Q3 2015 Missouri Pharmacist by Missouri Pharmacy Association

Missouri THE MISSOURI PHARMACY ASSOCIATION

VOL. 89, NO. 3, FALL 2015

2015

Conference Preview A Pharmacy Tech's Role in Compounding Get $$$ Back with a DASPA Certification PEER REVIEWED Cost of Dispensing

Rx Join us for the Mid-America Pharmacy Conference and Expo September 10-13

2 MISSOURI PHARMACIST

Know the difference. Make a difference. VSL#3 provides clinically proven benefits in the dietary management of UC and an ileal pouch. Recognized by the ACG Practice Parameter Committee1 and the Cochrane Library 2 as an effective tool for the management of pouchitis. VSL#3 adds billions of bacteria to the microbial barrier restoring balance and diversity in the GI tract.3 The research of the Human Microbiome Project [http://hmpdacc.org/] is investigating key links between human health and the balance of specific microbes in the human gut.

Knowing the difference makes all the difference when it comes to probiotic health.

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.

VSL#3 is a high potency probiotic medical food that must be used under medical supervision. Made in U.S.A. Distributed by Sigma-Tau Pharmaceuticals, Inc. Gaithersburg, M.D. ÂŠ2014 Sigma-Tau Pharmaceuticals. All rights reserved V1166 02/15

www.vsl3.com FALL 2015 3

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 LAURA STIEFERMAN, Meetings and Membership Coordinator Missouri Pharmacist Magazine Publisher GREG WOOD Editor in Chief DANITA ALLEN WOOD Advertising Director MARYNELL CHRISTENSON Advertising & Marketing Consultant BRENT TOELLNER Advertising Coordinator SUE BURNS Art Director SARAH HERRERA Custom Projects Editor NICHOLE L. BALLARD Associate Editor JONAS WEIR Graphic Designer and Staff Photographer HARRY KATZ Circulation Manager AMY STAPLETON

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

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 Samâ&#x20AC;&#x2122;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., CGP 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 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. 3, Fall 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.

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Travel with Fellow Missourians! France 2016 15 Days • September 9-24, 2016 current airfare price of $1,100 $3,671 Plus from Kansas City or St.Louis

This is the ideal vacation to explore France. Visit an ancient fishing village and seaside resorts. Enjoy scenic drives and a candlelight procession. Explore medieval villages. Drive along the famous Route Napoleon. Savor dinners at local restaurants and a wine-tasting. • •

• • • •

Ascend the Eiffel Tower Visit seaside resorts, Normandy Beaches, Mont St. Michel Abbey, Notre Dame Cathedral, a castle in Loire Valley, and Monte Carlo Enjoy wine tasting and special dinners at local restaurants Join the candlelight procession in Lourdes Walk along the Promenade des Anglais in Nice and ancient battlements in Carcassonne Ride first-class on the high-speed TGV train through Dijon-Paris

Special Tours

FOR MISSOURI LIFE READERS!

Costa Rica 8 Days • January 14-22, 2017* • Tortuguero National Park: guided cruise through the canals to view wildlife and a guided walk through the rainforest • Tour a banana plantation • Arenal: tour a pineapple plantation; sightseeing in La Fortuna; visit Natura Park, Tabacón Hot Springs, and the Arenal volcano • Monteverde: visit the Sky Walk hanging bridges, the Santa Elena Cloud Forest, Trapiche family-owned farm and homemade lunch, farewell dinner • Visit Sarchi Village: see artists in their workshops making the famous oxcarts in the center of Costa Rican handcrafts. *Dates subject to change.

For more information visit missourilife.com/travel/travel-with-fellow-missourians/ or travelerslane.com • 314-223-1224 • travelerslane@hotmail.com

FALL 2015 5

Missouri

IN THIS ISSUE THE MISSOURI PHARMACY ASSOCIATION

FALL 2015

8 > Th e Fun i n P h armacy MPA president talks about the upcoming conference and all the reasons why you should attend. 9 > B rus h F i re s MPA CEO thinks Samuel Adams said it best: now is the time to fight for pharmacy issues. 10 > M PA Me mb e r Ne w s Congratulate your fellow members elected to serve the American Pharmacist Association and former MPA President Christian Tadrus on his appointment to the State Board of Pharmacy. 12 > DASPA Learn more about the DASPA education and training and opportunities for scholarship through PSE.

14 > M PA An n ual Con fe re n ce and E xpo Get the schedule and read about all the events and continuing education courses that are available at this year’s Mid-America Pharmacy Conference & Expo in Overland Park, Kansas.

Learn about the exciting success of the Pharmacist Service Expansion Project Grant.

20 > Pe e r Rev i e we d: Cos t of P re s c r ipt io ns Read this peer reviewed, in-depth analysis of the cost of dispensing prescriptions in Missouri.

26> Te ch n i ci an ’s Corn e r Discover the pharmacy technician’s role in compounding in this age of personalized medicine. 28 > Sch ool Up date Get the latest news from the UMKC and St. Louis schools of pharmacy. 30 > M i le s ton e s , N e w Me mb e rs , a nd C a le nd a r Celebrate members’ anniversaries, welcome new members, and visit statewide events.

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COURTESY UMKC SCHOOL OF PHARMACY AND MPA; 123RF

18 > Me as uri n g W h at M atte rs This preview of the annual conference keynote speaker Rebecca Snead’s continuing education course addresses the journey to value-based payments in pharmacy.

Optimize patient results with accurate, efficient access to quality products. AmerisourceBergen is here to help you provide your patients with the best possible experience. Through our state-of-the-art supply chain technology and Lean Six Sigma-compliant business processes, your pharmacy and patients will benefit from the safest, most secure and efficent distribution system in healthcare.

For more information, email solutions@amerisourcebergen.com FALL 2015 7

President’s Letter

Check page 30 for information on regional meetings and visit MoRx.com for event details.

ERICA HOPKINS-WADLOW PHARM.D., MPA PRESIDENT

I hope everyone has enjoyed a wonderful summer and is gearing up all the fun activities autumn brings. Fall means different things for each of us. For me, it means football games, bonfires, and Halloween. But more importantly, it means the Mid-America Pharmacy Conference & Expo annual convention and regional meetings are near. If you have never attended MPA’s annual convention, I highly recommend you try to make the trip. This year’s convention brings together Missouri, Kansas, and Oklahoma for one awesome event. Last year was amazing when we had a joint meeting with Illinois, and this year will not disappoint. If it’s education you are looking for, or maybe just networking opportunities, the Mid-America Pharmacy Conference & Expo is where you need to be. There will be many educational courses to choose from, and it’s great to get to discuss some of pharmacy’s biggest issues with colleagues from surrounding states. Ideas can be shared and friendships can be formed. Conventions like these are truly the best places to either solidify the day-to-day practices you already have or discover better, more innovative ways to approach

8 MISSOURI PHARMACIST

your endeavors. Whatever reasoning you might have, I strongly urge all pharmacists, students, and technicians to register and attend this year’s meeting, September 10 to September 13. Also, this fall you will find there are several regional meetings offered around the state. These meetings were made to provide updates on legislative issues, provide you with a chance to meet other pharmacists in your area, and give access to coveted continuing education courses. MPA always provides quality speakers and allows time for networking before and after. It’s also the best time to meet with your current MPA board members and discuss the pharmacy issues you would like us to tackle in the upcoming year. I look forward to this time of year for many reasons, but mainly because it’s a time to come together as a profession to discuss our issues and meet new people who could have an impact on our profession. And it’s fun. I said at the beginning of my presidency that my goal was to put the fun back in pharmacy. I strive for this every day and hope that all of you will as well. I hope to see you all very soon at our annual convention.

