running for elected APhA offices. Randy McDonough is running for his second term as an APhA Board Trustee. Wendy Mobley-Bukstein, Morgan Herring, and Nic Lehman are also IPA members willing to answer the call to serve the profession. Again,

PRESIDENT’S PAGE

if you believe, as I do, that progress requires risk, please reflect upon the risks you have taken recently to ensure your own progress as well as the progress of our profession. Certainly, the unification of Iowa pharmacy 20 years ago was risky but resulted in progress for our profession.

Sand In her address, outgoing APhA President Nicki Hilliard shared a story of visiting the Grand Canyon where she witnessed a fellow visitor constantly complaining about sand in their shoes instead of enjoying the beauty of the view. It is easy for us to get distracted by the sand in our lives. The sand undoubtedly makes us uncomfortable. But it is discomfort that pushes us to risk, pushing us to progress. Similarly, keynote speaker Eileen McDargh spoke about how we can manage our viewpoints as a method to managing our energy; hence, fostering

resiliency. She suggested we don’t bounce back to our original state after challenge but we grow through the challenge. My summary of these two presentations is sand creates risk, which creates growth, which creates resiliency, then, ultimately, creating gratitude.

“The sand undoubtedly makes us uncomfortable. But it is discomfort that pushes us to risk, pushing us to progress.” On my flight home from the meeting, I was asked to give up my coveted aisle seat so a family could sit together. I agreed but felt the sand of discomfort. Unbeknownst to me at the time, by switching to this less comfortable seat, I had the most spectacular view of Mount Rainier that was not viewable from my previously assigned seat. As I marveled in this view, I thought about hiking with my family on vacation there a few years ago. I thought

about people who embrace risk by taking the more challenging climbs. I thought about how I almost missed this moment. I thought about what I would have missed if I had not attended the APhA meeting. I thought about how proud I am to be a pharmacist and how blessed I am to be part of the Iowa Pharmacy family. Ultimately, sand led me to gratitude. Please join the Iowa Pharmacy family for our reunion in June when we celebrate the 20th anniversary of the unification of IPA. We will acknowledge the sand in our shoes, applaud the risks we embrace to make progress, and, with fearless authenticity, enjoy the stories of our past while creating the stories of our future. ■

SEPTEMBER 6, 2019

The Legacy Golf Club, Norwalk, IA Proceeds benefit the IPA Foundationâ&#x20AC;&#x2122;s support of student pharmacists at Drake University & the University of Iowa.

www.iarx.org/EGGolfClassic

CEO’S COLUMN

MY BURNOUT STORY

was hired by the IPA Board of Trustees in July 2011, with an official start date of January 1, 2012. I was honored to be selected for the position and had high aspirations for fulfilling my duties as IPA’s 8th Executive Vice President and CEO. It was an incredible honor, and even more so – an incredible responsibility – to serve the members of IPA, and continue IPA’s strong tradition of leadership, innovation and collaboration.

closed out, I cried every day. For several weeks. At home and at work. I like to think I was still effective at the office, but things slipped and I know I wasn’t leading our team. When I needed it most, I didn’t reach out to mentors, colleagues and friends. I was going through the motions at home, but was disengaged from my husband and two children, who were 1 and 2 years old. I was burned out. And I couldn’t recognize it for myself.

I had everything in place to hit the ground running. A strong staff. A supportive Board. Dedicated mentors that were a quick call or email away. A predecessor offering to help generously or stay out of my way. And most importantly (to me), a loving family willing to make sacrifices for my success. My husband Bob, who encouraged me to apply for the position and committed, ‘it won’t be 50/50 at home; I’ll do more so that you can be all the places and do all of the things you need to do to succeed,” and helpful parents always willing to travel from Wisconsin for me, Bob and our young family.

Thankfully others helped me recognize that I was deep into the five stages of burnout. My husband and parents thought I was depressed (they weren’t necessarily wrong). But it was the IPA executive committee, during my annual review, that addressed my professional burnout. I am grateful to those who identified my burnout and supported me to make changes and reverse the syndrome.

And so I hit the ground running. Sprinting. I wanted to make a difference. Our son was 6 months old, and I was pregnant with our daughter. I wanted to exceed the expectations others had of me. I wanted to personally solve all the problems that crossed my desk from any Iowa pharmacy professional. In retrospect, it is obvious to me how unrealistic the expectations that I placed on myself were. Yet, in the moment, it felt like that was what I needed to do, what I was supposed to do. And as 2013

“It meant developing boundaries and respecting them.” It meant developing boundaries and honoring them. It meant recognizing, and accepting, what I could do as one individual and what IPA could do. It also meant recognizing, and accepting, what I cannot do. It meant being present with my family. It meant prioritizing and delegating. It included making tough decisions and hiring help at home. For me, it also meant medication. (I don’t have enough pages, but the details of these changes and boundaries are the critical elements of how I personally overcame burnout.)

Kate Gainer, PharmD Executive Vice President & CEO Iowa Pharmacy Association

While my personal burnout story is from five years ago, it has come back into focus and recent conversations as I attend our 2019 IPA Goes Local events across the state. In partnership with the Iowa Medical Society and Meyvn Group, these events focus on the burnout syndrome and what can be done by individuals, leaders and organizations to reverse it. Once again, I continue to learn and be inspired by Iowa pharmacists. I’ve been inspired to share my own burnout story, because I know I am not alone. Together we can learn from one another, support one another, and overcome the shame associated with burnout. Individuals who care deeply about their profession and their work are at greater risk for experiencing burnout. Naturally, IPA members are also the pharmacy professionals that care deeply about the profession. This connection is one of many reasons IPA is focused on burnout and resilience through priority focus, programs, research and resources (see page 17). If you or someone you know is experiencing any level of burnout, please know that IPA, and your colleagues, are here for you. ■

APR.MAY.JUN 2019 |

IT’S HERE! Your Guide to the Iowa MPJE Everything graduates and newto-Iowa pharmacists need to prepare for the Iowa Multistate Pharmacy Jurisprudence Examination, including:

of this text, must obtain express written

permission to do so by writing to the

• Information on how to register for the exam • Questions in a table format to fill in your answers • Answers to each question with references to information in Iowa code and administrative code • Terminology section of key terms to know

IPA members enjoy a substantial discount!

Order & Download Yours at

www.iarx.org/MPJEStudyGuide

“Iowa Pharmacy Association.”

IPA BOARD ELECTION

IPAâ&#x20AC;&#x2122;S NEWLY ELECTED LEADERS Congratulations to the newly-elected IPA Board of Trustee members! These members will be installed into office at the 2019 IPA Annual Meeting on June 20-21 in Cedar Rapids.

PRESIDENT

Connie Connolly, RPh, BCACP DeWitt

TRUSTEE - REGION 2

Shane Madsen, PharmD, BCPS North Liberty

TRUSTEE - AT LARGE

John Hamiel, PharmD Waterloo

PRESIDENT-ELECT

Diane Reist, BS Pharm, PharmD, RPh Cedar Rapids

TRUSTEE - REGION 4

Gary Maly, PharmD Sioux City

TRUSTEE - AT LARGE

Bill Doucette, PhD, FAPhA, RPh Iowa City

APR.MAY.JUN 2019 |

HEALTHCARE HOT TOPICS

Measles Outbreak Across the US The CDC confirmed 228 cases of measles in 12 states since the beginning of 2019. One outbreak, defined as three or more cases, is reported to be in Iowa’s neighboring state of Illinois. The cases have been linked to unvaccinated Americans who have returned from international travel, specifically from countries with large measles outbreaks such as Israel and Ukraine. This number puts 2019 on track to surpass the largest number of measles cases since 2000.

FDA Tightens Restrictions on Teen Tobacco Use FDA commissioner, Scott Gottlieb, released a new proposal designed to address the increasing incidence of teenage tobacco use. The proposal outlines new restrictions on flavored e-cigarettes, shortens the agencies deadline to review flavored products, and will allow the FDA to pull some e-cigarettes from the market. According to the CDC, 4.9 million middle and high school students were current users of some tobacco product in 2018. This was a 36% increase from 2017, with 3.6 million grade school students being current users in 2017. The FDA’s proposal is open for public comment until April 12, 2019.

Tabula Rasa acquires PrescribeWellness Tabula Rasa Healthcare signed a $150 million-dollar deal to acquire the California based company, PrescribeWellness. The purchase will allow Tabula Rasa to expand its network of pharmacy reach to an additional 10,000 pharmacies and more than 15,000 pharmacists that PrescribeWellness has contracted with over the years. CEO of PrescribeWellness, Al Babbington, says he believes the collaboration will accelerate innovation of healthcare in America and cut costs for government

programs, health plans, and consumers. The deal will lead to integration of Tabula Rasa’s platform, Medwise, into PrescribeWellness’s software for a more streamlined healthcare process.

Major Study Refutes Vaccine Skeptics A massive study from Denmark involving 657,461 Danish children born between 1999 and 2010 found no support for the hypothesis of increased risk for autism after MMR vaccination, no support of the hypothesis of MMR vaccination triggering autism in susceptible children, and no support for a clustering of autism cases in specific time periods after MMR vaccination. This study, published in the Annals of Internal Medicine, should help further refute vaccine skeptics.

Senate Hearings on Medication Pricing Late February, the Senate Finance Committee held a hearing with top executives from seven pharmaceutical companies to address increasing prescription drug prices. Chair of the committee, Iowa Sen. Chuck Grassley, began the hearing talking about Iowans being affected by high drug prices. The companies explained that they are not the only factor that contributes to drug costs: PBMs and insurance companies, they argued, have a greater impact on what price the patient sees at the counter. Without other reforms involving the other players that effect drug pricing, the companies are not willing to cut list prices.

FDA Commissioner Steps Down After less than two years in the position, the Trump administration announced Scott Gottlieb’s resignation as the commissioner of the Food and Drug Administration. Gottlieb was one of President Trump’s most popular appointees for his reputation of approving

generic drugs and lowering prescription drug costs for Americans. In his resignation letter, Gottlieb did not explain why he plans to leave the agency.

340B Policy from Caremark Repealed CVS Caremark listened to 340B pharmacies’ concerns about their proposed cut on reimbursements. The proposed change was that the PBM would reserve the right to apply “unique terms and conditions” to the 340B provider’s retail networks, due to the fact that manufacturers can deny rebates to 340B prescriptions. The second proposed change would have stopped the standard commercial pharmacy rates from going to pharmacies owned by 340B hospitals or clinics. After overwhelming pushback from 340B pharmacies, the PBM decided not to pursue these policy changes altogether. This marks a major win for 340B hospitals and pharmacies.

CMS Memo on LTC & Nursing Facilities In March, CMS issued a memo detailing the additional enforcement needed to bring 235 nursing facilities still noncompliant with decreasing the use of unnecessary antipsychotics up to standards. While there has been a decrease in the percent in residents receiving antipsychotic medications from 23.9% in 2011 to 14.6% in 2018, CMS will focus on these 235 “late adopters” through a dual-component approach: enhanced oversight with enforcement action, and outreach to corporations that own or operate the facilities. It is unknown where these 235 facilities are located. ■

APR.MAY.JUN 2019 |

NEW Weekday Format! NEW Poster Presentations & Innovation Forums! CELEBRATING 20 Years of Professional Achievements in Iowa Pharmacy! IPA’s Annual Meeting is the epicenter of pharmacy practice in Iowa. Each year pharmacists, pharmacy technicians, and student pharmacists come together from across the state to discuss policy, share innovative ideas, and making meaningful connections with colleagues and pharmacy leaders. With a new Thursday-Friday format this year, you can enjoy all of Annual Meeting and still have your whole weekend ahead of you. With this year’s revamped agenda, you can: • Take an active role in setting policy that will steer association action now • Hear and share innovative ideas to implement at your practice and advance the profession • Recharge by connecting with like-minded colleagues to build your network and opportunities for collaboration Join us at Annual Meeting to advance and celebrate your profession and you’ll leave refreshed and invigorated to better serve your patients!

AGENDA AT A GLANCE ADDITIONAL INFORMATION

Thursday, June 20, 2019 8:00-9:00 am

Registration/Breakfast

9:00-Noon

Cedar Rapids Marriott 1200 Collins Rd NE, Cedar Rapids, IA 52402 (319) 393-6600

House of Delegates Session 1 Keynote: ASHP and APhA Presidential Panel

12:00-2:00 pm

Lunch & Open Networking

1:00-2:30 pm

Policy Committee on Professional Affairs

Reserve your room by May 29 to secure a room at the block rate of $115-125.

2:00-3:30 pm

Innovation & Research Forums

3:00-4:30 pm

Policy Committee on Public Affairs

Silent Auction & Red Envelope Prize Donations

Hotel Information

5:00-6:00 pm

President’s Reception

To donate to the silent auction, please contact Laura at lmiller@iarx.org and provide a short description and approximate value (if available) of the item(s) you plan to donate. While items will be accepted up through the week of Annual Meeting, in order to have your item listed in the silent auction catalog, please notify Laura prior to June 1.

6:00-8:00 pm

Annual Banquet

8:00-10:00 pm

Silent Auction

6:30 am

Fun Run

Present Your Poster

7:00-8:00 am

Registration & Breakfast

8:00-9:00 am

Keynote: Matt Hosford, PharmD Vice President & Chief Pharmacy Officer Wellmark Blue Cross and Blue Shield

Continuing education credit will be available for several sessions throughout Annual Meeting. Details for CE are available at www.iarx.org/AMCPE.

9:00-9:45 am

Meet the Researchers - Poster Session 1

9:45-11:15 am

Innovation & Research Forums

11:15-Noon

Meet the Researchers - Poster Session 2

IPA developed two 30-minute webinars that provide additional background on two policy topics for CPE credit. The webinars are free to registered Annual Meeting attendees and are available at www.iarx.org/AMCPE.

Noon-1:00 pm

Lunch - 20 Years Unified Celebration Panel

1:15-3:30 pm

House of Delegates Session 2

3:30 pm

Adjourn

If you would like to present a poster, please submit an abstract at www.iarx.org/IPAAnnualMtg.

Continuing Education

Friday, June 21, 2019

| The Journal of the Iowa Pharmacy Association

YOU DON’T WANT TO MISS THIS! HOUSE OF DELEGATES

PRESIDENT’S RECEPTION

Session 1: Thursday - 9:00 am-Noon Session 2: Friday – 1:15-3:30 pm

Thursday - 5:00-6:00 pm

House of Delegates: Session 1 Keynote: ASHP and APhA Presidential Panel Kathleen Pawlicki, MS, RPh, FASHP President ASHP Brad Tice, PharmD, MBA, FAPhA President APhA Following the keynote, IPA’s Speaker of the House, Jim Hoehns, will preside over delegate orientation, the report of officers, policy committee hearings and new business review. This is your opportunity to provide feedback and participate in the discussions that will shape the policy decisions at Friday’s session. IPA will also present the Pharmacy Technician of the Year, Health-System Pharmacist of the Year, and Excellence in Innovation awards. House of Delegates: Session 2 Keynote: Matt Hosford, PharmD Vice President and Chief Pharmacy Officer Wellmark Blue Cross and Blue Shield Following the keynote, Speaker Hoehns will preside over the final policy debate, nomination of the 2019 Honorary President, ratification of the Nomination’s Committee report and the installation of Ashley Dohrn as the Speaker of the House. In addition, the 2019-2020 Vice-Speaker will be elected, and the Poster Presentation Award winner will be announced.

LUNCH & OPEN NETWORKING Thursday 12:00-2:00 pm A pause in a busy agenda to grab lunch and build that professional network or catch up with colleagues. Topic tables will be set up through the space to help stimulate conversations.

INNOVATION & RESEARCH FORUMS Thursday - 2:00-4:00 pm Friday – 9:45-11:15 am A new feature of the revamped Annual Meeting agenda is the inclusion of two Innovation and Research Forums to showcase innovations from pharmacists and pharmacy residents across the state to drive practice transformation. Each session will include tracks featuring presentations from Iowa pharmacy residents on their innovative research projects, giving you ideas to inspire, invigorate, and implement at your practice.

POLICY COMMITTEE MEETINGS Professional Affairs - Thursday 1:00-2:30 pm Public Affairs - Thursday 3:00-4:30 pm

ANNUAL BANQUET Thursday - 6:00-8:30 pm Celebrate, socialize and enjoy a great meal together as we install Connie Connolly as the 141st President of the Iowa Pharmacy Association. Prior to Connie’s inaugural address, we will present our most prestigious awards!

SILENT AUCTION Thursday - 8:30-10:00 pm Thursday evening will conclude with the popular IPA Foundation Silent Auction to support the Foundation’s educational and student programs. Plan to bid on an impressive array of items and participate in the wine/beer ring toss and red envelope fundraiser. Remember to come early during the President’s Reception and preview the silent auction items before the doors open!

FUN RUN/WALK Friday - 6:30 am Start the day off on the right (or left) foot! If you plan to participate, indicate your shirt size when you register.

MEET THE RESEARCHERS - POSTER SESSIONS Session 1: Friday - 9:00-9:45 am Session 2: Friday – 11:15-Noon IPA’s poster presentations, which highlight original projects or research that advance the practice of pharmacy in Iowa, have been expanded to two separate sessions on Friday. That’s twice the Iowa pharmacy innovation on display. Present your poster or meet with the presenters to discuss their projects (or both!). Posters are judged based on originality and innovation, reproducibility, impact on the profession, presentation and methodology. The IPA Foundation will present its Poster Presentation Award to the winner at the second session of the IPA House of Delegates on Friday afternoon.

