2015 Q1 Missouri Pharmacist

Missouri THE MISSOURI PHARMACY ASSOCIATION

VOL. 89, NO. 1, SPRING 2015

Essential The Important Role of Pharmacists in Quality Healthcare

Drug Apps Put to the Test Health Vocab: Tips and a Quiz to Help Inform your Patients Take Action! MPA CEO Asks for your Help on Critical Issues The Danger and Cost of the Cascade Effect MPA PRESIDENT ERICA HOPKINS-WADLOW, PHARM. D.

ISSUE 2014 6

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Missouri THE MISSOURI PHARMACY ASSOCIATION

Missouri Pharmacy Association Staff RON FITZWATER, MBA, CAE, Chief Executive Officer ROBYN SILVEY, Chief Operating Officer Missouri Pharmacist, Managing Editor CHERYL HOFFER, Vice President Pharmacist Program Initiatives TRAVIS FITZWATER, Director of Strategic Initiatives DREW OESTREICH, Pharmacy Provider Relations BRITTIANY TURNER, Communications Coordinator Missouri Pharmacist, Assistant Editor LAURA STIEFERMAN, Administrative Assistant Missouri Pharmacist Magazine Publisher GREG WOOD Editor in Chief DANITA ALLEN WOOD Sales Manager MIKE KELLNER Advertising Director MARYNELL CHRISTENSON Advertising & Marketing Consultant BRENT TOELLNER Sales Account Executive PAULA RENFROW Sales Associate GRETCHEN FUHRMAN Advertising Coordinator JENNY JOHNSON Art Director SARAH HERRERA Custom Projects Editor NICHOLE BALLARD Associate Editor JONAS WEIR Graphic Designer and Staff Photographer HARRY KATZ Executive Office Manager AMY STAPLETON Editorial Assistants ELISSA CHUDWIN, LAKSHNA MEHTA, AND JILLIAN VONDY

Board of Directors President ERICA HOPKINS-WADLOW, Pharm.D. D&H Drug, Columbia President-Elect JUSTIN MAY, Pharm.D. Red Cross Pharmacy, Sedalia Treasurer MARTY MICHEL, R.Ph., MBA, CDE Key Drugs, Poplar Bluff Secretary MELODY SAVLEY, B.S. ALPS Pharmacy, Springfield Immediate Past President CHRISTIAN TADRUS, Pharm.D., R.Ph., FASCP, AE-C Sam’s Health Mart Pharmacies, Moberly Member at Large SCOTT CADY, Pharm.D. Pharmacist Consultant, Chillicothe Member at Large CHRIS GERONSIN, Pharm.D. Beverly Hills Pharmacy, St. Louis Member at Large DANIEL GOOD, M.S., R.Ph. Mercy Health, Springfield Member at Large LISA UMFLEET, R.Ph. Parkland Health Mart Pharmacy, Desloge Ex-Officio Member RUSSEL MELCHERT, Ph.D., R.Ph. UMKC School of Pharmacy, Kansas City Ex-Officio Member JOHN PIEPER, Pharm.D., FCCP St. Louis College of Pharmacy, St. Louis

Missouri Pharmacist is produced for the Missouri Pharmacy Association by MissouriLife 501 High Street, Ste. A, Boonville, MO 65233 660-882-9898 l MissouriLife.com Missouri Pharmacy Association www.morx.com 211 E. Capitol Avenue, Jefferson City, MO 65101 phone: 573-636-7522, fax: 573-636-7485 Missouri Pharmacist is mailed to MPA members. All views expressed in articles are those of the writer and are not necessarily the official position of the Missouri Pharmacy Association.

Advertising rates are furnished upon request.

Missouri Pharmacist, Vol. 89, No. 1, Spring 2015, (ISSN 0026 6663, application to mail at periodicals postage prices is pending) is owned and published quarterly by the Missouri Pharmacy Association, 211 E. Capitol Avenue, Jefferson City, MO 65101. Postage paid at Jefferson City, MO and additional mailing offices.

Postmaster: send address changes to Missouri Pharmacist, 211 E. Capitol Ave., Jefferson City, MO 65101-3001.

4 MISSOURI PHARMACIST

SPRING 2015 5

Missouri

IN THIS ISSUE THE MISSOURI PHARMACY ASSOCIATION

SPRING 2015

8 > Hap py N e w Ye ar!

MPA president asks members to make a New Year's resolution.

10 > O ff an d R un n i n g MPA CEO calls for cooperation to tackle new legislation.

12 > M PA Me mb e r Ne w s See who took home awards at the UMKC Pharmacy Alumni Awards and Reunion Dinner.

16 > Mob i le Me di ci n e See how four drug reference apps stack up when put to the test.

12

18 > Th e Cas cade Effe ct A dangerous trend. What you can do to avoid adverse polypharmacy.

18

24

The prescribing cascade can be dangerous and costly. Learn how to avoid the trap.

20 > Me di cati on Th e rapy Se r v i ce s Everything you ever wanted to know about MTS. 24 > Commun i cati on B re akdown Health literacy: helping you help your patients.

28 > B oard of P h armacy Sp e ci alis t s Do you know the ins and outs of specialist certification?

32 > Addi n g Val ue to ACOs Discussing the importance of pharmacists in Accountable Care Organizations.

36 > P h armacy an d th e L aw Law and ethics work together in everyday decision-making, especially for pharmacists.

40 > Camp us N e ws UMKC School of Pharmacy Dean and Professor discusses the 2015-2020 Strategic Plan.

42 > O n Rotati on Experience a rotation with the MPA and G.L.O. and Associates.

44 > Star Qual i ty Me as ure s : CM R Co m ple t io n Ra te Learn about the CMS star ratings program and CMR completion rates, a quailty measure.

46 > M i le s ton e s , Ne w Me mb e rs , a nd C a le nd a r Celebrate members’ anniversaries, welcome new members, and attend statewide events.

6 MISSOURI PHARMACIST

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President’s Letter

ERICA HOPKINS-WADLOW PHARM. D.

Greetings. It’s a new year and once again time for resolutions. Many of us will start diets, join a gym, or vow to never smoke again. These are all worthy goals and I wish you the best of luck with your 2015 resolutions.

I am writing you today to ask that you set different goals this year. This would be goals/resolutions that can have a huge impact on your professional career and in the lives of your patients. I am writing to ask that you participate in at least one MPA activity in 2015. It could be serving on a committee or attending a MPA sponsored event or some other association program. Whether you serve on a committee, attend Legislative Day, attend the annual convention, attend a Fall Pharmacy Night, simply donate to the Political Action Committee, or participate in an educational program, it all makes a difference. Each of these events are structured to help us represent pharmacists and address the critical issues facing our profession.

If each member of the Missouri Pharmacy Association (students included) were to participate in one activity for the association over the next year just think of the impact we could make. Our profession is ever changing and it is vital that we stay abreast of changes

8 MISSOURI PHARMACIST

in laws and regulations and other opportunities. In addition, we have a responsibility to the public and other healthcare professions to educate them about the role of pharmacists and the services and information we can provide.

The Missouri Pharmacy Association is the perfect platform for us pharmacists to accomplish our goals.

There are many places where pharmacists can participate and assist MPA in their efforts. If you are unsure about how you can help, the MPA staff and Board of Directors are here to guide you. Call us, text us, email us. We want to know what the members are interested in and assist you in any way we can.

2015 is going to be a busy year for MPA. Continue to check our weekly electronic updates—The CEO Update, the MPA website (MORx.com), legislative action alerts, Missouri Pharmacist, the MPA Facebook page, and other communications to follow the activities of your association.

Thank you in advance for your participation and support. I personally would love to see all of your resolutions achieved by the end of 2015. I hope that you add MPA to your to-do list.

MPA

HAPPY NEW YEAR

SPRING 2015 9

The 98th Missouri General Assembly opened in Jefferson City Wednesday, January 7.

CEO News

RON L. FITZWATER MBA, CAE

As I sit here to write this letter, it has already been a busy and exciting week. On Tuesday, January 6, the 114th Congress began their legislative session in Washington, D.C. It’s hard to believe that it is time for the new Congress to begin work—but it is—and 2015 promises to be an extremely busy year for pharmacy.

As you know, we have some serious issues that need to be addressed. Any willing provider, Medicare Part D (preferred networks, etc.), and the continued push for recognition of pharmacists as providers in federal healthcare programs are just a few of the key issues we will again be addressing. It will take the cooperative efforts of all of us to make sure these issues get addressed this year. We have spent a lot of time working with the members of the Missouri Congressional Delegation and they have a good, basic understanding of the pharmacy profession. But we have a lot of additional work to do.

We are fortunate that a number of the members of the Missouri Delegation are beginning to move into prominent positions in both the United States House and Senate. This gives us an opportunity, but it also presents a challenge. We need to continue to work with and educate them about the serious issues facing their constituents and your patients. We are past the point of being able to “kick these issues down the road.” There needs to be resolution to these issues and the impact they have on our members and your patients.

Pharmacy recently had a significant victory in dealing with one of the Part D programs that had inappropriately directed patients to pharmacies/networks different than the ones they had signed up for. We need to build

10 MISSOURI PHARMACIST

on that success and continue to talk about the questionable practices of many of these plans.

In the state of Missouri, the 98th Missouri General Assembly opened in Jefferson City on Wednesday, January 7. The House was called to order with a record number of 117 Republicans (45 Democrats)—including Travis Fitzwater who is the new Representative for House seat 49. He and thirty-one other freshmen colleagues make up this year’s newest legislators. The Senate was called to order with twenty-five of the thirty-four Senate seats being held by Republicans.

The Missouri Pharmacy Association has a number of critical issues that we will be working on this session with these newly elected legislative bodies. It will take the collective efforts of pharmacists from all over the state to assist us in making these efforts successful. Here is how you can participate: 1. INVITE YOUR MEMBERS OF CONGRESS, the Missouri House and Missouri Senate, to visit your store and learn about the critical issues that your profession is facing. MPA can provide you with “talking points” or other materials that you need for these visits.

2. PLAN TO ATTEND the 2015 Missouri Pharmacy Association Legislative Day in Jefferson City on Wednesday, April 1. Please see MORx.com for additional information.

3. SIGN UP TO PARTICIPATE in the MPA Pharmacist of the Day Program. Contact Robyn@morx.com for additional information.

Happy New Year. It is going to be an exciting year. I encourage you to join our efforts. We are “off and running!”

COURTESY OF MISSOURI HOUSE OF REPRESENTATIVES

OFF AND RUNNING

A common purpose unites us... ...they are better off for it.