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FUN IN PHARMACY

CEO News “It does not require a majority to prevail, but rather an irate, tireless minority keen to set brush fires in people’s minds.” —Samuel Adams

BRUSH FIRES

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RON L. FITZWATER MBA, CAE

History often provides a glimpse into current events and activities. It’s amazing how in tune our forefathers were to how we might need to address issues centuries later. For example, the following quote from Samuel Adams is right on point with our battles today. Mr. Adams postulated that, “It does not require a majority to prevail, but rather an irate, tireless minority keen to set brush fires in people’s minds.” Anyone who has fought the pharmacy battles in Washington, DC, knows that pharmacists and other health care professionals are often in the minority as we fight the large insurance companies, pharmacy benefit managers (PBM), and other health care behemoths that we face daily in the legislative arena. For many issues on the state level, we have been able to hold our own and move some positive legislation for pharmacists. In addition, because of the partnership with pharmacists, we have been able to work with the legislature to address budget and reimbursement issues to the benefit of all parties: the State of Missouri, patients, and pharmacists. It is going to get tougher next session as we move forward in the legislature in Jefferson City and Washington, DC. Currently, there are two proposed mergers pending involving four large insurance companies. Over the past couple of years, we have seen the merger of two large

PBMs as well as vertical integration within the pharmacy industry. Medicaid managed care companies are trying desperately to convince the legislature to allow them to take over more of the MO Healthnet (Medicaid) program to “save” money for Missouri. It is going to take a coordinated effort from the pharmacy community to fight these continued intrusions into our profession on the state level and the encroachment of the aggressive Medicare Part D plans. But, as the quote above reinforces, if we can channel the frustration and irritation into constructive action, we can make a positive impact in the legislative process— even in these extremely challenging times. Maybe it is time to set some brush fires in the minds of legislators who are supposed to be representing their districts and addressing these issues instead of constantly buying into all of the commissioned reports offered by these large health care providers. I can assure you that the MPA board is fiercely focused on addressing these issues. If you would like to “grab a pack of matches” and join the fight, please let me know. We will be laying out part of that vision at the regional meetings this fall. I invite you to join us at one of our meetings as we come to your community. United, we can make a difference. FALL 2015 9

Member News

MEMBER NEWS

NICOLE M. GATTAS, PHARM.D., BCPS • Gattas is an associate professor of pharmacy practice and coordinator of Community Pharmaceutical Care Programs at St. Louis College of Pharmacy (STLCOP). She serves as the Community Pharmacy Residency Program Director and teaches on a number of topics related to community practice, including self-care, patient education, and immunizations. She coordinates the community pharmacy lab, Introductory Pharmacy Practice Experiences, and Advanced Pharmacy Practice Experiences. Gattas previously developed and implemented patient care programs as the clinical pharmacy coordinator for Schnucks Pharmacy. She is the advisor for the STLCOP Student Pharmacists Association and previously advised the STLCOP chapter of APhA Academy of Student PharNicole Gattas was elected as an macists. Gattas has served APhA in APhA-APPM executive committee various roles. member-at-large. Gattas is a graduate of the University of Iowa College of Pharmacy, and completed a community pharmacy residency with the University of Illinois at Chicago and Dominicks Pharmacy. A certified pharmacotherapy specialist, Gattas is also an active member of the American College of Clinical Pharmacy, the American Society of Health-System Pharmacists, the MPA, and the Illinois Pharmacists Association. 10 MISSOURI PHARMACIST

SANDRA BOLLINGER, PHARM.D., FASCP, CGP, CDE, CPT, CFTS • Bollinger received her bachelor of science in

Pharmacy from the University of Missouri-Kansas City School of Pharmacy and her Pharm.D. from Creighton University. She holds adjunct faculty positions for UMKC, CU, and STLCOP. Bollinger serves as the provider outreach coordinator for the State of Missouri’s CyberAccess web-based provider program. In 2000, she established a non-dispensing pharmacy that focuses on the prevention and management of the complications of chronic diseases. She is a certified diabetes educator, and a certified geriatric pharmacist. Bollinger has received a number of professional recognitions and awards, including the MPA President’s Award, the MPA Innovative Pharmacy Practice Award, the National Community Pharmacists Association Pharmacy Leadership Award, and the UMKC Alumni Outstanding Service to the Profession of Pharmacy Award. She previously served as past president of MPA and is the current president of the Cape Girardeau County Pharmacy Association. She has also served on Missouri’s Drug Utilization Review Board since 2000. Sandra Bollinger

TADRUS APPOINTED TO STATE BOARD

Governor Jay Nixon appointed former MPA president Dr. Christian S. Tadrus of Moberly to the State Board of Pharmacy. A licensed pharmacist, Dr. Tadrus is the owner of Sam’s Health Mart Pharmacies in Moberly. He has served on several workgroups and committees under the Board of Pharmacy and MPA. Dr. Tadrus has served as an adjunct instructor at both the University of Missouri School of Pharmacy in Kansas City and at the St. Louis College of Pharmacy, where he obtained his bachelor’s and doctorate degrees. The board issues renewal and original licenses to pharmacists, pharmacies, drug distributors, intern pharmacists, and pharmacy technicians. The board is also responsible for assuring safe, competent pharmacy services for the citizens of Missouri, and reviews complaints, investigates reports, and schedules fact-finding meetings with pharmacists regarding their pharmacy practices. Tadrus’s term ends June 10, 2020.

COURTESY OF NICOLE GATTAS AND SANDRA BOLLINGER

NEW OFFICERS ANNOUNCED FOR APHA

The American Pharmacists Association (APhA) announced the recent election results for the Academy of Pharmacy Practice and Management (APhA-APPM) and the Academy of Pharmaceutical Research and Science (APhA-APRS). The newly elected officers will be installed at the annual meeting in Baltimore in March. APhA-APPM elected Sarah Ray, Pharm.D., BCPS, of Mequon, Wisconsin, as the 2016-2017 president. Sandra Bollinger, Pharm.D., FASCP, CGP, CDE, CPT, CFts, of Sikeston; Nicole M. Gattas, Pharm.D., BCPS, of Saint Charles; and James A. Kirby, Pharm.D., BCPS, CDE, of Cincinnati, Ohio, were elected as 2016-2018 executive committee members-at-large. APhA-APRS elected Eric J. Jarvi, PhD, of Bangor, Maine, as the 2016-2017 Basic Sciences Section chair; Kimberly Scarsi, Pharm.D., MS, BCPS-ID, of Omaha, Nebraska, as the 2016-2017 Clinical Sciences Section chair; and Salisa C. Westrick, PhD, of Auburn, Alabama, as the 2016-2017 Economic, Social, and Administrative Sciences Section chair.

PHARMACIST SERVICE EXPANSION PROJECT GRANT AWARDED Nearly seventy pharmacists were certified in MTS or DASPA through the program. BY CHERYL A. HOFFER

The Department of Health and Senior Services (DHSS), in conjunction with a grant from the Centers for Disease Control and Prevention, awarded MPA the Pharmacist Service Expansion Project Grant. The grant provided scholarships for Medication Therapy Services (MTS) and Diabetes Accreditation Standards–Practical Applications (DASPA) certification. The project strives to increase the number of trainings for Missouri pharmacists to become certified in MTS and/or DASPA, increase the number of Missouri MTS-certified pharmacists and/or pharmacies with accredited Diabetes Self-Management Education (DSME) site accredited programs, increase the proportion of diabetics who have at least one enDHSS applauded the infrastructure counter at an accredited DSME and the number of pharmacists who education program site affiliated completed the certification programs. with a pharmacy, and facilitate the project’s support of other

CHERYL A. HOFFER, VICE PRESIDENT PHARMACIST PROGRAM INITIATIVES FOR MPA AND DIRECTOR OF PHARMACY PROGRAM SUPPORT FOR ST. LOUIS COLLEGE OF PHARMACY

v a Oct

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Oct

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Diabetes and hypertension programming from St. LouisCity College of Pharmacy coming soon. Please check the STLCOP Continuing Professional Development webpage for scheduled programming and continuing education details.

DHSS programs involving pharmacists. The 2014-2015 contract was the first year of MPA’s two-year DHSS grant project. DHSS applauded the infrastructure established to support project implementation and the number of pharmacists who completed the MTS or DASPA certification programs, held in St. Louis or Springfield this past May and June. Nearly seventy pharmacists were certified between the MTS and DASPA programs within a two-month time period. The implementation of the project required collaboration with key partners, including the St. Louis College of Pharmacy, University of Missouri School of Pharmacy, National Community Pharmacists Association, American Association of Diabetes Educators, and others. Year two is already underway. Additional MTS and DASPA programs are scheduled across Missouri, providing pharmacists multiple opportunities to capitalize on scholarship grant offerings. In addition, new programming has been added to support MTS-certified pharmacists’ renewal of their MTS license and focus on specific disease states, which include diabetes and hypertension. Those completing a PSE program will report on the advancement of patient care services delivered via a quarterly survey. Visit MoRx.com to register for the program and apply for the scholarship grant. The page will remain active until all grant awards have exhausted the available scholarship grant budget. FALL 2015 11

STEP AWAY FROM TRADITION WITH DASPA

This continuing education course covers how to effectively provide diabetes self-management education and bill for the service. BY SANDRA BOLLINGER

12 MISSOURI PHARMACIST

ducing risks (such as smoking cessation), and healthy coping (including stress management). Components of DASPA mirror facets of case manage that include evidenced-based actions that lead to improved outcomes in the community. Reimbursement opportunities exist for pharmacists who are willing to assume more clinically oriented responsibilities and take a step beyond the traditional role. For more information regarding the DASPA program or how to register contact Sue Hagler at (703) 683-8200 or sue.hagler@ncpanet.org.