20 YEARS UNIFIED CELEBRATION PANEL (LUNCH) Friday - Noon-1:00 pm In 2019, IPA is celebrating 20 years representing the profession in Iowa as a unified association. Throughout the meeting, you will have the opportunity to hear how the Iowa Pharmacists Association and the Iowa Society of Health-System Pharmacists united in 1999 and the impact of this collaborative model on the profession.

Policy committees will meet to incorporate delegate feedback from the first House of Delegates session into their policy proposals.

APR.MAY.JUN 2019 |

IOWA PHARMACY NEWS

IPA Names Amanda Abdulbaki as Executive Fellow Amanda Abdulbaki will be the IPA 2019-2020 executive fellow. She will graduate this spring from Mercer University College of Pharmacy in Atlanta.

While she comes to Iowa from Georgia, she has already been exposed to the vast opportunities for pharmacists in the state while completing several advanced practice pharmacy experiences within hospital pharmacy practice in central Iowa. As the fellow, Amanda will be immersed in the day-to-day activities of the association and work closely with IPA staff to continue advancing IPA’s mission. She will work to expand IPA’s clinical initiatives, attend state and national pharmacy meetings, gain exposure to all aspects of association work, and provide insight and assistance to the association. She will officially start with IPA on July 1, 2019. The IPA Executive Fellowship in Association Management was created to support the development of individuals interested in association management through training and experience in leadership, advocacy, professional affairs and problem-solving at IPA. Individuals who complete the fellowship will be well prepared for leadership positions in a variety of settings in the profession of pharmacy and health care.

IPA Hosts Adult Immunization Stakeholders

IPA and the Iowa Public Health Association co-hosted an Immunization Stakeholder Meeting at the IPA headquarters on February 19, 2019. There were 20 attendees representing a diverse group including various associations, health-systems, community pharmacy, industry, quality improvement organizations, academia, and the Iowa Department of Public Health. The group continued to discuss developing a joint policy statement to improve adult immunization rates and a public awareness campaign.

| The Journal of the Iowa Pharmacy Association

Also discussed was the anti-vaccine movement and potential legislation to relax immunization requirements.

Medication Safety and Effectiveness Roundtable

IPA staff and members continue to collaborate with the Iowa Healthcare Collaborative (IHC) to update the Medication Safety and Effectiveness statewide strategy. A group of state leaders were convened to discuss the current activities regarding medication management and pharmacist services. Also discussed were ideas to incorporate CPESN into IHC initiatives, advancing the IHC opioid strategy, and pharmacy’s role in the value-based healthcare environment.

MercyOne Medication History Program Celebrates 5-Year Anniversary

IPA was present to congratulate the team of eager technicians and innovative pharmacists that created the program to allow for a more efficient interaction between physicians and pharmacists through better utilization of pharmacy technicians in the hospital.

SIPA Awards 2019 Lou Carta Scholarship

The Southwest Iowa Pharmacists Association presented its 2019 Lou Carta Scholarship to Monica Nikseresht from Glenwood, Iowa, a P2 student pharmacist at Drake University. The amount of the scholarship is $1,000. Nikseresht is active in Kappa Psi Pharmaceutical Fraternity and is an ambassador for the Drake University College of Pharmacy and Health Sciences. Her community activities include volunteering for Reach Out and Read and the Ronald McDonald House. She is a recipient of Drake’s Kappa Psi Lon Larson Scholarship and Drake University’s Presidential Scholarship.

IPA Pilots BPS Exam Study Group

On March 5, MercyOne Hospital in Des Moines celebrated the 5-year anniversary of their medication history program, which utilizes pharmacy technicians to collect medication histories from patients in the emergency department. During the celebration, MercyOne spotlighted how certified pharmacy technicians have been successful in collecting complete medication histories for about 30 percent of the ED’s total unit admissions. MercyOne reported that their medication history technicians collect about 2,000 complete medication histories per month, or about eight histories per technician shift. As the program evolved, the medication history technicians expanded coverage to congestive heart failure bundled care patients and full coverage of multiple floors in the hospital, including pediatrics, intensive care units, and CSICU.

IPA has begun to pilot a BPS study group for pharmacists who will intend to take the initial or recertification BPS exam. The study group is designed for the BCPS or BCACP certifications as part of the spring examination period. The study group has met virtually one time per week for 10 weeks. Core topics were identified by the BPS exam review materials and supplemented the study group. The study groups were led by a mix of content experts and study group participants. IPA is looking forward to hosting the BPS study group in the future, and a pilot for a technician certification exam study group is in development as well. IPA will seek candid feedback about the process in order to develop a more robust program for the membership moving forward.

Iowa Pharmacist Tracking Reveals Key Trends in Profession As part of a service within the University of Iowa Carver College of Medicine, IPA and key pharmacy stakeholder groups

IOWA PHARMACY NEWS

received the 2017 report on the Iowa Pharmacist Tracking System. Current trends were presented, including: a net gain of 14 practicing pharmacists in Iowa for year end 2017 for a total of 2,991 practicing pharmacists, 62 percent of whom have a PharmD degree, and 64 percent of whom are female. The stakeholder group focused much of their discussion on the trends in the aging population of practicing pharmacists as 32 percent of pharmacists are 50 years of age and older. The tracking system revealed that there are 15 counties in Iowa with more than 50 percent of pharmacists over the age of 55. The tracking system also conducts similar studies for physicians, physician assistants, ARNPs, and dentists. Over the last 16 years, ARNPs had the largest increase in practitioners (189 percent) across the other professions being tracked. Pharmacists had a 21 percent increase over the same period.

IPA to Launch Two Podcasts on Pharmacy Podcast Network

IPA has joined the Pharmacy Podcast Network (PPN) and will launch two podcasts in the spring. PPN was established in 2009 and hosts over 25 different podcast shows and series dedicated to the profession and business of pharmacy to a listening audience of over 70,000. The first podcast to be launched on PPN will be ResilienceRx – focusing on helping pharmacists grow amidst stress. Each episode will feature a “Fail Forward” interview with a pharmacy leader and a personal growth and wellbeing tip by Tammy Rogers, founder of the Meyvn Group. The second podcast, Pharmacy: State of the States, will showcase pharmacy practice changes from those leaders and pharmacy organizations driving it in each state. Each episode will highlight the

collaboration, provider relationships, and legislative and regulatory priorities driving state and local level practice advancement. These podcasts will build off of the success of IPA’s BoP: What, Why & How podcast, which will continue independently from PPN. Be sure to subscribe to the Pharmacy Podcast Network on Apple Podcasts, Soundcloud, Spotify, Stitcher, and the PPN website – www. pharmacypodcast.com.

Shopko Closures Across Iowa

Shopko announced the closure of it’s 363 stores across two dozen states after declaring bankruptcy in January 2019. The company, based in Ashwaubenon, Wisconsin, was founded by pharmacist James Ruben in 1962. Over 30 stores will be closed in Iowa, leaving some communities with minimal options for pharmacy resources. One example of the impact is in Greenfield, where Shopko was the only pharmacy in town. Rachel Hall, previous manager of Greenfield Shopko pharmacy, and Bill Mather, a retired Greenfield pharmacist of 51 years, decided to open a NuCara in town for the benefit of their community after hearing that all of Greenfield’s Shopko pharmacy patient records would be transferred to Walgreens, whose closest store is over 50 miles away. Nucara opened the day after Shopko closed on February 12, 2019. All of Shopko’s stores will be closed by June 2019.

IPA Joins Campaign to Educate Public on Pharmacist’s Role

IPA has joined Pharmacists for Healthier Lives (PfHL) – a coalition of national and state pharmacy organizations coming together in a coordinated effort to raise the collective profile of the pharmacy profession. The coalition, led by the American Association of Colleges of Pharmacy, has created a national awareness campaign to highlight the important role of pharmacists in helping people live their healthiest, happiest lives. The IPA Board of Trustees approved financial and promotional support for the

campaign as it aligns with the association’s strategic plan to enhance public perception and awareness regarding the value of the pharmacy profession and its role on the healthcare team. In order to change the general public’s perception of pharmacists, PfHL sought to develop a unified message on the role of the pharmacist in patient care. Market research identified these four key messages deemed essential to change the perception of pharmacists: 1. Pharmacists are easily accessible. 2. Pharmacists help to ensure the best patient outcomes. 3. Pharmacists are highly educated. 4. Pharmacists are essential members of the healthcare team. Through these key messages, the campaign tagline “Pharmacists. Accessible. Knowledgeable. Indispensable.” was created. The messaging conveys the benefits a pharmacist provides patients including support when dealing with health and the healthcare system, confidence that their medication is the best option available, and availability of a knowledgeable healthcare professional. The campaign was developed using public relations to engage the media and a combination of organic and paid social media to reach target populations. The campaign launched in October and since then has reached over 4 million individuals on Facebook and the campaign video has had 8 million views and more than 10 million impressions. To get involved in the campaign, like or follow the Pharmacist for Healthier Lives Facebook page and share their posts and video on your own social networks. IPA will continue to provide updates on the campaign and share posts and opportunities for members to educate the public.■

APR.MAY.JUN 2019 |

ENGAGE CONNECT ENERGIZE ADVANCE

JOIN!

Find your spark, share your passion, or reinvigorate your fervor for pharmacy by plugging-in. IPA provides a unique opportunity for professional involvement that crosses the full spectrum of pharmacy practice. Tap into the wealth of knowledge and experience of the Iowa pharmacy community as you create meaningful connections with colleagues from a diverse array of practice settings. Share experiences and work sideby-side with your pharmacy family to advance the profession in Iowa.

Join IPA today at www.iarx.org

IOWA PHARMACY NEWS

RESOURCES TO UNDERSTAND AND ADDRESS PROFESSIONAL BURNOUT, BUILD RESILIENCY Addressing well-being and burnout within the pharmacy profession is a primary goal of IPA’s strategic plan. IPA recognizes that any advancement of the profession will never meet its full potential if those boots-on-the-ground pharmacists and pharmacy technicians tasked with providing additional services and patient care are compromised by burnout. Perhaps more importantly, a healthy and thriving clinician workforce is imperative to ensuring optimal patient health outcomes and safety.

individuals (including student pharmacists), online communitybuilding and peer support, promoting resiliency, and personal well-being.

IPA Goes Local Burnout and Resiliency Programming: Awareness. Management. Care.

Website

IPA is tackling this issue on several fronts, including compiling a website of resources – www.iarx.org/burnout - to help members understand and assess burnout, find self-care tools to improve their well-being, and help reverse burnout and build resiliency. Members are encouraged to use these resources for themselves or refer them to a colleague. Many of these resources are not profession-specific, so they can be used by your nonpharmacy colleagues as well.

This year’s IPA Goes Local events will address burnout and resiliency, exploring prevention and mitigation of burnout, reducing stress, and enhancing joy in the profession. This program is a partnership with the Iowa Medical Society, so nonpharmacy colleagues are invited too.

The Meyvn Group Partnership

IPA has partnered with the Mevyn Group to offer members additional resources and services to help pharmacists, student pharmacists, pharmacy technicians, and pharmacy organizations develop professional resiliency and avoid professional burnout at a discounted rate.

ResilienceRx Podcast Understanding Burnout: Understand what burnout is (and is not) and how it affects you, your colleagues, your practice, and potentially your patients. Included are the National Academy of Medicine’s extensive resource center, research articles, and the efforts of national organization to address burnout. Assessment: Here you will find tools to assess work-related dimensions of well-being and levels of burnout. These tools include those for self-assessment and team, practice, or institution-wide measurement. Resources: Find tools, tips, and strategies to build resilience and improve overall well-being in order to reverse or prevent burnout. This extensive list includes resources for leaders,

IPA will also be launching a nationwide podcast – ResilienceRx – on the Pharmacy Podcast Network focusing on resiliency, well-being, and helping pharmacists grow amidst stress. Each episode will feature a “Fail Forward” interview with a pharmacy leader and a personal growth and wellbeing tip from Tammy Rogers, founder of the Meyvn Group. This topic is of vital importance to the association and the profession. IPA will continue to provide resources for our members to address burnout in their own lives and the lives of their friends, colleagues, teams, and organizations. ■

APR.MAY.JUN 2019 |

STUDENT LOAN REFINANCING

Pay off student debt sooner. Save thousands. IPA and SoFi have teamed up to help you take down student debt—with student loan benefits, exclusively for IPA members, family and friends.

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Claim your 1001 toward your student loans at sofi.com/IPA. Checking your rate will not affect your credit score.2 Terms and Conditions Apply. SOFI RESERVES THE RIGHT TO MODIFY OR DISCONTINUE PRODUCTS AND BENEFITS AT ANY TIME WITHOUT NOTICE. To qualify, a borrower must be a U.S. citizen or permanent resident in an eligible state and meet SoFi’s underwriting requirements. See SoFi.com/elgibility for details. SoFi refinance loans are private loans and do not have the same repayment options that the federal loan program offers such as Income Based Repayment or Income Contingent Repayment or PAYE. Licensed by the Department of Business Oversight under the California Financing Law License No. 6054612. SoFi loans are originated by SoFi Lending Corp., NMLS # 1121636. Information as of July 2018. 1 Additional terms and conditions apply. Offer is subject to lender approval. To receive the offer, you must: (1) register and/or apply through the referral link you were given; (2) complete a loan application with SoFi; (3) have and provide a valid US bank account to receive bonus; (4) and meet SoFi’s underwriting criteria. Once conditions are met and the loan has been disbursed, you will receive your welcome bonus via automated clearing house (ACH) into your checking account within 30 calendar days. Bonuses that are not redeemed within 180 calendar days of the date they were made available to the recipient may be subject to forfeit. Bonus amounts of $600 or greater in a single calendar year may be reported to the Internal Revenue Service (IRS) as miscellaneous income to the recipient on Form 1099-MISC in the year received as required by applicable law. Recipient is responsible for any applicable federal, state or local taxes associated with receiving the bonus offer; consult your tax advisor to determine applicable tax consequences. SoFi reserves the right to change or terminate the offer at any time with or without notice. 2 To check the rates and terms you may qualify for, SoFi conducts a soft credit pull that will not affect your credit score. A hard credit pull, which may impact your credit score, is required if you apply for a SoFi product after being pre-qualified.

Celebrate your savings.

STUDENT COLUMN

STUDENT PHARMACIST PERSPECTIVE

PROFESSIONAL BURNOUT: A STUDENT’S PERSPECTIVE

urnout is a word that pharmacists and pharmacy technicians are all too familiar with. It is characterized by emotional and physical exhaustion brought on by high levels of stress and demand. Feeling burnout can stem from poor job satisfaction, lack of sleep, or reduced social support. It can go on to affect a person’s quality of work, personal relationships, and selfworth. Unfortunately for pharmacists, student pharmacists, and pharmacy technicians, it can also affect our patients. High stress environments and poor self-care can increase mistakes and decrease performance. Student pharmacists are well aware of the risk of burnout. Struggles with balancing work, studying for exams, writing papers, participating in extracurriculars, and searching for time to sleep and spend time with friends or family is what consumes our daily lives. Becoming a pharmacist is hard; however, it is disquieting to see our future profession in what seems to be a similar battle that students currently feel they are already facing. Many student pharmacists question, what does this mean for our future careers? As a third-year student pharmacist, I am consistently reminded in school of all the wonderful opportunities pharmacists have in expanding roles and improving the lives of our patients. Receiving my rotation list has only increased my excitement to

get out into the “real world” and see everything pharmacists can really do. When I begin my rotations, I expect to see the pharmacists I work with providing high quality and personal care to their patients, utilizing their extensive knowledge of a broad range of medications, and breaking down any barriers with different healthcare providers while building interprofessional relationships. I’m confident I will see this every single day for the next year, but what I hope to see is pharmacists and student pharmacists building one another up and searching for signs and symptoms of burnout and decreased mental health; something that we do every day for our patients.

Bridget Tunink 2020 PharmD Candidate Drake University 2018-2019 IPA Board of Trustees

symptoms. During my time on IPA’s board, I have watched professional burnout become a top priority on the strategic plan. A burnout and well-being resources page was created with links defining what burnout is and how to identify it, resources for leaders in their workplace, resilience podcasts, and sessions at the Midwest Pharmacy Expo.

“...what I hope to see is pharmacists and student pharmacists building one another up and searching for signs and symptoms of burnout and decreased mental health; something that we do every day for our patients.”

Students can also find resources from their colleges, and they should not go ignored. Free counseling centers, workout facilities, outreach programs, and many more are available to all students. Using these are beneficial when trying to learn how to balance all the aspects of pharmacy school.

In order to look out for one another, pharmacists, student pharmacists, and pharmacy technicians need to be familiar with their local, state, and national resources for burnout. This problem has gained the attention of many national organizations, including ASHP and APhA. Both organizations have resources for identifying burnout, and information on how to alleviate the signs and

Utilizing the resources that our pharmacy community and schools provide and asking our professors or coworkers for help are the first steps to improving our well-being as students and pharmacists. Entering into a profession that acknowledges burnout should not alarm students. Rather, it reminds us of our ability to rally together and help improve not only our patients’ lives, but our own. ■

APR.MAY.JUN 2019 |

COVER STORY

AN UPDATE ON OPIOID PRESCRIBING PATTERNS

How have measures to reduce the amount of opioids prescribed affected inappropriate opioid medication use?

he state of Iowa has been working to make positive strides in an attempt to address inappropriate opioid medication use in the state, while also leading by example for other states to follow. National data shows that the most prevalent population to receive an opioid prescription is rural, Caucasian females, under the age of 64 with Medicare coverage alone. This group only makes up 14% of the Iowa Medicare demographic, yet are responsible for filling the majority of opioid prescriptions in the state.

