Fall 2011 Minnesota Pharmacist

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MPhA Board of Directors Executive/Finance Committee: President: Scott Setzepfandt Past-President: Brent Thompson President-Elect: Martin Erickson Secretary-Treasurer: Bill Diers Speaker: Meghan Kelly Executive Vice President: Julie K. Johnson Rural Board Members: Eric Slindee Mark Trumm Metro Board Members: Cheng Lo James Marttila At-Large Board Members: Tiffany Elton Tim Cernohous Amy Sapola Jill Strykowski Jason Varin Student Representation: Duluth MPSA Liaison: Jeremy LeBlanc Minneapolis MPSA Liaison: Kandace Schuft 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: 651-697-1771 or 1-800-4518349, 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 55114-1469.

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.

Fall 2011 Volume 65. Number 4, ISSN 0026-5616

in this issue President’s Desk Who’s Your Pharmacist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Executive’s Report Protect and Advance, Your Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Viewpoint Chapter 151: Quo Vadis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 pharmacy and the law Do Employed Pharmacists Need an Individual Pharmacist Professional Liability Policy?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Financial Forum Common Financial Mistakes: A Few Things You Can’t Afford to Do. . . . . . . . . . . 13 Features Are You AWARxE Minnesota? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 ACA: Reducing Iatrogenic Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 MTM Update 2011: Patients, Pharmacists, Payers Seeing Positive Results. . . . . . . 17 2012 Medication Therapy Management Program Eligibility Information Available Via the Medicare Plan Finder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Accountability Increases Ability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Pharmacy Time Capsules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 The Changing Landscape For Vaccine Administration: Managing vaccine storage and delivery at the pharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2011 Minnesota Pharmacist Compensation and Labor Survey . . . . . . . . . . . . . . . . 26 The MPhA Readership Survey Identifies Strengths and Weaknesses of Various MPhA Publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Health Mart Healthy Living Tour Provides Free Health Screenings . . . . . . . . . . . . 31 Student Perspective Never Let A Disaster Go to Waste. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 K2: Is it Really Synthetic Marijuana?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 The Use of the Minnesota Immunization Information Connection in an Institutional Setting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

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Pharmacists Mutual Companies. . . . . . . . . . . . 6 Pharmacy Quality Commitment. . . . . . . . . . 10 Minnesota Pharmacist Fall 2011 n

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Who’s your pharmacist?

by Scott Setzepfandt, R.Ph., MPhA President The other day I was thinking about how pharmacists continue to struggle to be recognized as health care providers. As I usually do when a thought pops into my mind, I began to reflect on past experiences.

My first exposure to the public perception of pharmacists goes back to when I was growing up in a small rural town in central Minnesota. We had two pharmacists practicing in Bird Island throughout the 18 years I lived there. The first one was Al Ringness. He had a typical community store on Main Street with a soda fountain. When Mr. Ringness decided it was time to retire, pharmacist Leo Held bought the store. He continued to make changes to stay with the times, including the removal of the soda fountain. But what I remember about both was that there was a high degree of respect for them and residents would often go to them for medical advice. Though this was all prior to pharmaceutical care and MTM, people knew Al, and later, Leo were knowledgeable and helpful and could often solve your problems or knew where to send you if they couldn’t.

My second experience was when I was in college. I happened to bump into a friend with whom I shared many chemistry classes and excitedly told him I had just been accepted into the College of Pharmacy. His response caught me fairly off guard: “Why would you want to do that?!?” After talking a bit more it was clear that he thought pharmacy was some type of vocational degree. He was perplexed why I would drop out of college after taking all that chemistry and go to vocational school. I was perplexed to why he didn’t know anything about pharmacy after taking all that chemistry.

During my years in the College of Pharmacy there was a clear push to strengthen clinical skills for students. Dean Weaver was a strong advocate for the PharmD degree and the College of Pharmacy in Minnesota was the place to be. Only a handful of fortunate bachelor of science students were accepted into the elite PharmD program at the time, most having completed their BS degree. I was not one of them. But that was OK. I felt had a pretty good education just the same and thought I could do what I needed in community pharmacy with what knowledge I had. So I left the metro area and began practicing community pharmacy in Hutchinson. That’s when my third exposure to public perception hit me.