LIVE PROGRAM TOPICS INCLUDE: • Opportunities to Expand Diabetes Education Through Community Pharmacy • Building the DSME/T Team • Self-Care Behaviors Overview • Curriculum, Documentation, Documentation Systems • Case Management • Establishing and Marketing a DSME/T Program • Billing DSME/T 101 • Completing an 855B Form • AADE Facility Accreditation (non-CE) • Completing an AADE Accreditation Application (non-CE) • Preparing Your Site for DSME/T Accreditation

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SANDRA BOLLINGER, PHARM.D., FASCP, CGP, CDE, CPT, CFTS, HEALTH PRIORITIES, INC., OWNER AND XEROX HERITAGE, LLC, PROVIDER OUTREACH COORDINATOR

The clinical role of pharmacists continues to expand beyond the traditional glucose meter trainings, blood pressure screenings, provision of diabetic shoes, and point of service testing to include other clinical services such as Medication Therapy Management, anticoagulation clinics, pain management, weight management, and drug and disease screenings amongst others. Since pharmacists are not traditionally recognized as health care providers, they have been challenged with finding sources of payment for providing these services. One of the programs designed to offer community pharmacies a pathway for reimbursement to expand patient access to diabetes management is known as Diabetes Accreditation Standards-Practical Applications (DASPA). The development of the DASPA program resulted from the partnership between the American Association of Diabetes Educators (AADE) and the National Community Pharmacists Association. The continuing education course is designed to instruct pharmacists and other appropriate health professionals who may not hold the Certified Diabetes Educator (CDE) credential or Advanced Diabetes Management certification how to effectively provide diabetes self-management education and training (DSME/T) and how to successfully bill for providing the service. The DASPA program consists of two components: online pre-work with AADE and a live program. Pharmacists, including those who are not a CDE, are instructed how to provide DSME/T in an effective manner, how to establish a successful program and manage the business aspects of it, and how to accredit a DSME/T program through AADE. DSME/T is a collaborative process through which people with or at risk for diabetes gain the knowledge and skills needed to modify their behavior and successfully self-manage the disease and its related conditions. The training approach is an interactive, ongoing process involving the person with diabetes (or the caregiver or family) and a diabetes educator. It focuses on self-care behaviors that are essential for improved health status and greater quality of life. The seven AADE self-care behavior goals are: healthy eating, being active, monitoring, taking medication, problem solving (including pattern management), re-

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CREATE

WEEKEND AGENDA

This is the preliminary schedule & is subject to change.

THURSDAY, SEPTEMBER 10

CONNECTIONS

7:30 am - 2:00 pm

Golf Tournament - Ironhorse Golf Club

8:00 am - 5:00 pm

APhA Immunization Certification Course

BUILD

8:00 am - 5:00 pm

APhA Cardio Vascular Disease Risk Management Certification Course

5:30 - 7:00 pm

Alumni Reception - Sponsored by the Universities below

8:00 - 11:00 pm

Open Hospitality Suites

RELATIONSHIPS

TEAMWORK THE MID-AMERICA PHARMACY CONFERENCE AND EXPO is a great way to create connections and build relationships with individuals in the pharmacy community, not to mention catch up with friends! The weekend is full of professional development opportunities including informative continuing education course and updates on state and national legislative matters. Experience fun events such as the Alumni Reception, Political Action Committee Dinner, 5K Fun Run/Walk, and the Gala dinner recognizing pharmacists receiving national awards. Join us for the biggest conference of the year for all three states! It is an amazing platform that combines all aspects of pharmacy to help you better yourself and your profession.

ARE YOU IN?

FRIDAY, SEPTEMBER 11 7:30 - 8:45 am

Welcome Breakfast!

9:00 am - 12:15 pm

Continuing Education Sessions

12:30 - 2:30 pm

KPhA, MPA and OPhA Separate State Award & Officer Installation Luncheons

12:30 pm

Missouri Legislative Update by Jorgen Schlemeier, Gamble & Schlemeier

2:45 - 4:50 pm

Continuing Education Sessions & Student Business Plan Competition

5:00 - 6:00 pm

2015 Pharmacy Law Changes - Oklahoma State Board of Pharmacy

7:00 - 9:00 pm

Political Action Committee Dinner - Sponsored by PBA Health Dave and Buster’s (Legends Outlets Kansas City)

9:00 - 11:45 pm

New Practitioner’s Night on the Town - Dave and Buster’s

10:00 pm - Midnight

Open Hospitality Suites

SATURDAY, SEPTEMBER 12 7:00 - 8:30 am

5K Fun Run/Walk - Corporate Woods Founders’ Park

7:00 - 8:45 am

CPA® / HPP Quarterly Meeting Breakfast (Invitation Only)

7:00 - 9:00 am

KPSC Annual Meeting Breakfast (Invitation Only)

7:30 - 8:30 am

Cardinal Health Breakfast - All Attendees Welcome

8:45 - 11:00 am

Continuing Education Sessions

11:00 am - 3:00 pm

Expo and Poster Competition Presentations

3:00 pm - 5:00 pm

Continuing Education Sessions

6:00 - 7:00 pm

KPSC EOG Reception (Invitation Only)

6:00 - 7:00 pm

Open Cocktail Hour & Silent Auction

7:00 - 10:00 pm

Gala Awards Dinner - Sponsored by McKesson Ticket Needed to Attend

10:00 pm - Midnight

Open Hospitality Suites

For more details , visit these webs ite

KPhA - KSRx.org MPA- MoRx.com OPhA - OPhA.co m

SUNDAY, SEPTEMBER 13 7:30 - 8:45 am

Compliant Pharmacy Alliance (CPA ) Breakfast - All Attendees Welcome

9:00 - 10:00 am

Continuing Education Sessions

10:15 AM - 12:15 pm

Kansas & Missouri Boards of Pharmacy Law Updates

OVERLAND PARK & KANSAS CITY ATTRACTIONS

The Overland Park and the Kansas City area is filled with attractions for families and spouses, including the Kansas City Zoo, museums, such as the American Museum of Natural History and The National World War I Museum, along with the Deanna Rose Children’s Farmstead! Of course, lots of shopping and great dining. Go to VisitOverlandPark.com to learn more. FALL 2015 15

CONTINUING EDUCATION LINE-UP

The University of Oklahoma College of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

THURSDAY, SEPTEMBER 10 CERTIFICATION COURSES 8 am - 5 pm, lunch included

Go to the websites below to register.

APhA Pharmacy-Based Immunization Certification Program Registration through APhA: $99

pharmacist.com/pharmacy-based-immunization-delivery-2015

APhA Pharmacy-Based Cardiovascular Disease Risk Management Registration through APhA: $255 Member; $515 Non-Member

elearning.pharmacist.com/products/4107/pharmacy-based -cardiovascular-disease-risk-management

FRIDAY, SEPTEMBER 11 SESSION TITLE

SPEAKER

Measuring What Matter: The Journey Towards Value-Based Payment

Rebecca Snead, R. Ph., Executive Vice President & CEO National Alliance of State Pharmacy Associations, Richmond, VA

It’s Complicated: Sex, Lies and Hormones: The Trailer

Lisa Everett, R. Ph., FACA, CNN, O’Brien Pharmacy, Mission, KS

Immunization Update 2015

Clark Kebodeoux, Pharm.D., BCACP, Asst. Prof. of Pharmacy Practice, St. Louis College of Pharmacy, St. Louis

Evolution of the Stars

Lisa Umfleet, R.Ph., CGP, Parkland Health Mart Pharmacy, Desloge, MO

Updates in Diabetes Care

Katherine O’Neal, Pharm.D., MBA, BCACP, CDE, BC-ADM, AE-C, Clinical Asst. Prof. University of Oklahoma College of Pharmacy,Tulsa, OK

Transitions of Care: Overcoming Obstacles and Breaking Down the “Silos” in Patient Care

Jody Reel, Pharm.D., Sabetha Health Mart, Sabetha, KS

A Cure is Within Reach: A Review of New Medications for Hepatitis C Virus

Misty Miller, Pharm.D., BCPS, Clinical Asst. Prof. University of Oklahoma College of Pharmacy, Oklahoma City, OK