Pedati, the state medical director and epidemiologist at the Iowa Department of Public Health, which allowed for greater access to naloxone for people at risk of opioid overdose. Iowaâ&#x20AC;&#x2122;s statewide standing order is still in effect, allowing pharmacists to choose which route of naloxone prescribing and dispensing they deem appropriate. This allows at risk individuals along with family or friends to easily obtain the medication along with detailed instructions on how to properly use it. For more detailed information on naloxone, visit www.iarx.org/naloxone.

New federal legislation enacted the use of the Opioid Prescribing Mapping Tool, which allows healthcare professionals to better combat this crisis with improved data collection. Features include extra data like the Medicaid state opioid prescribing rates, which can be used in comparison with fee-for-service and managed care rates, along with Medicare Part D geographic opioid prescribing rates that can be used at an urban and rural level to allow for efficient comparison. These advancements raise awareness to the areas in greatest need of an intervention and provide the resources to counteract the issue.

Effective March 1, 2019, Iowa took a step further by capping the morphine milligram equivalents (MME) per day from 200 MME to 150 MME within the Iowa Medicaid program. Iowa Medicaid intends to continue this gradual reduction to 90 MME per day based on the CDC guidelines. In addition, prior authorization will be required for use of high-dose opioids over the set limit, not including patients undergoing active cancer treatment or end-of-life care. These efforts help to stop unnecessary prescribing of high-doses of opioids unless in necessary situations. Similarly, Wellmark has utilized an enhanced MME-based utilization management program (see Figure 1) for opioids that started on April 1, 2018.

Iowa recently passed a bill for a naloxone statewide protocol that builds on the successful expanded role of pharmacists and the current statewide standing order signed by Dr. Caitlin

| The Journal of the Iowa Pharmacy Association

With increased pressure on wholesale distributors and payers, many community

COVER STORY

pharmacies have also implemented new policies to assist in decreasing the number of opioid prescriptions dispensed. The following is how four prominent community pharmacies in Iowa are playing a role: CVS • Implementation of a 7-day supply limit of opioid therapy, or less, for patients new to opioid therapy with an acute condition • Enhanced counseling for community pharmacy patients new to an opioid prescription • Installation of safe medication disposal units Hy-Vee • No longer allow a subsequent fill of a Schedule II controlled substance or a refill of a Schedule III or IV controlled substance more than 72 hours early without authorization from the prescriber • No longer accept GoodRx coupons for controlled substance prescriptions

Walgreens • Installation of a year-round safe drug disposal option in all its pharmacies at no cost • Provide patient and support system education Wal-Mart • Implementation of a 7-day supply limit of initial acute opioid prescriptions, up to a 50 MME maximum per day • As of January 1, 2020, Wal-Mart and Sam’s Club will require e-prescriptions for controlled substances Additionally, the Iowa Board of Pharmacy continues to work with other states to integrate the state Prescription Drug Monitoring Program (PMP) into Iowa’s RxAware platform. Efforts in Iowa align with a new proposal set forth by the Department of Defense to expand all PMPs to include all 50 states to monitor overlapping opioid prescriptions. The Military Health System Prescription Drug Monitoring Program would allow for civilian and military providers to review patient opioid prescription histories

across the nation to combat the opioid crisis. Defense Health Agency officials are currently negotiating agreements with the states to begin the process for sharing prescription data. There continues to be a focus on inappropriate prescribing habits across the country. For example, in Ohio, a law was passed that now requires doctors to co-prescribe naloxone with opioids to select pain patients. The patients that qualify are taking high doses of opioids for chronic-pain conditions. The rule went into effect in December and aims to increase awareness of opioid related overdoses and strengthen prescriberpatient relations. Ohio and a few other states require a consultation on the risks of overdose or a prescription for naloxone when prescribing high doses of opioids. The nation is continually working to address this multifaceted issue that impacts not just healthcare professionals but every citizen. Continue to watch IPA communications for the latest news related to opioid medication misuse in Iowa and across the country. ■

Figure 1: Wellmark Enhanced MME-Based Utilization Management Program

Limit to 7-Day Supply

Limit Quantity of Opioids

Require Step Therapy

When appropriate, the length of the first prescription fill will be limited to seven days for new, acute opioid prescriptions for members who do not have a history of prior opioid use (based on their prescription claims).

The quantity of opioid products prescribed — including those that are combined with acetaminophen, ibuprofen or aspirin — will initially be limited to ensure amount does not exceed the maximum daily dose listed in labeling. Quantities are also ≤ 90 MME or less per day and contain ≤ 4 g APAP or ASA and ≤ 3200 mg ibuprofen.

Use of an immediate-release (IR) formulation will be required before moving to an extended-release (ER) formulation, unless the member has a previous claim for an IR or ER product, or the prescriber submits a PA request.

A physician can submit a prior authorization (PA) request if it is important to exceed the seven-day fill limit.

Prescribers who believe a patient should exceed CDC guideline recommendations can submit a PA request for up to 200 MME per day. Quantities higher than that would require an appeal. Note: Quantity limits will not apply to patients with cancer, a terminal condition or pain being managed through hospice or palliative care

APR.MAY.JUN 2019 |

Protect your patients. Protect your pharmacy. ERROR S CAN I NJU R E PAT I ENTS AN D P U T YOU R PHAR M ACY I N FI NANCIAL J E OPA R DY.

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Learn more at www.medicationsafety.org or call us at (866) 365-7472. The Alliance of Medication Safety (APMS) is a federally listed Patient Safety Organization (PSO).

PRACTICE ADVANCEMENT

IDPH/CDC Grants Awarded to Expand Pharmacist Services in Clinics As part of the CDC 1815 grant program, IPA and the Iowa Department of Public Health are working with pharmacists looking to expand their services within physician clinics. IPA has provided minigrants in the amount of $2,000 to three pharmacist/clinic teams, including: • Lucas County Health Center, Chariton, Iowa • MercyOne Medical Center, Waterloo, Iowa • Northeast Iowa Medical Education Foundation, Waterloo, Iowa The 1815 grant program is a multi-year CDC program that is looking to improve the health outcomes of patients with cardiovascular diseases in key target counties with poor rates of hypertension, dyslipidemia, and diabetes. IPA continues to work with IDPH to showcase the important role of pharmacists across all practice settings to improve these health outcomes when they are properly utilized by the rest of the healthcare system.

HIV Screening Initiative Underway Across the State The HIV point-of-care screening initiative is officially underway. Eight community pharmacies across the state have been providing free HIV screenings within their communities since January. The project, in conjunction with the Iowa Department of Public Health’s Bureau of HIV, STD and Hepatitis, aims to improve HIV routine screening rates and reduce the gap in linkage to care for any patients that test positive. A second cohort of six community pharmacies have been identified and will begin administered testing later this Spring. With the goal of 40 sites providing

HIV screenings, IPA is looking to gain more interest in the following counties: Palo Alto, Pocahontas, Calhoun, Webster, Humboldt, Kossuth, Clarke, Decatur, Wayne, Lucas, Monroe, Appanoose, Wapello. These are areas of the state that the Iowa Department of Public Health considers focus areas, based on their epidemiology reporting. To participate in the project or to learn more, please contact Kellie Staiert, IPA’s lead project manager, at kstaiert@iarx.org.

University of Iowa; IPA receive CPF Grant to Study Mental Health First Aid In partnership with the University of Iowa, the Community Pharmacy Foundation has chosen to support research on the impact of the Mental Health First Aid trainings offered to pharmacists and other pharmacy professionals by IPA and other pharmacist trainers across the country. The research will aim to understand the skills utilized by pharmacists in working with their patients, colleagues, family and friends. The research is set to commence in the Spring of 2019. In addition, the grant support will provide for the development of a toolkit to assist other pharmacy associations, colleges of pharmacy, and pharmacy stakeholders to offer similar trainings across the country.

New Practice Model Waiver Extended as Board Finalizes Rules For the 13 pharmacies still utilizing technician product verification (TPV) as part of the New Practice Model initiative, the workflow process to further optimize patient care opportunities in community-based pharmacies will soon be permanent. In March, the Board of Pharmacy approved a waiver extension for the pharmacies to utilize TPV as the Board is in its final steps to adopting rules to allow this practice to occur across all

types of pharmacy practice settings. While efforts in Iowa move forward, other state and national associations are continuing to utilize the TPV model to further enhance the opportunities for pharmacies to engage in patient care services. The National Association of Chain Drug Stores (NACDS) has worked closely with IPA and colleagues in Wisconsin and Tennessee to launch their website, https://www.nacds.org/ optimizing-care/, to showcase the efforts of all pharmacies involved. In addition, the research on the New Practice Model was showcased in March during the APhA Annual Meeting in Seattle. The data compiled from the entire research effort continued to demonstrate the safe and effective implementation of TPV for all prescriptions as a means to free up the time of the pharmacist for patient care services.

Medication Management Accelerator IPA is excited to announce and participate in a grant project with the Iowa Healthcare Collaborative that will give $15,000 to six clinics in Iowa to embed pharmacist delivered patient care services. IPA staff will provide technical assistance and support for these clinics: • Des Moines University Family Medicine – Des Moines • Horn Physician Clinic – Ida Grove • Lucas County Health Center – Chariton • Northeast Iowa Medical Education Foundation - Waterloo • Orange City Area Health System – Orange City • Primary Health Care Inc. – Des Moines The project will last five months with the goal of developing a sustainable model for the clinics to continue to offer pharmacist services. ■

APR.MAY.JUN 2019 |

FIRSTS, SECONDS, & FAVORITES AT THE 2019 MIDWEST PHARMACY EXPO! On February 8-10, nearly 300 pharmacists, pharmacy technicians, and student pharmacist from 17 states met at the brand new Hilton Des Moines Downtown for the 2019 Midwest Pharmacy Expo.

For the second consecutive year, Expo Friday featured Clinically Intensive Workshops. These popular sessions feature high-level, clinically-focused programming with topics this year covering biostatistics, infectious disease, interpreting labs, and cardiology. The topic of professional burnout and resiliency had a significant presence at this year’s Expo, beginning with Saturday’s keynote from Dr. Paul Radde, founder and CEO of the Thrival Institute. The topic was also one of Saturday’s four continuing education tracks in addition to Continuity of Care, Provider Readiness, and Hot Topics. In an Expo first, pharmacy technicians were fully integrated with pharmacists during Saturday’s breakout sessions with a slate of dually accredited sessions rather than a single pharmacy technician-focused track.

Expo wrapped on Sunday with long-time favorites New Drugs and Gamechangers. In between those sessions was one discussing electronic messaging and HIPAA compliance.

For the second year, several Saturday sessions were available through a livestream. Recordings of those sessions are available through CEI. Details on accessing the recorded sessions are available at MidwestPharmacyExpo.com/expo_encore.

Save the date: February 7-9, 2020

| The Journal of the Iowa Pharmacy Association

The 2020 Midwest Pharmacy Expo will again be held at the Hilton Des Moines Downtown. See you in 2020!

See also: Political Leadership Reception Welcomes Sen. Joni Ernst (pg. 36)

Expo Food Drive The Midwest Pharmacy Expo partnered with Pharmto-Tables to hold a food drive. With a raffle for gift cards and a meeting registration on the line, attendees responded generously by donating 272 pounds of food and $100 during the event.

In the week leading up to the Midwest Pharmacy Expo, the University of Iowa College of Pharmacy and the Drake University College of Pharmacy and Health Sciences engaged in a friendly â&#x20AC;&#x153;Phood Phight.â&#x20AC;? With statewide bragging rights on the line, the colleges competed against each other by earning a point for each pound of food or dollar collected. The combined totals from Expo and the Phood Phight were 394.5 pounds of nonperishable food donations plus $1,200. The food and monetary donations from Expo and Drake University were delivered to the Food Bank of Iowa. The University of Iowa donations went to the Johnson County Crisis Center.

IPA President Cheryl Clarke and Exec. Fellow Matt Pitlick delivered donations to the Food Bank of Iowa.

APR.MAY.JUN 2019 |

Your Next Great Hire is Here The Iowa Pharmacy Association Career Center gives you access to Iowaâ&#x20AC;&#x2122;s top pharmacists and pharmacy technicians. Our members are highly engaged and dedicated to taking pharmacy practice to the next level. Post your next open position to reach our top-level talent pool of active and passive job seekers to join your practice today!

www.iarx.org/CareerCenter

CPESN IOWA

ARE YOU READY?

he Iowa CPESN has continued to grow over the last few months. As of March 31, 2019, 105 pharmacies are participating in our local network. Our current statewide network contract with Tabula Rasa Healthcare to provide EMTM services for Medicare BlueRx patients is underway for 2019. The Iowa CPESN pharmacists are busy providing the first of two Medication Safety Reviews for high risk patients while we anxiously await the outcome of the efforts our pharmacists had with the project in 2018. Along with this EMTM program many local and regional conversations have begun percolating between network pharmacies and local employers, insurance brokers, ACOs, health systems and provider clinics. Network pharmacies have been asked to contract with CPC+ clinics to assist with meeting required metrics; collaborate in Chronic Care Management arrangements with local providers; Transition of Care services and at least one network pharmacy has signed an agreement with a small employer to provide a carve out pharmacy benefit for their employees. What an exciting and challenging time to be practicing pharmacy! I know every pharmacy is feeling the pressure of low product reimbursement and often unfair tactics by PBMs that challenge your patient’s access to local pharmacist care. You may be wondering how you can transform your pharmacy and your staff to join the network of pharmacies providing enhanced services across Iowa. Recently the Pharmacy Quality Alliance (PQA) released a new document called Strategies to Expand ValueBased Pharmacist-Provided Care Action Guide as a resource to assist pharmacists, payors and community pharmacy organizations to collaborate on pharmacist-provided care. As I read through the five actions community pharmacies can consider taking to advance pharmacist-provided care, I developed five questions each pharmacy should ask themselves when considering their readiness for

providing and participating in value based care initiatives: 1. Is my pharmacy operating model focused on pharmacist-provided care? Think about MedSync. If you are offering a true MedSync program in your pharmacy - allowing patients to pick up all of their ongoing prescription refills at the pharmacy on a single, convenient day each month and encourage increased pharmacist-patient dialogue to discover any medication related problems - you are on the right track! CPESN Iowa will soon be sending out a MedSync assessment for all network pharmacies to complete and review their current MedSync process and provide tips on enhancing the program at each site. 2. Do I and my “front line” pharmacists have up-to-date clinical knowledge and an understanding of the quality measures health plans are measured by and the role the pharmacist can play in that partnership? If not, the Iowa Pharmacy Association and CEI have incredible programs to assist in closing that knowledge gap and the CPESN hosts monthly webinars to discuss alternative payment models and the opportunities pharmacists have to affect quality measures for payors and providers. 3. Does my pharmacy provide efficient care delivery to patients? Pharmacy Management Systems, patient engagement technology as well as pharmacy support staff can all be used to identify which patients to contact, when and how often? If you haven’t thought about Technician Product Verification (TPV) this is something to consider as you begin to make necessary workflow changes to free up pharmacist time to engage with patients in value based care activities. Look for more information to come out from IPA in the near future to help you with this. 4. Does my pharmacy provide consistent clinical care and optimize outcomes for all patients? CPESN USA has developed a number of Service Set Standards that the local networks and

Lindsey Ludwig, RPh Executive Director CPESN Iowa

pharmacies can use when discussing services. These standards provide an outline for the pharmacy to adhere to and provide a consistent patient care service. Also, do my pharmacists document services provided? It is absolutely critical to document any patient encounters in order for you to be ready for value based care payment opportunities when they present. Practice now how you want to practice in the future. It is too late to start transforming when opportunities present…you must be preparing now. 5. Am I telling my story? If you can answer yes to all (or most) of the above questions get out and tell your story! You offer an amazing value to your local prescribers, hospitals, ACOs and employers so tell them how you can help them. Our network of enhanced service pharmacists collaborate across the state and across their counties to engage each other in conversations on payment for service models, share best practices and participate in value based services. As I mentioned in the last issue of the IPA Journal, disruptions are starting to occur throughout the healthcare system. The CPESN in Iowa is gaining momentum to participate in these disruptions. Our network of pharmacies, with a commitment to a core set of services and clinical integration, makes us uniquely poised to be able to contract with payors and assist providers and patients with meeting quality metrics while improving patient care. Contact me today if you are interested in learning more about the Iowa CPESN. To read the full report PQA created you can find it at www.pqaalliance.org.