I enjoyed being a “local druggist.” I worked in a clinic pharmacy across the hall from the main clinic in town and downstairs from the hospital. It was a perfect setting. And for the most part, 4

Minnesota Pharmacist Fall 2011 n

people seemed to appreciate my services. However, there was the occasional visitor who would get upset about a prescription not being ready yet, a product costing too much or not refilling a controlled substance that wasn’t authorized. But the thing that I remember bothering me the most was that while I was busy filling prescriptions from my platform behind the counter, I noticed people were asking my clerk for health care advice. I remember thinking, “this set up really seems backward” but I suspect I didn’t appear very approachable from their viewpoint. That was 30 years ago.

Over the years since, pharmacy has made some significant inroads on being recognized as important partners on the health care team. Physicians are experiencing more and more firsthand how pharmacists can help them solve complex medical problems.

Health systems are beginning to recognize the value of pharmacist cognitive services and pay for services such as MTM. Legislators are beginning to recognize that pharmacists can be part of the solution in reducing health care costs by improving health care outcomes. But I am not so sure the patients being directly served are with us yet. So I keep wondering, what can we do to change that?

During the MPhA Fall Clinical Symposium, Fred Eckel spoke of the future of pharmacy. A discussion emerged about the viability of incorporating clinical services such as MTM into a community setting. One participant shared his story of hiring a pharmacist and setting up MTM services only to end with a financial loss.

Fred’s advice made sense to me. “Take it slow.” He recognized that maybe we jump into these things too quickly. Maybe we don’t need to set up large systems, hire extra people, or redesign our facilities. Maybe all we need to do is build a clinical practice slowly one patient at a time. Make small changes to let our patients know we are there to help.

Take, for example, business cards: Ever notice that when you go to a doctor, dentist, chiropractor or an ophthalmologist, the first thing they ask you is “Who is your doctor?” There are business cards in holders at the counter with names and phone numbers to call. But rarely do you hear the same question or see the card holders in a pharmacy.

Why not?

Why not greet every customer with: “Who is your pharmacist?”

If they don’t have one, offer to be theirs. Give them your card.

How about having a personal cell phone dedicated to patient Who’s Your Pharmacist continued on page 5

Who’s Your Pharmacist continued from page 4 calls? Put that number on the card, include times you are available, carry that phone with you and only answer it while at work and have access to their profile, and begin establishing a clinical relationship with your patients.

Moved, graduated, or have a name change?

Update your profile through your online MPhA Member Portal page.

MPhA Office 1000 Westgate Drive Suite 252 St. Paul, MN 55114 phone: 651-697-1771 fax: 651-290-2266 Visit us online at www.mpha.org!

You could start with one or two patients who have a complicated drug regimen. And grow your caseload from there as time permits. And they will be your patients. And when someone asks them: “Who’s your pharmacists?” it will be your name they speak.

Upcoming Events Visit www.mpha.org for more information and to register January 29, 2012,

Midwinter Conference, Doubletree, Bloomington February 21 2012,

Pharmacy Legislative day, St. Paul

Minnesota Pharmacist Fall 2011 n

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executive’s report

Protect and Advance: Your Role

by Julie K. Johnson, Pharm.D., MPhA Executive Vice President/CEO

Ten years ago when I began this position with MPhA and was asked by pharmacists and others, “what does the association do?”, I found that I had different answers depending on who was asking and how I felt that moment about the issues at hand. It is as though the person asking will be exiting the elevator where we both stand and I only have a brief moment to sound profound and be compelling as to the value the association brings.

Sometimes I share upcoming events like our pharmacy nights or annual MTM Fall symposium. MPhA brings in more pharmacists each year and continues to do more outreach to communities where pharmacists live and work. We take the events to them and are pleased with the response for visiting their corner of the state.

Educational offerings continue to include valuable information for both clinical and business needs. Other times I talk about the board of directors and the leadership that gather in our conference room during board of directors meetings or committee meetings as pharmacists lend their expertise in areas of clinical patient encounters or the latest business strategies for survival in a tough economic environment.

This article is intended to bring this topic back to you. What does our future look like? As pharmacists, when we consider this question, several others may be considered first: • Are you practicing today where you thought you would be when you entered pharmacy school?

• Are you doing the kinds of things you thought you would do?

• What has changed in the environment since then?

• What adjustments, or plans have you made along the way?

Translation: the expertise of pharmacists will be included in these new models. So, back to what we can do to ensure this happens.

