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Minnesota Pharmacist Fall 2012
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INSIDE
Fall 2012
Volume 66. Number 3, ISSN 0026-5616
Upfront Views and News President’s Desk: This Organization Is What We Choose to Make of It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Executive’s Report: Together, We Are Stronger. . . . . . . . . . . . . . . . 7
Viewpoint Stay Hungry, Stay Foolish. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Healthcare Reform
On the Cover:
The Affordable Care Act: It’s Here To Stay So Buckle In . . . . . . . . . . . 12
The Affordable Care Act: FAQs for Pharmacists
Clinical Issues
page 12
Oral Health Zone Project: Tooth Decay Is a Preventable Disease and Pharmacists Can Make a Difference!. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Injection Drug Use on the Rise: The Pharmacist’s Role in Preventing Blood-Borne Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Ask the Pharmacist: Frequently Asked Questions about Probiotics . . . 24
Industry News 2012 Labor and Compensation Survey: Changes in the Pharmacist and Technician Workforce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 PharmD Life: Musings on the Life of a PharmD Candidate . . . . . . . . . . 27
Minnesota News News from the Dean: The Interoperable Electronic Medical Record and What it Means for Pharmacists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
MPhA News
Must-read
How MPhA is serving you: Welcome the PBM Audit Bill! page 30
Pharmacy Time Capsules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Academy News: Technician Academy . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Pharmacy Benefits Manager Audit Bill Now in Effect! . . . . . . . . . . . . . . . 30
Find us on Facebook... Minnesota Pharmacists Association
Minnesota Pharmacist Fall 2012 n
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MPhA Board of Directors
Executive/Finance Committee: President: Martin Erickson Past-President: Scott Setzepfandt President-Elect: Jill Strykowski Secretary-Treasurer: Bill Diers Speaker: Meghan Kelly Executive Vice President: Julie K. Johnson
Upcoming Events Visit www.mpha.org for more information and registration
Rural Board Members: Eric Slindee Jeff Lindoo Metro Board Members: Cheng Lo Brittany Symonds At-Large Board Members: Tiffany Elton Tim Cernohous Keri Hager Amy Sapola Jason Varin
Delivering Medication Management Therapy in the Community November 3, 2012 | University of Minnesota Rochester Campus fall mtm symposium, November 16, 2012 | DoubleTree Hotel, Bloomington Fall Pharmacy Nights September 25 – Duluth • October 9 – Rochester October 16 – Alexandria • October 23 – Twin Cities
Student Representation: Duluth MPSA Liaison: Brittany Novak Minneapolis MPSA Liaison: Amy Herbranson Ex-Officio: Rod Carter, COP Julie K. Johnson, MPhA MSHP Representative Pharmacy Technician Representative: Barb Stodola
MINNESOTA PHARMACIST
Official publication of the Minnesota Pharmacists Association. MPhA is an affiliate of the American Pharmacists Association, the American Society of Consultant Pharmacists, the Academy of Managed Care Pharmacy, and the National Community Pharmacists Association.
Editor: Julie K. Johnson Managing Editor, Design and Production: Anna Wrisky The Minnesota Pharmacist (ISSN # 0026-5616) journal is published quarterly by the Minnesota Pharmacists Association, 1000 Westgate Drive, Suite 252, St. Paul, MN 55114-1469. Phone: 651697-1771 or 1-800-451-8349, 651-290-2266 fax, info@mpha.org. Periodicals postage paid at St. Paul, MN (USPS-352040). Postmaster: Send address changes to Minnesota Pharmacists Association, 1000 Westgate Drive, Suite 252, St. Paul, MN 551141469.
Article Submission/advertising: For writer’s guidelines, article submission, or advertising opportunities, contact the editor at the above address or email julie@mpha.org. Bylined articles express the opinion of the contributors and do not necessarily reflect the position of the Minnesota Pharmacists Association. Articles printed in this publication may not be reproduced in any manner, either in whole or in part, without specific written permission of the publisher.
Acceptance of advertisement does not indicate endorsement. 4 Minnesota Pharmacist Fall 2012 n
MTM Symposium November 16 – DoubleTree Hotel in Bloomington, MN Featuring: • Motivational Interviewing in Primary Care • Round Table Discussions • Networking • Continuing Education credits available Register Online at mpha.org! Open to MPhA members and non-members Early Bird registration rates: (ends October 19) $115 member
$165 non-member
MPhA Mission:
Serving Minnesota pharmacists to advance patient care. The Minnesota Pharmacists Association is a state professional association, whose membership is made up of pharmacists, pharmacy students, pharmacy technicians, and those with a business interest in pharmacy. Besides offering a one-stop information site for our members, consumers are also welcome to use our pharmacy locator and browse for information specific to their needs.
Moved, graduated, or have a name change? Update your profile through your online MPhA Member Portal page to continue receiving important association updates.
Upfront Views and News
President’s Desk
This Organization is What We Choose to Make of It by Martin A. Erickson III, RPh, Director of Professional Services and Regulatory Affairs, Fargron Editor’s Note: Following is the acceptance speech from 2012-2013 President Martin Erickson, presented at the 2012 Annual Meeting.
limits the invasive, time-consuming random third party audits that have been the source of much frustration among pharmacists.
I am humbled and honored to receive this responsibility as president of the Minnesota Pharmacists Association.
Our executive vice-president, Julie Johnson, and her staff tirelessly pursued this issue, putting in long hours and skillfully negotiating among adversaries to reach the goal: A goal that benefits all pharmacists. Yes. Not only MPhA members, but ultimately all pharmacists, directly and indirectly.
Before I begin, please allow me a moment to acknowledge not only the help and support I receive from all of you, but most particularly my partner David, without whose support I would be unable to assume this position. I also recognize and thank my mother, whose devotion to the pharmacy profession is second only to her devotion to God and her family. Thanks to her for continuing to be my hero. Many of you know Jeanne Erickson, who has practiced pharmacy for years, most recently owning and managing the pharmacy that her dad, my grandfather, Ed Holland, founded in Warroad. I discovered something about my mother this afternoon, and Mother, you brought me into this world, so please don’t take me out for this, but ... Ron Hadsall (PhD, RPh, University of Minnesota) told me he was searching pharmacy license numbers and discovered that Jeanne Erickson holds the oldest residential active pharmacist license in the dtate of Minnesota. You, the members of MPhA, have spoken and we heard you. Last year, the association under Scott Setzepfandt’s leadership was instrumental in passage of the pharmacy audits bill, which
The point is, MPhA has been doing good work, quietly in good Minnesotan fashion, accomplishing much for our patients and for our profession. Not every action this association takes has been, nor will be, universally popular, but at the center of every action has been, and will be, patient safety and well-being. We all have participated in this difficult and rewarding work. It’s a Minnesota ethic: willingness to work hard when the outcomes are worthy. This year, your board will be examining mandatory mail-order prescription dispensing with a view to evaluating its effect on patient therapeutic compliance and disease state management against 1:1 patient-pharmacist direct interactions. It is well settled that pharmacists contribute to improved patient outcomes when practice includes medication therapy management. Improved outcomes mean better public health and more efficient (or lower cost) health care overall.
That patients desire to participate in their own health care is a generally accepted concept. The December 13, 2011, online issue of Pharmacy Times (Gamble 2011) states that data from the Gallup organization’s annual Honesty & Ethics Survey show that pharmacists, for the ninth consecutive year, have ranked in the top three trusted professions. As a profession, we must do all we can to maintain this level of the public trust. To this end, the next exciting step is full pharmacist participation in collaborative practice. The time is ripe — old ways are replaced or are being replaced by new concepts, better and more just delivery systems. New technologies and complex therapies are shaping health care delivery. No longer can quality health care be provided in the “physician as captain of the ship model.” I think we have all observed a gradual shift away from that model among medical school graduates. Nor should a new captain (in the form of third-party payors) determine patient therapies. If we are committed to full participation of all concerned — patients and professionals — then pharmacists must be allowed to participate in fully collaborative practice arrangements and be fairly compensated for their participation.
This Organization continued on page 10 Minnesota Pharmacist Fall 2012 n
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Upfront Views and News
Executive’s Report
Together, We Are Stronger by Julie K. Johnson, PharmD, MPhA Executive Vice President/CEO Hello, Minnesota Pharmacists! If you are reading us for the first time, welcome to the first of many Minnesota Pharmacist journals you will receive! MPhA’s voice for pharmacy just got a lot louder — and beginning with this issue, we are introducing to you a refreshed Minnesota Pharmacists Association! Building on a tradition of advancement and protection of our profession, we renew our pledge to serve you and provide enhanced services to all pharmacists in our state! I’m Pharmacist Julie Johnson; I serve as the executive director for the Minnesota Pharmacists Association. My background is community pharmacy and I have been with MPhA for 11 years. I’m a proud U of MN grad (twice☺). We are very excited to present this refreshed Minnesota Pharmacist journal to you. As a pharmacist, your desire to stay current, informed and involved in your profession is challenging when the priorities of family and life are ever-present. We are here for you — providing you with services and opportunities to grow in your profession and become involved at a level that fits you! Our goal is for the association to provide information of interest to you as a pharmacist. MPhA is providing this journal to you because it is important for us to communicate with all pharmacists in our state. We work on your behalf every day and seek your involvement and support because together we are stronger! MPhA’s activities are relevant and benefit all pharmacists
—we work on your behalf even if you are not a member. We hope that we can convince you to become a member by providing this journal to you on a regular basis. Feature articles on health care reform, a Minnesota pharmacy labor survey, and pharmacy audit legislation passed this year are all included in this first edition. Look for new member spotlights in editions to follow! Just as the practice of pharmacy has evolved over the years, MPhA has evolved as well! Now more than ever, your involvement is vitally important! Stay up to date on trends in pharmacy, new legislation, and board rules. Access our Career Center for employment opportunities! Go to the Resource Sections of the Web site. Keep up on things happening here and nationwide that affect you. MPhA is here to support your growth as a pharmacist. We provide networking opportunities of all kinds. Check out what MPhA looks like on Facebook. Join your colleagues as they pose important questions to discuss on LinkedIn. Attend one of our events! The Annual Meeting will be held in the Twin Cities May 17-18, 2013. Come and check us out!