2015 Pharmacy Law Changes

Cindy Hamilton, D. Ph., Chief Pharmacist Compliance Officer Oklahoma State Board of Pharmacy, Oklahoma City, OK

SATURDAY, SEPTEMBER 12 Using MTM to Improve Star Ratings

Amanda Applegate, Pharm.D., BCACP, Pharmacy Clinical Services Coordinator, Balls Food Stores, Kansas City, KS

HIV and Hep C 101

Chris Geronsin, Pharm.D., Beverly Hills Pharmacy, St. Louis

Building Your Pharmacy through Natural Interventions

Dr. Gary Kracoff, R. Ph., NMD, Johnson Compounding & Wellness Center, Boston, MA

Pharmacist Self-Care Challenge

Pat Hubbell, R. Ph., Auten Pharmacy, Osawatomie, KS

The Psychopharmacology and Neuroscience of Substance Use Disorders: The Anti-Reward Brain System

Merrill Norton, Pharm.D., D.Ph., ICCDP-D, Clinical Assoc. Prof. of Addiction Pharmacy Science, University of Georgia College of Pharmacy, Athens, GA

Pharmacists’ Role in Health IT & Health Information Exchanges

Shelly Spiro, Executive Director, Pharmacy HIT Collaborative, Alexandria, VA

Third Party Landscape

Melanie Maxwell, MPH, Vice President, RxSelect Pharmacy Services, Pharmacy Providers of Oklahoma, Oklahoma City, OK

SUNDAY, SEPTEMBER 13 Empowering Effective Patient Self-Management for Diabetes

Ben Bluml, R. Ph., Senior Vice President, Research & Innovation American Pharmacists Association Foundation, Washington, DC

High-Tech Highs: Nicotine & THC Delivery in the 21st Century

Scott Schaeffer, D. Ph., DABAT, Managing Director Oklahoma Center for Poison & Drug Info, Oklahoma City, OK

Kansas Pharmacy Law Update

Jim Kinderknecht, R. Ph., Pharmacy Inspector Kansas State Board of Pharmacy, Topeka, KS

Missouri Board of Pharmacy Update

Kimberly Grinston, J.D., Executive Director, Missouri Board of Pharmacy, Jefferson City

16 MISSOURI PHARMACIST

Download the Conference App

CONFERENCE FEATURES

Sponsored by

Dave & Buster’s • Legends Outlets Kansas City

This year the Political Action Committee (PAC) event is included in your event registration as a full conference attendee or Friday only. We want you to get involved and see what PAC is all about! Join us as we discuss legislative matters affecting pharmacy and learn how you can be a part of the supporting effort to maintain and advance the pharmacy profession. Registration includes a $15 game card.

5K Fun Run/Walk • September 12, 7-8:30 am

Bring the family!

Dave & Buster’s is a restaurant filled with fun games for both adults and kids. As you attend the PAC event, your friends and family can eat there, too. Dave & Buster’s is in the Legends Outlets of Kansas City, a small city of its own with outdoor shopping and restaurants. Your family will have plenty of things to do!

Gala Awards Dinner • September 12, 7-10 pm

Corporate Woods Founders’ Park • 9401 Indian Creek Pkwy (W 109th St), Overland Park, KS 66210 Get out and enjoy some fresh air by participating in the 5K! This is a non-competitive, fun run/walk for attendees and their families. Corporate Woods Founders’ Park is a short distance from the Sheraton Overland Park Hotel.

: Doug Hoey, R.Ph. MBA Gala Speaker:

Enjoy a fun evening of entertainment, recognizing your peers receiving prestigious awards, and listening to a pharmacy leader Doug Hoey, CEO of the National Community Pharmacists Association, give a general address over relevant pharmacy topics.

SPECIAL THANK YOU TO THE CONFERENCE SPONSORS PLATINUM SPONSORS

BRONZE SPONSOR

ADDITIONAL SPONSORS

ADDITIONAL SUPPORT PROVIDED BY

FALL 2015 17

MEASURING WHAT MATTERS

Defining and measuring quality in the journey toward value-based payment. BY REBECCA SNEAD

Measuring what matters is critical for this drive to value-based purchasing to be successful for our patients and for our profession. The Department of Health and Human Services seeks to have 85 percent of Medicare fee-for-service payments in value-based purchasing by 2016 and 90 percent by 2018. One of our biggest challenges in driving better quality is that we can’t always agree on how to define and measure quality. REBECCA SNEAD, CEO/EVP NATIONAL ALLIANCE OF STATE PHARMACY ASSOCIATIONS

NATIONAL QUALITY STRATEGY

In 2011, the Agency for Healthcare Research and Quality (AHRQ) first published the National Quality Strategy to provide better, more affordable care for individuals and the community. The strategy is guided by three goals. To achieve these goals, the National Quality Strategy applies six priorities: care coordination, clinical quality of care, population and community health, person- and caregiver-centered experience and outcomes, safety, and efficiency and cost reduction. PQA MEASURES

The Pharmacy Quality Alliance (PQA) develops quality medication performance measures that are aligned with the National Quality Strategy. PQA was established in April 2006. The organization is dedicated to improving the quality of medication management and use across health care settings with the goal of improving patients’ health through a collaborative process to develop and implement performance measures and recognize examples of exceptional pharmacy quality. TARGET PERCENTAGE OF MEDICARE FFS PAYMENTS LINKED TO QUALITY AND ALTERNATIVE PAYMENT MODELS IN 2016 AND 2018 All Medicare FFS (Categories 1-4) FFS linked to quality (Categories 2-4) Alternative payment models (Categories 3-4) 2016 30%

2018

STAR RATINGS

Patients are provided data on how their health care plan and providers are rated to encourage them to select high quality plans and providers with CMS star ratings. Within the Medicare program there are “compare” and “finder” search tools for providers and plans such as hospitals, nursing homes, physicians, and health plans. Often the ratings are displayed on a scale of one to five stars—the more stars the better. Medicare programs are rated on processes (e.g., did the patient receive an immunization), outcomes (e.g., did the patient’s blood pressure get to goal), and patientreported outcome measures (e.g., did the patient report that their pain was controlled). Many of the measures are directly related to appropriate medication use, and pharmacists are increasingly being asked to help the health care system improve their stars. The Department of Health and Human Services categorizes health care payments based on how providers receive payment for their services. SIX PRIORITIES OF THE NATIONAL QUALITY STRATEGY 1. CLINICAL QUALITY OF CARE • HHS primary care and CV quality measures • Prevention measures • Setting-specific measures • Specialty-specific measures 2. CARE COORDINATION • Transition of care measures • Admission and readmission measures • Other measures of care coordination 3. POPULATION & COMMUNITY HEALTH • Measures that assess health of the community • Measures that reduce health disparities • Access to care and equability measures

50%

4. PERSON- AND CAREGIVER-CENTERED EXPERIENCE AND OUTCOMES • CAHPS or equivalent measures for each setting • Functional outcomes

85%

90%

All Medicare FFS

5. SAFETY • Health Care Acquired Conditions (HCACs) including Health-care associated infections (HAIs) all cause harm

18 MISSOURI PHARMACIST

6. EFFICIENCY AND COST REDUCTION • Spend per beneficiary measures • Episode cost measures • Quality to cost measures

Category 1: Fee for Service–No Link to Quality

Category 2: Fee for Service–Link to Quality

Category 3: Alternative Payment Models Built on Fee-for-Service Architecture

DESCRIPTION

Payments are based on volume of services and not linked to quality or efficiency.

At least a portion of payments vary based on the quality or efficiency of health care delivery.

Some of the payment is linked to the effective management of a population or episode of care. Payments are still triggered by delivery of services, but opportunities for shared savings or two-sided risk.

Payment is not directly triggered by service delivery so volume is not linked to payment. Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (≥ 1 yr).