NACDS salutes the MPA, and values our partnership.

Our work together on policy issues is an extension of our commitment behind the counter. When we speak as one, we protect and advance the role of community pharmacy in healthcare.

We are proud to stand with you, as we stand up for those we serve.

NATIONAL ASSOCIATION OF

CHAIN DRUG STORES Pharmacies. The face of neighborhood healthcare.

SPRING 2015 11

MPA MEMBERS MAKE NEWS

Tadrus Elected to NCPA Officer Position

Christian Tadrus, Pharm.D., R.Ph., FASCP, AE-C, was named fifth vice president of the National Community Pharmacists Association. Tadrus was one of the elected officers sworn in during NCPA’s House of Delegates session held in conjunction with their Annual Convention and Trade Exposition late last year.

The community pharmacist owns three Sam’s Health Mart Pharmacies in central Missouri near Columbia. The St. Louis College of Pharmacy graduate is the immediate past president of the Missouri Pharmacy Association and is a leader in promoting medication adherence and other ways of expanding the clinical side of community pharmacy.

the 2014 UMKC Pharmacy Alumni Awards and Reunion Dinner. Grove received his bachelor of science in pharmacy from UMKC in 1975 and became owner of the family business, Grove Pharmacy, in 1980. His family has owned the company since 1952 and has expanded to two independent pharmacy locations.

Grove says he believes that optimal health encompasses mind, body, and spirit. Grove also opened Grove Spa in two locations in Springfield.

He devotes his spare time to community involvement and established a scholarship in honor of his father to support students seeking a career in independent pharmacy.

Tharp Receives Award for Suicide Prevention Efforts

Dr. C. Patrick Tharp, Ph.D., R.Ph., received the Missouri Department of Mental Health’s 2014 Survivor of the Year Award. Tharp is a partner in Pharmacists Preventing Suicides Inc., a not-for-profit corporation focused on suicide prevention education, training, research, and advocacy. Tharp works to educate pharmacists and others in the medical profession about how to detect early warning signs in patients who might consider committing suicide.

Pieper Named Chair of Board of Pharmacy Specialties

May Receives UMKC Alumni Service Award

Justin May, Pharm.D., received the University of Missouri-Kansas City Community Pharmacy Alumni Service Award at the 2014 UMKC Pharmacy Alumni Awards and Reunion Dinner. May, a certified immunizing pharmacist, has developed a medication adherence program that manages more than 5,500 patients and is currently developing processes for specialty pharmacy integration into community pharmacy. May received his doctor of pharmacy degree from UMKC in 2001 and is currently employed by Red Cross Pharmacy where he has been director of pharmacy since 2009.

Grove Receives UMKC Alumni Service Award

Gary Grove, R.Ph., received the University of MissouriKansas City Professional Pharmacy Service Award at 12 MISSOURI PHARMACIST

Missouri Pharmacist Magazine Wins Award

Missouri Pharmacist, MPA’s trade journal, received an award in the communications category from the Missouri Society of Association Executives. The magazine was nominated for the award after it returned to a printed version last year.

COURTESY BOB GREENSPAN

Justin May, Pharm.D., receives the UMKC Community Pharmacy Alumni Service Award at the 2014 UMKC Pharmacy Alumni Awards and Reunion Dinner. Gary Grove, R.Ph., (not pictured) was also awarded for his service.

John A. Pieper, Pharm.D., FCCP, FAPhA, President and Professor at St. Louis College of Pharmacy, will serve as the 2015 Chair of the Board of Pharmacy Specialties.

The BPS was established in 1976 as an autonomous division of the American Pharmacists Association.

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SPRING 2015 13

14 MISSOURI PHARMACIST

Legislative Day April 1, 2015 Capitol Plaza Hotel | Jefferson City, MO

Student

Pharmacist

Technician

Other

I would like to have pharmacy students shadow me during legislator visits.

Registration fees

Name: Business Name: Registered Voting Address:

MPA Member:

$59

Non MPA Member:

$79

Pharmacy Students:

FREE

City, State, Zip:

Total:

Cell Phone: Email: Visit House.mo.gov or Senate.mo.gov to find your represenatives.

My State Rep. is:

Payment information Check to the Missouri Pharmacy Association is enclosed.

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Missouri Pharmacy Association c/o Legislative Day 211 East Capitol Avenue Jefferson City, MO 65101 Ph: 573.636.7522 | Fax: 573.636.7485 SPRING 2015 15

CLINICAL PHARMACOLOGY BY ELSEVIER/ GOLD STANDARD

MOBILE MEDICINE

We put four drug reference apps to the test.

BY CHRISTOPHER FUCHS

CHRISTOPHER FUCHS 2015 PHARM.D. CANDIDATE, ST. LOUIS COLLEGE OF PHARMACY

As pharmaceutical experts, we know a lot about drugs. But, we can’t know everything about every drug. Drug references are relied upon in the field. With the rise of smart phones, drug references have moved to our pockets. But which one should you use?

Determining which drug reference is right for you depends on what you need from the application and what price you are willing to pay. Do you need a certain feature? Does it make more sense for each category to stand alone?

Most of the apps we evaluated offer free trials. Students may be able to receive a discounted rate on these apps through their schools.

We put four of these drug reference apps to the test. Learn about which one might be best for you and your practice.

The opinions of this piece are those of the author alone and not of the Missouri Pharmacist Association or St. Louis College of Pharmacy. The MPA or St. Louis College of Pharmacy does not endorse one drug reference app over another. All apps were tested on an iPhone 6+.

iOS and Android More than two thousand hospitals and thirty-five thousand retail pharmacies use the Clinical Pharmacology database. The app launched in mid-2014.

The Clinical Pharmacology app offers drug monographs, the ability to search by drug, indication, adverse effect or drug class, and drug interactions. It does not offer calculations or IV compatibility. With the press of a button, the app can switch from the adult to pediatric drug monograph.

Clinical Pharmacology tends to have more off-label indications and more descriptive mechanisms of actions than other drug databases. Clinical Pharmacology also has the ability to search indications and adverse effects. For example, if you searched cough, the app would then pull up all medications that might cause coughing.

Clinical Pharmacology has the most visually appealing user interface of these four apps. The large icons make it easy to tap on what you want, and the UI changes colors based on which patient type you search.

PRICE The Clinical Pharmacology app is available for free but only works with a subscription.

THE GOOD

• Detailed mechanisms of actions • Ability to switch from adult to pediatric monograph • Search by indication and/or adverse effect THE BAD

• Lacks IV compatibility • Lack of other clinical features FINAL VERDICT

If you just want drug information and interactions, this is the best app for you. If you need more information—such as IV compatibilities and calculations—then you might look elsewhere. Because this is a new app, additional features may be added in the future.

16 MISSOURI PHARMACIST

EPOCRATES BY ATHENA HEALTH

LEXICOMP BY WOLTERS KLUWER

iOS and Android Epocrates is a drug database with numerous features and more than one million active members, including 50 percent of US physicians.

Epocrates has tons of unique features that set it apart from the competition. The free version includes drug information, drug interaction, pill identification, provider directory, calculations, and information tables. A premium subscription adds guidelines, ICD-9, and CPT. When searching medications, Epocrates has less drug information than Lexicomp and Micromedex, especially with pharmacokinetic information.

The tables feature offers unique tables with brief information about disease states and drug dose equivalents.

The user interface is comparable to the Clinical Pharmacology and Lexicomp apps.

The home screen takes you to the different features and drop-down menus. This app can be added to your desktop as well.

iOS and Android Lexicomp is a drug database that contains detailed drug monographs and numerous other clinical decision support tools. The app’s drug monographs are some of the most detailed available. Tools include information on OTC medications, herbal supplements, dosing in special populations, drug interaction screening, toxicology, drug identification, IV compatibility, patient education material, The 5-Minute Clinical Consult, and numerous clinical calculations.

This app is simple and easy to use. You can search Lexicomp’s library, drug interactions, drug ID, calculations, and IV compatibilities from the home screen. Unlike other drug database apps, once you search, you can scroll search results on one page without clicking through menus.

Lexi Comp’s biggest drawback is that it does not auto-complete drug names, which can make finding terms a bit tricky. The user must know how to spell the name of the drug.

PRICE Free for base app and $159.99 per year for a premium subscription. Group discounts are available.

THE GOOD

PRICE After the thirty-day free trial, you must purchase a Lexi Comp subscription, which costs $595 for one year and $1,190 for three years.

THE BAD

• User interface • Detailed monographs • Easy to navigate • Numerous calculations

• Formulary search • Guideline integration • Price • Drug monographs slightly less detailed FINAL VERDICT Epocrates is very popular,

ranked as the number one medical app among physicians, and the reason is clear.

The free app offers many great resources, and the premium is cheaper than the competition.

THE GOOD

THE BAD

MICROMEDEX BY TRUVEN HEALTH ANALYTICS INC.

iOS and Android The Micromedex app contains concise information on over 4,500 search terms, covering common needs such as dosing, adverse effects, and drug interactions. Micromedex is made by Truven Health Analytics Inc. Micromedex takes a unique approach to the drug database app. Instead of one app with all the features, they have broken the features—drug information, drug interactions, and IV compatibility—into separate apps. Unfortunately, Micromedex does not offer any other features, such as calculations or drug identification.

The user interface is unique because there is no home screen. Each individual app has a screen with search at the top and then a list of every drug in the database in alphabetical order. Once a medication has been selected, you are taken to a screen with drop-down categories that expand when clicked. This feature is quite similar to the Clinical Pharmacology app.

PRICE The single drug information app costs $2.99 and comes with a Micromedex online subscription. Subscriptions are not offered to individual pharmacists but are available to pharmacies; pricing varies based on the number of users.

THE GOOD

• Detailed monographs • Price THE BAD

• Price • No autocomplete when searching

• Lack of other features • Separate apps

FINAL VERDICT Lexicomp has the most information on pharmacokinetics out of all the databases reviewed. Its user interface is simple and user-friendly. The addition of 5-Minute Clinical Consults and other tools help justify the high price.

FINAL VERDICT Micromedex has taken a unique approach to the app market. Having each function broken down makes each app easier to use; however, going to more than one place for information is inconvenient.

SPRING 2015 17

THE CASCADE EFFECT

How this trend can be dangerous and what you can do to avoid it.