APR.MAY.JUN 2019 |

PEER REVIEW

USE OF MEDICARE ADMINISTRATIVE CLAIMS TO IDENTIFY A POPULATION AT HIGH RISK FOR ADVERSE DRUG EVENTS AND HOSPITAL USE FOR QUALITY IMPROVEMENT Rachel Digmann, PharmD, BCPS Telligen, Des Moines, Iowa Anita Thomas, PharmD Centers for Medicare & Medicaid Services, Baltimore, Maryland Amanda Ryan, PharmD BCGP Qsource, Memphis, Tennessee Sherry Peppercorn, BS Lijing Zhang, MS Kimberly Irby, MPH Jane Brock, MD, MSPH Telligen, Greenwood Village, Colorado Author Correspondence: Rachel Digmann, PharmD, BCPS Clinical Pharmacy Specialist Telligen 1776 W. Lakes Pkwy. West Des Moines, IA 50266 515.273.8876 rdigmann@telligen.com

This article also appears in the Journal of Managed Care & Specialty Pharmacy, March 2019, Vol. 25, No. 3

| The Journal of the Iowa Pharmacy Association

Abstract Background A system using administrative claims to monitor medication use patterns and associated adverse events is not currently available. Establishment of a standardized method to identify Medicare beneficiaries at high risk for adverse events, by assessing Medicare Part D medication claim patterns and associated outcomes, including outpatient adverse drug events (ADEs) and hospital use, enhances prevention efforts and monitoring for quality improvement efforts. Objectives To (a) demonstrate that Medicare claims data can be used to identify a population of beneficiaries at high risk for adverse events for quality improvement and (b) define trends associated with adverse health outcomes in identified high-risk beneficiaries for quality improvement opportunities. Methods We used Medicare fee-for-service Part D claims data to identify a population at high risk for adverse events by evaluating medication use patterns. This population was taking at least 3 medications, 1 of which was an anticoagulant, an opioid, or an antidiabetic agent. Next, we used associated Part A claims to calculate rates of outpatient ADEs, looking for specific ICD-9-CM or ICD-10CM codes in the principal diagnosis code position. Rates of hospital use

(inpatient hospitalization, observation stays, emergency department visits, and 30-day rehospitalizations) were also evaluated for the identified high-risk population. The data were then shared for targeted quality improvement. Results We identified 8,178,753 beneficiaries at high risk for adverse events, or 20.7% of the total eligible fee-forservice population (time frame of October 2016-September 2017). The overall rate of outpatient ADEs for beneficiaries at high risk was 46.28 per 1,000, with anticoagulant users demonstrating the highest rate of ADEs (68.52/1,000), followed by opioid users (42.11/1,000) and diabetic medication users (20.72/1,000). As expected, the primary setting for beneficiaries at high risk to seek care for outpatient ADEs was the emergency department, followed by inpatient hospitalizations and observation stays. Conclusions Medicare claims are an accessible source of data, which can be used to establish for quality improvement a population at high risk for ADEs and increased hospital use. Using medication use patterns to attribute risk and associated outcomes, such as outpatient ADEs and hospital use, is a simple process that can be readily implemented. The described method has the potential to be further validated and used as a foundation to monitor population-based quality improvement efforts for medication safety.

PEER REVIEW What is already known about this subject • The 2014 National Action Plan for Adverse Drug Event Prevention identified anticoagulants, diabetes agents, and opioids as high-priority classes to focus on reducing adverse drug events (ADEs). • Medication safety efforts are limited by the lack of a national system to measure medication use patterns and associated health outcomes, such as ADEs and hospital use, for quality improvement efforts. • Measurement of outpatient ADEs is difficult, and no standard method for evaluation is currently available. What this study adds • This study describes a method, using Medicare claims data, to identify a population of fee-for-service Medicare beneficiaries at high risk for adverse events and hospital use based on nonhospital medication use patterns. • Use of Medicare claims data to establish a population of high-risk Medicare beneficiaries and track associated ADE rates provides a much needed public surveillance resource that can support medication management improvement efforts. • The high-risk Medicare beneficiary population had an annual ADE rate of 46.28 per 1,000 and used all hospital services at significantly higher rates compared with Medicare beneficiaries who were not high risk. Adverse drug events (ADEs) are common among older persons; however, information on outpatient ADEs is lacking. In 2003, Gurwitz et al. reported that ADEs are common among ambulatory geriatric patients, with an overall rate of ambulatory ADEs in a Medicare population of 50.1 per 1,000 person-years.1 Older adults are especially vulnerable, as age-related physiologic changes, coexisting conditions, and polypharmacy increases the risk of an ADE and the health impact of experiencing one.2,3 Reducing ADEs is a priority focus of the quality improvement

strategy of the Centers for Medicare & Medicaid Services (CMS).4 The Department of Health and Human Services (HHS) released the National Action Plan for Adverse Drug Event Prevention (ADE Action Plan) in 2014 identifying anticoagulants, opioids, and diabetes agents as high-priority drug class targets for ADE prevention efforts.5 One fundamental challenge for organizing national efforts to prevent ADEs, noted in the report, is the lack of a public health surveillance system that measures outpatient ADE rates and reports in a timely fashion. A system for evaluating population medication use in combination with ADE rates could not only track changes in ADE rates but also provide real-time insight on whether improvements in outpatient ADE rates are based on safety improvements or changes in medication use patterns. The report also notes the complex array of factors contributing to ADEs that are important considerations for prevention strategies, including polypharmacy and associated patient misuse of medications. These risks are particularly relevant to Medicare beneficiaries. Not only are they frequently exposed to polypharmacy, but the pool of medications present in their homes is also likely to far exceed their active medication lists as a result of modifications in medication regimens. The probably common but unmeasured extent and prevalence of this reality underscores the complexity of ADE prevention beyond the simpler situation implied by single specific exposure leading to a defined event.3 A decade ago, Budnitz et al. (2007) proposed applying principles of injury epidemiology to ADE reduction efforts by identifying potentially modifiable pre-event “host” characteristics and developing prevention efforts aimed at preoccurrence factors.6 CMS is using this conceptual strategy in the Quality Innovation Network–Quality Improvement Organization (QINQIO) program’s 11th Scope of Work by identifying a subset of the fee-forservice (FFS) Medicare population at

higher than usual risk for ADE through multiple medication exposures over the interval of a year.4 QIN-QIOs are charged with supporting ADE prevention through collaborative efforts to improve medication management processes across the care continuum. CMS initiated the work by defining “high risk” as use of at least 3 medications, 1 of which is a medication from 1 of the priority classes.1,3,4 The aim was to define a population subset large enough that improvement would have meaningful implications for the Medicare program yet focused enough to represent a population more than averagely exposed to risk of ADE. To measure ADE rates, we built on the work of others by choosing hospital care as a marker for prehospital gaps in medication management and developed a set of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes per priority drug class that feasibly represent ADEs’ given exposure.7-12 We calculated outpatient ADE rates per year for the beneficiary population at high risk and priority class-specific ADE rates by using the appropriate codes per exposure group. We compared all-cause hospital use rates among the population identified as high risk with the population not identified as high risk. Our approach is substantially different from traditional ADE measurement because our methods do not temporally couple known exposure to ADEs. Our approach monitored a population known to be in a high-risk temporally defined window for occurrence of ADE-compatible hospital care events (emergency department [ED] visits, observation stays, and inpatient hospitalizations) occurring during the same window. Our purpose was to enable claims data to serve as a population health-monitoring source for tracking mediation use patterns, health outcomes, ADE rates, and improvement in those rates associated with multistakeholder collaborative improvement activities. APR.MAY.JUN 2019 |

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Figure 1: Identification of Medicare FFS Beneficiaries at High Risk

Based on Medicare claims data from October 2016 to September 2017. FFS = fee for service.

Methods

We used Medicare fee-for-service (FFS) claims data available to the QIN-QIO program, including Part A (inpatient, observation stay, and ED) and Part D prescription drug claims. We limited the dataset for these analyses to FFS beneficiaries covered under the Medicare Prescription Drug Plan. FFS enrollment and eligibility were obtained from the Medicare Denominator File. All analyses were based on the most recent Medicare claims data covering a 12-month time period (October 2016-September 2017). The work reported in this study represents CMS quality improvement contract work that is part of health care operations so was exempt from institutional review board review. Defining a Population of Medicare Beneficiaries at High Risk Part D claims use the National Drug Code (NDC), a drug description system developed and maintained by the U.S. Food and Drug Administration (FDA).13 Because the NDC does not include a drug class categorization, we created a list of medications for each priority drug class list in the ADE Action Plan (anticoagulants, opioids, and diabetes medications) by proprietary and nonproprietary medication names.5 All identified names were matched to the FDA NDC file (first accessed January 2016) to create NDC number lists for each drug class, including any NDC (active and inactive) that contained a drug name on the initial list as a

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component (NDC numbers are available from the authors upon request).13 We merged the final NDC list with 12 months of Part D claims (October 2016-September 2017) by nonproprietary drug name, categorizing exposure as 30-59 days or 60 days or more. We maintained the definition of a “beneficiary at high risk,” as provided by CMS in the QIN-QIO 11th scope of work, and assigned high-risk status to any FFS Medicare beneficiary using at least 3 prescriptions for 60 or more nonconsecutive days, plus a highpriority medication for 30 or more nonconsecutive days or any Medicare FFS beneficiary receiving at least 2 prescription medications for 60 or more nonconsecutive days, plus 1 priority medication for 60 non-consecutive days within a calendar year.4

Outcomes

Outpatient ADEs. We started with a list of ICD-9-CM/ICD-10-CM codes, from previously published work, to identify codes reasonably associated with ADEs by priority drug class (Appendix A, available in online article).8-10 Additional codes were added to the initial list based on descriptions that reasonably represent priority drug class outpatient ADEs. We convened a technical advisory panel (Appendix B, available in online article) of pharmacists, physicians, and medical coding experts to review the list of proposed outpatient ADE diagnosis codes for beneficiaries exposed to an

anticoagulant, an opioid, or a diabetes medication. Three virtual meetings in early 2015 supported discussion and refinement of ADE code lists per drug class exposure. We cross-walked the final list of ADE ICD-9-CM codes to associated ICD-10-CM codes using general equivalence mappings to generate a list of codes that would be useful across the entire QIN-QIO 5-year contract cycle.14,15 We merged the list of Medicare identification numbers for all beneficiaries in the high-risk population with Part A claims and identified hospital care events for each beneficiary from October 2016 to September 2017 using national claims history (NCH) claim type, revenue center code, and Healthcare Common Procedure Coding System (HCPCS) code variables. We counted sequential levels of hospital service at the highest service level (i.e., we excluded any ED visit immediately preceding an observation stay and any observation stay immediately preceding an inpatient hospitalization claim). Any admission to a short-term acute care hospital, critical access hospital, psychiatric hospital, or psychiatric unit qualified as a hospitalization. We excluded long-term care facilities, rehabilitation hospitals and units, and children’s hospitals. Any hospitalization occurring within 24 hours of admission to a different hospital was considered a transfer, which we counted as a single event.

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Each principal diagnosis code for each hospital care event was compared with the list of ICD-9/10-CM codes designating outpatient ADEs. Beneficiaries flagged for exposure to more than 1 priority drug class were assessed for each set of relevant ADE codes. Occurrences of hospital care indicating possible ADEs were tallied per beneficiary. We expressed overall outpatient ADEs as rates per beneficiaryyear, by calculating total number of ADEs divided by total beneficiary days, using the Medicare enrollment file to calculate days of FFS eligibility per beneficiary at high risk. Drug class-specific rates were calculated across all beneficiaries exposed to the drug class. We did not risk adjust outpatient ADE rates, as our goal was to calculate an outpatient ADE rate for the entire population identified by medication use patterns, not to assess the independent risk conferred by the medication use pattern. Hospital Use (All Cause). We linked the file of beneficiaries at high risk to Part A claims to determine all-cause hospital use. We defined all-cause hospital use as the sum of all hospital care events for each beneficiary from October 2016 through September 2017, using NCH claim type, revenue center code, and HCPCS code variables. We did not stratify for any particular diagnosis. As previously mentioned, we counted sequential levels of hospital service at the highest service level. Any hospitalization in a short-term acute-care hospital, critical-access hospital, psychiatric hospital, or psychiatric unit qualified as a hospitalization. We excluded long-term care facilities, rehabilitation hospitals and units, and children’s hospitals. Any hospitalization occurring within 24 hours of a hospitalization at a different hospital was considered a transfer, which we counted as a single hospitalization. We expressed hospital use as rates per beneficiary-year, using the Medicare enrollment file to calculate days of FFS eligibility per beneficiary at high risk. To compare hospital use in the high-risk population with use in the population not at high risk, we dichotomized use

as “yes” for at least 1 hospital care event and “no” for none. We used multivariate logistic regression using SAS 9.1 (SAS Institute, Cary, NC) in a Unix environment to adjust for demographic factors.

Results

Our definition of high risk, based on medication use patterns and exposure to priority drug class medications, identified 20.7% (n = 8,718,753) of the total eligible Medicare FFS population (N = 42,006,051) as beneficiaries at high risk (Figure 1). More than half of the high-risk population were female (56.1%), and a majority were younger than aged 75 years (60.3%). Beneficiaries at high risk were primarily white (75.3%), not dual eligible (66.3%), and did not live in ZIP codes designated as rural (64.5%) by the U.S. Census Bureau definition of a urbanized area (Table 1).4

Table 1: Demographic Characteristics of Medicare Beneficiaries at High Risk Versus Beneficiaries Not at High Risk FFS Medicare Beneficiaries at High Risk (n = 8,718,753)

FFS Medicare Beneficiaries Not at High Risk (n = 33,287,298)

n (%)

<65

1,817,113 (20.8)

5,087,962 (15.3)

65-69

1,746,656 (20.0)

10,355,806 (31.1)

70-74

1,699,553 (19.5)

6,794,137 (20.4)

75-79

1,363,133 (15.6)

4,310,324 (12.9)

80-84

993,983 (11.4)

2,967,080 (8.9)

1,098,315 (12.6)

3,771,989 (11.3)

Male

3,825,726 (43.9)

15,784,706 (47.4)

Female

4,893,027 (56.1)

17,502,592 (52.6)

White

6,565,860 (75.3)

25,762,647 (77.4)

Black

1,024,569 (11.8)

3,205,701 (9.6)

Hispanic

644,253 (7.4)

2,106,424 (6.3)

Asian

257,661 (3.0)

904,405 (2.7)

North American Native

56,768 (0.7)

181,977 (0.5)

Other/unknown

169,642 (1.9)

1,126,144 (3.4)

Nondual

5,778,844 (66.3)

28,618,261 (86.0)

Dual

2,939,909 (33.7)

4,669,037 (14.0)

Nonrural

5,622,999 (64.5)

23,062,656 (69.3)

Rural

3,095,754 (35.5)

10,224,642 (30.7)

Characteristics Age group, years

85+ Gender

Race

Dual Eligible

Rural

Based on Medicare FFS Part D claims from October 2016 to September 2017. FFS = fee for service.

All demographic variables tested showed statistically significant differences between beneficiaries at high risk and those not at high risk, as could be expected in testing a dataset of more than 40 million observations. The overall outpatient ADE rate in the beneficiary population at high risk was 46.28 per 1,000 FFS beneficiaries at high risk. By priority drug class exposure, anticoagulant users had the highest rate

of outpatient ADEs at 68.52 per 1,000, followed by opioids users at 42.11 per 1,000 and users of diabetes agents with 20.72 per 1,000 (Figure 2 and Table 2). As expected, the ED is the most frequently used hospital setting for outpatient ADE treatment, followed by inpatient hospitalizations and observation stays. After adjustment for age, gender, race, dual eligibility status and rural residence, the beneficiary population at high risk APR.MAY.JUN 2019 |

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had higher risk for overall hospital use (odds ratio [OR] = 2.34, 95% confidence interval [CI] = 2.34-2.35, P < 0.0001) compared with beneficiaries not at high risk (Table 3).