MEDICARE FFS

PAYMENT OF TAXONOMY FRAMEWORK

• Limited in Medicare fee-for-service • Majority of Medicare payments are now linked to quality

• Hospital value-based purchasing • Physician value-based modifier • Readmissions/ hospital-acquired condition reduction program

• Accountable care organizations • Medical homes • Bundled payments • Comprehensive primary care initiative • Comprehensive ESRD • Medicare-Medicaid Financial Alignment Initiative Fee-ForService Model

• Eligible Pioneer accountable care organizations in years 3-5

REBECCA SNEAD is the Executive Vice President and CEO of the National Alliance of State Pharmacy Associations (NASPA). Previously, she served as the Executive Director of the Virginia Pharmacists Association for more than a decade. She also proudly serves as a preceptor for many schools and colleges of pharmacy throughout the nation. Snead is the secretary/treasurer for the Alliance for Patient Medication Safety Pharmacy, a non-profit supporting entity to NASPA. She serves on the Alliance for Integrated Medication Management Board, Pharmacy Compounding Accreditation Board, and the Pharmacy Quality Alliance Board. From March 2005 to June 2011 Snead served on the Advisory Panel on Outreach and Education (formerly known as the Advisory Panel on Medicare Education). She was the first pharmacist appointed to the committee, and from 2008 to 2011 she served as chair. The purpose of the panel is to advise the Secretary and the Centers for Medicare and Medicaid Services Administrator in the development of beneficiary and stakeholder outreach and education in all programs administered. She received her bachelor of science in pharmacy from the Medical College of Virginia.

Category 4: Population-Based Payment

AT THE CONFERENCE FRIDAY, SEPTEMBER 11, 2015, 9-10 AM

This program is intended for pharmacists, pharmacy technicians and other healthcare professionals. Upon completion of the program, the participant should be able to: Learning Objectives: 0053-9999-15-040-L04-P 1 contact hour (0.1 CEU): 1. Define the National Quality Strategy and top priorities identified in the strategy 2. Define the performance measurement types: outcome, process, and patient reported outcome measures 3. Explain how patients are encouraged to select high quality plans and providers in our health care system today 4. Discuss the Department of Health and Human Services value-based payment taxonomy framework and timeline Learning Objectives: 0053-9999-15-040-L04-T 1 contact hour (0.1 CEU): 1. Define the National Quality Strategy and top priorities identified in the strategy 2. Define the performance measurement types: outcome, process, and patient reported outcome measures 3. Discuss the Department of Health and Human Services value-based payment taxonomy framework and timeline FALL 2015 19

PEER REVIEWED

AN ANALYSIS OF THE COST OF DISPENSING PRESCRIPTIONS IN MISSOURI BY SCOTT K. GRIGGS,* MARK E. PATTERSON,** KENNETH W. SCHAFERMEYER,* YIFEI LIU,** WAYNE M. BROWN,** AND RAFIA S. RASU.*** (*ST. LOUIS COLLEGE OF PHARMACY, ** UNIVERSITY OF MISSOURI-KANSAS CITY, ***UNIVERSITY OF KANSAS)

According to the Missouri Department of Social Services, the Centers for Medicare and Medicaid Services requires “State Medicaid agencies to reimburse pharmacy at a rate no higher than the National Actual Drug Acquisition Cost (NADAC) rate.” The Department also asserted that, “To be compliant with this requirement, a cost of dispensing study is needed for the State of Missouri.” Accordingly, in 2013, the Missouri Department of Social Services commissioned a cost of dispensing (COD) study for the Missouri HealthNet Division (MHD). The study was conducted by the University of Missouri– Kansas City School of Pharmacy (UMKC) and the St. Louis College of Pharmacy (STLCOP). Dispensing fees for Medicaid and other third-party prescription programs have historically been well below pharmacies’ actual costs for dispensing prescriptions, but were subsidized by payment of estimated acquisition costs (EAC) that exceeded pharmacies’ actual acquisition costs. As state Medicaid programs begin to rely on the NADAC as a basis for reimbursing for drug ingredient costs, it is critical that they base dispensing fees on accurate estimates of pharmacies’ actual costs of dispensing prescriptions. For example, when the Alabama, Oregon, Idaho, and Louisiana Medicaid programs reduced their estimated acquisition costs by adopting the average actual acquisition cost as an alternative to average wholesale price (AWP), all four states found it necessary to increase dispensing fees significantly. Prescription reimbursement can be broken down into three components: (1) the drug ingredient cost (i.e., cost of goods sold or drug acquisition cost), (2) the cost of dispensing (i.e., the average overhead costs incurred in dispensing a prescription), and (3) a reasonable net profit, which would be that amount sufficient to enable or encourage a pharmacy to remain in business. These components and their relationships are shown in the following equation: FIGURE 1: COMPONENTS OF PRESCRIPTION DRUG PAYMENT BREAKEVEN COST REASONABLE RX PAYMENT = DRUG INGREDIENT COST + COST OF DISPENSING + NET PROFIT COGS

20 MISSOURI PHARMACIST

GROSS MARGIN

In theory, if a pharmacy were reimbursed for the actual acquisition cost for drug ingredients, the dispensing fee would cover the cost of dispensing plus an additional amount to cover the net profit (or return on investment). STUDY OBJECTIVES

The overall objective of this study was to determine the average Missouri pharmacy’s cost of dispensing a prescription. To accomplish this overall objective, three specific research objectives were developed: 1. Calculate the average Missouri pharmacy’s overall cost of dispensing and compare the costs of dispensing for independent versus chain pharmacies and urban versus rural pharmacies. 2. Calculate and compare the amounts that several major expense categories contributed toward the cost of dispensing. 3. Determine the relationships between the cost of dispensing and selected demographic and financial variables. STUDY METHODS

To eliminate sampling error, all 1,335 Missouri community pharmacies were included in this study. Pharmacies were determined to be ineligible if: (1) they changed location or ownership during the most recently completed fiscal year, (2) did not have Missouri provider tax information available, (3) dispensed fewer than 250 Missouri Medicaid prescriptions or had a total Medicaid volume of less than $15,000 in the last year, or (4) had less than a full year of cost data available. A validated survey instrument, modified to meet the needs of the Missouri HealthNet Division, was sent to all Missouri community pharmacies beginning in March 2014. Three additional follow-ups were sent between April and October 2014 to non-respondents. Upon receipt, all surveys were checked for completeness and accuracy. Data were entered in to an Excel database with double-entry verification to prevent data entry errors. Financial ratios and response frequencies were checked for unusual responses, with all incomplete and unusual responses checked by telephone or email. A cost accounting approach was used to allocate

the proper portion of shared expenses (such as rent and utilities) to the prescription department. The cost allocation methods are detailed in Table 3. Appropriate precautions were utilized to ensure the confidentiality of the survey data. The survey instrument was carefully designed to capture all forms of owners’ remuneration. To ensure that owner’s salary was properly allocated, the total personnel costs of pharmacy owners, pharmacists, and managers were regressed by prescription volume, and outliers (outside of the 95th percentile) were reduced to the 95th percentile limit. That portion of personnel costs that exceeded this limitation was considered to be part of profit, rather than as an includable expense. Selected key data (e.g., prescription volume, prescription sales, total sales, pharmacy square footage, total square footage, total expenses, and selected individual expenses) were compared to identify outliers that were checked and verified for accuracy. To improve reliability of the results, outliers (i.e., specialty and mail order pharmacies and the pharmacies with CODs at the top and bottom 3% of respondents) were excluded from the final analysis. There are several ways in which researchers have described the “average” cost of dispensing, including the mean (either unweighted or weighted by total volume or Medicaid volume) or the median (either unweighted or weighted by total volume or Medicaid volume). The median is a “blunt-instrument approach” of estimating the average that reflects only the costs of one pharmacy—the one that falls at the 50th percentile. The mean is preferable because it uses the data from all the survey respondents. When considering the mean, the unweighted mean is a more appropriate measure than the weighted mean because: (1) the unweighted mean takes into account each pharmacy’s costs equally instead of biasing the results toward the largest pharmacies, (2) small pharmacies serving disadvantaged and rural communities are inappropriately underrepresented when using the weighted mean, and (3) a cost of dispensing per prescription could be weighted based on a number of factors, such as total prescription volume, Medicaid volume, Medicare volume, private third-party volume,

or even cash prescription volume. Each of these weighting mechanisms could result in widely different COD figures even though the pharmacies’ prescription department costs are the same. To avoid this problem and allow comparisons with other COD studies, the mean COD per pharmacy (i.e., the unweighted mean) is used for this study. RESULTS

The entire population of 1,335 Missouri pharmacies was included in this study. Eighty-four pharmacies were found to be ineligible to participate because they had been in operation under current ownership for less than one full fiscal year, were closed, or had low Medicaid volumes (i.e., less than $15,000 in Medicaid sales or less than 250 prescriptions per year) and, therefore, were excluded from the study. Among the remaining 1,251 Missouri pharmacies that received surveys, 335 completed and returned usable responses. This yielded a usable response rate of 26.8 percent (335 of 1,251). This response rate was consistent with those of most voluntary cost of dispensing surveys. Of the 335 respondents, 97 (29.0%) were independent community pharmacies, and the remaining 238 (71.0%) were chain pharmacies. Sixty of the 335 respondents, (17.9%) were from rural areas and 275 (82.1%) were urban. Table 1 provides the unweighted means for some of the financial and demographic variables in the study for independent versus chain pharmacy respondents and urban versus rural respondents, after exclusion of outliers. AVERAGE MISSOURI PHARMACY’S COST OF DISPENSING