BY ASHLEY BUEHLER

ASHLEY BUEHLER 2015 PHARM.D. CANDIDATE, UMKC SCHOOL OF PHARMACY AT THE UNIVERSITY OF MISSOURI, MPA ROTATION STUDENT, JULY 2014

It’s a sort of snowball effect—the kind that has the potential to get out of hand if you don’t arm yourself with knowledge. A cascade effect draws from the idea of a sequence of events, with the previous event initiating and influencing the outcome of the next. Defined within the healthcare realm, a cascade effect occurs when medicines are mistakenly prescribed to treat what is believed to be a new condition but are actually side effects caused by another drug.

The cascade effect can have a few negative outcomes.

The prescribing cascade can be dangerous if patients take more and more medications to combat side effects.

Additionally, medication-adverse events can place financial strain on the healthcare system and create additional health problems, according to an article by Lisa Kalisch et al. published by the Australian Prescriber.

Polypharmacy—“the practice of administering or us-

ing multiple medications especially concurrently as in the treatment of a single disease or of several coexisting conditions"—then becomes a concern.

According to a study from Centers for Disease Control (CDC), from 2007 to 2010, 89.2 percent of adults taking 5 or more drugs in the past 30 days were at least 45 or older. These adults were also more likely to report being in fair or poor health.

Other statistics are also alarming: 10 percent of patients who visit general practitioners will have had an adverse drug event in the past six months, which results in about 190,000 hospital admissions each year. These adverse drug events—“any undesirable event experienced by a patient whilst taking a medicine, regardless of whether or not the medicine is suspected to be related to the event”—include errors in the way the medicine is used and adverse drug reactions that result from the

THE CASCADE EFFECT AT WORK IN PHARMACY

• NSAIDs → hypertension → antihypertensives prescribed • ACE inhibitors → cough → cough suppressants or antibiotics prescribed • metoclopramide → movement disorders → levodopa prescribed • cholinesterase inhibitors → incontinence → anticholinergics • antipsychotics → extrapyramidal adverse effects → levodopa or anticholinergics Information courtesy of Australian Prescriber 18 MISSOURI PHARMACIST

HOW TO AVOID THE PRESCRIBING CASCADE EFFECT

Begin new medicines at low doses, and tailor doses to reduce the risk of adverse reactions.

Consider the potential for any new symptoms to be caused by an adverse reaction, particularly if a medicine has been recently started or the dose changed.

Ask patients if they have experienced any new symptoms, particularly if a medicine has been recently started or the dose changed.

Provide patients with information about possible adverse effects of medicines and what to do when adverse drug reactions occur.

pharmacological properties of the drug itself, either alone or in combination with other medicines, Kalisch wrote. Additionally, adverse drug reactions are often reported within four months by 90 percent of patients who take a new medication, and 75 percent of those patients experienced the reaction within one month. Adverse drug reactions cause about 15 percent of patients to discontinue their medications—and they don’t tell their doctors.

Kalisch also reported that common drugs causing the prescribing cascade effect include, “drugs for dementia, antihypertensives, sedatives, opioids, NSAIDs, antiepileptics, antibiotics, and medicines for nausea.” Also, certain people—like elderly patients, women, patients taking multiple medicines, and patients taking high-risk medications—are more prone to adverse drug reactions.

Some high-risk medications can include cardiovascular drugs, NSAIDs, anticoagulants, and antibiotics.

Additionally, elderly patients taking anticholinergics, antipsychotics, benzodiazepines, hypnotics, and sedatives are at a higher risk of adverse drug events. It has been reported that hospital visits caused by adverse drug effects are four times higher in elderly patients (17 percent) when compared to younger patients (4 percent) because elderly patients often need to take more medications, and, over time, there are changes in their body’s pharmacodynamics and pharmacokinetics properties.

An article written by J. Ruscin and Sunny Linnebur sug-

The decision to prescribe a second medicine to counteract an adverse drug reaction from a first medicine should only occur after careful consideration, and where the benefits of continuing therapy with the first medicine outweigh the risks of additional adverse reactions from the second medicine.

Information courtesy of Australian Prescriber.

gests prescribers need to be very careful with elderly patients to make sure they are treating a new symptom and not a new side effect. The Beers Criteria provided by the American Geriatrics Society can help health care professionals make appropriate decisions when prescribing for elderly patients.

A lack of communication and education to patients about possible side effects is a common cause for the prescribing cascade. Approximately 25 percent of patients reported to the CDC that they did not receive informa89.2 percent of adults taking tion about the possible adverse 5 or more drugs in the past 30 days effects associated with the medwere at least 45 or older. ication they took. If an adverse drug event occurs, pharmacists should consider lowering the dose of the medication or switching to a different medication that has less potential for side effects.

The cascade effect should be a cause for concern with pharmacists. Patients are at an increased risk each time new medications are prescribed. Therefore, pharmacists can play an important role in educating patients about side effects and help them recognize the difference between a drug side effect and a new disease symptom.

SPRING 2015 19

MEDICATION THERAPY SERVICES: IN A NUTSHELL

Everything you ever wanted to know about MTS: initiating, altering, or modifying medication therapy.

ASHLEY BUEHLER 2015 PHARM.D. CANDIDATE, UMKC SCHOOL OF PHARMACY AT THE UNIVERSITY OF MISSOURI, MPA ROTATION STUDENT, JULY 2014

The pharmacy profession is continuously growing and pharmacists are becoming even more of a resource for patients. There are many clinical activities pharmacists can participate in nowadays. For example, pharmacists in the outpatient setting within retail pharmacies commonly perform Medication Therapy Management (MTM) and Medication Therapy Services (MTS). Although these activities sound the same, they are not, and are sometimes confused with each other.

MTM is defined by Pharmicist.com as “a service or group of services that optimize therapeutic outcomes for individual patients.” There are five core elements used in MTM: medication therapy review, personal medication record, medication related action plan, intervention and/or referral, and documentation/followup. Medication therapy review is composed of gathering patient information and determining medication related problems. The personal medication record is a list of the patient’s current and past medications compiled by the pharmacist. The medication related action plan

20 MISSOURI PHARMACIST

is provided for the patient to determine their goals and help track their progress. The pharmacist can then discuss the patient’s medication related problems through consultation and refer them on if necessary. Finally, the pharmacist must document everything discussed during the MTM consult and determine an appropriate time for follow-up.

It appears fewer individuals know about MTS. MTS is defined as “the designing, initiating, implementing, or monitoring of a plan to monitor the medication therapy or device usage of a specific patient, or to enhance medication therapeutic outcomes of a specific patient, by a pharmacist who has authority to initiate or implement a modification of the patient’s medication therapy or device usage pursuant to a medication therapy protocol.”

In 2007, the Missouri legislature amended the Revised Statutes of Missouri 338.010 to allow pharmacists the chance to provide MTS. The Board of Pharmacy began issuing certificates of medication therapeutic plan authority on August 30, 2012.

123RF.COM

BY ASHLEY BUEHLER

MTS is basically initiating, altering, or modifying medication therapy. Modifications are considered to be (1) selecting a new, different, or additional medication or device; (2) discontinuing a current medication or device; or (3) selecting a new, different, or additional strength, dose, dosage form, dosage schedule, or route of administration for a current medication or device.

It is critical to understand who is able to provide these services. A pharmacist must have an active Missouri pharmacist license and have acquired a certificate of medication therapeutic authority from the Missouri State Board of Pharmacy. Pharmacy residents are also able to provide MTS as long as they have proof of a MTS certificate from the board, are enrolled in a residency program accredited by ASHP or a program with valid application for accreditation pending with ASHP, and provide services under the supervision of a Missouri pharmacist with a current MTS certificate. In order to receive MTS certification, a pharmacist must show documentation of one of the following, which is further explained in CSR 2220-6.070: 1. Doctor of pharmacy (Pharm.D.) degree obtained from a school that is accredited or granted by the Accreditation Council for Pharmacy Education (ACPE) or; 2. Successful completion of a postgraduate medication therapy certificate course or program accredited or granted by the ACPE, ASHP, American Society of Consultant Pharmacists, or the American Pharmacist Association or; 3. Current certification from the Board of Pharmaceutical Specialties, the Commission for Certification in Geriatric Pharmacy, or the National Certification Board for Diabetes Educators or; 4. Completion of a postgraduate medication therapy certificate course that included the following areas of focus, at a minimum: • Assessing patient specific data and issues, • Establishing medication therapeutic goals or medication related action plans for identified medication conditions and medication related concerns, • Assessing and addressing adverse reactions and

adverse drug events.

• Modifying and monitoring medication regimens, • Improving patient care and outcomes through medication therapy services, • Evaluating treatment progress, • Assessing and monitoring pharmacokinetic and pharmacodynamic changes in medication regimen reviews, Medication reconciliation, • Drug utilization review, Mo. Medication Therapy Services • Applicable state or federal 20 CSR 2220-6.060 law, 20 CSR 2220-6.070 • Formulating and docu20 CSR 2220-6.080 menting personal medication records, • Documenting clinical outcomes, • Interpreting, monitoring, THE DEFINITION ordering, and assessing paThe designing, initiating, tient test results, implementing, or monitoring of a • Patient education and plan to monitor the medication counseling. therapy or device usage of a specific Applications take about one to two weeks to process once received, and the application fee is $50. Once approved, the board will reissue the pharmacist’s license with “Medication Therapy Services” listed on the license. Pharmacists will need to renew their MTS certificate biennially along with their pharmacist license and will also need to complete 6 out of 30 continuing education hours in courses or programs related to medication therapy management. As mentioned above, in addition to having MTS certification, a written protocol must be established with a Missouri licensed physician in order for a pharmacist to provide MTS services.

The authorizing physician “shall be actively engaged in the practice of medicine in the state of Missouri and shall hold a current and

patient, or to enhance medication therapeutic outcomes of a specific patient, by a pharmacist who has authority to initiate or implement a modification of the patients medication therapy or device usage pursuant to a medication therapy protocol.

Selecting a new, different, or additional medication or device.

Discontinuing a current medication or device.

Selecting a new, different, or additional strength, dose, dosage form, dosage schedule, or route of administration for a current medication or device.

A Pharmacist Shall Not It is also important to understand what a pharmacist cannot perform under MTS. A pharmacist shall not: • • • •

Modify controlled substance prescriptions, diagnose, or provide activities considered practice of medicine.

Prescribe new medications for patients.

Delegate MTS tasks to another individual.

Consider a MTS service to be dispensing a drug or device pursuant to a valid prescription for the product, generic substitutions, or medication therapy management.

• Consider a MTS service to be administering drugs/vaccines pursuant to prescription or by protocol.

SPRING 2015 21

Authorizing Physician: The physician identified in the written protocol as authorizing the pharmacist to provide medication therapy services.