Much has been written about the efforts of pharmacists in our state working with staff of MPhA. Rita Tonkinson’s article on page 17 briefly catalogs years of advancement and protections led by this association and its partners. Now, allow me to share some thoughts that I recently shared with seminar participants when asked this question: Position yourself. Keep your clinical skills up to date. Take advantage of programs to certify, accredit or distinguish yourself and your role in areas vital to serving public health. Participate in immunizations, health screenings, take-back events, or whatever above and beyond normal pharmacy business suits you and your ambitions.

Second, get in front of patients. Pharmacists have long been considered the most accessible point of care to patients. Don’t let this get away from you. Get out from behind the counter more often, get into patient rooms, and participate in community education.

Demystifying what you do to more patients puts a face on pharmacy they will not forget. Show patients what you do to contribute to their health.

Third, put yourself in a position/responsibility that cannot be replaced by someone less qualified than you. Strive to spend more of each day doing the things that you went to pharmacy school to do. Learn to use technology and support help to advance the expertise and contribution that you make to patients.

And finally, push. Continue to push yourself, your association, your manager, your boss and your co-workers to keep pharmacy in the forefront, where we belong.

• What have you done to advance and protect yourself and your profession?

Given the few minutes before the elevator door closes on this question, help me with the answer. What can you do as an individual pharmacist in your practice setting today to ensure medication expertise is included in emerging payment models? The recent College of Pharmacy’s Leadership Management Seminar brought in experts involved in aspects of health care reform activity to discuss the creation of accountable care organizations and pharmacists’ opportunities in these new health homes. It seems clear that few are prepared to describe specifics of the new health home models, how they will work, how and who will get paid what. But several things are clear. Payment models will change.

Optimal medication use is dead center and is a vital component to increased efficiencies and measurement of quality of care.

Julie K. Johnson, Pharm.D. MPhA Executive Vice President/CEO

Minnesota Pharmacist Fall 2011 n

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viewpoint

Chapter 151: Quo Vadis?

by Lowell J. Anderson, D.Sc., FAPhA

Session Law, Chapter 354, 1937 Section 1. Definitions.— As used in this Act. (a) The term “pharmacy” shall mean a drug store or other established place regularly registered by the State Board of Pharmacy, in which prescriptions, drugs, medicines, chemicals and poisons are compounded, dispensed, vended or sold at retail. (b) The term “pharmacist” shall mean a natural person licensed by the State Board of Pharmacy to prepare, compound, dispense and sell drugs, medicines, chemicals, and poisons.

Several months ago I wrote about the need for the profession to take a look at our Practice Act that directs many of our activities as pharmacists, and our abilities to fully participate in the new delivery models being developed.

Since then, the Center for Leading Healthcare Change convened a group of Minnesota pharmacists to review Chapter 151. This group will make recommendations to the Minnesota pharmacy profession, the Board of Pharmacy and the allied-health communities on how to bring our Practice Act into conformity with contemporary practitioner abilities and consumer needs.

WHY THIS REVIEW?

The practice of pharmacy has changed far beyond that which was envisioned in the 1937 Practice Act. In 1937, the demands on pharmacists were restricted to the preparation, compounding, dispensing and selling of drugs, medicines, chemicals and poisons.

Our current practice act and the supporting rules and additional statutes that govern the distribution of medicines and the practice of pharmacy have built on the 1937 concept of practice.

In the intervening three-quarters of a century, the Minnesota Board of Pharmacy, Minnesota Pharmacists Association and Minnesota Society of Hospital Pharmacists have periodically sought amendments to the Act in efforts to provide a contemporary underpinning to the distribution of medicines and practice of pharmacy. The Legislature has also initiated changes in the Act in response to a variety of interest groups. In spite of these changes, however, the Practice Act and the various Acts and rules that surround it still approach pharmacy practice from the viewpoint of pharmacists as dispensers of medicines who also provide clinical services. The changing consumer and systems demands on pharmacists would dictate that the emphasis should be the reverse: practitioners who provide medication-related clinical services, who also manage the medication supply and distribution.

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The market, and the society that it reflects, is driving changes in the roles of pharmacists faster than either the profession or the pharmacy board can keep up. It is impossible to anticipate the direction that many of these changes will take. And, there will most likely be no ultimate endpoint to changes in the delivery system. The competing forces of public policy, legislation, consumer/ voter and payer demands, professional aspirations and resistance, and financial constraints work together in such strange and mysterious ways as to make strategic planning difficult. Likewise it is a challenge to regulators to fulfill their statutory mandates while allowing those who they regulate to respond to this changing market.