We work on your behalf every day and seek your involvement and support because together we are stronger! double our membership in recent months! To see who has recently joined, go to mpha.org to view logos. To learn more about this, call me at 651-697-1771. Please join today if you are not a member already. We need to add your voice to make sure pharmacists are being heard at the Capitol and throughout the state.
Julie K. Johnson, PharmD, MPhA Executive Vice President/CEO
We have made it easier for you to become a member by lowering our membership rates. It’s super easy to sign up online at www.MPhA.org. Additionally, we wish to welcome all of our new organization member companies. Their commitment to MPhA has allowed us to more than Minnesota Pharmacist Fall 2012 n
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Viewpoint
Stay Hungry, Stay Foolish by Lowell J. Anderson, D.Sc., FAPhA
For those of you who have not read the recent Walter Isaacson biography called Steve Jobs, I recommend it as an essential read. It is that rare book that is interesting, informative and has value beyond the story that it tells. When I picked it up, my first reaction was doubt of the value of reading 658 pages about the computer industry, in spite of my long-time fascination with Steve Jobs as a character, innovator and iconoclast. Walter Isaacson made him to be more significant than any of those — there is much that applies to life and our profession. Building on some of Jobs’ quotes, these are some of the other thoughts I have. “Stay Hungry. Stay Foolish.” This was Steve Jobs’ advice to the 2005 graduates of Stanford University. The quote was from the 1970s final edition of The Whole Earth Catalog. I think that as pharmacists we would benefit from being hungry. Hungry, in the sense of being creative: seeking new services to offer, and new ways to deliver them. Hungry, as a way to feed a revitalization of pharmacy practice. Pharmacists who are hungry are sometime labeled as foolish. Patient profiles, immunizations, pharmaceutical care and MTM: When pharmacists first began to offer these services, conventional pharmacist wisdom saw these as “foolish.” Thanks to the hun-
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Minnesota Pharmacist Fall 2012 n
gry and foolish among us, many of these have become standards of our profession. Give some thought to today’s “foolish” ideas for opportunities to strengthen your pharmacy practice: pharmacy practice accreditation, collaborative practice, transitional care, and walking away from unsustainable managed care contracts. Come up with a “foolish” idea of your own! “...we don’t know where it will lead. We just know there’s something much bigger than any of us here.” Steve Jobs Health care reform is much bigger than any of us. As Americans we are looking at health care in vastly different ways than we did even 10 or 15 years ago. This change in the consumer view of health and the care of health is having a huge effect on the health care industry and the way it is responding to its markets. Legislative reform initiatives are a political response to this cultural change. In turn, these reform activities have disrupted the markets for health care services, to the consternation of all practitioners. We don’t know where this will lead. We can be assured that it is leading somewhere. Those professionals and businesses that survive and prosper will lead the change by adapting their practices and products to emerging markets and delivery systems. Be assured that the real and permanent changes will occur at the interface of
the consumer of services and provider of services. Our industry is schizoid on this: We are, on the one hand, acting protectively, and on the other, opportunistically. It is evocative of the definition of the Chinese word for “crisis” as being composed of two characters: One represents danger and the other represents opportunity. There is opportunity in health reform for the attentive. There is danger for the inattentive. “Everyone here has the sense that right now is one of those moments when we are influencing the future.” Steve Jobs Our response to these changes will not only influence but also define the future of our profession. If we respond by only seeking to protect what we have, we will lose. We must grab the opportunities to use our knowledge and skills to respond to real consumer needs in the emerging health care system, while protecting our traditional place in health care. The report of the Working Group on the Pharmacy Practice Act, which I wrote about last issue, is an attempt to free pharmacists to fully participate in these opportunities. (http://www.pharmacy.umn.edu/clhc/practiceact/) Mark Bertolini, CEO of Aetna, views the ACA as “...an action-forcing event, through which we can drive some change, not only inside our company, but across the industry. That otherwise wouldn’t have happened.” 1
“Be a yardstick of quality. Some people aren’t used to an environment where excellence is expected.” Steve Jobs When I was a member of the Board of Pharmacy in the early ‘70s, there was a board member by the name of John Nelson. John told every class of new pharmacists that life in practice was different from life in school. In school, a passing grade was often sufficient. In practice, every patient expected and every pharmacist must deliver 100%. Now that I no longer practice, I visit pharmacies as a consumer. Knowing what I know about the capabilities of the pharmacist to deliver 100%, I observe that “a passing grade” seems to be the value proposition of some pharmacists. These pharmacists seem totally absorbed in managing the filling of the prescription, to the exclusion of managing the patient’s achieving the full value of the prescription. Where is the excellence? Indifference to consumer needs is not a sustainable brand for pharmacy practice! “Innovation distinguishes between a leader and a follower.” Steve Jobs To be innovative is more than having a lot of good ideas. To be innovative is to make good ideas become real. We make good ideas become real through personal leadership – by describing the value of our ideas in such terms that people will follow us. By this measure, we have a lot of innovators and leaders in pharmacy – pharmacists who are meeting the needs of their communities and who, as a result, are financially and professionally rewarded. Unfortunately there are also pharmacists with good ideas that are never tried. These ideas are never tried because of the perceived limitations of board rules, managed care, fear of physicians, management’s reticence, and lack of time.
It is terrible to waste the personal opportunity for leadership through innovation and to accept a careerlong position of follower! As Ann Bancroft, the first woman to sled to the North Pole observed: if you are not the lead dog, the view never changes. “People DO judge a book by its cover. We may have the best product, the highest quality, the most useful software, etc. If we present them in a slipshod manner, they will be perceived as slipshod; it we present them in a creative, professional manner, we will impute the desired qualities.” Mike Markkula, angel investor and second CEO of Apple, brought the concept of ‘imputation’ to Apple. “Imputation” emphasized that people form an opinion about a company or product based on the signals that it conveys. If you own an Apple product you have “experienced” opening the box it came in. When I bought my first iPod, it came in a box that could have come from Tiffany. This box was so cool, I knew this box contained something special — even the part of the packing that was “hidden” was beautifully designed and executed. Pharmacy may be similar. We know that the products we manage are miracles: They can cure diseases that previously meant certain death or disability. We also know that our knowledge of medicines and their uses are second to none and this knowledge is absolutely essential for the clinical success of these miracle medications. How does pharmacy “impute” its value? What is the “packaging” that surrounds our professional services? Consider the busy pharmacist, who tosses the bag containing the “mira-
. . . the products we manage are miracles: They can cure diseases that previously meant certain death or disability . . . our knowledge of medicines and their uses are second to none and this knowledge is absolutely essential for the clinical success of these miracle medications. cle medicine” across the counter for the clerk to sell to the patient. What value is imputed? Or, discusses a new prescription across the raised dispensing counter, while on telephonic hold, as the patient writes a check. What value is imputed? Or, provides medication management services in a cluttered office on the fly, with no history, no take-away information or follow-up plans for the patient, and no sharing of information with the physician. What value is imputed? Or, drive-up prescription windows, “right to counseling” waivers, tele-MTM, mailorder prescriptions. What values are imputed? This may be the 200th patient the pharmacist saw today. But for the patient, it was the only opportunity for interaction he or she had with a pharmacist. What imputation of value was received? These are the slipshod practices that Markkula spoke of. They define the value of our services, our practice, our profession — and us as individuals. As Markkula observed: “People form an opinion about a company or product based on the signals that it conveys.” What signals does your practice convey? “And one more thing ... you can’t connect the dots looking forward; Stay Hungry, Stay Foolish continues on page 10 Minnesota Pharmacist Fall 2012 n
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This Organization continued from page 5 The studies are completed, and clinics are operating efficiently and successfully with this model. I frankly see no reason why collaborative practice must be centralized: the independent practitioner on Main Street, given the relatively inexpensive availability of today’s technologies, should be able to participate in collaborative practice as seamlessly as if in the same physical location as other primary care providers, should they wish to. Other hard work has been accomplished during this year, and that work will continue to blossom and come to fruition this year and next. It is well documented that nationally, professional associations almost without exception are experiencing membership reductions. There’s no way to sugar-coat the fact. MPhA is no different, and although we have participation levels similar to other pharmacy associations, maintaining membership has been a challenge. As a board, we have decided that the Minnesota experience will be different. The board has embarked on an aggressive recruiting plan that requires our Minnesota willingness to work hard for a worthy cause—the continued growth of the Minnesota Pharmacists Association. To this end, you’ll be pleased to notice that as of June 1, 2012, our dues structure changed significantly: individual memberships dropped by $100, to $295. Group discounts are available.
lished more frequently for the busy practitioner.
Stay Hungry. Stay Foolish continued from page 9
And to ensure that we are truly serving the profession and our patients, our journal, The Minnesota Pharmacist, will be sent to every pharmacist in the state. Every. Pharmacist.
you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future. You have to trust in something — your gut, destiny, life, karma, whatever. This approach has never let me down, and it has made all the difference in my life.” Steve Jobs
Finally, Pharmacy Nights: formatting and venue changes are being contemplated to provide greater relevance and increase participation. Here’s where, though I am not Harvey Milk, I am here to recruit you! This organization is what we choose to make it — if we are looking for a place where we can find old friends and meet new friends, this organization and its events are that place! We can continue to be that place if we are all intentional about welcoming our professional acquaintances, peers, and friends to join us at our events and meetings. When we “talk shop,” we will refer to MPhA’s accomplishments and ongoing commitment to excellence. We must encourage our colleagues to join the association and attend our meetings and events and meet them there! Please, join with the board in meeting the challenge: Read the journal and other material so that when your non-member colleagues ask questions — and they will — you can offer the evidence of the association’s work on their behalf. Julie and her staff are willing and able to help. Please contact them when you have questions, need help with recruiting, or for news.
During this next year, our journal is undergoing a significant evolution, with more practice-oriented material designed to meet the unique needs of the Minnesotan pharmacist.
In closing, my remarks this evening may have raised some questions for you or you may have other issues that you’d like to discuss. I will do my level best to be available for you today, tomorrow and onward.