Figure 2: Total ADE Rates by Drug Class

Discussion

The definition of beneficiaries at high risk accounts for the dual risks of multiple medication use and exposure to the high-priority medications targeted by the ADE Action Plan.5 It can also support ADE reduction efforts through describing a subgroup in which event detection is more likely and more effective, ensuring that improvement activities focus on those most likely to benefit.11 The subset of the Medicare FFS population identified by our high-risk criteria is at increased risk for all types of hospital use, including hospitalization, ED visits, and observation stays. It is especially true for beneficiaries on multiple medications and using an anticoagulant. Although anticoagulant users are the smallest proportion of the high-risk population, they have the highest rates of hospital use and the highest rates of ADEs (Table 2). To validate the association between the medication use characteristics we used to define our high-risk population and hospital use, we performed a simple logistic regression comparing use in the high-risk population with the population not included in the high-risk category, adjusting for common demographic factors (Table 3). The population at high risk had 2.34 times higher risk of hospital use than those not at high risk (95% CI = 2.35-2.35, P < 0.0001), and high-risk status was more strongly associated with hospital use than gender, race, dual eligibility, or rural residence. The only factor more strongly associated with hospital use was advanced age, with those aged 80 years or older having the highest risk. The selection of 3 or more medications as a criterion for elevated risk in the elderly aligns with previous research and provides a metric of risk easily remembered by clinicians and patients.4,7 Use of annual days supply to determine medication exposure and adherence is established in the literature and is easily

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ADE = adverse drug event; ED = emergency department; FFS = fee for service.

tracked through Medicare Part D data.16 Monitoring a high-risk population over time provides a population-based, claimsbased approach for analyzing trends in medication use patterns, and health outcomes that are not tied to specific types of medical services. It identifies risk outside of institutional care, laying the foundation for managing the challenge of safe medication use as a community problem that requires cooperative work among an array of providers. The striking differences in proportion of the total FFS Medicare population included in the high-risk population per state (range: 12.6%-28.7%; average: 20.6%) also suggests a wide degree of localized variation in medication use practices, which might be used to illuminate best practices for reducing ADE occurrence through improved prescribing. Our finding of an overall outpatient ADE rate of 46.28 per 1,000 beneficiaries at high risk is similar to a previous report by Gurwitz et al. (2003; 50.1 ambulatory ADEs/1,000 person-years) and Gabriel et al. (2017; 21-44/1,000 Medicare diabetes beneficiaries).1,11 However, our numbers may still represent a conservative estimate for a high-risk population. We calculated our rates using only principal diagnosis codes or the coding reflecting the â&#x20AC;&#x153;condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital

for care.â&#x20AC;?14,15 Our count, therefore, limited detection to events not only severe enough to require hospital care but also to the subset of those that were the principal cause of the hospital contact. We believe this conservative approach minimized the capture of hospital-related ADEs and supports our intention to estimate the prevalence of events related to nonhospital medication management. We undertook this work to define a population in which rates would be high through known risks and that can be monitored using only administrative (claims) data. It is not a replacement for other more rigorous surveillance efforts but is intended to supplement them with an available, easily produced measurement strategy that can be used to track change produced by improvement efforts enacted in local health care markets without burdening medical providers. The Centers for Disease Control and Preventionâ&#x20AC;&#x2122;s National Electronic Injury Surveillance SystemCooperative Adverse Drug Events Surveillance System (NEISS-CADES) measures outpatient ADE by detailed clinical record review and sampling of ED visits and emergent hospitalizations attributed to harm from outpatient drug use.17 NEISS-CADES participation is time and effort intensive, requiring a dedicated data collection coordinator. To be counted as an ADE, the clinical

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Table 2: Outpatient ADEs and Hospital Use for Beneficiaries at High Risk by Priority Drug Class Anticoagulant (n = 2,262,523) Measures

Adverse drug events

Hospital use

Setting

Per 1,000 FFS BHRs

Diabetic (n = 4,823,414) n

Per 1,000 FFS BHRs

Opioid (n = 3,877,876) Per 1,000 FFS BHRs

ED visits

79,312

35.05

55,513

11.51

73,284

18.90

OBS stays

12,352

5.46

28,854

5.98

32,342

8.34

Inpatient hospitalizations

63,357

28.00

15,588

3.23

57,681

14.87

Total ADEs

155,021

68.52

99,955

20.72

163,307

42.11

ED visits

1,712,188

756.76

2,966,547

615.03

3,993,915

1,029.92

OBS stays

324,709

143.52

460,116

95.39

543,511

140.16

Inpatient hospitalizations

1,809,426

799.74

2,207,583

457.68

2,740,260

706.64

Total hospital use

3,846,323

1,700.01

5,634,246

1,168.10

7,277,686

1,876.72

Based on Medicare FFS claims from October 2016 to September 2017. ADE = adverse drug event; BHR = beneficiary at high risk; ED = emergency department; FFS = fee for service; OBS = observation.

documentation must include specific notation of drug exposure and the timing of that exposure. Resulting national estimates are calculated from a set of representative hospitals. The Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP) uses administrative claims and ICD-9/10-CM codes like our method, but they do not report an outpatient ADE rate.18,19 Rather, they rely on voluntary participation of hospitals, leading to variation among states in degree of participation and data elements submitted among those choosing to participate. Neither NEISS-CADES nor HCUP can estimate the size of the population using high-risk medications, account for risks associated with multiple medication use, associate medication use patterns with health outcomes, nor track medication use patterns over time. This method for ADE measurement is not intended, and is not appropriate, for performance measurement applied to individual providers. Although we tested the independent association of high-risk status with hospital use outcomes, we did so to verify that our population definition and ADE measurement strategy were reasonable for use in tracking medication management quality and that the association of high-risk status with important outcomes were not due to demographic confounders. In our quality improvement initiatives, we do not use

this metric as a risk-adjusted measure. We also do not recommend complete reliance on this measurement strategy as a substitute for provider-collected internal data in assessing the gains made by individual provider-specific efforts.

Limitations

Although the methods described are a good foundational start, there remain important limitations. First, most of the ICD-9/10-CM codes used for these analyses were not designed for the purpose of conducting ADE surveillance and do not reflect linkage of harms to medication use. Diagnostic codes that are designed to identify adverse events attributable to a drug (i.e., External Causes of Injury Codes [E-codes]) are included in the set of codes we used, but as in other research, they represent a small fraction of identified codes and have been found to lack sensitivity for capturing ADEs.20 Because we used the codes in association with a population defined by exposure, sensitivity should be enhanced, but coding practices often reflect local and variable norms, making ICD codes an imperfect data source for determination of outcomes. Additionally, we may have omitted relevant codes, causing us to miss hospitalizations that should be considered ADE related. Future quality improvement initiatives should include a focus on assisting providers in better using the ICD-10-CM codes designed to capture ADEs and/or

building the capacity of coding systems to capture nuances related to possible medication related events. Second, the current method calculates prevalence of events per year in a population known to be high risk each year but does not temporally tie exposure with event. Much of the previous research on ADEs seeks to establish “causation” of an event based on timing of exposure to specific medications. Our method is similar to public health surveillance, which is “the ongoing, continuous collection, analysis and interpretation of data, closely integrated with the timely dissemination of these data to those responsible for preventing and controlling disease and injury.”21 A fundamental principle of public health surveillance is that surveillance should be designed and implemented to provide information in a timely manner at the lowest possible cost.21 Sacrificing precision—in this case timing of medication fills related to adverse events— makes sense to improve timeliness of data dissemination and save resources that can be used for interventions. The notion that ADEs only occur within a specified timeframe associated with medication fill dates fails to consider that patient medication fills do not necessarily equal medication exposure. Often patients will have numerous medications and various doses available at home with easy access to use. Although

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Table 3: Hospital Use Adjusted Odds Ratios Characteristic

Odds Ratio (95% CI)

ADE risk status Beneficiaries at high risk

2.34 (2.34-2.35)

Beneficiaries not at high risk

1.00a

Age group, years < 65

1.91 (1.90-1.91)

65-69

1.00a

70-74

1.45 (1.45-1.46)

75-79

1.91 (1.90-1.91)

80-84

2.48 (2.48-2.49)

85+

3.39 (3.38-3.40)

Gender Female Male

1.09 ( 1.09-1.09) 1.00a

Race White

1.00a

Black

1.13 (1.12-1.13)

Hispanic

0.79 (0.79-0.79)

Asian

0.48 (0.48-0.48)

North American Native

1.06 (1.05-1.07)

Other/unknown

0.62 (0.61-0.62)

Dual eligibility status Dual eligible Nondual eligible

1.84 ( 1.83-1.84) 1.00a

Geographic location Rural Nonrural

1.13 (1.12-1.13) 1.00a

Based on Medicare claims from October 2016 to September 2017. a Reference group. ADE = adverse drug event; CI = confidence interval.

claims data provide a medication fill date, we do not know when ingestion of that medication occurs, nor do we know the effect of retained medication in the home. Consideration of timing of priority medication fills via Part D claims and event timing in Part A claims may provide more precise and actionable information for health care

improvement activities in the future but may ultimately delay the ability to disseminate information in a timely fashion. Our main purpose, however, was to enable claims data to serve as a public health monitoring source for tracking medication use patterns, health outcomes, ADE rates, and improvement in those rates associated with multistakeholder collaborative improvement activities via the QIN-QIO program.

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Conclusions

Our method is an effective way to use claims data to identify a FFS Medicare population at high risk for ADEs, which is likely to be useful in tracking improvement in ADE rates generated through comprehensive approaches to improving medication management generally. We estimate that 46.29 per 1,000 beneficiaries at high risk experience an ADE within a 12-month exposure period. These methods allow tracking and trending of ADE rates and population medication use patterns, which addresses the lack of a public health surveillance process, an important limitation of national safety work that aims to reduce ADEs. The identified population has double to triple the rate of events compared with the overall FFS population. Data generated using an administrative claims-based process to identify a high-risk population can guide timely quality improvement efforts to improve medication management. Additionally, this method lays the foundation for establishing national public health surveillance of outpatient ADE rates and associated health outcomes by priority drug classes.

Disclosures

This work was performed under contract HHSM-500-2014-QINNCC, Modification No. 000004, funded by Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. CMS did not have a role in the analysis. At the time of this analysis, Digmann, Peppercorn, Zhang, Irby, and Brock were employees of Telligen, which was awarded the National Coordinating Center-Quality

Improvement Organization contract from CMS, which supported the work. Ryan was an employee at Qsource, which was awarded the Quality Innovation Network Quality Improvement Organization contract from CMS, which supported the work. Thomas was employed by CMS. The content is solely the responsibility of the authors and does not necessarily represent the official views or policies of the CMS. This work is posted on the QIOprogram.org website, as recommended in the Common Rule (https://www.hhs.gov/ohrp/regulationsandpolicy/regulations/common-rule/ index.html).

Acknowledgments

This project depended on the coordinated efforts of several participants in the government, the QIN-QIOs, and the community. The writing team is grateful to Jim Turpin with TMF (formerly); Darren Triller, PharmD, with IPRO (formerly); and Kyle Campbell, PharmD, with HSAG, who provided guidance in the initial construction of the ADE ICD code lists based on experience from previous work. Also, thanks to Beth Stevens, with Telligen, for analytic guidance and support. The Quality Innovation Network National Coordinating Center (QIN NCC) and CMS are grateful to the entire Technical Advisory Panel for their insight and feedback on the development and finalization of the ADE ICD code lists. The medication safety work depended critically on these leaders and their expertise, which was provided without compensation.

References

1. Gurwitz J, Field T, Harrold L. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107-16. 2. Salvi F, Marchetti A, Dâ&#x20AC;&#x2122;Angelo F, Boemi M, Lattanzio F, Cherubini A. Adverse drug events as a cause of hospitalization in older adults. Drug Saf. 2012;35(Suppl 1):29-45. 3. Medicare Payment Advisory Committee. Chapter 5: Polypharmacy and opioid use among Medicare Part D enrollees. In: Relationship between polypharmacy, adherence, and patient confusion: report to the Congress: Medicare and the health care delivery system. June 2015. Available at: http:// medpac.gov/ docs/default-source/reports/june2015-report-to-the-congress-medicare-andthehealth-care-delivery-system.pdf. Accessed January 22, 2019. 4. Centers for Medicare & Medicaid Services. Quality

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Innovation Network (QIN) Quality Improvement Organizations (QIOs). QIN-QIO 11th Statement of Work awards. 2014. Available at: https://www.fbo. gov/?s=opportunity&m ode=form&id=9a679a5cb e7f3a8b5098e6a366939852&tab=core&_cview=1. Accessed January 22, 2019. U.S. Department of Health and Human Services. National action plan for adverse drug event prevention. 2014. Available at: https://health.gov/ hcq/ pdfs/ade-action-plan-508c.pdf. Accessed January 22, 2019. Budnitz D, Layde P. Outpatient drug safety: new steps in an old direction. Pharmacoepidemiol Drug Saf. 2007;16(2):160-65. Bourgeois FT, Shannon MW, Valim C, Mandl KD. Adverse drug events in the outpatient setting: an 11-year national analysis. Pharmacoepidemiol Drug Saf. 2010;19(9):901-10. Ginde AA, Blanc PG, Lieberman RM, Camargo CA Jr. Validation of ICD9-CM coding algorithm for improved identification of hypoglycemia visits. BMC Endocr Disord. 2008;8:4. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002-12. Shehab N, Sperling LS, Kegler SR, Budnitz DS. National estimates of emergency department visits for hemorrhage-related adverse events from clopidogrel plus aspirin and from warfarin. Arch Intern Med. 2010;170(21):1926-33.

11. Gabriel M, Powers C, Encinosa W, Bynum J. E-prescribing and adverse drug events: an observational study of the Medicare Part D population with diabetes. Med Care. 2017;55(5):456-62. 12. Braden JB, Russo J, Fan MY, et al. Emergency department visits among recipients of chronic opioid therapy. Arch Intern Med. 2010;170(16):1425-32. 13. U.S. Food & Drug Administration. National Drug Code directory. December 11, 2018. Available at: https://www.fda.gov/Drugs/ InformationOnDrugs/ ucm142438.htm. Accessed January 22, 2019. 14. Centers for Disease Control and Prevention. ICD10-CM official guidelines for coding and reporting. 2014. Available at: https://www.cdc.gov/nchs/ data/icd/icd10cm_guidelines_2014.pdf. Accessed January 22, 2019. 15. Centers for Medicare & Medicaid Services. ICD10-CM official guidelines for coding and reporting. 2016. Available at: https://www.cms.gov/ Medicare/ Coding/ICD10/Downloads/2016-ICD-10-CMGuidelines.pdf. Accessed January 22, 2019. 16. Taitel M, Fensterheim L, Kirkham H, Sekula R, Duncan I. Medication daysâ&#x20AC;&#x2122; supply, adherence, wastage, and cost among chronic patients in Medicaid. Medicare Medicaid Res Rev. 2012;2(3):pii: mmrr.002.03.a04. 17. Office of Disease Prevention and Health Promotion. National electronic injury surveillance system-cooperative adverse drug event surveillance

18.

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project. January 19, 2019. Available at: https:// www.healthypeople.gov/2020/ data-source/ national-electronic-injury-surveillance-systemcooperativeadverse-drug-event. Accessed January 22, 2019. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP). January 2019. Available at: https://www.hcupus. ahrq.gov/. Accessed January 22, 2019. Weiss A, Bailey M, Oâ&#x20AC;&#x2122;Malley L, Barrett M, Elixhauser, Steiner C. Patient characteristics of opioid-related inpatient stays and emergency department visits nationally and by state, 2014. HCUP Statistical Brief #224. June 2017. Available at: https://www.hcup-us.ahrq.gov/reports/ statbriefs/sb224-PatientCharacteristics-OpioidHospital-Stays-ED-Visits-by-State.pdf. Accessed January 22, 2019. Leonard CE, Haynes K, Localio AR, et al. Diagnostic E-codes for commonly used, narrow therapeutic index medications poorly predict adverse drug events. J Clin Epidemiol. 2008;61(6):561-71. Nsubuga P, White M, Thacker S, et. al. Public health surveillance: a tool for targeting and monitoring interventions. In: Jamison DR, Breman JG, Measham AR, et al, eds. Disease Control Priorities in Developing Countries. 2nd ed. New York: Oxford University Press; 2006:997-1016.

APPENDIX A: High-Priority Drug Class ICD-9/10-CM Codes Indicative of an Adverse Drug Event Anticoagulant (ICD-9-CM)

E9804, E9342, E8582, 9642, 79092, 78639, 78630, 7848, 7847, 7827, 71919, 71918, 71917, 71916, 71915, 71914, 71913, 71912, 71911, 71910, 6271, 59971, 59970, 5789, 5781, 5780, 5693, 56881, 53551, 53541, 53541, 53521, 53511, 53511, 53461, 53460, 53441, 53440, 53421, 53420, 53401, 53400, 53361, 53360, 53341, 53340, 53321, 53320, 53301, 53300, 53261, 53260, 53241, 53240, 53221, 53220, 53201, 53200, 53161, 53160, 53141, 53140, 53121, 53120, 53101, 53100, 53082, 53021, 4590, 4558, 4552, 4551, 4329, 4321, 4320, 431, 430, 4230, 37923, 37632, 37272, 36281, 2859, 2851, 2800

Anticoagulant (ICD-10-CM)

T45525S, T45525D, T45525A, T45524S, T45524D, T45524A, T45521S, T45521D, T45521A, T45515S, T45515D, T45515A, T45514S, T45514D, T45514A, T45511S, T45511D, T45511A, R791, R58, R319, R310, R233, R049, R0489, R042, R041, R040, N950, M2508, M25076, M25075, M25074, M25073, M25072, M25071, M25069, M25062, M25061, M25059, M25052, M25051, M25049, M25042, M25041, M25039, M25032, M25031, M25029, M25022, M25021, M25019, M25012, M25011, M2500, K922, K921, K920, K661, K648, K625, K2991, K2971, K2961, K2951, K2941, K2931, K286, K284, K282, K280, K276, K274, K272, K270, K266, K264, K262, K260, K256, K254, K252, K250, K228, K2211, I629, I621, I6203, I6202, I6201, I6200, I619, I618, I616, I615, I614, I613, I612, I611, I610, I609, I608, I607, I606, I6052, I6051, I6050, I604, I6032, I6031, I6030, I6022, I6021, I6020, I6012, I6011, I6010, I6002, I6001, I6000, I312, H4313, H4312, H4311, H4310, H3563, H3562, H3561, H3560, H1133, H1132, H1131, H1130, H05239, H05233, H05232, H05231, D649, D62, D500

Diabetic (ICD-9-CM)

2511, 2512, 7802, 78097, 9623, 99523, E8588, E9323, E9804

Diabetic (ICD-10-CM)

E08649, E160, E161, E162, R410, R4182, R55, T383X1A, T383X1D, T383X1S, T383X4A, T383X4D, T383X4S, T383X5A, T383X5D, T383X5S

Opioid (ICD-9-CM)

E9804, E9800, E9620, E9352, E9351, E8502, E8501, 96509, 96502, 7991, 79902, 79901, 78097, 7802, 7801, 78009, 78003, 78002, 78001, 51882, 51881, 51851, 30553, 30552, 30551, 30400, 2929, 29289, 29289, 29285, 29284, 29281, 2922, 29212, 29211, 2920

Opioid (ICD-10-CM)

T40695S, T40695D, T40695A, T40694S, T40694D, T40694A, T40693S, T40693D, T40693A, T40691S, T40691D, T40691A, T40605S, T40605D, T40605A, T40604S, T40604D, T40604A, T40603S, T40603D, T40603A, T40601S, T40601D, T40601A, T404X5S, T404X5D, T404X5A, T404X4S, T404X4D, T404X4A, T404X3S, T404X3D, T404X3A, T404X1S, T404X1D, T404X1A, T403X5S, T403X5D, T403X5A, T403X4S, T403X4D, T403X4D, T403X4A, T403X3S, T403X3D, T403X3A, T403X1S, T403X1D, T403X1A, T402X5S, T402X5D, T402X5A, T402X4S, T402X4D, T402X4A, T402X3S, T402X3D, T402X3A, T402X1S, T402X1D, T402X1A, R55, R443, R442, R440, R4182, R410, R404, R403, R4020, R401, R400, R092, R0902, R0901, J9692, J9691, J9690, J9602, J9601, J9600, J80, F1199, F11988, F11982, F11981, F11959, F11951, F11950, F1194, F1193, F11929, F11922, F11921, F11920, F1129, F11288, F11282, F11281, F11259, F11251, F11250, F1124, F1123, F11229, F11222, F11221, F11220, F1119, F11188, F11182, F11181, F11159, F11151, F11150, F1114, F11129, F11122, F11121, F11120

ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; ICD-10-CM = International Classification of Diseases, Tenth Revision, Clinical Modification.