As shown in Table 2, the average cost of dispensing for all survey respondents was $20.28. The standard deviation of $76.17 indicates that there were wide variances among the respondents in the sample. When eliminating specialty and mail order pharmacies, the mean and standard deviation for the overall cost of dispensing were reduced to $13.32 and $5.84, respectively. Excluding other outliers (i.e., the top and bottom three percent of respondents) as well as specialty and mail order pharmacies resulted in further reduction of the both

TABLE 1: FINANCIAL AND DEMOGRAPHIC DATA OF SURVEY PARTICIPANTS (EXCLUDING OUTLIERS) Overall Average Independent Chain Urban Pharmacies (n=318)a,b (n=88)a (n=230)a (n=261)b

Rural Pharmacies (n=57)b

Total Store Sales

$7,684,929

$3,705,192

$9,207,612 $8,388,393

$4,463,808

Rx Dept Sales

$5,528,603

$3,480,723

$6,312,140 $5,909,339

$3,785,232

# Rxs Dispensed

94,894

65,180

106,263 102,058

62,095

Avg. Rx

Pricec

$63.98

$54.78

$67.50 $62.86

$69.11

Store Size (ft2)

8,302

2,386

10,566 9,083

4,728

Rx Dept Size (ft2)

997

1,051

976 1,032

836

a Excludes specialty and mail order pharmacies (5 independents; 2 chains) and other outliers (4 independents; 6 chains) b Excludes specialty and mail order pharmacies (6 urban; 1 rural) and other outliers (8 urban; 2 rural) c The unweighted mean is based on the average of each pharmacy’s average Rx price, not Rx sales ÷ total Rxs

FALL 2015 21

the mean COD to $12.99 and the standard deviation to $4.71. The mean COD without specialty, mail order, and other outlier pharmacies is considered more representative of the average Missouri pharmacy’s cost of dispensing. Adjusting to a standard date of October 31, 2014, using the CPI-U for All Items resulted in an overall COD of $12.99 ($13.16 and $12.93 for independents and chains, respectively). Using the CPI-U for Rx Drugs, on the other hand, resulted in somewhat higher cost of dispensing figures ($13.39 overall, $13.64 for independent pharmacies, and $13.30 for chains). While one could build a case for using either of these figures, the more conservative adjustment using the CPI-U for All Items was used in this analysis. As shown in Table 2, the unweighted mean of Missouri pharmacy’s cost of dispensing prescriptions (after excluding outliers) was $12.99. The average independent

pharmacy’s COD was $13.16 and the average chain pharmacy’s COD was $12.93. The lower COD for chain pharmacies reflects the economy of scale with largervolume pharmacies. Table 2 also compares the COD of urban and rural pharmacies as classified by RUCA Codes. The average urban pharmacy had a COD of $12.67 while the average rural pharmacy had a COD of $14.50. The higher COD for rural pharmacies reflects both the higher costs to attract pharmacy personnel to rural locations and the significantly lower volumes for rural pharmacies. Table 3 shows the unweighted means for various components of the cost of dispensing. The footnotes to Table 3 detail the specific costs included in each of these components. As would be expected, personnel costs contribute the most (54%) to the cost of dispensing. Of particular interest is the provider tax, which contributes about 7.9 percent of the overall COD.

TABLE 2: COST OF DISPENSING FOR RESPONDENTS WITH AND WITHOUT SPECIALTY, MAIL ORDER, AND OUTLIER PHARMACIES Overall Mean (Std. Dev.)

Independent Mean (Std. Dev.)

Chain Mean (Std. Dev.)

Urban Mean (Std. Dev.)

Rural Mean (Std. Dev.)

$20.28 ($76.17) [n=335]

$36.34 ($140.13) [n=97]

$13.74 ($8.59) [n=238]

$18.64 ($70.74) [n=275]

$27.71 ($97.63) [n=60]

Respondents without $13.32 specialty or mail ($5.84) order pharmacies [n=328]

$13.58 ($5.57) [n=92]

$13.22 ($5.95) [n=236]

$12.92 ($5.09) [n=269]

$15.15 ($8.29) [n=59]

Respondents without specialty, mail order or outlier pharmacies

$13.16 ($3.95) [n=88]

$12.93 ($4.97) [n=230]

$12.67 ($4.07) [n=261]

$14.50 ($6.77) [n=57]

All respondents

$12.99 ($4.71) [n=318]

TABLE 3: MISSOURI PHARMACIES’ COSTS OF DISPENSING Store Personnel Costs1 Rent2 Prescription Containers and Labels3 Provider Tax4 Other Direct Expenses5 Other Variable Expenses6 Other Fixed Expenses7 Rx Inventory Carrying Costs8 Central Administration9 Total Cost of Dispensing

Overall COD (n=318)a,b $7.03 $0.38 $0.20 $1.02 $0.58 $1.38 $0.77 $0.16 $1.47 $12.99

Independent (n=88)a $8.13 $0.41 $0.23 $0.90 $0.57 $1.71 $1.07 $0.14 $0.00 $13.16

Chain (n=230)a $6.62 $0.37 $0.19 $1.06 $0.58 $1.26 $0.65 $0.16 $2.04 $12.93

Urban (n=261)b $6.72 $0.38 $0.20 $1.00 $0.56 $1.38 $0.76 $0.16 $1.52 $12.67

Rural (n=57)b $8.47 $0.39 $0.21 $1.11 $0.68 $1.43 $0.80 $0.16 $1.25 $14.50

a Excludes specialty and mail order pharmacies (5 independents; 2 chains) and outliers (4 independents; 6 chains). b Excludes specialty and mail order pharmacies (6 urban; 1 rural) and outliers (8 urban; 2 rural). Totals may not add exactly because of rounding. 1Store Personnel included salaries, wages, bonuses, overtime, profit sharing, personnel taxes, and fringe benefits. Personnel costs were applied to the prescription department for each employee in proportion to the person’s percentage of total work hours spent in prescription department-related activities. 2Rent was allocated in the manner in which it was actually incurred. Rent paid as a fixed monthly amount was allocated in proportion to the percentage of total store area occupied by the prescription department. Rent paid as a percentage of sales was allocated in proportion to the percentage of total store sales generated by the prescription department. 3Prescription Containers and Labels are a direct expense but are identified separately for this analysis. 4Provider Tax is the amount assessed by the Missouri Department of Revenue pursuant to RSMo §338 and is based on pharmacies’ gross receipts. 5Direct Expenses included items such as pharmacy license fees, third-party claims processing, enrollment and switch fees, and professional trade and association dues. Direct expenses were allocated entirely to the prescription department. 6Variable Expenses included advertising and promotion, bad debt, credit card and bank charges, telephone, and charitable contributions. Variable expenses were allocated to the prescription department in proportion to the percentage of total store sales that were generated by the prescription department. 7Fixed Expenses included depreciation on buildings and fixtures, utilities, accounting, legal, taxes (other than personnel, sales, or income taxes), insurance, repairs, store supplies, interest paid on borrowed money, postage, janitorial services and security. Fixed expenses were allocated to the prescription department in proportion to the percentage of total store square footage occupied by the prescription department. 8Carrying Costs for Rx Inventory are an opportunity cost for cash that could otherwise be invested. The cost is based on ending inventory multiplied by the prime rate of interest (3.25%). 9Central Administration includes expenses for chain stores’ corporate and regional offices, central computer processing and support, centralized insurance or self-insurance expenses, and third-party department expenses and are allocated in proportion to the percentage of chain sales represented by that given store.