The electronic offerings have been reorganized, shortened, and are pub-
I look forward to serving you during the upcoming year. Thank you.
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Lowell J. Anderson, DSc, FAPhA, practiced in community pharmacy for most of his career. He is a former president of MPhA, the Minnesota Board of Pharmacy and APhA. In addition, he has held positions in the Accrediting Council on Pharmacy Education, National Association of Board of Pharmacy and the United States Pharmacopeia. Currently he is co-director of the Center for Leading Health care Change at the University of Minnesota, and co-editor of the International Pharmacy Journal. He is a Remington Medalist. If you have feedback about this article, we would like to hear it! Send your comments to MPhA at journal@mpha.org. 1 “Health-care Law or Not, Insurance Is
Set to Change,” Anna Wilde Mathews, Wall Street Journal, 13 June 2012
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Healthcare Reform
The Affordable Care Act it’s Here to Stay So Buckle in By Julie Johnson, PharmD, Executive Vice President/CEO, Minnesota Pharmacists Association
Countless articles have been written about the new health care reform law. Too many to absorb, it seems. So how, then, do you? How do you as a pharmacist sift through the information to understand what you need to know? How do you position yourself to continue to contribute to the patients you serve at a level most beneficial to them while facing the ongoing economic challenges in pharmacy? 12
Minnesota Pharmacist Fall 2012 n
This article is intended to provide you some basic information in simple, concise terms we hope will be of value. The rest will be up to you. Let’s start with a timetable of events: • President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA) on March 23, 2010; the announcement of incentives for hospitals, doctors, and other health care providers by the Department of Health and Human Services took place on
March 31, 2011; and finally, 32 health organizations across the country were unveiled as part of the rollout of the Centers for Medicare and Medicaid Services (CMS) sponsored Pioneer Pilot on January 1, 2012. The age of the Accountable Care Organization (ACO) began. • The constitutionality of the law was challenged and the U.S. Supreme Court took testimony. The Court’s decision was announced on June 28, 2012. The law’s most con-
troversial component, known as the “individual mandate,” requires all Americans to purchase health insurance or pay a “shared responsibility payment” to the government. On the day the law was enacted in 2010, 26 states (including Minnesota), several individuals, and others sued to have the law struck down as a violation of the Constitution’s Commerce Clause, which gives the federal government the power to regulate commerce between the states. In its ruling, the court held that the law could not be upheld under the Commerce Clause, which was the government’s primary argument in its support. “The Federal Government does not have the power to order people to buy health insurance,” Justice Roberts wrote. However, the court did uphold major portions of the law as constitutional under Congress’ taxing authority. These events bring up many questions. We tackle them here: Q: I’m confused—doesn’t the Court’s ruling mean the law should’ve been struck down? A: The Commerce Clause argument was only one of three the government made in support of the law. It also argued that the law could be considered a tax, and this is the argument the court agreed with. Specifically, the court held that the individual mandate is not a “penalty,” as the health care law identified it, but a tax, and therefore a constitutional application of Congress’ taxation power. Q: I’m still confused — how can the court call the mandate a tax if the law didn’t call it a tax? A: The court is not bound to inter-
pret laws exactly as they are written, but uses what it calls a “functional approach” — considering the substance of a law in addition to its formal language. Under this approach, the court ruled that the penalty the law imposes on people who don’t buy health insurance “looks like a tax in many respects,” and that it is permissible under the court’s previous case law for several reasons: the amount of money due is “far less than the price of insurance” and it is collected by the Internal Revenue Service (IRS) under normal means of taxation. The court acknowledged that the mandate “is plainly designed to expand health insurance coverage,” and noted that “taxes that seek to influence conduct are nothing new” — for example, the taxation of cigarettes to discourage smoking. Finally, the court reasoned, the mandate does not make the failure to buy health insurance unlawful. Beyond the payment to the IRS, the court explains, “neither the Act nor any other law attaches negative legal consequences to not buying health insurance.” Q: Will my taxes go up? A: Starting in 2016, when the “shared responsibility payment” is fully in place, the amount you would owe for not having health insurance is the greater of 2.5 percent of your income or $695. (There is currently no means to criminally prosecute those who do not have health insurance and also refuse to pay the shared responsibility payment.) Q: What’s that part about the Medicaid expansion? A: The health care law also expanded Medicaid to cover all nonelderly people with an income below 133 percent of the poverty line, and gave the government the authority to penalize states that choose not to participate in this
expansion by taking away their existing Medicaid funding. The court called this “economic dragooning” that leaves states with no option but to accept the expansion, and found that it violated the Constitution because states could not have anticipated such a dramatic restructuring of Medicaid. However, the court found that the Medicaid expansion could be saved by removing the government’s authority to remove all of a state’s Medicaid funds if it chooses not to accept the expansion. Minnesota’s expansion of this is well underway. Q: Will the PPACA be repealed? A: Following the court’s ruling, House Majority Leader Eric Cantor immediately called for a vote to repeal the law. The vote on July 11 was 244-185 in favor of repeal — the most recent of 33 votes taken in the House. However, Senate leaders have refused to consider a repeal vote. Q: So if I don’t like the new health care law can we get rid of those politicians who passed it? A: 2012 is an election year. All U.S. House members and approximately one-third of U.S. Senators are up for re-election. We don’t know what impact the elections of 2012 will have on the balance of power and specifically what the impact will be on health care reform. The current make-up of the federal government has the Senate majority held by the Democrats; the House majority held by the Republicans; and the White House currently held by a Democrat. Q: Even if it is changed, will the current changes be halted? A: Most believe that the current overhaul of the country’s health care sys-
Affordable Care Act continued on page 15 Minnesota Pharmacist Fall 2012 n
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Affordable Care Act continued from page 13 tem will have a profound impact on the way health care professionals ultimately care for their patients and that it will happen and needs to happen regardless of the status of the new law. Moreover, with more than 3.7 billion prescriptions filled at retail pharmacies in the United States in 2010, it is imperative that the pharmacist’s role within the health care system evolve as well. Q: What is an Accountable Care Organization? A: Accountable Care Organizations (ACO) were made possible in the Medicare program by the new law and are seen as a way to improve the coordination of care while lowering costs. An ACO is a type of payment and delivery reform model that starts to tie provider reimbursements to quality metrics and reductions in the cost of care for an assigned group of patients. This group of patients receives care from a group of providers who share information about the patient and make decisions regarding the care of the patient while coordinating with the other providers. This group of providers makes up the ACO.
Pharmacists can help patients better manage their medications and chronic conditions, thereby reducing hospitalizations and re-hospitalizations. Pharmacists’ participation in ACOs will help ACOs to reach CMS-determined clinical and financial performance targets that show improved patient results and lower health care costs. Q: Where are the ACOs in Minnesota? How do I find more? A: Here are the ACOs to date: • Northwest Metro Alliance — Health Partners (medical group and health plans) and Allina • Pioneer Care (CMS Pilot mentioned above) — Allina, Fairview, and Park Nicollet • Fairview and Medica and other payers • Fairview with the Premier ACO (23 systems, 20 states) • More information can be found at www.cms.gov/ACO. Q: What do I need to do to get involved and not be left in the dust as ACOs develop? A: Reach out to the physicians in your area to find newly developing ACOs. Ask about “medical homes” as well. These are likely steppingstones to ACO development. These simple steps are most important to be part of the discussion. Also, regularly check state Web sites – Minnesota Department of Health and Minnesota Department of Human Services.
It comes as no surprise that the biggest cost savings in the ACO model comes from keeping patients out of hospitals. Again, it’s no surprise that this environment will require pharmacists to participate in direct patient care to positively impact quality measures. ACOs offer hospitals and pharmacists an opportunity to leverage their medication expertise in the hospital and ambulatory care settings to improve patient health outcomes and reduce health care costs.
Q: When I am part of the discussion, what do I say?
Care coordination will be an important element for ACOs — and pharmacists are experienced at collaborating with physicians, nurses, and other health care providers.