Medication Therapy Protocol: A written agreement between a physician and a pharmacist for the provision of medication therapy services.

Pharmacy Resident: A Missouri licensed pharmacist enrolled in a residency training program accredited by the American Society of Health-System Pharmacists or a residency training program with a valid application for accreditation pending with the American Society of Health-System Pharmacists.

Prescription Order for Medication Therapeutic Plan: A lawful order that is issued by the authorizing physician within the scope of his/her professional practice for the provision of medication therapy services by a pharmacist for a specific patient, including, patients of a health care entity.

unrestricted Missouri physician license.” The authorizing physician and pharmacist may not be separated by more than 50 miles of road from each other. The protocol must have specific requirements in order to be valid and must describe the medication therapy services the pharmacist is allowed to provide. It must be reviewed, dated, and signed annually by both the physician and pharmacist. Any changes made to the protocol must be documented in writing, dated, and signed by both the physician and pharmacist. Protocols can be terminated by either party with or without cause, but must be documented in writing. The protocol must be maintained for eight years after termination and may be maintained electronically.

A physician must provide a valid prescription that expires in one year and it can be communicated orally, 22 MISSOURI PHARMACIST

electronically, or in writing. Prescriptions must be maintained for seven years after termination of the protocol.

The prescription must have the following to be valid: 1. Patient’s name, address, and date of birth; 2. Date the prescription order for a medication therapeutic plan is issued; 3. Clinical indication for medication therapy services; 4. Length of time for providing MTS (if less than one year); 5. Authorizing physician’s name and address.

The pharmacist is required to document and maintain an adequate patient record (may be maintained electronically) of the services provided, which requires a minimum of specific information, and the record is required to be maintained for seven years after termination of the protocol. If the pharmacist modifies a patient’s drug therapy they must make a new prescription under the authorizing physician’s name. Written notification to the authorizing physician must be provided within 24 hours of therapy modifications, adverse events, adverse needle sticks, adverse medication reactions, or anaphylactic medication reactions.

There are some important differences between MTM and MTS. MTM is considered “within the scope of the ‘practice of pharmacy’ and can be performed by any Missouri licensed pharmacist.” MTS requires certification in order to provide these services, whereas MTM does not. Pharmacists also have the possibility to be reimbursed for the services provided through MTM. For more information about MTS and to find the MTS application, visit the Missouri Board of Pharmacy website (http://pr.mo.gov/pharmacists.asp). MTS is a great opportunity for pharmacists to provide specialized services for patients. The services that pharmacists can now offer show the public that pharmacists can do more than just dispense medications.

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COMMUNICATION BREAKDOWN

How being aware of health literacy can help you help your patients.

BY CHRISTOPHER FUCHS

CHRISTOPHER FUCHS 2015 PHARM.D. CANDIDATE, ST. LOUIS COLLEGE OF PHARMACY

If a physicist explained how to capture a photonic crystal, would you understand? Probably not, if you didn't have knowledge of physics to begin with. The same can be asked about our patients’ understandings of medical terms and conditions. This is why, as pharmacists, we have to be aware of our patients’ health literacy.

Health literacy is defined as the ability to read, understand, and act on health information. The main part of that definition is health information. Low health literacy does not equate to low literacy. As a student pharmacist, I have high health literacy, but if I were to talk to an engineer about quantum physics, I would seem illiterate.

It is easy, in the medical field, to assume that everyone knows medical terms and procedures. Going to St. Louis College of Pharmacy, I was surrounded by people who had high health literacy. When I go into the field and work at a hospital or community pharmacy, I have to change my mindset and simplify the terms and language I use.

Over ninty million Americans struggle with health literacy. That is roughly 30 percent of the population.

Statistics from the recent edition of the well-cited book Teaching Patients with Low Literacy Skills reports that 1 in 5 American adults read at a fifth-grade level or below. The average American reads between the eighth to 1 out of 5 adults read below the fifth grade reading level.

ninth grade levels. But, most medical and health materials, including the medication printouts that come with prescriptions, are written at the tenth grade reading level. This means that medical terminology is not completely understood by the general public. If our patients are completely lost, they will tune out the information we give them.

Low health literacy causes more than just confusion; it has been linked to poorer health outcomes. According to a systematic review funded by the Agency for Healthcare Research and Quality, patients with low health literacy were less likely to correctly identify their medications, less able to open and take their medications, and less able to describe how to take medications.

These factors lead to increased use of emergency care and hospitalization and decreased use of preventative 24 MISSOURI PHARMACIST

services. The National Academy on an Aging Society (NAAS) estimates low health literacy costs the healthcare system $73 billion annually. The personal cost to the patient and his or her family is immeasurable.

In the spring of 2013, I took an elective course called Indigent Populations: Focus on Health Literacy. The course opened my eyes to the gilded birdcage of medical knowledge I lived in. Each class, Doctors Anastasia Armbruster and Abigail Yancey would guide my fellow classmates and I through the basics and taught us the tools of health literacy. The elective concluded with a student presentation of a medical topic to the residents

at Gateway 180 homeless shelter in St. Louis. My partner and I presented on immunizations. The women of Gateway 180 participated in our presentation and were eager to learn.

More than 90 million patients struggle with health literacy.

“Witnessing our students’ knowledge and awareness of health literacy grow throughout the semester is such a joy,” Dr. Armbruster says. “They all seem to leave the course with a greater understanding and passion for

health literacy. We hope that with these skills and tools they are able to make a significant impact throughout their careers.”

As pharmacists, we are in a great position to increase awareness regarding health literacy and help our patients understand health information. We are readily available to patients, are often the first healthcare professional to discuss their medications in detail, and are one of America’s most trusted professions. We can bring a personal and empathetic touch to patients’ healthcare and let them know that we are here to help. There are several tools to help medical professionals understand SPRING 2015 25

HOW TO USE THE SHORT ASSESSMENT OF HEALTH LITERACY (SAHL)

SHORT ASSESSMENT OF HEALTH LITERACY STEM

KEY

DISTRACTER

DON'T KNOW

1. kidney

__urine

__fever

__don't know

2. occupation

__work

__education

__don't know

3. medication

__instrument

__treatment

__don't know

4. nutrition

__healthy

__soda

__don't know

5. miscarriage

__loss

__marriage

__don't know

6. infection

__plant

__virus

__don't know

7. alcoholism

__addiction

__recreation

__don't know

4. The interviewer should have a clipboard with the score sheet hidden so that he or she can record the patient’s response.

8. pregnancy

__birth

__childhood

__don't know

9. seizure

__dizzy

__calm

__don't know

5. The interviewer will then read the key and distracter (the two words at the bottom of the card) and then say: “Which of the two words is most similar to the top word? If you don’t know the answer, please say ‘I don’t know’.”

10. dose

__sleep

__amount

__don't know

11. hormones

__growth

__harmony

__don't know

12. abnormal

__different

__similar

__don't know

13. directed

__instruction

__decision

__don't know

14. nerves

__bored

__anxiety

__don't know

15. constipation __blocked

__loose

__don't know

16. diagnosis

__recovery

__don't know

__heart

__don't know

1. Before the test the interviewer should say to the patient: “I’m going to show you cards with three words on them. First, I’d like you to read the top word out loud. Next, I’ll read the two words underneath and I’d like you to tell me which of the two words is more similar to or has a closer association with the top word. If you don’t know, please say ‘I don’t know.’ Please don’t guess.”

2. Show the patient the first card.

3. The interviewer should say: “Now, please, read the top word out loud.”

6. The interviewer can now repeat the instructions or continue on with the test in the same manner as before.

7. A correct answer for each item is determined by both the correct pronunciation and accurate association. Each correct answer equals one point.

8. At the end of the examination, tally the number of points.

__evaluation

17. hemorrhoids __veins 18. syphilis

__contraception __condom

__don't know

http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy/index.html

9. A score between 0 and 14 suggests the patient has low health literacy.

HOW TO USE THE RAPID ESTIMATE OF ADULT LITERACY IN MEDICINE — SHORT FORM (REALM-SF) 1. Give the patient a laminated copy of the REALM-SF form.

2. Score answers on an un-laminated copy attached to a clipboard. Hold the clipboard so that the patient is not distracted by your scoring.

3. Say: “I want to hear you read as many words as you can from this list. Begin with the first word and read aloud. When you come to a word you cannot read, do the best you can or say, 'blank' and go onto the next word.”

26 MISSOURI PHARMACIST

4. If the patient takes more than five seconds on a word, say "blank" and point to the next word. If the patient begins to miss every word, have him or her pronounce only known words.

5. One point is given for each correctly pronounced word.

6. The scores correspond to reading levels at right.

READING LEVELS 0 – Third grade and below: the patient will not be able to read most low literacy material.

1 to 3 – Fourth to sixth grade: the patient will need low-literacy material, may not be able to read prescription labels.

4 to 6 – Seventh to eight grade: the patient will struggle with most patient education material, may need low literacy material.

7 – High School: the patient will be able to read most patient education materials.

and assess their patients’ health literacy. By having this knowledge, we can help patients better understand their disease states and take part in their therapies.

Low health literacy costs the healthcare system $73 billion annually.

The Agency for Healthcare Research and Quality provides health literacy assessment tools such as the Short Assessment of Health Literacy (SAHL); and the Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM). Both tools have been clinically validated for efficacy. The SAHL can be used for English- or Spanishspeaking patients and can be administered in two to three minutes. This short amount of time could greatly benefit the efficacy of the patient’s therapy.

The interviewer administers the SAHL by reading three words: the stem, key, and distractor. A correct answer is when the patient selects the key word, not the distractor. A score between 0 and 14 suggests the patient has low health literacy. The REALM uses word recognition to determine a patient’s reading level based on the number of words the patient can recognize and pronounce.

The National Patient Safety Foundation has developed a patient education program called Ask Me 3. At the core of the program are three questions that every patient should ask their healthcare professional:

bag medication reviews. A brown-bag medication review is a community outreach service where patients are encouraged to bring their medications to a pharmacist so that the pharmacist can review the medications with the patient.

By using these tools and practices, pharmacists can improve health literacy. It is our vocation to ensure our patients understand their medications and medical conditions and to let them know that we are here for them. As a student pharmacist, one of the most rewarding experiences has been educating patients. There is no greater feeling than helping a patient truly understand his or her medications.

1. What is my main problem?

2. What do I need to do?

3. Why is it important for me to do this?

Asking these three questions ensures that the patient will have at least a basic understanding of his or her medical condition. It is very important to educate patients to use this tool each time they see their doctor.

Ask Me 3 information can be found at https://npsf.siteym.com/default.asp?page=askme3.