APPENDIX B: List of Technical Advisory Panel Members

Rosa Baier, Brown University; Dr. Dale Hu, CMS HHS; Dr. Rob Schreiber, Hebrew Senior Life/Harvard; Julie Kuhle, PQA; Brian Isetts, University of Minnesota; Deborah Perfetto, AHRQ; Andy Romero HealthInsight; Nelly Leon, AHA; Keela Herr, University of Iowa; Nadine Shehab, CDC APR.MAY.JUN 2019 |

PUBLIC AFFAIRS

Sen. Ernst Speaks at Political Leadership Reception

Nebel received his law degree from Drake University and has a bachelor’s degree in finance from the University of Iowa.

Diabetes Supplies to be billed as DME

Sen. Joni Ernst (R-Iowa) was the featured speaker at the Midwest Pharmacy Expo’s Political Leadership Reception held on Saturday, February 9. Sen. Ernst discussed the work she has done to improve access to care, bring down drug costs, and curb problematic PBM practices.

As of April 1, 2019, the Iowa Medicaid Enterprise (IME) will require all diabetes supplies to be billed under the medical benefit as durable medical equipment (DME) and no longer at pharmacy point of sale. IME will no longer require use of preferred diabetes supplies which created an exception to the previous policy of billing the supplies as DME. Please reach out to IPA if you are having trouble enrolling as a DME provider. IPA has created resources to assist pharmacies with DME which are available on the IPA website. IPA will continue to advocate on your behalf to best care for Medicaid beneficiaries.

In addition, DIA is currently in a learning phase about USP 800 and the impact of these standards on facilities around the state. IPA provided some initial education during our meeting and provided the current NIOSH list of hazardous medications for DIA to better understand the impact that enforcement would have on DIA-regulated facilities. IPA will continue to advocate to DIA regarding concerns and questions presented by our members that practice in facilities regulated by DIA.

IPA attends NACDS RxIMPACT Day on Capitol Hill

IPA Meets with DIA Representatives

The Political Leadership Reception is an opportunity for pharmacists to hear from a leader in national government and discuss issues that are important to the pharmacy profession. It is a stand-alone event that coincides with the Midwest Pharmacy Expo and serves as a fundraiser to state pharmacy political action funds.

New Executive Director for the Iowa Board of Medicine

The Iowa Board of Medicine has appointed Kent Nebel as its new executive director. Nebel has been the board’s legal director for the last 20 years and has served as interim executive director since July 2018.

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In early February, IPA members and staff met with representatives from the Iowa Department of Inspections and Appeals (DIA) to discuss issues presented by hospital and long-term care practitioners. While the meeting helped to serve as a mechanism to continue to build a strong working relationship with both parties, the group discussed concerns around implementation and enforcement of USP 800 standards for handling of hazardous medication and the presence of stateapproved medical cannabidiol products. DIA referenced ongoing dialogue with CMS to address the use of medical cannabis by allowing for the use of the product if it follows the Iowa state law. DIA does not want to get in the way of patient care if the product follows state program. However, there are still several questions and concerns that DIA has with the use of medical cannabis in facilities and couldn’t directly answer many questions posed by IPA.

IPA joined pharmacy advocates from all 50 states in Washington, D.C. for the National Association of Chain Drug Stores’ (NACDS) RxIMPACT Day to advance pharmacy value and viability, and to help further address the opioid abuse epidemic. With a patient-focused agenda, IPA and NACDS discussed with Iowa’s congressional offices the threat of direct and indirect remuneration (DIR) fees and the urgency for reform. Also on the agenda was advocating for pharmacists to provide additional services given their extensive education and discussing additional ways to build on longstanding and ongoing efforts to help address opioid abuse and addiction. ■

PUBLIC AFFAIRS

BOARD OF PHARMACY: REGULATORY UPDATE

IPA WORKING FOR YOU

The Iowa Board of Pharmacy convened for open session on March 12, 2019 to discuss multiple requests, reports and informational items, as well as several proposed rules.

Addressing Your Iowa Medicaid & MCO Concerns

New Members of the Board Announced

Director Andrew Funk informed the Board of the new members recently appointed by the Governor. Kathy Stone of Missouri Valley will be the Board’s newest pharmacist member. Dane Nealson of Nevada was appointed as the Board’s first certified pharmacy technician member. Public member Joan Skogstrom was also re-appointed to her second term.

USP 800 Presentation

Director Funk also presented to the Board regarding USP 800. Following the public comment period on the Board’s proposed rule to make Dec. 1, 2019 the effective date of enforcement for USP 800 in Iowa, the Administrative Rule Review Committee instructed the Board to consider either delaying implementation for 18 months or ensuring there is a process in place for pharmacies to demonstrate their plan to become compliant if they will likely not meet the requirements by that date. The Board will decide which option to pursue at their May 2, 2019 meeting.

Iowa uniform controlled substance Act (CSA) registration, a requirement that dispensing of controlled substances by prescribers be reported to the PMP, and a requirement that administration of an opioid antagonist by a first responder be reported to the PMP. The rules also include a requirement for pharmacists who are involved in direct patient care to register with the PMP simultaneously to licensure or renewal. Furthermore, the specific number of authorized delegates was removed from the proposed rules to allow practitioners the ability to designate delegates according to their individual practice settings. Vote on Statewide Protocols The Board also voted to approve the individual statewide protocols for immunizations, naloxone, and nicotine replacement therapies. Some minor changes were recommended to remove ambiguity regarding the pharmacist as the prescriber. The protocols became effective on April 5, along with the statewide protocol rules. ■

Vote of Adoption on New Regulations

Adoption of Rules Relating to the Iowa Prescription Monitoring Program The Board approved adoption of rules stemming from legislation passed in 2018 which affected the PMP. These included a requirement that prescribing practitioners register with the PMP simultaneously to

Tune-in to IPA’s BOP: What, Why & How podcast following each Iowa Board of Pharmacy meeting to recap the board’s actions and earn pharmacy law CE. More information at www.iarx.org/BOP_Podcast.

IPA has begun to engage Iowa Total Care, a subsidiary of Centene, which will start in the managed care marketplace in Iowa on July 1, 2019. Twila Johnson, PharmD, has been named pharmacy director for the MCO and IPA looks forward to collaborating with Iowa Total Care. Iowa Total Care is now enrolling all provider types including pharmacy and durable medical equipment providers. Beginning January 25, 2019, the overthe-counter polyethylene glycol 3350 powder will be the preferred product on the Iowa Medicaid PDL for all ages. There will be a quantity limit of 527 grams per 30 days and the powder packets will not be covered. As the prescription product was discontinued and phased out, we heard from IPA members about lack of coverage for Medicaid patients which was communicated with Iowa Medicaid. Effective March 1, 2019, the morphine milligram equivalents (MME) per day limit will be reduced from 200 MME per day to 150 MME per day for Medicaid beneficiaries on opioid therapy. Prior authorization (PA) will then be required for high-dose opioids of 150 or more MME. Patients undergoing active cancer treatment or end-of-life care are excluded from the PA requirements.

APR.MAY.JUN 2019 |

LEGISLATIVE DAY

A RECORD DAY FOR ADVOCACY IPA’s 2019 Legislative day saw over 200 pharmacists, pharmacy technicians, and student pharmacists come together to advocate for their profession. Equipped with pharmacy-forward talking points, members met with their legislators at the Iowa State Capitol for some good, old-fashioned grassroots advocacy. With significant turnover in the legislature following this year’s election, members engaged legislators to educate them on pharmacy issues and build new relationships or strengthen established ones. Members reported back that their discussions on collaborative practice agreements, immunization expansion, and statewide protocols were well received. These conversations lay the groundwork for IPA’s advocacy work throughout the session to advance the association’s legislative priorities. New this year was the Young Legislator Forum for student pharmacists. For

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the first hour of capitol visits, student pharmacists remained at the hotel as Rep. Joe Mitchell (R-Wayland) discussed his experience deciding to run for the Iowa legislature and the importance of civic engagement for young professionals. After returning from the capitol, members participated in IPA’s Legislative Day pharmacy law continuing education programming. The CE slate included an update on provider statues, a panel featuring Iowa’s two pharmacist-legislators Rep. John Forbes (D-Urbandale) and Sen. Tom Greene (R-Burlington), and national update on PBMs from NCPA’s Ann Cassidy, and an Iowa Medicaid update from Iowa Medicaid Enterprise’s director Mike Randol. IPA’s Legislative Day is an important opportunity for members to engage with their legislators and learn about important pharmacy, public health and regulatory issues in Iowa. Mark your calendar for IPA’s 2020 Legislative Day on January 29, 2020.

LEGISLATIVE DAY

SEN. PAM JOCHUM RECEIVES IPA’S GOOD GOVERNANCE AWARD

IPA recognized State Senator Pam Jochum (D-Dubuque) with its annual Good Governance Award in recognition of her work and strong support of the pharmacy profession and public health. Sen. Jochum has long been a leader at the Capitol on healthcare issues, and has worked closely with IPA as a member of the Human Resources and State Government committees, as well as the former President of the Senate. She supported several of the association’s major legislative initiatives, including last year’s statewide protocol and technician product verification bill. She was a key ally in protecting pharmacy reimbursement under Medicaid during the transition to managed care, as well as an instrumental partner when IPA passed landmark PBM reform in 2015. “Sen. Jochum understands the importance of protecting patients and has worked tirelessly to ensure healthcare providers are equipped to provide the best care possible. She has been a constant source of advice to the pharmacy profession and has positively influenced our legislative priorities over the past 25-plus years,” stated Kate Gainer, PharmD, the association’s executive vice president and CEO. The award was presented at IPA’s Legislative Day. APR.MAY.JUN 2019 |

CONGRATULATIONS! - TO OUR -

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LEGISLATIVE DAY

CAPITOL SCREENINGS CONNECT STUDENT PHARMACISTS WITH LEGISLATORS Coinciding with IPA’s Legislative Day, student pharmacists from Drake University and the University of Iowa provided health screenings and education to state legislators, capitol staff, and other visitors for the annual Capitol Screenings. Students were excited to demonstrate pharmacists’ abilities and qualifications to provide clinical services to patients and further establish our value to the healthcare system. Student pharmacists provided nearly 40 blood pressure, bone density, and blood glucose screenings. Their presence in the Capitol Rotunda provided the opportunity to educate on the importance of immunizations, smoking cessation, and the lifesaving properties of naloxone. These conversations provided additional and important touchpoints with legislators to augment IPA’s Legislative Day and session-long advocacy on IPA’s legislative priorities. Capitol Screenings offers a great opportunity for students to directly meet and greet their legislators and showcase the various skills that pharmacists are capable of providing. This event provided an invaluable experience for them while showcasing the strength of students’ voices and actions for the future of the profession.

APR.MAY.JUN 2019 |

TECHNICIAN CORNER

FAQ on E-Cigarettes

(From IPA’s January 2019 Tech Tidbits newsletter) With the FDA keeping a close eye on e-cigarette companies as of late, here is some information to help with questions you may have about vaping and e-cigarette use. Is “vaping” a gateway drug, or is it a smoking cessation device? As vaping becomes more and more popular, especially among the nation’s youth, it is important to know the facts and how they relate to you or your patient’s health. There are some that suggest that new vape pens are a great step-down product from cigarettes and can lead to better health outcomes. However, there is an alarming rate of high school and middle school children trying the new electronic cigarettes each day. Although new studies have not been able to determine the overall health impact of the electronic cigarettes, they have shown the relationship between using e-cigarettes as a teenager who go on to smoke actual cigarettes1. Wouldn’t using an e-cigarette be better for you than regular cigarettes? Many people were excited about the invention of the electronic cigarette, saying it was going to help them to quit smoking. In fact, there are many patient testimonials that suggest e-cigarettes have helped saved lives. Although a 2017 study based in Europe found that people who tried e-cigarettes to quit smoking did help that person to quit smoking, the abstinence from actual cigarettes lasted three months on average2. Not only did it only last three months on average, but the study also showed that after one year, the person is more likely to be a dual user of e-cigarettes and regular cigarettes. Are e-cigarettes better than traditional nicotine replacement therapy for reducing nicotine cravings? A study published in July 2018, showed that 1284 patients, half of whom tried to quit smoking with e-cigarettes and the other half using other over-the-counter

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measures, the rates of people still smoking after one year were the same3. This is not to say that it cannot help someone to quit smoking, but this study provides more evidence that using electronic cigarettes to stop smoking does not work everyone. Are e-cigarettes becoming a possible health issue in minors? As mentioned earlier, studies have shown the relationship of young e-cigarette users eventually using regular cigarettes. In 2017, the National Youth Tobacco Survey found that 11.7% of high schoolers and 3.3% of middle schoolers use e-cigarettes4. Can anything be done to reduce the number of minors using e-cigarettes? Use of e-cigarettes in teenagers has risen 75% from 2017-2018. Although data has not yet been published by the FDA, estimates suggest that rise in numbers means around 3 million high schoolers are using e-cigarettes5. Two months ago, the FDA issued more than 1,300 warning letters and fines to stores that sold vaping products to minors. Is there any data about the health effects of e-cigarettes? A systematic review by the Journal of Preventive Medicine, reviewed 76 studies about e-cigarettes, and produced their own conclusions. They maintain that, although there have not been enough long-term studies on e-cigarettes and their effects on personal health, e-cigarettes cannot be regarded as safe. In their study they also mention that although e-cigarettes may be less harmful than regular cigarettes, the “harm-reduction” method may only be beneficial for current smokers and that non-smokers are at increased health risk by using e-cigarettes6. Recently, the FDA “cracked-down” by trying to cut down on sales of flavored vapes to teenagers, as well as banning sale of menthol flavored cigarettes. What can we do to inform our patients as pharmacy technicians? A systematic review by the Journal of Preventive Medicine reviewed 76 studies about e-cigarettes and produced their own conclusions. They maintain that, although

there have not been enough long-term studies on e-cigarettes and their effects on personal health, e-cigarettes cannot be regarded as safe. In their study they also mention that although e-cigarettes may be less harmful than regular cigarettes, the “harm-reduction” method may only be beneficial for current smokers and that non-smokers are at increased health risk by using e-cigarettes6. The FDA is “cracking-down” by trying to cut down on sales of flavored vapes to teenagers, as well as banning sale of menthol flavored cigarettes. References:

1. https://www.yalemedicine.org/stories/teenvaping/. Accessed 11/19/2018. 2. https://www.healthline.com/health-news/90percent-of-smokers-couldnt-quit-after-vapingone-year#1. Accessed 11/19/2018. 3. Weaver, S. R., Huang, J., Pechacek, T. F., Heath, J. W., Ashley, D. L., & Eriksen, M. P. (2018). Are electronic nicotine delivery systems helping cigarette smokers quit? Evidence from a prospective cohort study of U.S. adult smokers, 2015–2016. PLOS ONE, 13(7), e0198047. https://doi.org/10.1371/journal.pone.0198047. 4. https://www.cdc.gov/media/releases/2018/ p0607-youth-tobacco-use.html. Accessed 11/19/2018. 5. http://time.com/5413690/fda-juulinvestigation/. Accessed 11/29/18. 6. Pisinger, C., & Døssing, M. (2014). A systematic review of health effects of electronic cigarettes. Preventive Medicine, 69, 248–260. https://doi. org/10.1016/j.ypmed.2014.10.009

Conducting Prescription Transfers (From IPA’s February 2019 Tech Tidbits newsletter)

In late 2018, the Iowa Board of Pharmacy voted and approved changes that would allow pharmacy technicians to transfer prescriptions. Previously, only pharmacists or student pharmacists, could transfer prescriptions between pharmacies. Now, certified pharmacy technicians are be able to transfer prescriptions for non-controlled medications between pharmacies. This new Board of Pharmacy regulation took effect on January 23, 2019. These transfers can be completed via fax, phone, or electronically. Additionally, any schedule III-V medication still has to be transferred by either a pharmacist or student pharmacist.