22 MISSOURI PHARMACIST

RELATIONSHIP OF EXPENSES & PRESCRIPTION VOLUME

To describe the relationship of prescription department expenses to prescription volume, a regression analysis was conducted to determine the relationship of total prescription department expenses to the total number of prescriptions dispensed. Figure 2 is a scatterplot in which each data point represents the prescription volume and the corresponding prescription department expenses for one pharmacy, excluding specialty and mail order pharmacies and other outliers. A linear, upward-sloping pattern demonstrates that as prescription volume increased, total prescription department expenses also increased.

prescription volume increased indicates that there was certain economy of scale for Missouri pharmacies’ dispensing costs. This economy of scale exists because fixed costs (such as utilities, insurance, and depreciation) can be spread over more prescriptions, thereby decreasing the average cost per prescription. This may also be true to a lesser extent for personnel expenses since a small increase in prescription volume does not always require the addition of work hours. The influence of volume on the cost of dispensing is not a linear one, however, because each pharmacy has a point of diminishing returns—a point where an increase in volume would necessitate additional store expenditures. Therefore,

FIGURE 2. THE RELATIONSHIP BETWEEN PRESCRIPTION DEPARTMENT EXPENSES AND PRESCRIPTION VOLUME FOR MISSOURI PHARMACIES N = 318; R = 0.988; R2 = 0.975; P<0.000

$8,000,000 $7,000,000

Rx dept expenses

$6,000,000 $5,000,000 $4,000,000 $3,000,000 $2,000,000 $1,000,000 $0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Total Prescrip=ons Dispensed

The regression analysis resulted in a Y-intercept of $52,737 and a slope of $11.31. Therefore, if a pharmacy dispensed 100,000 prescriptions during the year, it would be predicted that the total prescription department expenses for the year would be $1,183,737 (i.e., $52,737 plus the product of $11.31 per prescription times 100,000 prescriptions). RELATIONSHIP OF OVERALL COD & PRESCRIPTION VOLUME

Figure 3 is a scatterplot showing the relationship of the overall cost of dispensing (on the Y-axis) with the total number of prescriptions dispensed annually. Review of the scatterplot reveals that prescription volume has an inverse and curvilinear relationship with the cost of dispensing. In other words, the effect of increased prescription volume on reducing cost of dispensing is more dramatic at lower volumes; there is a point (around 100,000 prescriptions) where increasing prescription volume has little impact on decreasing the cost of dispensing. The fact that the cost of dispensing decreased as

increasing prescription volume has more influence on the cost of dispensing for low-volume pharmacies that it does for high-volume pharmacies. Since the scatterplot showed prescription volume to have curvilinear relationships with the cost of dispensing, the correlation was recalculated using a log transformation of the data. The Pearson’s correlation coefficient (r) for prescription volume (independent variable) compared to cost of dispensing (dependent variable) was –0.602 and the coefficient of determination (r2) was 0.3627. In other words, 36.3 percent of the variance in pharmacies’ costs of dispensing is explained by the number of prescriptions dispensed. The scatter plot also indicates that there was considerable variance in the cost of dispensing figures even among pharmacies that had similar volumes. Therefore, some of the variance in the cost of dispensing figures cannot be explained by prescription volume alone; some variance could be explained by factors unique to each pharmacy, such as quality of store management, local competition, or differences in type or level of services offered. FALL 2015 23

FIGURE 3. THE RELATIONSHIP BETWEEN THE COST OF DISPENSING AND PRESCRIPTION VOLUME FOR MISSOURI PHARMACIES N = 318; R = - 0.602; R2 = 0.3627; P<0.000

Cost of Dispensing to the Total Number of Rx Dispensed-‐ Excluding Specialty and Outliers $40

Cost of Dispensing

$35 $30 $25 $20 $15 $10 $5 $0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Total Number of Prescrip?ons Dispensed

DISCUSSION

Sampling error was eliminated by surveying the entire population of Missouri community pharmacies. Data entry error was reduced through double entry verification. Any data entry errors are assumed to be normally distributed as random error. Data collected by the survey instrument were dependent upon pharmacy managers’ valuations and reports. Although all surveys were reviewed carefully for completeness, consistency, and reasonableness of responses and all unusual responses were checked by telephone or email (with outliers removed from the analysis), there was still the opportunity for error. Any inaccuracies were assumed to be normally distributed as random error without bias affecting the results. It is possible that there could be some non-response bias. While approximately 63 percent of the population of Missouri pharmacies were chains and about 37 percent were independents, 71 percent of the respondents were chains and 29 percent were independents. Since chain pharmacy respondents were over-represented and had an average cost of dispensing that was lower than the overall average COD for independent pharmacies, this could result in a lower estimate of the actual cost of dispensing. Likewise, while 78 percent of the population of Missouri pharmacies were located in urban communities and 22 percent were located in rural areas, approximately 82 percent of the respondents were from urban areas and about 18 percent were from rural areas. Since urban pharmacy respondents were overrepresented and had an average cost of dispensing that was lower than for rural pharmacies, it is likely that the results of this study slightly underestimate the actual average cost of dispensing. While we could have corrected 24 MISSOURI PHARMACIST

for this effect by weighting independent pharmacy responses and rural pharmacy responses to have a more proportional influence in the overall COD calculation; instead, we have reported the lower, more conservative estimates. While carrying costs for inventory investment are included, it is recognized that this is an opportunity cost rather than an outlay cost and is more closely related to cost of goods sold than the cost of dispensing. This cost is, however, identified separately in recognition of the fact that a reasonable business manager would consider this cost in pricing decisions and a new reimbursement mechanism based on actual acquisition costs would no longer provide a spread between actual cost and reimbursement for ingredients to cover this cost. CONCLUSIONS

The study demonstrated that the average Missouri pharmacy had a cost of dispensing of $12.99. Since cost of dispensing was shown to be dependent on the number of prescriptions dispensed, it is possible that much of the differences in COD figures between chain and independent pharmacies ($13.16 and $12.93, respectively) and between urban and rural pharmacies ($12.67 and $14.50, respectively) could be related to differences in prescription volume. The results demonstrate that the average Missouri pharmacy needs an average gross margin of at least $12.99 to break even on its prescription sales. This figure does not include a provision for profit or a reasonable return on investment. Since the average independent pharmacy earns a net profit of about three percent of sales, one can estimate a reasonable net profit as three percent of the average prescription price, or $1.92 per

prescription (i.e., average Rx price of $63.98 multiplied by 0.03). If Missouri Medicaid were to base reimbursement for drug ingredient costs on actual invoice prices instead of the current estimated acquisition cost (EAC), then profit would have to be earned from the dispensing fee rather than from the difference between EAC and actual acquisition costs, necessitating a dispensing fee of $14.91 (i.e., $12.99 COD plus $1.92 for return on investment). It should be kept in mind that the oversampling of chains and urban pharmacies is likely to have resulted in a COD estimate that is slightly less than the actual COD in the market. It should also be noted that basing drug cost reimbursement on invoice prices does not take into account costs for inventory shrinkage (i.e., inventory lost to breakage, pilferage, and obsolescence). Likewise, these costs are not captured in the cost of dispensing calculation. According to the 2011 National Retail Security Survey, retail shrinkage averaged 1.42 percent of sales. These cost can be covered either by a small markup on invoice cost or added to the cost of dispensing. It is recommended that Missouri HealthNet conduct cost of dispensing surveys every two or three years, and that during the interim between surveys, the COD figure should be adjusted according to changes in the Consumer Price Index. ACKNOWLEDGEMENTS

The authors acknowledge the contributions that the following individuals and organizations made to this project: Rhonda Driver, Pharmacy Director for Missouri HealthNet; Ron Fitzwater, Executive Director of the Missouri Pharmacy Association and his staff; The National Association of Chain Drug Stores; George Oestreich, CEO of G.L.O. & Associates; Andrew O. Oestreich, Director of the Pharmacy Agent Corporation; Steve Stoner, Chair of the UMKC Department of Pharmacy Practice and Administration; Christy Hanks and Josh Loeshe, student research assistants at the St. Louis College of Pharmacy; and James Gray, Janna Brown and Hye-Wan Ham, student research assistants at UMKC. 1 Missouri Department of Social Services, Contract Number AOC14380056, §1.6. 2 Alabama Medicaid Agency Pharmacy Reimbursement Modification found at: http://medicaid.alabama.gov/CONTENT/4.0_Programs/4.5.0_Pharmacy/4.5.1_AAC.aspx,

referenced December 1, 2014. 3 Oregon Health Authority, Pharmacy Reimbursement Methodology, found at http://www.oregon.gov/OHA/pharmacy/index.shtml, referenced November 21, 2010. 4 Idaho Department of Health and Welfare, Pharmacy Reimbursement Changes Effective September 28, 2011 – Frequently Asked Questions. Found at: http:// healthandwelfare.idaho.gov/LinkClick.aspx?fileticket=6EBbVwNg1gA%3D&tabid=119&mid=1111, referenced February 3, 2012. 5 Louisiana Medicaid – Historical Methodology: 1990 – Present. 6 RUCA = Rural-Urban Commuting Area Codes (See http://depts.washington.edu/uwruca/index.php) 7 Tyco International Ltd., “National Retail Security Survey Reveals U.S. Retail Industry Lost More than $35.28 Billion to Theft in 2011,” found at http://investors.tyco. com/phoenix.zhtml?c=112348&p=irol-newsArticle&ID=1762020, referenced Dec. 30, 2014. The amount of inventory shrinkage for Missouri retail pharmacies was not determined as part of this study.