A: Explain how you can work alongside them to improve the focus of the triple aim. (Triple aim refers to improving patient care and quality while reducing costs.) Talk about the ways
in which you currently provide value to the health care system. You may want to focus on the ways you engage patients to improve medication adherence, provide additional patient education, assist in drug selection and optimization, provide health screenings/ immunizations, enhance the patientprovider relationship, improve patient performance in the community and workforce, reduce re-hospitalizations, assist with keeping patients in their homes longer, treat patients with overthe-counter products when necessary and/or appropriate thus saving primary/urgent care visits, to name a few! Q: What will I need to do differently at my pharmacy to be involved in ACO and health care reform? A: Be truly involved in the care coordination patients need to stay healthy. Pharmacists have been involved in this forever. Now in the ACO model, which cannot meet its quality goals for patient care without pharmacists, you have the opportunity. A pharmacist or pharmacy group that is interested in being part of an ACO will need to partner with physician groups and work with hospital/clinic administration to raise the level of awareness of what their staff is capable of in the direct patient care arena. By and large, these folks are completely unaware of what pharmacists can do and what the scope of practice of pharmacy is. Q: So what about working with private payers? A: Although ACOs under the ACA focus on Medicare patients, ACOs can incorporate patients with private insurance to further improve patient outcomes and reduce costs. A large Minnesota health care provider and several employers created targeted care packages to improve patient outcomes and lower health care costs for certain types of patients, such as those receiving prenatal care or those Affordable Care Act continued on page 23 Minnesota Pharmacist Fall 2012 n
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Clinical Issues
Oral Health Zone Project
Tooth decay is a preventable disease and pharmacists can make a difference! by Rita Tonkinson
In the capricious world of TV and movie personalities, we see only designer smiles and pearly white teeth. We may forget that this scenario of spending thousands of dollars for cosmetic dentistry that is never covered by any dental insurance exists only in the world of the favored few who can purchase the best dental care available. However, this is not the world that many Minnesotans live in, and it is definitely not the world that a vast number of Minnesota’s children know. This article draws our attention to the children at risk for early childhood caries and what pharmacists can do in their communities to intervene. The Minnesota Department of Health Oral Disease Prevention Unit and the National Children’s Oral Health Foundation (NCOHF) have created the Oral Health Zone® (OHZ) Project, a multi-year endeavor; the goal of the project is to assist participating communities in Minnesota in addressing the dental caries problem that is affecting their children, particularly those who are at high risk (i.e., those covered by Medicaid or MNCare and who have no dentist that will see them whenever there is a problem and regardless of the nature of the problem). Amos S. Deinard, MD, MPH, is the principal investigator of the OHZ project, which is one of several subprojects that are part of Minnesota’s commitment to the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC), which have funded 16
Minnesota Pharmacist Fall 2012 n
Caries is an infectious disease, theoretically preventable. the Minnesota Department of Health to create the first-ever oral health plan for the state. The overarching goal is to develop a public oral health infrastructure that can and will support oral health workforce development as well as curb the silent epidemic that childhood caries has become nationwide. In the Minnesota Department of Health’s effort to develop a comprehensive oral health plan, Deinard serves as a workgroup chair for Prevention, Public Education and Awareness, one of three workgroups. The PDF of the state’s plan, titled, “2011 Minnesota Oral Health Plan, Answering the Call to Action” can be found at http://www. health.state.mn.us/oralhealth/oralhealthplan.html. “Pharmacists are integral stakeholders in the health of the communities where they practice,” said Deinard. “They are aware of the needs of the high-risk children and their families. Thus, they
are in a unique position in every community to counsel, educate and refer to appropriate clinics. Caregivers of children in this group likely visit their pharmacy at least monthly, perhaps even weekly to pick up medication(s) that a child is taking on a chronic, longterm basis. The opportunity to counsel is great.” Deinard said because caries is an infectious disease, it is theoretically preventable. Furthermore, he added, early intervention and application of topical agents such as fluoride varnish can retard the development of dental caries by remineralizing as well as preventing demineralization of the tooth’s enamel. A major thrust of the OHZ project is to educate the following medical health care professionals who see these children on a regular basis (12 times in the first 3 years of life for wellness care and other times for illness care): primary care physicians (pedi-
“Caries is the most common chronic disease of childhood,” Deinard said, “Five times more prevalent than asthma and seven times more prevalent than hay fever.” atrics, family medicine, nurse practitioners, and physician assistants), dentists (general and pediatric), dental hygienists, public health nurses, social workers, and others such as obstetricians (education on how to care for the mouth of a newborn starting with the first feed after delivery can begin late in the third trimester). The OHZ project was established originally with a generous grant from the 3M Foundation and support from NCOHF. Initially, the focus was on training primary care medical providers on integrating a caries prevention intervention (CPI) into the wellchild (child and teen checkup [C&TC]) examination. CPI training addresses performing a gross oral examination, performing a 30-second, paper-andpencil caries risk assessment, offering anticipatory guidance to caregivers about caries etiology and the caregiver’s role in prevention, applying fluoride varnish (FV) quarterly (the American Dental Association’s recommendation) to the teeth of the high-risk child, and counseling the caregiver
that FV is not a substitute for regular, comprehensive dental care or for sealants. Dental caries, Deinard said, is the disease process, the end result of which is the cavity (hole). It has reached silent epidemic proportions among the nation’s and Minnesota’s high-risk children, i.e., those on Medicaid or MNCare or those from working poor, uninsured families. Statistics show that 20 percent of high-risk 2-year-olds and 50 to 60 percent of 5-year-olds have dental caries. “Caries is the most common chronic disease of childhood,” Deinard said, “Five times more prevalent than asthma and seven times more prevalent than hay fever.” He added that mortality from caries is rare, but has occurred. In 2007 a 12-yearold boy in Maryland and a 6-year-old boy in Mississippi died, respectively, from a brain abscess and generalized infection. In both cases, the causative factor was an abscessed tooth for which the children’s mothers could not find a dentist who would provide care, he said.
In his synopsis on the OHZ project, Deinard wrote the following: “Morbidity from badly decayed teeth is common. It can range from simple cosmetic effects which may have an impact on self-esteem to more significant health problems, e.g., pain, abscess, difficulty eating secondary to the pain, and delay in growth and development as well as poor facial and jaw development. If left untreated into adulthood, systemic, long-term effects from periodontal disease may lead to increased risk for cardiovascular disease and difficulty controlling diabetes mellitus can occur. Children in pain can experience poor school performance and miss school days. In 1999, it was estimated that 51 million hours or more of school time were lost annually because children were in such pain they could not go to school. This leads to parental loss of wages and potentially loss of employment due to the parent missing work because of the need to stay home with the child.”
Minnesota Pharmacist Fall 2012 n
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According to Deinard, tooth decay can occur soon after an infant’s teeth begin to appear (6 months of age), and is caused by frequent and prolonged exposures of the teeth to sugar-containing liquids (e.g., breast milk, formula, sugar water, fruit juice), and liquid medications that are sweetened to make them taste better. In addition, some medications can cause dry mouth (xerostomia) which is another caries risk factor. He cautions that with each exposure to sugar, the bacteria in the plaque digest the sugars in the food/drink for their own metabolic needs and create excrement that lowers the oral cavity’s pH from 7 to 2 (acidic). This acidic environment etches the enamel, starting the caries process. Within the next 20 to 40 minutes, the pH will rise to 7 (neutral) but with the next exposure to sugar, the acidic environment is re-created. Please refer to the table, “Common Children’s Medications Containing Sugar,” on page 19. Therefore, good dental health in young children is important to ensure that primary teeth are not lost prematurely, as primary teeth are important for the following reasons: 1) They allow children to chew food, 2) They help the child speak clearly, 3) They guide permanent teeth into place, 4) They aid in the formation of the jaw and face, and, 5) They add to the child’s good health and self-esteem. In moving forward with the statewide structure of the OHZ project, Deinard first divided the state into nine sectors and then identified the county in each sector that has the largest number of public program-eligible children. He then contacted a member of each of those counties’ Board of County Commissioners to inquire whether the board would approve its county to be part of the OHZ project. Each commissioner replied in the affirmative, saying: “We know we have a serious problem with childhood cavities.” Deinard then asked the commissioner to name a member from the commu18
Minnesota Pharmacist Fall 2012 n
nity to be the link between him and the board. He next approached that link to get names of community members who would be good representatives of each stakeholder group. As he began to talk to the nine counties, it became apparent that counties work with contiguous counties on matters of health and human services in order to provide maximum service to community members in times of tight finances. Once the contiguous counties were added to the project, 9 counties became 29. The approach has been the same for each of the 29 counties: Send a synopsis of the OHZ project not only to the stakeholder group leaders but to all members of each stakeholder group and then follow up with conference calls. Because of the role that pharmacists play in educating patients about their medications, Deinard hopes pharmacists will begin to include the caregiver (i.e., the patient’s surrogate) in counseling sessions about the medications prescribed for the child. He believes this system approach of involving community stakeholders is key to success because they will be best equipped to build upon the community’s strengths and coordinate existing services to facilitate the solutions.
The best example to date of this community process can be found in the northern Minnesota counties of Carlton, Cook, Lake and St. Louis, where Julie Myhre, RN, PHN, MS, an Robert Wood Johnson Foundation (RWJF) executive nurse fellow and director of the St. Louis Community Health Board, is providing oversight. To date, she has held three stakeholder meetings, at two of which Deinard spoke. He expects to have similar meetings set up throughout the remainder of Minnesota by early Fall. In addition to the stakeholders mentioned above, he also plans to engage people from the business community, including radio/TV/newspaper, community organizations such as Kiwanis, Rotary and Lions, Boys and Girls clubs, pro-bono legal, educators, Head Start/Early Head Start, Early Childhood Family Education (ECFE), and others. Regular communications will be managed through individual telephone calls, conference calls (Conference Call Center of the University of Minnesota or the Minnesota Department of Health), video conference calls (the Oral Health continues on page 20
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Common Children’s Medications Containing Sugar Please Note: This list is not exhaustive. Drug
Strength, flavor, US trade name
Carbohydrate grams*
Analgesics and antipyretics Acetaminophen elixir
160 mg per 5 mL, Tylenol®
Acetaminophen liquid suspension
160 mg per 5 mL, cherry, Tylenol®
5 per 5 mL
Acetaminophen tablet chewable
80 mg per tablet, fruit flavor, Tylenol®