TECHNICIAN CORNER FAQs on Prescription Transfers How many times can a prescription be transferred? For non-controlled medications, the number of transfers cannot be greater than the number of refills on the prescription. Also, the prescription must be within 18 months of its written date, otherwise it is no longer valid. Can pharmacy technicians transfer prescriptions within a telepharmacy? Yes. Certified pharmacy technicians working in telepharmacies are also able to transfer non-controlled medications. What information is required for a transferred prescription? There is specific information that must be collected and documented with a prescription transfer. In addition to the patient information, medication name, strength, quantity, prescriber, and refills, the transfer must include: 1. Written date and date of first fill 2. Prescription number from issuing pharmacy 3. Refills remaining and date of last refill 4. Name and address of transferring pharmacy 5. Date of transfer 6. Name of the person receiving the prescription transfer 7. Name of the person transferring the prescription Who can request a prescription transfer? Transfers can only occur by patient or caregiver request. For example, if the prescription was sent to the wrong pharmacy by the prescriber and the prescriber would like it transferred to the correct pharmacy, it cannot be done unless the patient or caregiver approves. Tips for a Successful Prescription Transfer Receiving a prescription transfer can be stressful for both parties involved. One of the easiest ways to make the process smoother is to take your time. Before picking up the phone to call the pharmacy, be sure to ask when the patient

needs the prescription transferred. Often, they won’t be back until later that day or even the next. This gives you time to complete the transfer when it is more convenient for you and your workflow.

providing helpful resources and getting the word out about this serious healthcare issue to its members in order to help healthcare workers in Iowa lead a happier, healthy life.

The Institute for Safe Medicine Practices recommends using telephone transfers as a true emergency measure. Mistakes are easily made when transcribing information taken over the phone. Most pharmacy software systems allow for electronic or facsimile transfers to be completed. This is the most ideal way to transfer prescriptions. If the patient is in no rush to get the transferred prescription, requesting a fax or electronic transfer is the best way to prevent errors from occurring.

Do you know the signs and symptoms of burnout? Some of its most common symptoms include: job dissatisfaction, fatigue, insomnia, gastrointestinal issues, increased drug or alcohol use, and many others. Burnout is often described as a trifecta of emotional exhaustion, depersonalization, and reduced person accomplishment. This trifecta can show itself in the forms of irritability, isolation, withdrawal, absenteeism, or inattention to work.1

Unfortunately, some patients will need their prescriptions right away. On top of taking your time going through each of the required sections of a prescription transfer, make sure to use legible handwriting and avoid any abbreviations which may cause confusion. The Institute for Safe Medicine Practices also has a list of abbreviations that should be avoided. Before hanging up the phone, repeat back the transfer information you just collected as this is an easy way for the other pharmacy to inform you of any errors you may have made. Finally, asking the transferring pharmacy if they have any medication allergies on file will help your pharmacist when they provide Drug Utilization Review and final verification.

Professional Burnout

(From IPA’s March 2019 Tech Tidbits newsletter) Healthcare worker burnout is a welldocumented, impending crisis we have in our healthcare system today that effects our well-being and as a consequence, our ability to care for others. As far as burnout goes, pharmacy technicians are no exception. Knowing the signs and symptoms is the first step to identifying the problem and secondly, knowing where you can reach out to get help is of utmost importance. That is why IPA is

So, what do you do if you are experiencing burnout or know someone who is? The first step is having a conversation with yourself or the person you know experiencing the above symptoms to assess your level of burnout. IPA provides its members with links to many assessment tools you can utilize to evaluate your level of burn out and provide recommendations to alleviate these health-havocking symptoms. Other resources about well-being, meditation, mindfulness, and resilience are also readily available on IPA’s website as well as focusing on this topic during this year’s IPA Goes Local events. Take advantage of these resources and educational events today and take the steps to improving your well-being. You are worth it! References:

1. Barker A. Pharmacists and Burnout: The First Step Is to Acknowledge the Data about Providers. https://www.pharmacytimes.com/ contributor/alex-barker-pharmd/2018/12/ pharmacists-and-burnout-the-first-step-isto-acknowledge-the-data-about-providers. Published December 5, 2018. Accessed March 1, 2019.

Technician Members!

To receive the Tech Tidbits newsletter each month, be sure that your email is up-to-date in your member profile on IPA’s website www.iarx.org.

APR.MAY.JUN 2019 |

Specializing in certifying pharmacy technicians because patient safety matters. Choose PTCB. Choose Excellence.

ptcb.org

TECHNICIAN CORNER

Advanced Technician Roles IPA continues to advocate and promote pharmacy technicians practicing in advanced roles such as technician product verification and performing medication histories. IPA has begun to collate technician career ladders and promotion best practices for pharmacy technicians from hospital and community-based pharmacies. Look for resources about advanced technician roles on the IPA website in the near future.

PTCB Developing 5 Certificate Programs, Advanced CPhT Credential The Pharmacy Technician Certification Board (PTCB) will add five assessmentbased certificate programs for advanced technician roles and an Advanced Certified Pharmacy Technician (CPhTAdv) credential. The new certificate programs will recognize the important contributions pharmacy technicians make to advance medication safety. They include: • Technician Product Verification (Tech-Check-Tech) • Medication History • Controlled Substance Diversion Prevention • Billing and Reimbursement • Hazardous Drug Management Those seeking to apply for one of these certifications must hold an active PTCB CPhT certification and complete a PTCBrecognized education/training program. Current PTCB CPhTs who have completed at least four of the certificate programs and 3 years of work experience will be eligible to earn a CPhT-Adv as early as mid-2020. ■

NEWLY CERTIFIED IOWA TECHNICIANS January 1 - March 31, 2019

Congratulations to the following pharmacy technicians on becoming PTCB-certified! Jenna Alff Nicole Baker Katrina Bearce Mackenzie Benning Erika Benson Cassandra Birkicht Jennifer Bisom Jessica Boesen Ramsundar BridgemohanHiggins Ana Brukar Brittany Cameron Diane Carroll Melissa Ceaser Dalton Colby Allen Correll Lauren Cummings Zachary Davis Joy Davis Jazlyn Davis James DeSchinckel Jack Dykema Je Ann Farrell Tanner Frey Loralie Gomez Whitney Hemann Paige Higgins Taylor Hoven Amairany Hurtado

Trinh Huynh Sally Hykes JaNiese Jensen Brodie Johnson Kimberly Kelly Angel Lamoreux Krista Likeness Andrew Maas Madison Magedanz Caitlyn Maher Fatima Mahfouz Caitlin Marsh Paula McLaren Ramon Mendoza-Jaramillo Marissa Merrill Yovana Meza Munoz Sandeep Misri Ruby Noble Harlee Palmitier Lindsey Peacock Tawanda Perkins Haley Pertzborn Bethany Peterson Krista Pettepier Natalie Polich Cynthia Porter MaryJane Postma Mischa Prochaska Nicole Pulley

Shyanne Raff Xander Rait Joshua Reeder Jessica L. Reilly Alexander Riley Jamie Saddoris Mitchell Schemmel Andrew Schemmel Jennifer Schmidt MichelleSchramm Danielle Simon Susan Smeenk Kimberly Smith Jesse Smith Emma Smith Kari Starbeck Alycia Summers Phuong Thai Nandi Thomas Courtney Tigges Kelsie Tingle Hannah Trentz Deana Wegner Tessa Weir Cheyenne Williams Stefanie Williamson Aimee Winter Brooke Wolter Muris Zenelji

CPhT Recertification CPE for FREE! Join IPA for your FREE subscription to CEI’s Technician Catalog! CEI’s Technician Catalog is a web-based subscription that contains accessible and convenient continuing education courses for technicians to recertify and advance their career path.

Members: Login at www.iarx.org/cei_libraries to take advantage of this new benefit for members and spread the word to your colleagues.

JOIN NOW & Receive Your Free CPE!

www.iarx.org/membership | 515.270.0713 | ipa@iarx.org APR.MAY.JUN 2019 |

IPA FOUNDATION

FOUNDATION AWARDS OUTCOMES INNOVATIVE PHARMACY GRANTS OUTCOMES INNOVATIVE PHARMACY GRANT The IPA Foundation has awarded $20,450 to two unique projects through the Outcomes Innovative Pharmacy Grant program. The grant program was established to provide financial support for research, education and promotion of innovative pharmacy practice initiatives within the state of Iowa. Congratulations to the recipients and their innovative projects! “Community Pharmacist Use of Mobile ECG to Inform Drug Therapy Decision Making for Patients Receiving QT Prolonging Medications” submitted by Jim Hoehns, PharmD, BCPS, FCCP, from Northeast Iowa Family Practice Center “Initiation of Pharmacy Services in a Rural Health Clinic” submitted by Naomi Graves, PharmD, from Hawarden Regional Healthcare Clinic Each recipient will present a poster on their project at the 2020 IPA Annual Meeting and the summaries will be published in a subsequent issue of The Journal of the Iowa Pharmacy Association. The grant program stems from the Outcomes Innovative Pharmacy Endowment that was established by the original investors of OutcomesMTM, a medication therapy management (MTM), service provider based in Iowa. In 1999, the Iowa Pharmacy Association provided seed money to support this innovative startup, which became a national leader in MTM services. Following the purchase of OutcomesMTM by Cardinal Health in 2015, the endowment was created as a way for those original investors to give back to the pharmacy profession and keep the innovative spirit and legacy of the company and Iowa pharmacy alive. Applicants must be an Iowa-licensed pharmacist or an Iowa-based researcher working with Iowa pharmacists in an innovative pharmacy practice. Applicants must also be active members of the Iowa Pharmacy Association. The application deadline for the next grant cycle is December 1, 2019. Additional details and the application can be found at www.iarx.org/outcomesgrant.

| The Journal of the Iowa Pharmacy Association

WELCOME OLIVIA WELTER, IPA’S 2019 EXECUTIVE INTERN IPA has named Olivia Welter, a P2 student pharmacist from Drake University, the 2019 Max W. Eggleston Executive Intern in Association Management. Olivia is from Neenah, Wisconsin, and currently works at Medicap Pharmacy in Urbandale and is an intern at Broadlawns Outpatient Pharmacy. At Drake, she is involved in APhA-ASP and will soon begin a term as GenerationRx chair. Olivia will be actively involved in several initiatives and events, including IPA’s 2019 Annual Meeting, throughout the 12-week internship. When you see her, be sure to introduce yourself and welcome her to the IPA team. “I am eager to get to work with IPA to make sure the pharmacy profession continues to advance as needs change in the state of Iowa,” said Olivia. The IPA Foundation’s Max W. Eggleston Executive Internship in Association Management is a 12-week program held each year during the summer months at IPA’s office in Des Moines to provide student pharmacists with an educational experience in professional association management.

BID FOR A GREAT CAUSE AT THE 2019 IPA FOUNDATION SILENT AUCTION Friends and friendly competition await at the 2019 IPA Foundation Silent Auction on Thursday, June 20, at the Cedar Rapids Marriott. Plan to bid on your favorite items and participate in the wine/beer ring toss and red envelope fundraiser. The silent auction will conclude the Thursday activities of the IPA’s 2019 Annual Meeting. Items can be previewed during the President’s Reception and on the Annual Meeting app. Proceeds from the silent auction will support the foundation’s educational and student programs.

To Donate an Item

If you or your pharmacy would like to donate to the silent auction, please contact Laura at lmiller@iarx.org and provide a short description and approximate value (if available) of the item(s) you plan to donate. While items will be accepted up through the week of Annual Meeting, in order to have your item listed in the silent auction catalog, please notify Laura prior to June 1.

IPA FOUNDATION

IPA FOUNDATION AWARDS SCHOLARSHIPS! Congratulations to these student pharmacists who received an Iowa Pharmacy Association Foundation scholarship for the 2018-2019 academic year!

Drake University IPAF Eggleston-Granberg Scholarships Carter Chapman Matt Glasow IPAF Mike & Terry Pursel Scholarship Tessa Heitkamp IPAF Russell E. Johnson Jr. & Lucille Johnson Scholarship Valerie Meyer IPAF General Scholarships Michelle Lin Alexander Maciejewski Alex McCormick Erin Simpson

The University of Iowa IPAF Eggleston-Granberg Scholarships Austin Miller Nickolas Scott IPAF General Scholarships Brandon Hefel Ji Yun So

The generosity of IPA members makes an impact. Here is what scholarship recipients say about how it has affected them:

“[IPA members’] generosity has allowed me to continue to pursue my passion for pharmacy.” Carter Chapman, Drake University 2018-2019 IPAF Eggleston-Granberg Scholarship

“The Iowa Pharmacy Association has opened up the door to so many professional opportunities for me... All of these experiences have allowed me to learn about the importance of advocacy in the profession and further develop my leadership skills.” Alexander Maciejewski, Drake University 2018-2019 IPAF General Scholarship

“Your willingness to back up your principles with actions and to give deeply are truly inspiring. Thank you again for supporting my education.” Casey O’Connell, The University of Iowa 2017-2018 IPAF Eggleston-Granberg Scholarship

MAKE AN IMPACT TODAY! Make a donation or consider joining the IPA Foundation Institute with your sustained gift. Your donation to the IPA Foundation supports initiatives to build strong leaders, invest in innovative practice initiatives and secure high-quality education for tomorrow’s practitioners.

Donate or find more information at www.iarx.org/IPAFoundation

APR.MAY.JUN 2019 |

MEMBERS SECTION

IPA MEMBER SPOTLIGHT:

Melissa Nelson, PharmD

Written by:

Mitchell Myers 2019 PharmD Candidate University of Iowa

very morning, Dr. Melissa Nelson sits down at her desk in her corner office at UnityPoint Health and reviews a list of patients on her computer; these will be the patients she provides care for today. Every patient on her list has been enrolled in a care management program. Also on the team is a nurse, the referring provider, social worker, and the patient. Together, the healthcare team works with the patient to improve their health by developing an individualized care plan. “The purpose of care management is to help the patients meet their goals, but often their goals are nowhere close to the rest of the team’s. It takes creativity to bring those goals together,” she elaborates. Today, Dr. Nelson is in her office at the UnityPoint Family Medicine clinic located within Methodist Medical Center. I say today because she spends part of her week at this clinic, and the other part at a clinic near Lutheran Hospital. She helps patients in-person at Methodist and Lutheran, and remotely at the Lakeview Internal Medicine Clinic in West Des Moines. Most of her time is spent providing medication therapy management (MTM) services to her patients, either in-person or over

| The Journal of the Iowa Pharmacy Association

the phone. The services can range from completing a comprehensive medication review (CMR) to taking a medication history, or even providing medication counseling for patients. Addressing adherence is a big part of her job, identifying barriers patients may experience, and finding creative solutions to help patients become more adherent to their medications. Each care management team meets once-weekly to discuss how their patients’ care is progressing. When she first took this position as a clinical pharmacist three and a half years ago, the transition to remote care was worrisome. “However, the amount of work I can get done remotely has surprised me. When I perform a CMR by phone to a highrisk patient sitting in the comfort of their own home, I realize they truly appreciate not having to come into the clinic for another appointment.” Dr. Nelson and her team were recently featured in a UnityPoint Health video highlighting the impact their service had for an elderly patient who could remain living at home because of their interventions and care. As the pharmacist on the team, she was responsible for examining the medication list, determining what was needed and making sure the patient was able to be adherent. The patient and the team were able to work together to help her stay living at home with her dogs, which was a goal of the patient’s. In addition to MTM services, Dr. Nelson is passionate about transitions of care and the impact of transitions on patients’ health. Her goal with every patient that undergoes a transition of care is to have them more comfortable with their medication regimen afterward than before the transition, “Transitions of care are when a patient is the most

vulnerable and where a pharmacist can insert themselves and have a major impact. When done correctly, the patient will never forget you.” Everyone on her team is just as passionate. “We have our fingers on the pulse of the patient.” She goes on to further say healthcare is becoming more team-based, and professions are learning from one another, knowing when to refer the patient to the team member best equipped to help. “I see pharmacy, both now and in the future, as a way to help other professions focus on their strengths to provide great patient care.”