Pharmacists can use these tools during counseling to help assess and address a patient’s health literacy. During a consultation, as a pharmacist, it is important not to use medical jargon. The use of plain language guarantees that most patients will understand what is being said.

The teach-back method can also be helpful during a patient consultation. Teach-back is a method in which the patient restates what the pharmacist said in the patient’s own words. This allows the pharmacist to see if the patient truly understands the consultation. A good way to ask the patient to restate the consultation is by asking, “To make sure I didn’t miss anything, can you tell me how you are going to take this medication?”

Phrasing the question like that ensures that patients will not feel like their intelligence is being questioned.

Another great opportunity for pharmacists is brown-

MEDICAL JARGON PLAIN LANGUAGE Cardiologist Heart doctor Analgesic Pain reliever Benign Not cancer Cardiac Heart Hypertension High blood pressure Lipids Fat in blood Monitor Keep track of Contraception Birth control Myocardial Infarction Heart attack Pulmonary Embolism Blood clot in lungs SPRING 2015 27

BOARD OF PHARMACY SPECIALTIES

Recognizing the value of specialized training, knowledge, and skills.

The Board of Pharmacy Specialties, or BPS, was organized in 1976 following the recommendations of the Task Force on Specialties in Pharmacy, a group developed three years prior by the American Pharmacists Association (APhA) in response to changing healthcare practices in the United States.

According to bpsweb.org, “The overriding concern of BPS is to ensure that the public receives the level of pharmacy services that will improve a patient's quality of life,” and to achieve this goal, the Board has recogMELISSA nized specialty practice areas.

LUECHTEFELD As the premier post-licensure certification agen2015 DOCTOR cy, BPS promises to ensure recognition within the OF PHARMACY healthcare delivery system for Board Certified PharmaCANDIDATE, cists and to serve the needs of the public and the pharUNIVERSITY OF macy profession. BPS promotes the recognition and MISSOURI-KANSAS value of specialized pharmacy training, knowledge, and CITY SCHOOL OF skills used to improve patient care. BPS also recognizes, PHARMACY AT MU sets standards for, and provides certification in specific clinical specialties to allow for expanding roles in the pharmacy world.

The certification process, including both specialty recognition and exam content, is dependent on an expanded peer group. A specialty council of content experts works with BPS to develop a bank of test questions when a new specialty area has been recognized. The council consists of six pharmacists practicing in the specialty area and three outside pharmacists. In addition, practitioners working in the field are also consulted for test questions. About every five years, a new study is conducted for each specialty to update the certification and recertification processes and modify exams accordingly.

Certification examinations consist of two hundred multiple-choice questions. Exams are administered twice a year, mid-April through early May and midSeptember through early October, at designated sites in the US and other countries. The certification application fee is $600, and the retake application fee is $300 if the candidate had failed the exam within the past year.

Pharmacists can only sit for one specialty exam in each testing cycle; of note, each Specialties include: Oncology, Nuclear, specialty has a requirement to Pediatric, Pharmacotherapy, Nutrition have practiced for three to four Support and Psychiatric Pharmacy. years in that specialty to qualify for certification, making it hard for pharmacists to hold more than a few. The BPS website reports only a small number of pharmacists hold more than one certification.

BPS pharmacists must recertify every seven years.

The application fee is $400 for recertification via the one hundred-question multiple-choice examination or continuing education hours. It costs $200 to retake the 28 MISSOURI PHARMACIST

recertification examination if the candidate had failed the recertification exam at the last exam administration date. The amount of continuing education hours required for recertification differs by specialty; exact requirements can be found under the certification maintenance and recertification tab at bspweb.org.

In preparation for the exam, the BPS website includes a section under the “2014 Exam” heading titled “Preparing for the Exam.” Links to specialty-specific exam content outlines and review-information from outside organizations are listed as study tools. Sample questions and study suggestions including attending continuing education programs and courses in the area of specialization desired, reading relevant journal articles and textbooks, and participating in study groups and exam prep courses can increase confidence and knowledge.

The available BPS certifications are Ambulatory Care Pharmacy, Critical Care Pharmacy, Oncology Pharmacy, Nuclear Pharmacy, Pediatric Pharmacy, Pharmacotherapy, Nutrition Support Pharmacy, and Psychiatric Pharmacy. Click “News Room” on the BPS website for fact sheets and brochures outlining each specialty.

Board Certified Ambulatory Care Pharmacist (BCACP), the first specialty, “addresses the provision of integrated, accessible healthcare services for ambulatory patients in a wide variety of settings, including community pharmacies, clinics, and physician offices,” as documented on its fact sheet.

As a BCACP, focus will be on the special needs of patients with concurrent illnesses taking multiple drugs at home or with caregiver assistance. Pharmacists will strive to integrate the care of acute illness and exacerbations with chronic disease-state management, engaging the patient in health promotion and wellness. By assessing for appropriate treatment, monitoring patient compliance, refilling prescriptions, and providing patient education, sustained partnerships with ambulatory patients will be made. According to the BPS website, 1,659 pharmacists hold the BCACP title as of June 2014.

Board Certified Critical Care Pharmacists work to guarantee the safe and effective use of medications in critically ill patients, as described on the specialty’s fact sheet. In addition to the patients’ primary conditions, their focus is on the specialized pharmacologic or technological interventions the critically ill may need to maintain blood pressure, respiration, nutrition, and other homeostatic functions. As a Critical Care Pharmacist, multifaceted clinical and technological data will be reviewed frequently for patients with life-threatening conditions and complex medications; this information will be used to make reasoned decisions, taking into account the differences in pharmacokinetic and phar-

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BY MELISSA LUECHTEFELD

SPRING 2015 29

30 MISSOURI PHARMACIST

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macodynamic parameters between critically ill and non-critically ill patients. The first examination for this specialty will be administered in the fall of 2015.

Oncology pharmacy is centered on the provision of evidence-based, patient-centered medication therapy management for cancer patients. A Board Certified Oncology Pharmacist (BCOP) has the ability to manage adverse events that are both cancer-related and drugrelated as well as disease-specific clinical situations arising from the complexity of drug therapies to treat and prevent cancer. The BCOP fact sheet states pharmacists will be “specially trained to recommend, design, implement, monitor, and modify pharmacotherapeutic plans to optimize outcomes … and reduce medication errors” for their patients. The BCOP will work as a part of a multidisciplinary team in hosOnly 528 pharmacists held pitals and ambulatory clinics; the title of Board Certified Nuclear they will serve as a resource for Pharmacist as of June 2014. community pharmacists filling prescriptions for outpatients with malignant disease. As of June 2014, the number of board certified oncology pharmacists is 1,626.

Nuclear pharmacy was the first specialty approved by BPS according to the online fact sheet. A Board Certified Nuclear Pharmacist (BCNP) has the expertise to prepare and handle highly toxic radiopharmaceuticals.

Pharmacists are also involved in quality control, testing, and health and safety issues related to the products; their role allows for minimal error, drug-drug interactions, and patient exposure to radiation. As of 2014, there are 528 Board Certified Nuclear Pharmacists.

BPS Pediatric Pharmacist certification is another new specialty for fall 2015. As described on the fact sheet, providing patient care to those under 18, including alternate dosage forms and specialized drug therapy monitoring, will be the focus. Pharmacists will serve as an advocate for the pediatric population, providing education and promoting health and wellness to advance

Specialty pharmacists fill important administrative roles in health facilities and can deliver more complex and complete patient care.

knowledge and skills in pediatric pharmacy.

Board Certified Pharmacotherapy Specialist (BCPS) is the largest specialty certification, with 14,282 certified pharmacists as of June 2014. As a BCPS, pharmacists work as a part of an interprofessional team to guarantee the “safe, appropriate and economical use of medications … in a variety of settings, including hospitals and health systems,” as described by the online fact sheet.

BCPS pharmacists work with physicians to design and/ or modify treatment plans, serving as an objective, evidence-based source for therapeutic recommendations and information. In the outpatient setting, they again team with physicians to optimize medication therapy by tracking progress and compliance. Suggestions on diet and lifestyle changes are also made by pharmacists in order to improve health management.

As a Board Certified Nutrition Support Pharmacist (BCNSP), the care of patients receiving specialized nutrition support is addressed. Patients receiving parenteral (IV) or enteral (feeding tube) nutrition are included; pharmacists work to “promote the maintenance of and/or restore optimal nutrition status through design and modification of individualized treatment plans,” as outlined on the online fact sheet.

Direct patient care, type of feeding design, dosing of specific nutrients, compatibility issues, clinical monitoring and identification of nutrient deficits, parenteral and enteral feeding formulation preparation, and maintenance of nutritional status during critical transition to outpatient care highlight the main responsibilities of a BCNSP. Only 533 pharmacists held the BCNSP title as of June 2014.

BPS Board Certified Psychiatric Pharmacist (BCPP), per the fact sheet for this specialty, have a slightly higher pharmacist population, 805 as of June 2014. BCPP provide care to patients with psychiatric-related illnesses.

Expertise is demonstrated when providing care to patients with multi-sided symptoms. Treatment assessment, cost-effective medication regimen design, appropriate dosing, and monitoring of complex medications for potential adverse reactions and interactions and adjusting medications accordingly encompass a few of the responsibilities of a BCPP. Specialty pharmacists also fill important administrative roles in psychiatric, mental retardation, and substance abuse facilities. A BCPP is a valuable resource for healthcare teams and patients.

Specialty roles allow pharmacists to deliver more complete and complex patient care. With a board certification, BPS emphasizes pharmacists will be confident and prepared to step into evolving pharmacy positions on multidisciplinary teams. As an added bonus, in a competitive employment market, a certification will put the holder one step ahead of contenders.

Holding a specialty certification promotes lifelong learning and provides recognition for pharmacists’ expertise by other healthcare professionals, employers, patients, and insurers.

Perniciaro and Associates Senior Care Consultants Paul G Perniciaro, R.Ph., CGP, FASCP President, Director of Consultant Pharmacy Services 636-391-7555 | paulrphcgp@sbcglobal.net 2209 Sycamore Drive, Chesterfield, MO

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DO PHARMACISTS ADD VALUE TO ACCOUNTABLE CARE ORGANIZATIONS?

Making the case for the importance of pharmacists in ACOs.

MELISSA LUECHTEFELD DOCTOR OF PHARMACY CANDIDATE CLASS OF 2015, UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF PHARMACY AT MU

Accountable Care Organizations (ACOs) are networks of physicians and other providers that voluntarily work as a team to improve the quality of healthcare provided to a defined patient population, and as a result, reduce associated costs.