0.25 per tab
Ibuprofen suspension
100 mg per 5 mL; berry, bubble gum, grape; Motrin®
1.6 per 5 mL
50 mg per tablet, orange, Motrin®
0.3 per tab
Ibuprofen tablet chewable
1.6 per 5 mL
Antihistamines Cetirizine syrup
5 mg per 5 mL, grape, Zyrtec®
3 per 5 mL
Cetirizine tablet chewable
10 mg per tab, grape Zyrtec®
1 per tab
Diphenhydramine liquid
12.5 mg per 5 mL, cherry, Benadryl® children’s allergy
1.5 per 5 mL
Fexofenadine syrup
30 mg per 5 mL, berry, Allegra®
1 per 5 mL
Loratadine orally disintegrating tablet
10 mg per tab, citrus or bubble gum, Alavert® Children’s Allergy
0.2 per tab
Antibiotics Amoxicillin suspension
50, 125, 200, 250 or 400 mg per 5 mL, Amoxil® (Dava generic:
1.6 to 1.9 per 5 mL
bubble gum; Sandoz or Teva: berry) Amoxicillin tablet chewable
125 mg per tab, berry, Amoxil®
0.1 per tab
Amoxicillin and clavulanate suspension
200, 400 or 600 mg per 5 mL, orange or strawberry, Augmentin®
<0.1 per 5 mL
Azithromycin suspension
100 mg per 5 mL, cherry-vanilla-banana, Zithromax®
3.9 per 5 mL
Cefdinir suspension
125 or 250 mg per 5 mL, Omnicef®
2.8 per 5 mL
Cephalexin suspension
125 or 250 mg per 5 mL, Keflex® (Teva generic: berry)
3 per 5 mL
Clindamycin solution
75 mg per 5 mL, cherry, Cleocin Pediatric®
1.9 per 5 mL
Penicillin V potassium suspension
125 or 250 mg per 5 mL
2.5 to 3.3 per 5 mL
Trimethoprim and sulfamethoxazole suspension
40 mg trim. and 200 mg sulf. per 5 mL, grape, Septra®
2.4 per 5 mL
Gastrointestinals Calcium carbonate antacid suspension
400 mg per 5 mL, Mylanta® Children’s suspension
1.75 g per 5 mL
Docusate sodium syrup
20 mg per 5 mL
1.4 per 5 mL
Famotidine suspension
40 mg per 5 mL, Pepcid®
1.2 per 5 mL
Lansoprazole orally disintegrating tablet
15 mg, Prevacid® SoluTab™
0.17 per tab
Loperamide
1 mg per 5 mL, Imodium® A-D
4.1 per 5 mL
Senna syrup
5 mL, Senokot®
3.3 per 5 mL
Simethicone
40 mg per 0.6 mL, Mylicon®
<0.1 per 0.6 mL
Vitamin and mineral supplements Ferrous sulfate syrup
90 mg per 5 mL, Fer-In-Sol®
6.3 per 5 mL
Iron, vitamins, A, D, E, C liquid
10 mg iron per 5 mL, Vi-Daylin® liquid with iron
5 per 5 mL
Iron, vitamins B, D drops
10 mg iron per mL, Poly-Vi-Sol® with iron
0.9 per 1 mL
Multiple vitamin and mineral supplement liquid
15 mL, Centrum® Advanced Formula Liquid
6.25 per 15 mL
Multiple vitamin and mineral supplement tablet
One tab, Bugs Bunny, Centrum® Kids Rugrats™, Flintstones®
<0.7 per tab
Sugar-free types
<0.4 per tab
chewable
*Approximate maximum grams of total carbohydrate, including sugars, per usual dose unit. Above table is adapted from: Lacy CF, Armstrong LL, Goldman MP, Lance LL. Lexi-Comp Drug Information Handbook, 21st Edition. Hudson, OH: Lexi-Comp, 2012. Copyright © 2012. Prepared by Nada Abou-Karam, PharmD Candidate, Class of 2013
The AWARxE campaign was founded by the Minnesota Pharmacists Foundation in 2009, in order to educate communities and individuals on the dangers of abuse or misuse of prescription medications. VISIT MPHA.ORG FOR MORE INFORMATION. Minnesota Pharmacist Fall 2012 n
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Oral Health continued from page 18 Health Department has a facility in St. Paul where Deinard and his staff can speak with an unlimited number of communities in regional offices of the department), local PHN agencies, WebEx, and site visits. Deinard is aware that pharmacists have the expertise and the opportunity to contribute significantly in their specific communities to moving this project forward. Pharmacists’ intervention and counseling provide a unique education opportunity. Pharmacists can inform caregivers on the care of teeth when certain medications are consumed by infants and children over a long period of time. Many caregivers are likely not aware of the seriousness of infant and early childhood tooth decay. They likely are not aware that certain medications may be harmful to their child’s teeth while such medications are curing or preventing other ailments. They may not know where to begin to find a dental home for their children. Through participating in the community program, pharmacists will have information to refer these parents and caregivers to a clinic where CPI can be offered. Please begin using the talking points supplied by Deinard. More information will be available as the community sectors are set up and meetings are scheduled. Amos S. Dienard, MD, MPH, is the principal investigator of the Oral Health Zone (OHZ) project, a subproject of Minnesota’s overall commitment to Health Resources and Services Administration and the Centers for Disease Control and Prevention. He is a 1957 graduate of Harvard University, Cambridge, Mass., with a B.A. in chemistry. In 1962, Deinard graduated from the University of Minnesota Medical School and graduated from the University of Minnesota School of Public Health with emphasis on Maternal and Child Health in 1985. From 1975 to present, he has been an associate professor in the Department of Pediatrics, and Program in Maternal and Child Health, School of Public Health, University of Minnesota. He is a member of numerous organizations including The Society for Research in Child Development, the American Public Health Association, the American Academy of Pediatrics, the American Association of Public Health Dentistry, the American Association of Community Dental Programs, Medicaid – SCHIP Dental Association, the National Network of Oral Health Access, the Association of State and Territorial Dental Directors (associate), and the Medicaid/CHIP Dental Association. Recent honors and awards include the Rosalie E. Wahl Justice for Children Award – Children’s Law Center of Minnesota, 2010; the First a Physician Award – Twin Cities Medical Society, 2010, and the American Association of Public Health Dentistry, President’s Award, 2012. Deinard is currently a member of the Pharmacy and Therapeutics Committee at Fairview-University Medical School. To the present, he is a member of a number of community endeavors including: Membership Committee, Oral Health Section, American Public Health Association; Advisory Committee, American Academy of Pediatrics; and the Oral Health Policy and Advocacy Committee, American Association of Public Health Dentistry. Abstracts and presentations number around 45, the most recent being “Role of Primary Care Medical Provider in Caries Prevention Among High-Risk Children, Growing Healthy Children Conference, Charleston, W.Va., Nov. 2009. Deinard resides in Minneapolis. 20
Minnesota Pharmacist Fall 2012 n
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Clinical Issues
Injection Drug Use on the Rise
The Pharmacist’s Role in Preventing Blood-Borne Infections by Sarah Ertl, Pharmacy Syringe Access Initiative Educator, University of Minnesota Duluth
Remember those years when you spent your spare time hanging out with friends, making out with your crushes, sneaking out late, going on thrill-seeking adventures, and basically defying all rules and testing the limits set by adults? Practically whatever happened during this time, it happened with no regrets. This was the stage of growth when we went through adolescence and early adulthood. Our behavior was marked as being rebellious, impulsive, risk-taking, irritable, incommunicative, obsessed with style, friend focused, and sleep deprived. Time was spent pursuing and shaping our own personality and independence. During this phase, many of us were involved in at least one activity that was hazardous and endangered our health. These activities would include the nights we stayed out late partying and trying sex, alcohol, and drugs. Sure, we remembered learning about sexually transmitted diseases and blood-borne infections in health class. However, the majority of us felt invincible to infections and the potential consequences. At that age, it was easy to conclude that if we got sick there was a pill to cure it or it would go away on its own like the common cold.
Adolescent impulsivity has to do with biological brain development (slow maturity of frontal lobe), peer pressure, social networking, and the acceptance of substance abuse. Most teens can’t purchase beer without an ID, but cheap heroin is sold everywhere on the streets. How many kids can get high off a single $20 purchase? The problematic difference between heroin and beer is heroin’s mode of delivery through intravenous injection. When we see young people in obituaries, we wonder about cause of death. How old are these kids? 50-80% of injectors acquire hepatitis C virus (HCV) within the first five years of injecting.1 So if the popular thing to use is heroin, how many will be exposed to a bloodborne pathogen before even maturing to a point of awareness of needing testing and treatment? Once one begins injecting, stigma and shame play a huge role in seeking outside services, and a pharmacist might be the only contact an injection drug user (IDU) will have with a health care professional. The primary focus here is that pharmacists can prevent disease. Pharmacists can save lives until the person can save him- or herself.
supporting proper syringe needle disposal2 certified with the Minnesota Department of Health (MDH). So why is it vital for pharmacists to participate in this legal right? Pharmacies are the most accessible sites for IDUs to gain new injection supplies without having to identify as a drug user. Pharmacists are openly available to provide IDUs with new syringe needles, expert medical advice, reference to sites for health services and treatment, and education on safe syringe needle disposal.
Injection Drug Use continues on page 22
Local pharmacists are the most accessible health professionals for the public. Community pharmacies are located in virtually every town and city. On July 1, 1998, Minnesota pharmacists were granted legal permission through the Syringe Access Initiative (SAI) legislation to sell 10 or fewer hypodermic syringe needles without a prescription to any person as long as the participating pharmacy has a method Minnesota Pharmacist Fall 2012 n
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Injection Drug Use continued from page 21
ing blood-borne infections if IDUs donâ&#x20AC;&#x2122;t have access to new syringe needles.
According to the MDH SAI registry, less than half of the community pharmacies in the state of Minnesota are actively participating in the SAI. There are several benefits to participation. Since the passage of the SAI legislation, IDUs have decreased their use of shared needles by accessing participating SAI pharmacies.3 IDUs who acquire syringe needles through pharmacies and needle exchange programs have been shown to reduce their risky drug use behaviors (i.e. sharing and reusing syringe needles).4 Syringe access programs have resulted in decreased transmission of blood-borne pathogens such as Human Immunodeficiency Virus (HIV) and HCV by providing clean syringe needles and education regarding safer injection practices.4
Contracting hepatitis C from injection drug use leaves a huge economic burden on health care. About 40,000 new cases of hepatitis C are documented each year in the US.7 HCV typically attacks the liver over several years, which results in liver cirrhosis and sometimes liver cancer.1 About 8,000 to 10,000 people die each year from liver disease associated with chronic HCV infection.7 The US spends $1-1.3 billion on liver disease care resulting from chronic hepatitis C infection.7 Injection treatments to treat chronic hepatitis C for one person cost $25,000 to $30,000 per year.1 The average cost of a liver transplant is $250,000.7 Medical care and treatments after the transplant cost about $20,000 each year.7 The economic burden of hepatitis C could be dramatically decreased through pharmacy sales of syringe needles, which cost about $2 for a 10-pack.
Pharmacies are prime sites for providing heroin users with new supplies and medical education to prevent the spread of blood-borne infections. The prevalence of HIV among IDUs in the US is between 1 and 10% and HCV is between 30 and 85%.5 IDUs are more likely to contract hepatitis B and C from sharing needles due to their higher rate of infectivity and longer period of survival outside of the body (see Table 1 on page 23). Injection drug use has been on the rise in Minnesota due to the high availability and low cost of heroin. Its large availability is due to several drug trafficking organizations receiving distributions from Mexican sellers who travel on Interstate Highway 35 from the Mexican border to Minnesota. The primary way to obtain the full effects of heroin is through the intravenous route. Heroin is relatively cheap compared to prescription opiates on the black market. One gram of heroin typically costs from $100 to $200 and about $20 for a single heroin dose.6 An increase in heroin use in the state can result in a greater risk of contract-
22
Minnesota Pharmacist Fall 2012 n
Participation in the SAI is an excellent opportunity for community pharmacies to continue to demonstrate their commitment to improving health care. With your help, we can prevent new bloodborne infections, reduce the negative consequences of injection drug use, and facilitate entry into drug treatment centers. Together, we can protect the health of all Minnesota residents and visitors.