The current law in many ways restricts the practitioner to roles or procedures that are not that different from those in the 1937 Act. It is the belief of the Working Group that the current restrictions and requirements make it difficult for pharmacists to fully participate in new developing and envisioned delivery systems.

That having been said, it is then important to free the pharmacist practitioner to be responsive and innovative in delivering services while still protecting the public health. It is also important to assure pharmacists’ continued participation in the health-care system.

COMPOSITION OF THE WORKING GROUP

The members of the group were chosen because of their understanding of their practice specialty, understanding of the progress of health-reform initiatives, and capabilities and aspirations of the profession and its practitioners. Obviously, there are many pharmacists in Minnesota who meet these criteria. In the interest of management of the Working Group it was limited to twelve members and a chairman. The members of the Working Group brought experience from hospital, clinic, MTM, community, chain, health-care law, practice faculty as well as Board of Pharmacy experience and new practitioners.

GOALS OF THE WORKING GROUP

In considering Chapter 151, the Working Group reviewed each section by comparing it with contemporary pharmacy practice or with practice after reasonable assumptions of changes that might occur. More importantly, the Working Group considered the inherent barriers to practice development that might be imbedded within the section. And then, providing guidance for the profession and the Board of Pharmacy on updating the section so as to Chapter 151: Quo Vadis? continued on page 9

Chapter 151: Quo Vadis? continued from page 8 allow the pharmacists to fully use the knowledge and skills gained in their education, ongoing continuing education and practice experience to improve quality and accessible pharmacist services.

There were a number of questions that were imbedded in the discussions in which existing sections and proposed concepts of Chapter 151 were measured: • Does/will it maintain assurances of consumer safety?

• Will it remove historical accretions that impede pharmacists’ innovations?

• Will it free the pharmacists to respond to consumer needs and market opportunities in a safe and optimal manner?

• Does/will it provide opportunities for pharmacists to fully participate in new multi-disciplinary delivery systems?

• Does/will it allow pharmacists to share in both the risks and the rewards of ACOs and health homes?

• Does/will it enhance the ability of the pharmacist to provide pharmacist services wherever there are consumer needs?

CONSIDERATIONS BY THE WORKING GROUP

Beginning with an initial meeting in November 2010, there were seven meetings of the Working Group in which it considered the content of Chapter 151. The Working Group spent several sessions on the Definitions (§151.01) because of the criticality of definitions to the understanding and direction of the body of §151 itself.

to be translated into action by the profession and support of such action by the members of the profession.

Beyond the development of agreement and support by the pharmacist and allied health community, the consensus that develops will need be expressed in language that can be the content of bills submitted to the Legislature. This difficult work will need to be done by others than the members of the Working Group.

Ultimately, the National Association of Boards of Pharmacy (NABP) and the national professional associations must provide leadership in the modernization of the practice acts of all 50 states.

Absent that leadership and resulting changes the practice of pharmacy will be a crazy-quilt of new and old that will only serve to diminish the quality of services that the pharmacist practitioner can provide and allow the continuance of the fuzzy brand that the practice of pharmacy experiences.

Lowell J. Anderson, D.Sc., FAPhA, practiced in community pharmacy for most of his career. He is a former president of MPhA, MN 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 Healthcare Change, University of Minnesota and co-editor of the International Pharmacy Journal. He is a Remington Medalist.

Those sections that did impact the pharmacists’ abilities to practice in a responsible and responsive manner were discussed, and the report will provide the thinking and recommendations that resulted from those discussions.

FUTURE DIRECTION

Having completed the review, the Working Group is currently beginning a review of the completed report.

It is the intent of the Working Group that the Minnesota pharmacist community broadly engage in discussions on the report.

The Working Group will seek to discuss the report with the relevant professional and trade associations that have a presence in Minnesota as well as the College of Pharmacy. It will also be presented and discussed with the members of the Board of Pharmacy and its staff.

Recognizing that the direction of health systems is toward multidisciplinary health practices, the Working Group and profession should also seek audiences with leaders in allied-health professions, notably medicine and nursing.