FALL 2015 25

Technicians Corner

MIXING IT UP

The pharmacy technician’s role in compounding. As the community pharmacist’s role in health care continues to expand, the role of the pharmacy technician becomes increasingly vital to a successful pharmacy practice. According to the US Bureau of Labor Statistics, “Employment of pharmacy technicians is projected to grow 20 percent from 2012 to 2022, faster than the average for all occupations.” Compounding is often thought of as the foundation of the practice of pharmacy. It not only involves skill and HEATHER knowledge, but can also be seen as an art. CompoundLYONS-BURNEY ing allows the pharmacist to creatively and scientifically PHARM.D., CLINICAL meet the specific needs of the patient and provider. ASST. PROFESSOR The USP-NF Chapter <795> describes compounding UMKC SCHOOL OF as “the preparation, mixing, assembling, altering, packPHARMACY AT MSU aging, and labeling of the drug, drug-delivery device, or device in accordance with a licensed practitioner’s prescription medication order, or initiative based on the practitioner/patient/pharmacist/compounder relationship in the course of professional practice.” As we enter an age of personMany pharmacists are turning to alized medicine, the benefits of skilled technicians to assist with a compounded medication in a specialized areas of practice, such patient-specific dose and dosage as compounding. form become increasingly evident. A compounded medication can meet the specific needs of patients, such as a child requiring palatable medication, an elderly patient with difficulty swallowing, a specific concentration of a drug that is not commercially available, medication for dental or dermatological procedures, or veterinary needs. In response to the increasing demand for trained technicians, more pharmacies are requiring technicians to become certified through the Pharmacy Technician Certification Exam (PTCE). This exam is reassurance for the pharmacist that a technician has a strong 26 MISSOURI PHARMACIST

knowledge base to perform the necessary duties in a pharmacy. The Pharmacy Technician Certification Board’s examination contains nine knowledge domains: information systems usage and application, law and regulation, medication safety, compounding (sterile and nonsterile), quality assurance, medication order and fill process, billing and reimbursement, inventory management, and pharmacology. Technicians can increase their compounding skills beyond their pharmacy’s training by attending programs developed by companies such as Professional Compounding Centers of America (PCCArx.com), Medisca (Medisca.com), or the American College of Apothecaries (acainfo.org), among others. In addition to learning good compounding technique, a pharmacy technician is responsible for understanding federal and state laws pertaining to compounding, as well as appropriate record keeping and documentation. Technicians with an interest in compounding are comfortable with performing pharmacy calculations required to accurately compound various dosage forms. And technicians become proficient in appropriate use of the various pieces of equipment available to assist with compounding. “Well trained compounding technicians make all the difference in the world,” says Jennifer Essary, Pharm.D., a compounding pharmacist at Grove Pharmacy in Springfield. “They free me up to concentrate on counseling and working with providers to customize patient care. They are great problem solvers and come up with patient solutions I would have never thought of on my own.” The ability to assist with compounding is a highly marketable skill, and one that can bring great job satisfaction for any pharmacy technician looking for a challenge.

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BY HEATHER LYONS-BURNEY

FALL 2015 27

Student Update Phase II construction of the STLCOP campus includes a seven-story building with a residence hall, dining and kitchen facility, student and recreation centers, and multiple gymnasiums.

PHASE II

JOHN A. PIEPER PHARM.D., FCCP, FAPHA, PRESIDENT AND PROFESSOR OF ST. LOUIS COLLEGE OF PHARMACY

The St. Louis College of Pharmacy continues to improve the educational landscape of the city by announcing plans for a seven-story student center, residence hall, and recreation facility on the northeast corner of campus. “This is the second phase of our transformational campus construction project at St. Louis College of Pharmacy,” says College President John A. Pieper, Pharm.D. “This new building and our soon-to-open academic and research building and library will provide resources to help prepare our student pharmacists for their changing role in the health care system and transform the college into a global leader in health care and pharmacy education.” The first floor of the new 190,000-square-foot building will consist of a large dining hall and kitchen, reception area, and a competition gymnasium. The second floor will have additional seating for the dining hall, meeting rooms, and an intramural gymnasium. A recreation center with a two hundred-meter, threelane indoor track will be the main feature on the third floor. The student center, including a success center and student support offices, will be on the fourth floor. The

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college’s second residence hall, with room for 220 beds, will be on the fifth through seventh floors, nearly doubling on-campus housing space. Forum Studio, a St. Louis-based company, was chosen as the architectural firm for the project. PARIC Corporation is serving as general contractor. Demolition of Whelpley Hall will begin shortly to make way for the new building. The college plans to fund this second phase in a similar way to Phase I— through donor contributions and a bond issue. “Through our campus master planning process, we’ve committed to build for the future to provide outstanding facilities for the campus community,” Pieper says. “We remain on firm financial footing thanks to our careful planning and the generosity of our alumni and donors.” When complete, the St. Louis College of Pharmacy will have added more than 400,000-square-feet of usable space on its eight-acre campus. The building is tentatively scheduled to open December 2016. View the building renderings and stream images of the ongoing construction at stlcop.edu/construction.

BRAD BROWN

The second phase of the STLCOP campus transformation is on schedule to open December 2016.

Student Update

Along with the new class of pharmacy students, the UMKC School of Pharmacy welcomes new staff.

WELCOME NEW FACULTY MEMBERS

Faculty changes and accreditation are just part of the new school year.

COURTESY UMKC SCHOOL OF PHARMACY

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

We are currently undergoing a comprehensive selfstudy for continued accreditation status from the Accreditation Council for Pharmacy Education (ACPE). Our lengthy self-study process began in January 2014 and will culminate in submission of our self-study documents in August 2015 followed by a site visit in November. Unlike previous cycles that were six years in duration, this time our program will be considered for renewal of full accreditation status for an eight-year period. Throughout the last 18 months, we have worked hard to collect input from all stakeholders, and we have made plans for how the school will meet the new ACPE accreditation standards for 2016, which will become effective July 1, 2016. We are so very thankful for all the hard work that students, staff, faculty, preceptors, alumni, and others have put into helping us with this process. Some bitter sweet news comes with the changes we are experiencing. Dr. Wayne Brown has retired after serving an incredible 44 years with the UMKC School of Pharmacy. Many pharmacists around the country are thankful for all of the instruction Dr. Brown provided and especially for his efforts in preparing students for the pharmacy law examinations required for licensure. Also departing this summer are Dr. Kristy DiDonato in Kansas City and Drs. Lynn Kassel and Lauren Odum in Columbia. We will miss them all and wish them the best of luck in their new ventures. The good news is that we have five new faculty members joining the school this summer. Those include Drs. Barbara Kasper and Jamie Koerner on the University of Missouri-Columbia campus and Drs. Lisa Cillessen, Heather Taylor, and

Elizabeth Englin at the Missouri State University campus. We are eager to get them on board! As always, the accomplishment we are most proud of is our graduates. May 2015 marked the celebration of 123 Pharm.D. graduates and five PhD graduates. Our PhD graduates have gone on to excellent research positions with a variety of drug companies and post-doctoral fellowships at other universities. While we are always somewhat sad to see our students leave, it is our primary goal, and we celebrate their accomplishments. However, we are also eager to welcome our new class of students in the fall. Like last year, we will admit up to 95 Pharm.D. students in Kansas City and up to 30 each in Columbia and Springfield. Research continues to be a major focus for the UMKC School of Pharmacy. We are excited to report that Dr. Anil Kumar was recently named a University of Missouri Curatorsâ&#x20AC;&#x2122; Professor. This distinction is only given to a few faculty at UMKC, University of St. Louis, University of Missouri, or MS&T who have reached significant national and international recognition as researchers and scholars. Our other Curatorsâ&#x20AC;&#x2122; Professor is Dr. Ashim Mitra. We are also happy to announce major new grant funding awarded by the National Institutes of Health to Dr. Simon Friedman ($1.4 million over four years) to further develop his technology aimed at cannula-free and pump-free delivery of insulin using light. Dr. Kun Cheng was also awarded a major grant from the American Cancer Society to develop novel techniques for delivering gene-modulating treatments for breast cancer. Have a great fall! Go Royals!! FALL 2015 29