Sarah Ertl is a Pharmacy Syringe Access Initiative Educator and student pharmacist (Class of 2013), at the University of Minnesota College of Pharmacy, Duluth. She can be contacted at ertlx026@umn. edu
References: 1 Department of Health and Human Services: Centers for Disease Control and Prevention. 2010; Available at: http://www.cdc.gov/. Accessed July 14, 2012. 2 151.40 Possession and Sale of Hypodermic Syringes and Needles. Subdivision 2. 2007 July 1, 1998. 3 Cotten Oldenburg NU, Carr P, DeBoer JM, Collison EK, Novotny G. Impact of pharmacy-based syringe access on injection practices among injecting drug users in Minnesota, 1998 to 1999. J Acquir Immune Defic Syndr 2001; 27(2):183-192. 4 Neaigus A, Zhao M, Gyarmathy VA, Cisek L, Friedman S, Baxter R. Greater drug injecting risk for HIV, HBV, and HCV infection in a city where syringe exchange and pharmacy syringe distribution are illegal. Journal of urban health 2008; 85(3):309-322. 5 Paintsil E, He H, Peters C, Lindenbach B, Heimer R. Survival of hepatitis C virus in syringes: implication for transmission among injection drug users. J Infect Dis 2010; 202(7):984-990. 6 Falkowski CL. Drug Abuse Trends in Minneapolis/St. Paul, Minnesota: June. 2012 June 27, 2012:1-7. 7 Kim WR, Brown RS, Terrault NA, El-Serag H. Burden of liver disease in the United States: Summary of a workshop. 2002; Available at: http://www.hcvadvocate. org/hepatitis/About_Hepatitis_pdf/1.1_Hepatits_C/ Burden.pdf. Accessed July 18, 2012. 8 Thompson S, Boughton C, Dore G. Blood-borne viruses and their survival in the environment: is public concern about community needlestick exposures justified? Aust N Z J Public Health 2003; 27(6):602-607. 9 Abdala N, Stephens PC, Griffith BP, Heimer R. Survival of HIV-1 in syringes. Journal of acquired immune deficiency syndromes human retrovirology
For further information on how to 1999; 20(1):73-80. actively participate in the SAI, please contact Sarah Ertl, student pharmacist and SAI educator, at ertlx026@umn. Have you and your pharmacy edu. For information on how to reg- reached its full potential? ister your pharmacy Let us show you what your pharmacy can do for you! By signing up as a NuCara Partner store, you with MDH, contact can access the NuDeal Buying program which Sarah Gordon, MDH provides you with some of the biggest discounts in SAI coordinator, at the industry AT NO COST TO YOU. sarah.gordon@state. Call us today for more information. mn.us. Contact Brian at brian@nucara.com or 641.366.3440
P H A R M A C Y MANAGEMENT
Injection Drug Use continued from page 22 Table 1: Common Blood-Borne Pathogens Among IDUs Blood-Borne Pathogen
Prevalence among US IDUs
Current Primary Modes of Transmission in the US
Hepatitis C
About 3.2 million cases in the US (1.03% of US Population)1
Injection Drug Use1
Hepatitis B
HIV
About 800,000–1.4 Sexual contact and million cases in the Injection Drug Use1 US (0.26-0.45% of US Population)1 About 1,178,350 MSM (Men who cases in the US have sex with men)1 (0.38% of US Population)1
Survival in Blood Survival in Level of Outside the Blood Inside a Infectivity Body* Syringe at Room Compared to HIV Temperature (22oC) Up to 4 days1
Up to 8 months, but generally 1 day in 1 mL insulin syringes (2 μL volume) and about 7 days in 1 mL tuberculin syringes (32 μL volume) 5,8
5-20 times more infectious 5
At least 7 days1
Up to 8 months8
50-100 times more infectious1
Up to a few hours1
Up to 30 days in the lumen of a syringe, but usually 1-2 days8,9
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www.jayscompany.com 14400 James Road • P.O. Box 309 Rogers, Minnesota 55374-0309 Phone: 763.557.0056 • 800.647.5297 Fax: 763.557.0165 • 800.547.0165 e-mail: jaysco@jayscompany.com
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who have migraines or hypertension. They are moving toward basing compensation from insurers on meeting patient measures and total costs-ofcare thresholds.
Minnesota companies are beginning to experience a fully-integrated EMR that allows hospital staff and primary care providers to access a patient’s record and see what care was provided in the other setting. Electronic capability is essential and e-prescribing is a step, but continued development of pharmacists accessing appropriate patient records and two-way communication is a must.
• Statements & Envelopes
Affordable Care Act continued from page 15
• Pharmacy Supplies
*At room temperature, on environmental surfaces. During survival time outside the body, if the virus invades the human body, it can still result in infection.
• Unit Dose Pill Cards & Supplies
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Clinical Issues
Ask the Pharmacist Frequently Asked Questions about Probiotics By David Q. Hoang, PharmD, Minnesota Multiple Contracting Alliance for Pharmacy, St. Paul
What are probiotics? Probiotics are live “good” bacteria or yeast that are consumed to help maintain the natural balance of “good” and “bad” bacteria in your body. Lactic-acid producing bacteria bifidobacteria, lactobacilli, and the yeast Saccharomyces boulardii are commonly used, alone or in combination, in commercial probiotics products. PRObiotics are different from PREbiotics in that PREbiotics are carbohydrates that encourage the growth of the “good” microbes in the gut. How do probiotics work? Beneficial or “good” microbes, such as bifidobacteria, live in the intestine with pathogenic or “bad” microbes. Certain medicines, particularly antibiotics, and illness are responsible for the overgrowth of “bad” microbes causing an imbalance between beneficial and pathogenic microbes. In addition to preventing the overgrowth of “bad” microbes, “good” microbes may increase the production of intestinal mucus, providing a protective barrier on the intestinal lining. Once ingested, probiotics must be able to withstand the effects of stomach acid and bile. Effective probiotics must also be able to colonize the gut and attach to the intestinal wall.
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What are probiotics used for? Probiotics are promoted to recolonize the gut or vagina with beneficial microbes and to strengthen immune systems. Virtually all probiotics are dietary supplements and foods; and therefore are not FDA-approved for the indications proposed by the manufacturers. There is clinical evidence to suggest that probiotics are effective in preventing and treating diarrhea caused by antibiotics use. Additionally, there is also clinical evidence to promote the role of probiotics in the management of ulcerative colitis, irritable bowel syndrome, and pouchitis. There is not sufficient clinical evidence to recommend the use of oral or vaginal probiotics for the treatment of bacterial vaginosis or the prevention of urinary tract infection or vaginal yeast infection. Furthermore, there is no clinical evidence to suggest the effective use of probiotics in the prevention of flu. What are the common side effects of probiotics? The most common side effects of probiotics are stomach and intestinal upset, including mild gas and bloating. These side effects are due to the changing environment in the digestive system and usually improve within a few days. What are the common drug interactions with probiotics? Since the probiotic Saccharomyces boulardii is a fungus, its effective-
ness can be reduced when antifungal medications are co-administered. Recommendation for dose separation between Saccharomyces boulardii and antifungal medication is not available. Antibiotics can also reduce the effectiveness of probiotics containing lactobacilli and bifidobacteria. Patients are advised to take probiotics containing these microbes at least two hours before or after the antibiotic. Additionally, calcium in yogurt can decrease the effectiveness of some antibiotics. Therefore, patients may need to allow at least two hours between eating yogurt and taking an antibiotic. How do I choose the probiotics that are available at the drug store? Product selection is important because not all probiotic products are the
same. It is also important to note that efficacy of one probiotic product cannot be extrapolated to other products. There is no conclusive evidence to suggest that fresh preparations are more effective than freeze-dried products. Culturelle (Lactobacillus GG) and Florastor (Saccharomyces boulardii) are the most studied probiotics. These products can be recommended for the prevention of diarrhea caused by antibiotics. VSL#3 (Bifidobacterium/ Lactobacillus/Streptoccus thermophilus) can be recommended for ulcerative colitis, irritable bowel syndrome, and ileal pouch. Patients with milk allergy or lactose intolerance should be advised that Align (Bifidobacterium) and Lactinex (Lactobacillus) contain milk protein. Lactinex also contains lactose. Is yogurt a source of probiotics? Yogurt is a source of probiotics if it contains the right kind and amount of microbes because certain microbes in yogurt are killed when yogurt products are heat-treated after fermentation. Patients are advised to choose products with the National Yogurt Association’s “Live and Active Cultures” seal on the label because these products contain the stated amount of active live microbes (100 million organisms per gram) throughout the stated shelf life. Examples of such products are Yoplait or Dannon. In order to prevent diarrhea caused by antibiotics, patients will need to eat about 8 ounces of yogurt twice daily. Are there any probiotics that require a prescription? While virtually all probiotics are considered dietary supplements and foods and therefore do not require a prescription, there are exceptions. Certain probiotic products, such as VSL#3-DS, require a prescription. Even though high-potency VSL#3-DS is not considered a drug, it is a medical food for the dietary management of an ileal pouch or ulcerative colitis. It may be helpful to note that medical foods are foods that are defined in the Food and Drug
Administration’s 1988 Orphan Drug Act Amendments and are subject to the general food and safety labeling requirements of the Federal Food, Drug, and Cosmetic Act. Medical foods are specially formulated and intended for the dietary management of a disease that has distinctive nutritional needs that cannot be met by normal diet alone. Who should not take probiotics? Even though probiotics are generally safe and well tolerated, there is a small risk of infection associated with the use of these products because they contain live microbes. Patients with a weakened immune system should avoid the use of these products. Additionally, routine use of probiotics in healthy people to maintain a healthy digestive system or to strengthen the immune system is unnecessary. What are the storage requirements for probiotics? While refrigeration is required or strongly recommended for most probiotics, certain products do not require refrigeration (Culturelle) or cannot be refrigerated (Florastor). Some probiotic products, especially dairy products and beverages, have short shelf-lives. Patients are advised to follow package instructions regarding specific storage requirements for each particular product.