This model has become a potential system to promote the integration of healthcare. Through ACOs, shared electronic health records will minimize paperwork and repeat diagnostic and medical testing, according to an article by the Academy of Managed Care Pharmacy.

Through the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) is authorized to contract with ACOs under the Medicare program.

Following the pioneer ACO model, in 2011, CMS established the Shared Savings Program to facilitate coordination and cooperation among providers with the goal of improving the quality of care for Medicare FeeFor-Service beneficiaries and reduction of unnecessary cost. By creating or participating in an ACO, eligible providers, hospitals, and suppliers can participate in the

32 MISSOURI PHARMACIST

Shared Savings Program. This program rewards ACOs that “lower their growth in healthcare costs while meeting performance standards on quality of care and putting patients first.” Quality standards are set in five key areas: patient/caregiver experiences, care coordination, patient safety, preventative health, and at-risk population/frail elderly health.

According to a 2013 article by Marie Smith et al. in Health Affairs, more than 480 public and private ACOs are already in existence, but very few engage pharmacists to provide medication management services as a core element of the establishment’s work. The article reports “enormous variation” between staff composition and roles for ACOs. Reasons suggested include the lack of payment models and absence of provider status for pharmacists who provide medication management services. Challenges exist, but integration of pharmacists into healthcare teams is projected to assist in achieving patient-specific and system-level goals across the care field.

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BY MELISSA LUECHTEFELD

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THE PENNSYLVANIA PROJECT

In Pennsylvania, the impact of pharmacist intervention on medication adherence and reduced healthcare costs was analyzed in a 2010 large-scale community pharmacy study. This project measured the effect of a screening and brief intervention approach on medication adherence for medication classes commonly associated with chronic disease management and total downstream health care costs. Calcium channel blockers, oral diabetes medications, beta-blockers, statins, and renin angiotensin system antagonists were included in the analysis.

Around 60,000 patients were followed between the intervention and control groups.

In the study, adherence was measured by whether the patient achieved a proportion of days covered greater or equal to 80 percent, a common claims-based measure of adherence used by the Medicare star ratings sys34 MISSOURI PHARMACIST

tem. Prior to intervention, adherence rates were almost equal or lower for the intervention vs. control group for all medication classes. During the intervention period, January-December 2011, a significant improvement (p value < 0.05) in adherence was seen for all five common medication classes in the intervention group. Financially, the authors translate the study findings to a potential $1.4 million savings over one year for a payer with ten thousand members taking either a statin only, antidiabetic medication only, or both. This result can also be viewed as an increase by one star in the Medicare star rating if the pharmacy exclusively contracts with intervention pharmacies.

Although the study is limited by assuming a filled prescription is consumed, it is a common research technique used to investigate adherence over a large patient population. A major strength of the study is the consistent, positive results for intervention in all five common medication classes. In addition, the authors report the project was â&#x20AC;&#x153;implemented under real-world conditions with very limited funding to the community pharmacy organization.â&#x20AC;? Cost to the pharmacy was considered in that pharmacist intervention improved adherence, increasing prescription volume by an estimated 900 pills per 1,000 patients in each medication class six months after implementation. Improvement in the Medicare star rating system score would generate more dollars. With more revenue, the intervention project can be supported.

Pharmacists add value to ACOs both clinically and financially. As shown by the Pennsylvania Project, a screening and brief intervention process by the pharmacist can significantly improve medication adherence, leading to better control of chronic disease. For payers, decreased downstream healthcare spending and improved Medicare star ratings are two ways costs can be reduced and revenue increased.

With pharmacists on board, medication-related care coordination and quality improvement functions, both of which physicians often do not have time to complete, can be accomplished. Pharmacists have the ability to help healthcare teams reach performance targets or shared-savings goals, reducing emergency department visits, specialty consultations, and hospitalizations.

Substantial value will be added to ACOs upon engaging pharmacists to provide MTM services and other patientcentered interventions.

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PHARMACIST INVOLVEMENT

Medications are the foundation for management of chronic health conditions. It is reported, in the primary care setting, clinician-influenced gaps in care involving inappropriate prescribing, lack of care coordination, and inconsistent monitoring account for approximately 75 percent of medication problems. Smith notes patient factors such as health beliefs, health illiteracy, past medication experiences, and non-adherence make up the remaining 25 percent. These statistics provide opportunity for pharmacist involvement to offset difficulties; comprehensive medication reviews and medication reconciliation, drug therapy management clinics, drug utilization review and identification of gaps in care, and prescription drug adherence clinics are some of the many ways Academy of Managed Care Pharmacy suggests pharmacists can play a role in ACOs through medication therapy management (MTM) services.

It is estimated that primary care physicians spend 37 percent of their time on activities related to chronic care monitoring. Management of complex medication regimens is often a large piece, and providers may not have sufficient time to verify and extensively discuss medication lists during routine office It is estimated that primary care visits. With inaccurate and inphysicians spend 37 percent of their complete medication histories, time on activities related to chronic inappropriate or unsafe medicare monitoring. Management of cation decisions may occur. If complex medication regimens is pharmacists are integrated into often a large piece, and providers care teams through ACOs, they may not have sufficient time to can develop trust and friendship spend verifying and discussing with patients and their families, extensively medication lists during as well as other health care proroutine office visits. viders. These relationships can be used by pharmacists to focus on patient-specific prescribing options, adherence at home, pharmacotherapy monitoring and management, and follow-up for desired outcomes. Special attention can be paid to high-risk patients, who use more healthcare services and generate high costs, Smith wrote.

SPRING 2015 35

PHARMACY AND THE LAW: LAW VS. ETHICS

Pharmacists should stay abreast of current laws, that is a given, but the role of ethics in decision-making is oft overlooked.

BY DON R. MCGUIRE JR.

I recently attended a conference which had some very thought-provoking sessions1. While the conference was billed as a pharmacy law conference, ethical issues kept percolating to the surface. What is the difference between law and ethics? Why should I care? What impact can ethics have on pharmacy practice?

We should care because law and ethics work together to maintain our society. Law is a rule of conduct that is formally recognized by a society as binding and is enforced by that society. Ethics, on the other hand, is less structured and less formal. As professionals, pharmacists must use their professional skills for the benefit of their patients. Ethics involves the decision-making process required to treat patients. Many times the choices faced are not dealt with directly by laws.

Some commentators view laws as the baseline for professional conduct. This must mean that there is some advanced mode of practice that exceeds the requirements of the law. For example, if a pharmacist is required to undergo an annual skills assessment, there would be nothing to prevent the assessment being done every six months if it was thought that it provided better care for the patient. It still complies with the requirement set by law. The cost/benefit analysis and the decision-making process that ensues to decide if every six months is warranted is where ethics comes into play.

Some pharmacists don’t believe that ethical questions will affect them. They follow the law every day and that will suffice. However, there is a limitation on the effectiveness of the law. Law tends to be reactionary, not proactive. Law deals with yesterday’s problems, not tomorrow’s. Also, law is limited.

Ethics is the measuring stick for There are not laws to address situations where black and white laws every single issue that comes up don’t exist, which is most of the time. in today’s society. If there were, our code books would be enormous. This is why lawyers are always talking about the “reasonable person.” What would a reasonably prudent pharmacist have done in your situation? This is the measuring stick for situations where black and white laws don’t exist, which is most of the time. These situations make pharmacists nervous because there may not be one “right” answer. Most likely there will be a best answer.

Many people wish that more laws were simple right or

DON R. MCGUIRE JR. R.PH., J.D., IS GENERAL COUNSEL, SENIOR VP OF RISK MANAGEMENT & COMPLIANCE AT PHARMACISTS MUTUAL INSURANCE COMPANY

wrong choices, but the reality is that our society is too complicated for such laws. Changing one little factor in a scenario may drastically change your conclusion.

If following the law is your only criteria, then there is little to debate here. But, ethical questions can arise because of a number of different reasons. It could be a conflict between the pharmacist’s moral values and the law. It could be competing laws that don’t coincide leaving the individual to try to reconcile the two different laws. They might also arise when there is no applicable law at all. Ethical questions might also arise when a patient’s needs cannot be met within the legal guidelines.

Chances are we will all come across these types of choices at some point. Take time to prepare before you are faced with an urgent decision. There are plenty of ETHICAL DECISIONS Look at this list of issues if you think pharmacists aren’t faced with ethical decisions; • Should pharmacists be involved in the dispensing of Medical Marijuana?

• Should pharmacies sell alcohol or tobacco products?

• Should pharmacists take part in executions by lethal injection?

• Should pharmacists have the right to refuse to dispense drugs based on their personal morals?

• Should pharmacists dispense drugs for assisted suicide?

references available that explain the principles of ethics and the decision-making process. When you are better prepared, the challenges are easier to handle. The ostrich approach is not going to prepare you well. Pharmacists are required to study the applicable laws. They should also study ethics because law and ethics work hand in hand. Neither alone is sufficient for pharmacists’ practices in the 21st Century.

This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

1. American Society for Pharmacy Law’s Developments in Pharmacy Law XXV. Thanks to Ken Baker and Bruce White for planting the seeds of this article.

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

36 MISSOURI PHARMACIST

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SPRING 2015 37

FINANCIAL FORUM: IRA ROLLOVERS FOR LUMP SUM PENSION PAYOUTS

Give those dollars the opportunity for further tax-deferred growth.

BY PAT REDING AND BO SCHNURR OF BERTHEL FISHER & COMPANY FINANCIAL SERVICES, INC.

This material was prepared by MarketingLibrary.Net Inc., and does not necessarily represent the views of the presenting party, nor their affiliates. All information is believed to be from reliable sources; however we make no representation as to its completeness or accuracy. Please note—investing involves risk, and past performance is no guarantee of future results. The publisher is not engaged in rendering legal, accounting or other professional services. If assistance is needed, the reader is advised to engage the services of a competent professional. This information should not be construed as investment, tax or legal advice and may not be relied on for the purpose of avoiding any Federal tax penalty. This is neither a solicitation nor recommendation to purchase or sell any investment or insurance product or service, and should not be relied upon as such. All indices are unmanaged and are not illustrative of any particular investment.

38 MISSOURI PHARMACIST

123RF

A BIG PAYOUT LEADS TO A BIG QUESTION. If you are taking a lump sum pension payout from your former employer, what is the next step for that money?

It will be integral to your retirement; how can you make it work harder for you? Rolling it over might be the right thing to do.

If you just take your lump sum payout If you don’t have substantial and deposit it, all that money will be retirement savings, that lump considered taxable income by the IRS. sum may be just what you need. The key is to plan to keep it growing. That money shouldn’t just sit there.