To achieve the goal of professionals who can respond to the full panoply of medication related needs and demands, the pharmacy profession in Minnesota must agree that significant changes need to occur in the pharmacy practice and related acts and rules in order that the pharmacists can continue to be an integral part of healthcare delivery. Further, the consensus for needed modernization of the statutory and regulatory underpinnings of practice will need Minnesota Pharmacist Fall 2011 n

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4 Fraud and Abu se Training 4 Pseudoephed rine Log 4 OSHA Requ irements 4 HIPAA Priva

Policies an cy and Security d Procedur es Quality As Program surance (QA)

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AWARxE

Are You AWARxE Minnesota?

By Julie K. Johnson, Pharm.D., MPhA Executive Vice President/CEO

AWARxE was founded by the Minnesota Pharmacists Foundation (MPF) in 2009. MPF strongly believes that pharmacists have a critical role in providing medication safety information and helping raise awareness of the dangers of abusing and misusing medications.

MPF is providing specific AWARxE information on safe drug use in the state of Minnesota. St. Cloud, Minn., was the home of Justin Pearson, the young man whose death was the inspiration for AWARxE. Due to Justin’s story <http://www.awarerx.org/about. php>, Minnesota has committed to an elevated responsibility in educating the public on the vital public safety and public health issue of prescription drug abuse and misuse.

The Minnesota focused initiatives include AWARxE school and corporate presentations, which directly align with the following goals: • Inform parents and children of prescription drug abuse and misuse dangers.

• Inform people of safe and proper medication disposal options.

• Alert parents and children to the danger of online pharmacies. Let people know there is a chance they could be getting counterfeit medications.

• Help people understand the importance of their relationship with their pharmacist in obtaining their prescription drugs.

• Address the public perception gap – medicine is more than a commodity and individuals must take personal responsibility for their health care.

Progress to date includes:

AWARxE provides a wide variety of educational tools and programs for youth.

During the 2010-2011 school year, student pharmacists delivered 100 presentations about prescription drug use and abuse to middle school students in the Twin Cities and Duluth, impacting 2,582 students. Middle school students are targeted because 12- and 13-year-olds are the most common abusers of prescription drugs.

These educational presentations provide vital information and a mentoring opportunity for college and middle school students.

The goal for the 2011-2012 school year is to deliver a minimum of 150 presentations, primarily in the Twin Cities metro area.

AWARxE billboards can be found on major highways across Minnesota, and the campaign’s commercials and radio spots are broadcast on major stations. Educational brochures are distributed to students during presentations.

preferred way to ensure proper incineration. A few counties in Minnesota now offer drop boxes. However, when consumers do not have access to these methods, recommendations for consumers still include the avoidance of flushing and the mixing with coffee grounds, cat litter, or another household garbage substance to render the medications unusable and unappealing to humans and animals. The Minnesota Pharmacists Foundation and the AWARxE Project recently joined Minnesota SMARxT Disposal in an effort to better educate the public, and give guidance to consumers on the proper disposal of unused and expired prescription over-thecounter medications and keep medication away from children and animals. Minnesota SMARxT disposal brings together a diverse group of organizations and includes support from healthcare professionals, senior citizen organizations, pharmaceutical manufacturers and the outdoor conservation community. Minnesota supporters and partners in this effort include the Minnesota Pharmacists Association, the Pharmaceutical Research and Manufacturers of America (PhRMA), U.S. Fish and Wildlife Service, Metro Meals on Wheels, the Minnesota Outdoor Heritage Alliance (MOHA), Minnesota Waterfowl Association, Aging Services of Minnesota, Lutheran Social Services’ Senior Corps programs, Mature Voices Minnesota, and the Vital Aging Network. Visit www.smarxtdisposal.net for more information.

AWARxE has created a comprehensive curriculum for prescription drug safety that is available for nationwide use. South Dakota and Arizona have replicated Minnesota’s AWARxE campaign with the help of this curriculum.

The MPF and the AWARxE Campaign wishes to recognize two new state sponsors in 2011. Thanks goes out to Health Partners and Target Corporation for their monetary support of educational efforts in Minnesota middle schools! 2012 will see expanded outreach because of the generosity of these two sponsors!

Pharmacists are urged to join us in changing and saving lives by supporting the AWARxE Program with your tax deductible donation. Please donate online at mpha.org and click on the Minnesota Pharmacists Foundation or send your check to MPF, 1000 Westgate Drive, Suite 252, St. Paul, MN. 55114.