“Transitions of care are when a patient is the most vulnerable and where a pharmacist can insert themselves and have a major impact. When done correctly, the patient will never forget you.” When asked about why she chose pharmacy, she responds “I was lucky. In high school, I knew I wanted to do pharmacy. Helping patients by thinking through their medications just clicked.” Graduating in 2003 from Drake University, Dr. Nelson transitioned into an acute care residency program at the University of Iowa Hospitals and Clinics. Upon completion, she began working at a critical access hospital, Guthrie County Hospital. Next, a ten-year tenure at Mercy Outpatient Pharmacy spanned the time before starting at UnityPoint Health. Finding a great mentor is important, Dr. Nelson stressed, but it’s not always a fast process. “The most important thing to remember is it comes naturally. You often don’t go into the relationship knowing they will be a mentor. It more often starts as small talk around a table before a meeting,

MEMBERS SECTION

finding commonality with those around you. My advice is to just meet people. Getting people together and providing introductions is something IPA does very well, and a lot of great mentorships have come from that.” She goes on to explain mentors are a great resource when change is on the horizon. She likes to bounce ideas off mentors to find out how they have addressed similar changes in their careers and how she might best implement changes herself. One of the objectives of the Iowa Pharmacy Association is to advance the art and science of pharmacy practice. Doing so requires leaders, and IPA members have the resources to carry the flag forward. Dr. Nelson says to be sure and encourage both non-members and less active members when trying to push a topic forward. “These non-active members have lots of untapped potential. We need their help getting the ball rolling and advancing practice, so don’t be afraid to reach out.” ■

WELCOME NEW IPA MEMBERS! JAN. 1 - MARCH 31, 2019: Amanda Abdulbaki, Des Moines Maisaa Abudagga, Coralville Ali Altaie, Des Moines Joe Anderegg, Waverly Jill Bode, Ames Kent Breems, Pella Cynthia Conn, Pleasant Hill Belinda Dorman, Ft Dodge Fatima Fadl, Iowa City Steven Gilbert, Moorestown, NJ Heidi Goebel, Estherville Jordan Gran, Soldier Dawn Grittmann, Clive Jessica Growette, Moorestown, NJ Trisha Hoffmann, Webster City Heidi Holsapple, Ankeny Mackenzie Lenz, Dubuque Mikaela Newlun, Fort Dodge Carey Stickfort Jones, North Liberty Jennifer Stoltenberg, Shell Rock Logan Sudbeck, Cedar Rapids Kendra Teeling, Denver

THANK YOU FOR SUPPORTING IPA!

MEMBER MILESTONES Congratulations to Sarah Derr, PharmD, who was named executive director of the Minnesota Pharmacists Association! Sarah was IPA’s inaugural executive fellow in 2016. Congratulations to Ashley Dohrn, PharmD, BCGP, as she was selected to serve as clinical pharmacy specialist with Centralized Healthcare Solutions in Iowa City! Congratulations to Rachel Hall, PharmD, MBA, as she takes on the role of pharmacist in charge for the newly opened NuCara Pharmacy in Greenfield! Rachel collaborated with NuCara in order to open a pharmacy in town after the closure of Shopko created a gap in pharmacy services for the community. Congratulations to Jennifer James, PharmD, as she begins as a pharmacy clinical services manager for Wal-Mart Pharmacies! Congratulations to Rick Knudson, PharmD, MBA, BCPS, as he begins his new role as executive director of clinical pharmacy for Mount Sinai Health System! Congratulations to Eugene, RPh, and Susan Lutz, RPh, FAPhA, who will receive the 2019 Weaver Medal of Honor from Drake University College of Pharmacy and Health Sciences!

Congratulations to Stacie Maass, BSPharm, JD, as she begins in her new role of vice president of legislative and government affairs for Iowa Total Care! Congratulations to Justin Rash, PharmD, BCGP, for his new role as medical science liaison in LTC for Avanir Pharmaceuticals!

Congratulations to Amanda Rosmann, PharmD, for her new role as clinical pharmacist at Diplomat - Specialty Infusion Group! Steve Sayler, RPh, was named employee of the year by the Indianola Chamber of Commerce for his work at the Indianola HyVee pharmacy. Congratulations, Steve! Congratulations to Andy Stessman, PharmD, as he was selected as the retail pharmacy manager for Broadlawns Medical Center in Des Moines! Congratulations to Susan Vos, PharmD, FAPhA, who was promoted to assistant dean for professional education at the University of Iowa College of Pharmacy! Congratulations to Mylo Wells, PharmD, for opening Wells Hometown Pharmacy in Bloomfield after the closure of Shopko in town created a gap in pharmacy services for the community! Congratulations to friend of pharmacy, Terry Meek, on her retirement! Terry served in the Bureau of Chronic Disease Prevention and Management within the Iowa Department of Public Health and coordinated with IPA on multiple grant initiatives.

IN MEMORIAM Terry Carley, RPh, passed away on March 6, 2019, at the age of 75. Terry was a 1965 graduate of Drake University and owned and operated Carley Drug in Avoca for 44 years until he retired in 2014. Shirley Winckler, RPh, passed away on March 2, 2019, at the age of 88. She was a 1954 graduate of the University of Iowa College of Pharmacy and worked at the university for several years before moving to Sioux City to practice at Tollers. Shirley was IPA’s honorary president from 98-99 and received the Bowl of Hygeia in 2000. APR.MAY.JUN 2019 |

IPA IN ACTION Presenting at the CDC HIV Prevention Conference

IPA staff recently attended the CDCâ&#x20AC;&#x2122;s National HIV Prevention Conference in Atlanta, Georgia. This yearâ&#x20AC;&#x2122;s conference theme, Getting to No New HIV Infections, highlighted innovative approaches to HIV prevention, testing and treatment.

While people living with HIV receive care from multiple healthcare providers, they often get their medications from one pharmacy, making their pharmacist a key point of contact. Pharmacy-led interventions have led to improvement in a variety of therapeutic and adverse event outcomes in several disease states. The conference included a dedicated session that emphasized the role of pharmacy in HIV care and prevention. Although still in early stages of the project, IPA was selected to present their findings thus far in the HIV POC Screening project that launched in late 2018. The presentation highlighted community pharmacies and how they are well positioned to collaborate with primary medical providers to improve access and efficiency of health care in the community. A re-occurring theme heard throughout various sessions was the importance of collaborating across all boundaries. The conference was a great opportunity to share knowledge as well as strengthen partnerships and discuss ways to help end the epidemic. Much progress has been made in recent years, but much work remains.

Pharmacy Stakeholders Discuss 2019 Legislative Strategy

A group of stakeholders met on January 29, 2019, the day before IPA Legislative Day, to discuss pharmacy related legislation. The group included representatives from IPA, the Iowa Board of Pharmacy, Drake University, the University of Iowa, CEI, Rep. John Forbes, and Sen. Tom Greene. The group had a very engaging discussion regarding legislative priorities, implementation strategies, and the need to update the Iowa Pharmacy Practice Act.

Pharmacist Involvement in Falls Prevention

IPA continues to advocate and communicate the importance of pharmacist involvement in falls prevention strategies. IPA staff made two presentations in January 2019, one to the Iowa Falls Prevention Coalition and the Telligen/Iowa Nursing Home Quality

| The Journal of the Iowa Pharmacy Association

Partnership to showcase the important work being done by Iowa pharmacists to aid in falls prevention. Both groups were very supportive of pharmacist involvement on the healthcare team.

MHFA Trainings Continue Across Iowa

IPA continues to offer the 8-hour Mental Health First Aid trainings across the state. With a focus on serving the needs of State Innovation Model (SIM) community and clinical care (C3) communities, IPA trained over 30 pharmacy professionals and members of the community with two events in Burlington on January 15 and Sioux City on February 13. IPA is working to secure funding to continue to bring more trainings to pharmacy professionals in 2019. The training helps you to (1) assess a situation, (2) offer initial help and support, and (3) connect someone to appropriate care if an individual is experiencing a mental health or substance use problem. With a focus on learning risk factors, warning signs, and resources for mental illness and substance use disorders, attendees will be provided with the skills to display calmness, non-judgmental attitude, empathy, and support in order to be a reassuring and encouraging professional in your area of practice. With support from the Community Pharmacy Foundation, the National Community Pharmacists Association (NCPA) developed pharmacy-specific patient cares for use during the training program, which is ACPE-accredited for pharmacists and pharmacy technicians.

IPA Educates at TPA Winter Meetings

IPA attended the recent Tennessee Pharmacists Association (TPA) Winter Meetings in Nashville, TN on February 23-24, 2019. IPA staff was invited to present information on Mental Health First Aid and professional burnout to student pharmacists and hospital-based pharmacists as TPA considers implementing similar initiatives. In addition, this meeting served as a great mechanism to reconnect with pharmacists that previously practiced in the state of Iowa.

IPA IN ACTION IPA Members Shine at APhA Annual Meeting 2019

Iowa Pharmacists Jeanine Abrons, PharmD, MS, FAPhA APhA Fellow Bill Doucette, PhD, FAPhA, RPh APhA–APRS Clinical Research Paper Award Steve Firman, BSPharm, MBA, FAPhA Chair, APhA PAC Board of Governors Randy McDonough, PharmD, MS, CGP, BCPS, FAPhA APhA Trustee-at-Large

(l to r) Steve Firman, Connie Connolly, Cheryl Clarke, and Nora Stelter serve as Iowa Delegates in the APhA House of Delegates

The theme for APhA Annual Meeting 2019 was “Moving Pharmacy Forward,” so it may come as no surprise as Iowa pharmacists, student pharmacists, and pharmacy technicians were honored in so many ways throughout the meeting in Seattle, WA. The following is just a short list of the IPA members that were showcased for their leadership and achievement at this year’s meeting:

Wendy Mobley-Bukstein, PharmD, BCACP, CDE, FAPhA APhA-APPM Executive Committee Member-at-Large Student Honors Kelli Jo Welter Drake University 2019-2020 APhA-ASP National President Michael Harvey Drake University APhA–ASP Good Government Student Pharmacist-of-the-Year Award

MEMBERS: Have You Accessed Your FREE Continuing Education Benefits Yet? IPA members receive a FREE subscription to CEI’s web-based Pharmacist or Pharmacy Technician Course Catalog, which include all required CPE for pharmacist relicensure and pharmacy technician recertification, for FREE.

In addition, you also receive FREE continuing education credit for IPA’s BOP: What, Why & How podcast series and select 2/2/2 webinar recordings!

Have you taken advantage yet? See how to at www.iarx.org/accesscpe

APR.MAY.JUN 2019 |

IPA IN ACTION

CALENDAR OF EVENTS

Find additional details to these events and more at www.iarx.org. Click on the “Calender of Events” link under the Events tab.

MAY 2019

JULY 2019

Iowa Board of Pharmacy Meeting - Des Moines, IA

IPA 2/2/2 Webinar: Biosimilars in the Marketplace

Precision Genomic Medicine Conference - Iowa City, IA

Iowa Board of Pharmacy Meeting - Des Moines, IA

2-5

Independent Pharmacy Conference - San Antonio, TX

13-17 Pharmacy Education Meeting - Chicago, IL

Zada Cooper Leadership Symposium - Iowa City, IA

21-27 RAGBRAI

8-11 2019 MAD-ID Annual Meeting (MAD-ID) - Orlando, FL 14

IPA 2/2/2 Webinar: Diabetes Management Across the Spectrum – Addressing Gaps in Iowa

IPA Goes Local Burnout and Resiliency Programming - Fort Dodge, IA Ethics In Healthcare 2019 - Iowa City, IA

IPA 2/2/2 Webinar: Current Issues & Trends in Health IT

IPA Goes Local Burnout and Resiliency Programming - Atlantic, IA

SEPTEMBER 2019

JUNE 2019

Eggleston-Granberg Golf Classic - Norwalk, IA

IPA Goes Local Burnout and Resiliency Programming - Cedar Rapids, IA

IPA 2/2/2 Webinar: TBD

IPA 2/2/2 Webinar: Technician Product Verification: Where to Start

Iowa Board of Pharmacy Meeting - Des Moines, IA

IPA Goes Local Burnout and Resiliency Programming - Ottumwa, IA

IPA Residents Meeting - Iowa City, IA

19-20 Immunization Summit - Altoona, IA 20-21 IPA Annual Meeting - Cedar Rapids, IA

2/2/2 is IPA’s free monthly webinar series that keeps you engaged and informed on the hot issues impacting the pharmacy profession. When is it? 2nd Tuesday of every month at 2:00 p.m.

JOIN US ON:

May 14, 2019: Diabetes Management Across the Spectrum – Addressing Gaps in Iowa June 11, 2019: Technician Product Verification: Where to Start July 9, 2019: Biosimilars in the Marketplace Register for these upcoming webinars and view previous ones at www.iarx.org/222. Topics subject to change

24-26 Total Store Expo - Boston, MA

16-18 NABP Annual Meeting - Minneapolis, MN 21

AUGUST 2019

| The Journal of the Iowa Pharmacy Association

Burnout and Resiliency Programming: Awareness. Management. Care. This educational program, co-hosted by the Iowa Pharmacy Association and Iowa Medical Society (IMS) in conjunction with Meyvn Group, will explore what you can do to prevent burnout and how to recognize the warning signs; help you identify changes that can mitigate burnout; and explore simple, evidence-based solutions to enhance your joy in practicing medicine and reduce stress.

Schedule May 15 – Fort Dodge June 11 – Cedar Rapids August 13 – Atlantic September 11 – Ottumwa

October 8 – Sioux City November 5 – Iowa City December 3 – Ames

For more information and to register for the nearest event, visit www.iarx.org/GoesLocal

PHARMACY TIME CAPSULE

19 72

Issues & events that have shaped Iowa pharmacy (or are fun to remember!)

FEBRUARY:

The Iowa Pharmaceutical Association (IPhA) sponsored Venereal Disease Awareness Month. Pharmacists were encouraged to take a leadership role in three different areas: education, prevention, and treatment of venereal disease to help inform the public about the disease.

Gov. Robert Ray signs the proclamation declaring February Venereal Disease Awareness Month

MARCH:

The National Commission on Marijuana and Drug Abuse submitted a report to Congress and the President to address the facts and controversy surrounding marijuana. The Commission found that marijuana use did not constitute a major threat to public health and that the problems associated with marijuana use have been oversimplified, overgeneralized, and overdramatized.

APRIL:

IPhA held its 93rd annual convention. This convention hosted several speakers who spoke on topics ranging from “Better Pharmacy Communication” between chain and independent pharmacy to “Legal and Public Health Aspects of Rx Price Posting and Discount Advertising Practices”.

MAY:

Hammer Pharmacy celebrated its 100th Anniversary! Hammer Pharmacy was founded in 1872 by Alvin G. Hammer who was best known in the early days for selling leeches for relief of swelling and discoloration of bruises and black eyes.

SEPTEMBER:

The Food and Drug Administration put in place a new policy for packaging, labeling and dispensing of nitroglycerin. The FDA required that the tablets be packaged in a glass container with a metal screw cap with no more than 100 dosage units dispensed at one time. The label must also contain directions for proper storage and a warning about the potential loss of potency.

NOVEMBER:

On November 10, a pharmacy postage stamp was issued in Cincinnati, Ohio to honor the 120th anniversary of the American Pharmaceutical Association. The stamp pictured a Bowl of Hygeia, that was associated with the American Pharmaceutical Association, and a Mortar and Pestle, associated with the National Association of Retail Druggists.

The Iowa Pharmacy Association Foundation is committed to the preservation of the rich heritage of pharmacy practice in Iowa. By honoring and remembering the past, we are reminded of the strong tradition we have to build upon for a prosperous future for the profession.

APR.MAY.JUN 2019 |

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| The Journal of the Iowa Pharmacy Association

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2018 Recipients of the “Bowl of Hygeia” Award

Ronda Lacey Alabama

Dennis McAllister Arizona

Cissy Clark Arkansas

Debby Johnson California

Catherine Jarvis Colorado

Marghie Giuliano Connecticut

Lisa Stonesifer Delaware

Michael A. Moné Florida

Sharon Sherrer Georgia

Starlin Haydon-Greatting Illinois

Bernadette Brown Indiana

Mickey Cooper Iowa

Brian Caswell Kansas

Pat Mattingly Kentucky

Nick LeBas Louisiana

Betty J. Harris Maine

Dixie Leikach Maryland

David Sencabaugh Massachusetts

Phil Hagerman Michigan

Laura Schwartzwald Minnesota

Ricky Cash Mississippi

Gene Forrester Missouri

Tricia Campbell Montana

Angie Svoboda Nebraska

Roseann Visconti Nevada

Jennifer Towle New Hampshire

Rupal Mansukhani New Jersey

Michael Raburn New Mexico

John Westerman, Jr. New York

Davie Waggett North Carolina

Robert Biberdorf North Dakota

Dan Karant Ohio

Don Ritter Oklahoma

Penny Reher Oregon

Richard Williams Pennsylvania

Abigail Vazquez Puerto Rico

Kelley Sanzen Rhode Island

Robert Hubbard South Carolina

Hugh Mack South Dakota

Larry Calhoun Tennessee

Carol Reagan Texas

Darryl Wagner Utah

Allen Huffman Virginia

Linda Garrelts MacLean Washington

Ivan Cephas Washington DC

Charles “Laddie” Burdette, Jr. West Virginia

Brook DesRivieres Wisconsin

Stephen Rogers Wyoming

The “Bowl of Hygeia”

The Bowl of Hygeia award program was originally developed by the A. H. Robins Company to recognize pharmacists across the nation for outstanding service to their communities. Selected through their respective professional pharmacy associations, each of these dedicated individuals has made uniquely personal contributions to a strong, healthy community. We offer our congratulations and thanks for their high example. The American Pharmacists Association Foundation, the National Alliance of State Pharmacy Associations and the state pharmacy associations have assumed responsibility for continuing this prestigious recognition program. All former recipients are encouraged to maintain their linkage to the Bowl of Hygeia by emailing current contact information to awards@naspa.us. The Bowl of Hygeia is on display in the APhA History Hall located in Washington, DC. Boehringer Ingelheim is proud to be the Premier Supporter of the Bowl of Hygeia program.

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• 65+ Offerings

• Weekly Generic Rx Specials

• Specialty Pricing & Offers

• Bonus Monthly Generic Rx Rebates

OTC Advantage

• Additional Rx Specials Year-round

• Average Savings = Cost -15%

• Brand Rx at Cost -3.00% or Better

• Starter Displays and Planograms

• Controlled Substances to Qualifying Stores