Even tame inflation whittles away at the value of money over time, according to online articles by CNN and Kiplinger. Most corporate pension payments aren’t

inflation-indexed, so those monthly payments eventually purchase less and less. Lump sums are just as susceptible: if you receive $100,000 today, that $100,000 will buy 50 percent less by 2028 assuming consistent 3 percent inflation (and that is quite an optimistic assumption).

Putting it in the bank might cause you some financial pain. If you just take your lump sum payout and deposit it, all that money will be considered taxable income by the IRS. (There are very few exceptions to that rule.) Moreover, you won’t get the whole amount that way: per IRS regulations, your employer must withhold 20 percent of it.

Don’t you want to postpone paying taxes on those assets? By arranging a rollover of your lump sum distribution to a traditional IRA, you may defer tax on those dollars. You can even defer tax on a distribution already paid to you if you roll over the taxable amount to an IRA within sixty days after receipt of the payout.

In doing so, you are keeping those assets in a taxdeferred account. They can be invested as you like, and that money will not be taxed until it is withdrawn. (You may only transfer a lump sum distribution from a company pension plan into a traditional IRA—you may not transfer it to a Roth IRA.) If you are considering taking a lump sum payout, make sure you position that money for additional taxdeferred growth. Talk to a financial professional who can help you with the paperwork and get your IRA rollover going.

This series, Financial Forum, is presented by PRISM Wealth Advisors, LLC and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

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a potent probiotic medical food References: 1. Kornblut A, et al. Am J Gastroenterol. 2004;99(7):1371-1385. 2. Holubar SD, et al. The Cochrane Library. 2010, Issue 6. 3. Gionchetti P, et al. Gastroenterology, 2000;119(2):305-309.

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www.vsl3.com SPRING 2015 39

Student Update

UMKC Pharmacy progam at MSU

RUSSELL B. MELCHERT DEAN AND PROFESSOR, UMKC SCHOOL OF PHARMACY

I am very happy to report that the UMKC School of Pharmacy faculty and staff have completed and ratified the new 2015-2020 Strategic Plan. The new plan focuses on four major goals: placing student success at the center of our goals, advancing statewide engagement, promoting diversity, and leading in life and health sciences by excelling in research and promoting economic development.

Our annual reports will provide specific information on our progress, as we achieve each of these goals over the next five years. However, I would like to mention a few highlights from 2014 that will provide a sneak peek of what, I think, will be continued success in 2015 and beyond.

We continually review a variety of metrics to determine progress on achieving our first goal of placing student success at the center of our plan. One metric of student success includes the repeated national recognition our pharmacy students receive for their commitment to community engagement and service. Early indicators suggest that 2015 will be equally, if not more, successful as our students performed very well in the APhA-ASP Midyear Regional Meeting in the fall of 2014. Out of sixteen participating chapters, the UMKC APhA-ASP Chapter was recognized as the Region 6 winner for Operation Self-Care, Operation Heart, and Operation Immunization, thus winning first place in three of four patient-care awards. This success strongly suggests that our pharmacy students will once again highlight UMKC during the national competition at the 2015 APhA meeting. In addition to national recognition, we look at the ultimate indicators of success of our students: graduation and placement. For 2014, placement of graduates was high, as 94 percent of respondents indicated current employment, and median salary was $125,420 for fulltime employment, excluding residency positions.

For our second goal of advancing statewide engagement, we intend to promote pharmacy, equip pharmacists to provide high-quality progressive patient-care services, advocate for the advancement of pharmacist delivered care, and partner with other health professions and institutions around the state. We have just reached

40 MISSOURI PHARMACIST

a major milestone with our expansion of the pharmacy program to Springfield in cooperation with Missouri State University. As highlighted in this issue of Missouri Pharmacist, we are extremely proud to have admitted our first cohort of students in Springfield. In addition to MSUâ&#x20AC;&#x2122;s Information Technology staff member, Robin Kennedy, and our Associate Dean for the site, Dr. Paul Gubbins, we also hired two new faculty members in 2014, Heather Lyons-Burney and Diane McClaskey, and one staff member, Manndi DeBoef. For 2015, we eagerly await reporting to you the success of our ongoing recruitment efforts with our partners at CoxHealth, Mercy, and Jordan Valley Community Health Center, as we fill four more faculty positions in Springfield.

We will also ensure that our diversity initiatives are actively reviewed and implemented by our students, faculty, and staff. To ensure progress on our third goal, we need your assistance to recruit a diverse academic community. We encourage all pharmacists to get involved as ambassadors to bring new and diverse talent to the profession. More information on this program is available on our website, UMKC.com, and through our student affairs office.

Our graduate students in the pharmacology and pharmaceutical sciences continue to enjoy success and contribute toward our fourth goal: to become leaders in the life and health sciences. In completing their dissertation research, graduate students and their faculty mentors present their findings at international meetings, publish outstanding studies in high-impact journals, and often patent their innovations. We look at graduate student graduation and placement as well, and all of our graduates are obtaining excellent positions in pharmaceutical industry and academia.

All of this and more will be detailed in our 2014 Annual Report, and all signs indicate 2015 will be a great year as well.

As always, I invite you to visit us at any one of our three locations. We enjoy having visitors and especially the opportunity to catch up with alums, preceptors, and all those with an interest in UMKC Pharmacy. I wish all of you the best!

COURTESY OF UMKC AT MSU

CAMPUS NEWS

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SPRING 2015 41

ON ROTATION

A firsthand look inside the Missouri Pharmacist Association and G.L.O. and Associates.

BY CHRISTOPHER FUCHS

MISSOURI PHARMACIST ASSOCIATION

The MPA is an organization that I have been a member of for years, but didn’t actually know a lot about. My chief duties at the MPA were to write weekly blog posts for The Pharmacy Blog and articles for the quarterly MPA magazine, Missouri Pharmacist. I hadn’t written anything like a blog post or article in years, and I was nervous at first, to say the least.

Most of my pharmacy experience has The MPA staff was always willbeen in hospital in-patient pharmacy. ing to help with my writing and Visiting Tolson Drug allowed me to see was great to work with. the day-to-day operation of owning As the rotation went on, and managing a community pharmacy. I found myself enjoying the writing process. My blog posts included topics such as pneumonia, influenza, heartburn, and aspirin use. In addition to my articles and blog posts, I had the opportunity to help write Pharmacy Technician Continuing Education.

I co-wrote two continuing education pieces about HIPAA and pharmaceutical mathematics. (Hopefully, those will be approved and published in the coming months.) It was interesting to be on the other side of education and help write the material.

I did not spend all my time writing, though. Having never been to a formal meeting that used Robert’s Rules of Order before, I had the chance to experience one first hand at a MPA board meeting. During the meeting, I was able to get an inside peek at the inner workings of the MPA and their projects for advancing pharmacy. I met all the board members, including STLCOP President, John Pieper.

Two other unique opportunities presented themselves while at the MPA. I had the chance to sit in during a review of a piece of legislation and visit a local independent pharmacy. I never realized the attention to detail it takes to write a law. Adding, changing, or deleting one word can drastically change what the bill says and how it will be implemented.

42 MISSOURI PHARMACIST

I also visited Tolson Drug in downtown Jefferson City. Tolson Drug is owned and operated by Dr. Cameron Schulte, a recent graduate of STLCOP. Most of my pharmacy experience has been in hospital in-patient pharmacy, and the visit allowed me to see the day-today operation of owning and managing a community pharmacy.

G.L.O. AND ASSOCIATES

As I said earlier, the MPA was only half my rotation.

At G.L.O. and Associates, I worked with Dr. George Oestreich and his partner Dr. Jennifer Kemp-Cornelius.

With Dr. Kemp-Cornelius, I contributed to Extension for Community Healthcare Outcomes (ECHO). ECHO is a new telecommunication project that connects primary care physicians with a team of specialist. The ECHO project is targeted for chronic pain patients. Every week, Dr. Oestreich and Dr. Kemp-Cornelius receive a patient from a primary care physician that he or she needs assistance with. Dr. Oestreich and Dr. Kemp-Cornelius act as the pharmacy experts on the medical team.

Dr. Kemp-Cornelius was also able to set up a visit to Xerox. At first I was curious as to what copiers had to do with pharmacy, but it turns out Xerox does much more than copies. Xerox is the vendor for Cyber Access, a web-based tool that allows physicians to prescribe electronically, view diagnosis data, receive alerts, select appropriate preferred medications, and electronically request drug and medical prior authorizations for MO HealthNet patients. Dr. Joshua Moore, the MO HealthNet Executive Account Manager at Xerox, demonstrated Cyber Access and gave me some behind-the-scenes information on MO HealthNet. At Xerox, I met the clinical pharmacists responsible for making the clinical edits that allow patients to have certain medications covered by MO HealthNet. Xerox is a side of pharmacy I never would have known about if it weren’t for this rotation.

Throughout the rotation I learned about Missouri Medicaid, Missouri Medicare, third-party insurances, and how they all work together in the healthcare system. I had very limited knowledge about these subjects before this rotation. Now, I feel better prepared to answer patient’s and physician’s questions about Medicaid or Medicare.

The MPA rotation has been, by far, the most unique rotation I have been on. I never realized how many different paths pharmacy can take someone down. My preceptor and the staff at the MPA made me feel at home right away. I would recommend this rotation to anyone and encourage future P4 students to check out the MPA’s student resources page for more information.

123RF.COM

CHRISTOPHER FUCHS 2015 PHARM.D. CANDIDATE, ST. LOUIS COLLEGE OF PHARMACY

At St. Louis College of Pharmacy (STLCOP), when a student joins a professional pharmacy organization they receive a complementary membership to the Missouri Pharmacist Association (MPA) or the Illinois Pharmacist Association. My sole experience with the MPA before this rotation was their annual Legislative Day. So, I was excited to see firsthand the day-to-day operations of the MPA. My rotation was split between the MPA and time with my preceptor, Dr. George Oestreich. Dr. Oestreich is a consulting pharmacist with G.L.O. and Associates. This arrangement allowed me to experience two rotations in one.

SPRING 2015 43

STAR QUALITY MEASURES

CMR Completion Rate

BY NICHOLAS DORICH

NICHOLAS DORICH PHARMD, PHARMACY QUALITY CONSULTANT

In understanding the Centers for Medicare and Medicaid Services Star Ratings program and quality measures in general, it is of upmost importance that pharmacists stay tuned in to updates in the program. While quality measures revolving around medication adherence are inherently part of pharmacists' routine work, other measures are more ingrained with providing total patient care. At this point, measures such as High Risk Medication Use and the Appropriate Treatment of Hypertension in Patients with Diabetes, can be impacted through proactive interventions conducted by pharmacists in conjunction with prescribers.