Do you have a question?
Ask the Pharmacist by emailing your questions to info@mpha.org.
Pharmacy Time Capsules By: Dennis B. Worthen, Lloyd Scholar, Lloyd Library and Museum, Cincinnati, OH
1987—Twenty-five years ago: • Major pharmacy issue of the year was the increase in physician office-based dispensing. • Acuvue, launched by J&J, was the first disposable soft contact lens. 1962—Fifty years ago: • Trivalent oral polio vaccine (Sabin) was licensed in the U.S. • Rite-Aid (Pennsylvania), Meijer’s Michigan), and Wal-Mart (Arkansas) were formed. 1937—Seventy-five years ago: • Cook County Hospital in Chicago, IL, was the site of the first blood bank, set up by Bernard Fantus. 1912—One hundred years ago: • Phenobarbital (Luminal) first marketed by Bayer in 1912. 1887—One hundred twenty-five years ago: • The National Institutes of Health established. The National Institutes of Health traces its roots to 1887, when a one-room laboratory was created within the Marine Hospital Service (predecessor agency to the U.S. Public Health Service [PHS]). One of a series contributed by the American Institute of the History of Pharmacy, a unique non-profit society dedicated to assuring that the contributions of your profession endure as a part of America’s history. Membership offers the satisfaction of helping continue this work on behalf of pharmacy, and brings five or more historical publications to your door each year. To learn more, check out: www. aihp.org
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Industry News
2012 Compensation and Labor Survey:
Changes in the Pharmacist and Technician Workforce in Licensed Minnesota Pharmacies between 2002 and 2012
Jon C. Schommer, PhD, RPh, Professor; Caroline A. Gaither, PhD, RPh, Professor; Ronald S. Hadsall, PhD, RPh, Professor; Tom A. Larson, PharmD, RPh, Professor; Stephen W. Schondelmeyer, PhD, RPh, Professor; Donald L. Uden, PharmD, RPh, Professor; University of Minnesota College of Pharmacy, Minneapolis
Funding for this study was provided by the University of Minnesota. We gratefully acknowledge Minnesota pharmacists who received and responded to the survey. We appreciate their time and effort in providing requested information. Without their assistance, the report would not be possible. Background and Study Purpose To help track changes in the Minnesota pharmacy workforce, our goal for this study was to describe the underlying trends of the Minnesota pharmacy market at the licensed pharmacy level. The specific objectives of this study were to describe the pharmacist and technician workforce in Table 1 licensed pharmacies during the years 2002, 2004, 2006, 2008, 2010, and 2012 in the state of Year Minnesota in terms of: 1) the demand for pharmacists and 2002 pharmacy technicians, 2) the degree the demand for pharma2004 cists and pharmacy technicians is being met, 3) the stability of 2006 the pharmacist and pharmacy technician market, and 4) 2008 the wage rates the pharmacy market is willing to offer phar2010 macists and pharmacy technicians. This study builds upon 2012 26
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earlier research in which we reported workforce changes on a biennial basis. Methods Each pharmacy location in Minnesota (as recorded by the Minnesota State Board of Pharmacy) was used as the unit of analysis. For each biennial survey, samples of pharmacies were selected as summarized in Table 1. Inpatient pharmacies included hospital, institutional, and specialty practices. Outpatient pharmacies included pharmacies that were determined as being reasonably accessible by any ambulatory patient/client for receiving prescription medications and associated services.
Data were collected from key informants (i.e. owners, directors, or managers) at each pharmacy. The key informant was mailed a cover letter, a postage paid return envelope, and a questionnaire. Approximately four weeks after the initial mailing, another survey form and postage paid return envelope were mailed to non-responders.
The rest of this article is available on the MPhA Web site, (www.mpha.org) under the Communications tab > Minnesota Pharmacist Journal.
Inpatient Pharmacy Sample
Outpatient Pharmacy Sample
TOTAL
All 169 pharmacies
302 out of 970 pharmacies
471 out of 1,139
All 185 pharmacies
332 out of 997 pharmacies
517 out of 1,182
All 171 pharmacies
All 1,042 pharmacies
1,213 out of 1,213
All 179 pharmacies
All 1,060 pharmacies
1,239 out of 1,239
All 178 pharmacies
All 1,035 pharmacies
1,213 out of 1,213
All 156 pharmacies
All 1,077 pharmacies
1,233 out of 1,233
Industry News
Musings on the Life of a PharmD Candidate By Kandace Schuft, PharmD Candidate
Every day I am asked by family members, friends, and colleagues the infamous question of a fourth year pharmacy student, “how are rotations going?” Even after only three rotation blocks, this question falls under the category of “How are you?” and no one stops to listen to your response — but nonetheless, this question needs to be answered very carefully. Depending on who asks you the question, sometimes it is necessary to answer with a well thought out, strategic answer or with a short, to-the-point response. No matter how a person answers the question, there are always other thoughts racing through your mind. These thoughts dance over the options of answering what you wish you were or weren’t doing, what you expected or didn’t expect, and how you might use or even might not use what you are doing on rotation in your future pharmacy career. I can definitely relate to this last point: Sometimes as a student, I wonder “Where can I use this skill or experience in the future and will I have the ability to build upon it in the years to come?” Beginning rotations, I am sure I was like most other students with a little bit of apprehension built up inside, but deep down I knew this was going to be the time of my life.
I was actually going to be using and applying what I learned in class, but in the real world and with real patients — no more simulated patients for me!
This is probably the best part so far regarding clinical skills; I have used my knowledge and my resources discussing health with patients and educating the patients about their medications. I have just started my ambulatory care rotation and love it! I enjoy knowing I am making decisions and following through with projects, which will in the end impact the health of others. In addition, I completed a previous community rotation. Not only did I learn about and dispense more birth control and travel medications than I knew existed but also counseled patients, allowing me to use the verbal and non-verbal skills I have learned throughout the last four years of pharmacy school. Along with using skills from class, I have also learned a great deal from my preceptors, technicians, pharmacists, and other colleagues I have worked with throughout my three rotations this summer. My first rotation site was at MPhA with Julie Johnson and I can truly say I learned such a variety of things, but not one of them could I have learned while sitting in the classroom listening to a lecture. I attended an assortment of meetings, ranging from the Professional Affairs Committee to the Editorial Advisory Board. I was also stunned as to how much work goes on behind the scenes, such as the planning for the annual conference and contributing to a variety of publications and organizations. I did not expect to write an article for a publication printed for pharmacists. Writing was a new task for me to take on, but as I started writing my thoughts and connected them piece-by-piece, it became fun and inspiring. This might
seem boring and dull to most, but writing had always been a weakness of mine and writing this article boosted my confidence to a new level. During my second rotation at Boynton Pharmacy with Steve Cain, I thoroughly enjoyed my experience, especially because the technicians and pharmacists were overwhelmingly helpful and eager to teach and share wisdom they had gathered over their individual experiences through the years. Although the site was not as busy as I expected, we were always busy working with formulary projects and answering physicians’ and nurses’ questions, which really showed the need for interdisciplinary teams working together. Another unexpected opportunity was the ability to work with another Advanced Pharmacy Practice Experience (APPE) student on rotation and a total of three other Introductory Pharmacy Practice Experience (IPPE) students. This was fabulous because working as a team and bouncing ideas, thoughts, and questions off of each other was an effective way to learn new information and review old information we had learned during class. It was also fun to be the person who others ask questions and advice of, considering the fourth year student as a role model for the first year students. Only two weeks into my third rotation and I feel as if it has gone by in a whirlwind, traveling to different Walgreens stores, collaborating with MPhA to complete projects, and organizing a diabetes kick-off event with other students and preceptors. Not PharmD Life continues on page 29 Minnesota Pharmacist Fall 2012 n
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Minnesota News 00011010010101010000010010100011111010101100110100010001001010010010101100011110010010101
The Interoperable Electronic Medical Record and What it Means for Pharmacists
001001100000110100101010100000100101000111110101011001101000100010010100100101011000111100 100101010010011000001101001010101000001001010001111101010110011010001000100101001001010110 001111001001010100100110000011010010101010000010010100011111010101100110100010001001010010 01010110001111001001010100100110000011010010101010000010010100011111010101100110100010001 001010010010101100011110010010101001001100000110100101010100000100101000111110101011001101 By Marilyn Speedie, PhD, Dean and Professor, University of Minnesota College of Pharmacy, Minneapolis 000100010010100100101011000111100100101010010011000001101001010101000001001010001111101010 I have just returned from the AACPNABP District V meeting whose theme was the impact of technology on the pharmacy profession. It is clear that advances in technology are pervasive, from the evolution of biosimilar drugs to professionalism related to social media. However, none may have as much impact on our daily practices as the interoperable (two-way communication between the physician or prescriber and the pharmacist) Electronic Medical Record (EMR). Spurred on by the federal government, with both carrots and sticks, health systems are rapidly moving to EMRs that can be distributed for medical use to all members of the health care team, including pharmacists. APhA President-Elect Steve Simenson serves on the state’s E-Health Task Force and is helping those individuals understand that pharmacists need to be in the loop with receiving patient health information, in viewing patient charts, and in documenting directly to the medical record. A health team can only function well if all members of the team, including the pharmacist, have equal access to a patient’s health information.
“ ... none may have as much impact on our daily practices as the interoperable (twoway communication between 28
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the physician or prescriber and the pharmacist) electronic medical record.” Steve Simenson
health record is the standard way to accomplish this interactivity. It is this interactivity that truly establishes us as health providers, worthy of being paid for our services.
Our job, as pharmacists, is severalfold. First, we must make sure we have access to all relevant health information for our patients. This involves obtaining the necessary computer programs, communication with the health systems and having patients complete the proper forms to give you permission to have access. (Simenson says the patient release forms can be obtained in paper form for signature.)
I am sufficiently realistic to know that this is a culture change for many pharmacists and is somewhat daunting for those of us in my generation, who grew up without technology. However, the world will not come asking or establishing our access for us. We must engage in the changes. We must demonstrate our value in this new age of team-provided health care. There are people to help. Talk with Steve Simenson and others who have figured this out. They can — and are willing to — provide solutions derived from their real life experiences. MPhA and the College can provide programs on the topic. Let’s do it together!
Second, we must learn to select the relevant pieces from all available information and use this information to guide our consultation and advice to patients. Whether this is done in a consultation discussion at the point of dispensing or in a formal medication management appointment, you cannot accurately resolve drug-related issues without knowledge of the patient’s health information, including, but not limited to, the medications they are taking. And then, if you do not let other health professionals know what you have recommended, you are not completing the cycle and contributing to the overall coordination of care. Electronic communication through the
Marilyn Speedie, PhD, is Dean of the College of Pharmacy at the University of Minnesota in Minneapolis. If you have feedback on her article, please contact her at speed001@umn.edu — or contact the MPhA office.
PharmD Life continued from page 27 only have we been busy, but also having a preceptor like Michelle Aytay inspires me as a student to go above and beyond. Having a preceptor’s support throughout every activity and project boost my confidence that much more, pushing me to strive for excellence. Another concept, which I have learned throughout all three rotations, is balancing work and personal life. I have realized that in order to be more effective a break is much needed from the daily work routine. A short break of even 15 minutes seems to reset my mind and lets me regain focus on the project at hand. Some of these experiences and skills might seem like textbook answers to most people when they ask how fourth year rotations are going. If someone wanted to hear a more down-to-earth and simplified answer, I would say I am happy to graduate in less than a year. It is exhilarating to realize as a student (going to school for eight years) at the University of Minnesota, and within a year I will be graduating with a PharmD. This feeling is one of those times in my life where I have to stop what I’m doing, take a step back, and just smile — not only because I am graduating, but also because I will never have to say I am “just a student.”
MPhA News
Pharmacy Technician Academy Participate TODAY!
The academy meets monthly on the third Friday of the month from 1:30 to 2:30 p.m. at the MPhA office. Those not able to attend meetings in person are encouraged to participate via conference call. An agenda and conference call-in information is provided prior to meeting date. ACADEMY MISSION: To promote the professionalism and education of pharmacy technicians. To participate and engage with other pharmacy professionals to improve patient safety. The MPhA Technician academy’s mission statement and goals provide direction to technician members. The Pharmacy Technician Academy provides a local and state network assisting you with your professional goals. As a leader in continuing education for pharmacy technicians, MPhA programs provide ongoing career development and education of today’s pharmacy topics. The academy offers advocacy for technicians with a focus on current issues,
such as Minnesota Board of Pharmacy technician registration, competency exams, and standard educational requirements. Technician students are encouraged to get involved with MPhA and the technician academy to further expand the education and professional goals of our future leaders. The personal and professional pharmacy relationships you develop here will last you a lifetime. The Pharmacy Technician Academy is here to advance the role of technicians in Minnesota. Be a part of advancing the profession of pharmacy and your career! If you have questions, comments, or are interested in being a MPhA technician member, please contact the MPhA office at 651-697-1771, or any of the academy officers below: • Chair – Cheryl Hetland, CPhT: Cheryl.Hetland@yahoo.com • Vice-Chair – Robbin Leach, CPhT: robbin.leach@walgreens.com • Secretary – Barb Stodola, CPhT: stodolab@aol.com
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MPhA News
Pharmacy Benefits Manager Audit Bill Now in Effect By Matthew J. Lemke, MPhA Lobbyist and Winthrop & Weinstine, PA Shareholder
On August 1, 2012, the Pharmacy Audit Integrity Program took effect. Thanks in large part to the successful advocacy of the Minnesota Pharmacists Association, the new law passed on a bipartisan basis and provides standards for an audit of pharmacy records carried out by a pharmacy benefits manager (PBM) or any entity that represents a PBM. The need for the law became clear following increasing complaints from pharmacists that some PBMs had adopted heavy-handed audit practices that interfere with or impede service to pharmacy patients at the time of an audit. The intent of the law is to curb abusive audit practices by the bad actors, while allowing those that do not engage in overaggressive and far-reaching audit practices to protect against fraud, willful misrepresentation or abuse. Some of the changes under the new law are described below.
Notification Requirements • The law requires that a change to pharmacy audit terms in a contract between the PBM and pharmacy must be disclosed to the pharmacy at least 60 days prior to the effective date of the proposed change. • A pharmacy must be given notice 14 days before an initial on-site audit is conducted. • If the audit involves clinical or professional judgment, it must be conducted by, or in consultation with a licensed pharmacist. Conducting the Audit The new law also sets standards for how the audit itself must be conducted, unless superseded by federal law. These include standards relating to scheduling audits and the information required during an audit: • Unless the pharmacist consents, an onsite audit may not take place during the first five business days of the month, traditionally the busiest time for pharmacies. • A PBM can no longer audit claims more than 24
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Minnesota Pharmacist Fall 2012 n
months old, unless a longer period is required by a state or federal law. • The auditor may not receive payment based on a percentage of the amount recovered in the audit. • If a PBM uses random sampling, the pharmacist must be given a masked list that provides a prescription number or date range that the PBM is seeking to audit. • Auditors may not enter the pharmacy area unescorted where patient-specific information is available. • A PBM may not require additional information to be written on the face of a prescription unless required by state or federal law. However, a PBM may require that information be readily available for the auditor at the time of the audit if the information is not written on the prescription. Chargebacks and Recouping Money Before a PBM can chargeback or recoup money from a pharmacy, the PBM must wait until after the appeals pro-
cess and until after both parties have received the results of the final audit. This requires that PBMs have a written appeals process in place that includes appeals of preliminary and final reports. Other criteria for recoupment or chargeback: • Audit parameters must consider consumer-oriented parameters based on manufacturer listings. • For compounded medications, the usual and customary price is considered the reimbursable cost, unless the provider manual outlines a different methodology. • A finding of overpayment must be based on the actual overpayment, not on a projection based on the number of patients having a similar diagnosis or on the number of similar orders or refills for similar drugs. In addition, a PBM may not use extrapolation in calculating the recoupment or penalties unless required by state or federal law. • Calculations of overpayments may not include dispensing fees unless the prescription was not actually dispensed, the prescriber denied authorization, the prescription was a medication error or the overpayment is solely based on an extra dispensing fee. • Interest may not accrue until after the final audit report. Clerical Errors In the case of clerical or record-keeping errors that have no actual financial harm to the patient or plan, the PBM may not assess any chargebacks or claim that the pharmacy engaged in fraudulent activity. This includes typographical errors, scrivener’s errors or computer errors that do not cause financial harm. However, such errors may be subject to recoupment if there is indeed financial harm to the patient or plan. Documentation Finally, in addition to documentation parameters contained in the PBM’s provider manual, the new law allows pharmacies to rely on other authentic and verifiable statements or records, which include medication administration records of a nursing home, assisted living facility, hospital, physician or other authorized practitioner. Any legal prescription may also be used to validate claims including medication administration records, faxes, e-prescriptions, or documented telephone calls from the prescriber or prescriber’s agents. Exemptions The law does not apply to audits involving suspected fraud, willful misrepresentation or abuse, or any audit completed
by Minnesota health care programs. Should these exemptions become problematic in the future, the law will need to be revisited to ensure that all audits are conducted in a fair and equitable manner. Conclusion The provisions of the law are expected to help pharmacists better serve their patients while under the scrutiny of an audit, while still allowing PBMs the ability to confirm that there are no instances of fraud, willful misrepresentation or abuse. Pharmacists should be aware of the changes to the audit process to ensure that all PBMs are in compliance. Session Law Chapter 215 can be found on the Minnesota Legislative Web site: http://www.leg.state.mn.us/ Matthew J. Lemke is a shareholder at the law firm of Winthrop & Weinstine, PA and provides legal counsel and lobbying services for MPhA. Contact him at 612-604-6462 of mlemke@winthrop. com.
“I’M ALWAYS WATCHING OUT FOR MY PATIENTS, BUT WHO’S WATCHING OUT FOR ME?”
WE ARE. We are the Alliance for Patient Medication Safety (APMS), a federally listed Patient Safety Organization. Our Pharmacy Quality Commitment (PQC) program: • • • •
Helps you implement and maintain a continuous quality improvement program Offers federal protection for your patient safety data and your quality improvement work Assists with quality assurance requirements found in network contracts, Medicare Part D, and state regulations Provides tools, training and support to keep your pharmacy running efficiently and your patients safe
Call toll free (866) 365-7472 or visit www.pqc.net PQC IS BROUGHT TO YOU BY YOUR STATE PHARMACY ASSOCIATION
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Welcome
Organizational Members!
You Take Your Career Seriously, Now Take it to the Next Level Join the Minnesota Pharmacists Association Today to Be the Best at What You Do MPhA members have direct access to 2,000+ pharmacy and technician professionals located across the state of Minnesota. Through MPhA programs and web services you can easily ask questions, network with colleagues, and gain valuable information on the latest insights and trends in pharmacy. Join today at our new individual member rate of $295 (was $395)! We are pharmacy professionals, employed by community pharmacies, retail chains and hospital clinics. As members, we look to MPhA to educate, promote, advocate at the state Capitol, and support us in our unique roles. Visit www.mpha.org to learn more about membership and why membership is so important.
Not Your Mother’s MPhA
2013 MPhA Annual Conference May 17-18, 2013
Marriott Minnea polis Northwes t The MPhA annual conference offers sp eakers who are knowledgea ble about the challe nges you face in pharm acy and the skills ne ed ed to meet those chal lenges. Multiple ed uc ational sessions help ensu re that you take ho m e information that will help you within your organization.
The MPhA annua l conference is co to the Twin Ci ming in May 2013 ó ties ma it closer for king m members to att ost end!