As the pharmacy profession continues to move forward with new services and opportunities in healthcare, more capabilities to impact total patient care will arise.

This holds true for quality measures. Slated to start as a quality measure January 1, 2016, pharmacists will further be able to impact star ratings through the Comprehensive Medication Review (CMR) Completion Rate.

Many pharmacists may recognize the term CMR, as it is often used or mentioned when discussing Medication Therapy Management or MTM. However, in this context, it is important for pharmacists to know and understand what constitutes a CMR vs. a MTM opportunity that they may see in practice.

IT’S WRITTEN IN THE STARS

To understand how the CMR Completion Rate measure will be evaluated, we first have to begin with the process. The CMR Completion Rate measure was endorsed by the Pharmacy Quality Alliance (PQA) in 2011 and began as a “display measure” by Centers for Medicare and Medicaid Services (CMS) using 2012 data. In following this process, display measures used by CMS are not a part of the star ratings. They are however, used to 44 MISSOURI PHARMACIST

provide benchmarks and feedback to plans.

CMS also monitors display measures to assess plan performance; of which poor performers can face compliance actions by CMS. In assessing a measure as a display measure, CMS will use this data to evaluate whether or not a measure should be elevated to a Star Measure and to determine the appropriate thresholds from one to five stars. With this process, CMS has previously looked to move the CMR completion rate to a star measure in 2015. Based upon the CMS process in 2013, it was ultimately held as a display measure. However, in a November 2014 release, CMS announced a plan to elevate the CMR Completion Rate to a star rating for 2016.

FOR GOOD MEASURE

In order to better understand how pharmacists can help improve this new star rating, we first need to be familiar with the minute details of the measure, first, by defining the measure.

PQA defines the completion rate for CMR as: The percentage of prescription drug plan members who met eligibility criteria for medication therapy management (MTM) services and who received a CMR during the eligibility period.

Now, defining the eligibility criteria set forth by CMS: The general requirements for a MTM program are for patients who have multiple chronic diseases, are taking multiple Part D drugs, and are likely to incur annual costs for covered Part D drugs that exceed a predetermined cost threshold (the 2014 MTM program annual cost threshold was $3,017). As for multiple chronic diseases, CMS sets a ceiling (maximum) of three and floor (minimum) of two for the number of chronic diseases for eligible patients. This means that a plan sponsor has the ability to determine whether to target its beneficia-

ries with at least two or three chronic diseases. It is important to note that these are minimum requirements for the program, and in 2014, 19 percent of MTM programs hosted by plan sponsors exceeded the minimum requirements set by CMS. Another defined threshold within the eligibility criteria is number of drugs. Again, CMS sets a ceiling and floor for number of drugs, allowing patients to have between two and eight filled medications.

While eligibility criteria can be very specific, the enrollment methods must also be considered. Plan sponsors must enroll beneficiaries using an opt-out method of enrollment only. Furthermore, plan sponsors must target beneficiaries for enrollment in the program at least quarterly during each plan year. For the 2014 year, 67 percent of plans targeted beneficiaries monthly, while others targeted beneficiaries much more frequently.

This includes 6.7 percent of plans, which targeted patients daily.

Now that the eligibility criteria has been defined, it is also important to understand what constitutes delivery and completion of a CMR. CMS defines the CMR as “an interactive, person-to-person, or telehealth consultation performed by a pharmacist or other qualified provider for the beneficiary with an individualized, written summary in CMS standardized format.” The CMR includes evaluation of the patient’s prescriptions, over-the-counter (OTC) medications, herbal therapies, and dietary supplements. The CMR should identify and address problems or concerns the patient may have and aid the patient in self-management of their medications and health conditions.

As mentioned in the definition, pharmacists are implicitly able to provide CMRs. As such, all plan sponsors list pharmacists as a provider of MTM services. Of listed providers, no other type of professional exceeds 50 percent in this regard. Nurse practitioners are listed as able providers for 27.8 percent of plans while “other” is listed in 45.2 percent of plans (other is defined by CMS as pharmacy technicians, students/interns and case workers).

CALL TO ACTION

Based upon the information provided in defining the CMR and the appropriate eligibility criteria, many are left to wonder why it has not been previously elevated to an integral aspect of care. While the criteria is not fully inclusive of all patients that a pharmacy may provide services for, the fact that all Part D beneficiaries are eligible for a CMR should offer enough opportunities for pharmacists to complete these services. To date, we have not seen this to be the case. In terms of both defining the CMR eligibility criteria and elevating the measure to a star rating, the opposition to these cases has been the traditionally low rate of completion given current eligibility criteria.

Based upon CMS data for the 2015 Star Ratings (meaning data claims are taken from the 2013 calendar year), the overall completion rates for CMRs are lower

than many would expect. In past years, experts have stated that based on the eligibility criteria, only about 10 percent of Medicare Part D beneficiaries are eligible for a comprehensive medication review.

Additionally, expectations for the CMR completion rate have generally ranged from 9 percent to 14 percent. Based on the 2015 Display Measure Output data released by CMS, the unweighted average for CMS contracts (540 have enough data to be analyzed) is about 21 percent. Interestingly, of those 540 contracts, only 19 were able to surpass a CMR completion rate exceeding 50 Pharmacists are implicitly able to percent. Suffice to say, there is provide CMRs. Plan sponsors list 100 significant room for improve- percent of pharmacists as providers of ment to increase the perforMTM services. No other type of listed mance for this measure. professional exceeds 50 percent.

FROM THEORY TO PRACTICE

With this information in hand, how can pharmacists improve the CMR completion rate in their pharmacy?

Here are some helpful hints and tips so that your pharmacy can showcase its value: 1. Understanding the CMR: While you, the pharmacist may understand the CMR process—does your patient?

Many patients are confused as to what this entails and may even inquire as to why this isn’t evaluated every time they fill a prescription. Be prepared to answer these questions and to explain the differences between the typical dispensing process and what is included in a CMR. 2. Offering the CMR: How does your pharmacy offer a CMR? What is your Part D patient base like? In most cases, offering CMRs at point of sale will be ineffective to complete this service. Does your pharmacy offer these via telephone or some other virtual platform?

Do you schedule times that can fit around a patient’s schedule? Services such as a CMR are much more time intensive than an immunization—be clear with patients about these expectations. Patients are eligible for a CMR annually—make sure they are aware of this.

3. Making the best of your opportunities: Nobody knows their patient better than the pharmacist— leverage this ability. Has your patient enrolled in a new health plan after open enrollment? Or any new medical diagnosis or medication regimen which may take special consideration? Be sure to think about these opportunities. Not only do you provide a beneficial service to make your pharmacy competitive, but you are also likely to help make that patient a devoted customer to your pharmacy.

As we move closer to 2016 there will be increased discussion on how pharmacies can improve this measure. Stay tuned to this discussion and when able, share your thoughts with the larger pharmacy community.

The best way to be successful with any quality measure is to start early, be prepared, and to learn quickly as you implement your service. Community pharmacists are a tremendous resource to patients—this is another opportunity to showcase that value.

SPRING 2015 45

MILESTONE MEMBERS

Celebrate our pharmacistsâ&#x20AC;&#x2122; MPA anniversaries.

50 30

Richard Miller, Macon Benjamin Bluml, Lee's Summit Bryan Hercules, Bridgeton Debra Schoen, Dallas

25

Barbara Wood, Waterloo Deborah Tady, Mission David Eden, Mount Vernon Tom Hunt, St. Louis Sidney Kent, Chesterfield

10

Jane Stubbs, Columbia Kevin McCullough, El Dorado Springs Tabitha Brant , Lebanon James Ivie, Polo

5

Michaela Curtis, Cameron John Tonjuk, Marionville Dennis Stockstill, Lebanon Miranda Henley , Eugene

UPCOMING EVENTS MPA LEGISLATIVE DAY

April 1, 2015 > Capitol Plaza Hotel, Jefferson City This event draws more than three hundred pharmacists, students, and faculty from around the state to the Missouri Capitol. A few highlights include educational sessions and bipartisan roundtable discussions that relate to healthcare legislation and pharmacy-specific initiatives. Meet with legislators, participate in healthcare screenings, and enjoy a dessert social on the rotunda.

PHARMACIST OF THE DAY

NEW MEMBERS

Welcome our new members.

MID-AMERICA PHARMACY CONFERENCE & EXPO

September 10-13, 2015 > Overland Park, KS Celebrate the pharmacy profession. The 2015 annual conference will bring together pharmacy professionals in Missouri, Kansas, and Oklahoma for networking opportunities, educational sessions, and a trade show featuring suppliers who specialize in pharmacy related products and services.

MPA

Reihan Areb, Parkville Jennifer Curran, Oâ&#x20AC;&#x2122;Fallon Diane McClaskey, Brookline Station Roger Sommi, Overland Park, KS Katie Unthank, Teutopolis, IL

Now through May, 2015 > The MPA encourages you to work with our lobbying staff in Jefferson City, speak with legislators, attend hearings, monitor floor actions, and learn more about hot topics during the 2015 legislative session. Visit MORx.com for dates and information.

46 MISSOURI PHARMACIST

SPRING 2015 47

Better Together with Health Mart.

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Team up with Health Mart to drive success today. www.BecomeAHealthMart.com

Save the Date for McKesson ideaShare 2015!

June 24–27, San Diego, CA McKesson ideaShare is an opportunity for community pharmacy owners and representatives to network and inspire each other to implement new ideas in support of better pharmacy health. McKesson facilitates this annual event to provide hands-on demonstrations, the latest in trends and technology, special deals, and in-depth industry knowledge from thought leaders and peers.

Visit www.McKessonideaShare.com for regular updates.

McKesson Pharmacy Systems & Automation

Need to improve your patient adherence?

Health is on the way!

Our dynamic new Adherence Performance Solution will use data from within your pharmacy-management system to provide your pharmacy with an adherence rating and actionable information that makes starting or enhancing an established adherence program easier.

Adherence Performance Solution is designed to make adherence programs simpler by helping you focus on the patients who need adherence support from your pharmacy team.

It’s a pain-free way to improve the adherence of your patients and prove the value of your pharmacy to payors. Enhance your performance and boost your bottom line.

Speak with your McKesson representative or visit www.betterpharmacytech.com for more information.

48 MISSOURI PHARMACIST

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