Get your 2011 donation in today!

Officers of the Minnesota Pharmacists Foundation President: Marilyn Eelkema, and Board of Trustees: Howard Juni, Debbie Anderson, Dave McLean, Todd Sorenson, Linnea Forsell, Justin Anderson, Leslie Helou, Chuck Cooper, and Steve Simenson The AWARxE consumer protection program is brought to you by the NABP Foundation®.

AWARxE has created a guide for the safe disposal of medication that may be used at “take back events” which are still the Minnesota Pharmacist Fall 2011 n

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PHARMACY MARKETING GROUP, INC. • PHARMACY and the law

DO EMPLOYED PHARMACISTS NEED AN

INDIVIDUAL PHARMACIST PROFESSIONAL LIABILITY POLICY?

By Don McGuire, Jr., R.Ph., J.D.

Most employed pharmacists believe that their employer’s insurance policy protects them in the event of a professional liability claim. This is usually correct. The fact that it is not always correct is reason enough for pharmacists to consider buying their own individual professional liability policy. There are three factors, which when considered together, show the need for a pharmacist to obtain their own coverage.

1. Control – The employed pharmacist has no control over the coverage purchased by their employer. During my years as an employed pharmacist, I never saw my employer’s policy. I worked on their word that I was covered. I did not know what the coverage limits were, what services the policy covered or even if employed pharmacists were an insured under the policy. If limits are too low or if the policy doesn’t cover immunizations or MTM, the employed pharmacist is potentially left exposed. If this lack of control weren’t enough, the employee doesn’t know if/when the policy lapses or if the employer fails to pay the premium.

The worst time to find out these things is when a claim is staring you in the face. While the typical individual professional liability policy is secondary or excess, it can drop down to provide primary coverage for the pharmacist when the employer’s policy is missing or inapplicable.

2. Coverage – The typical employer’s policy only provides the pharmacist with professional liability coverage for “for acts within the scope of their employment.” In other words, the pharmacist is only covered while they are at work. For a pharmacist who volunteers at a senior center or a church, provides advice to friends and neighbors, or occasionally moonlights, their primary employer’s policy won’t cover them in these situations. An individual policy, on the other hand, covers the pharmacist 24 hours a day. This additional protection allows the pharmacist to give back without worrying about personal exposure.

3. Target – One additional concern is often expressed by risk managers and employers. That is, the existence of an individual professional liability policy makes the employed pharmacist a target for the plaintiff’s attorney. Our experience has shown this not to be true. The trend is that plaintiffs’ attorneys are naming the individual pharmacists as defendants many more times today than they were 20 years ago. A good plaintiff’s attorney will bring all potentially liable persons into the suit. Most often, this happens even before the existence of the individual policy is known. We have even had cases where the individual policy was not discussed 12

Minnesota Pharmacist Fall 2011 n

until two or three years into the litigation process. While I believe this target idea is a myth, even if it is true, it is outweighed by the other considerations above.

The ease of application and low cost of individual professional liability coverage make this choice even easier for the employed pharmacist. It provides an extra measure of protection over and above that carried by their employer. Individual pharmacist professional liability policies are secondary in nature. However, if there is a problem with the employer’s coverage for the employed pharmacist, the pharmacist’s individual coverage can provide the missing, and much needed, protection. This is especially important when it comes to the cost of defending lawsuits. Even winning a lawsuit can be expensive. Every pharmacist should take steps to protect their own career and reputation. Some things are not better left to others.

© Don McGuire, R.Ph., J.D., is General Counsel at Pharmacists Mutual Insurance Company.

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

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

PHARMACY MARKETING GROUP, INC. • Financial Forum

COMMON FINANCIAL MISTAKES A few things you can’t afford to do

By Pat Reding, CFPof Pro Advantage Services Inc.

Are you making mistakes with your money? Many people do, because of inattention, a lack of knowledge or confidence, or relying of the advice of friends rather than professionals. Here are some all-too-common money errors to avoid …

of the growth of your retirement savings and assets. If you’re holding back because you’re unsure, speak with a financial advisor.

Putting off financial planning. This may be the biggest mistake of all. Procrastination does not help you save for retirement, and it will not help you reduce your taxes or transfer money to your heirs. Delaying necessary financial planning can be perilous. Some avoid planning out of fear – they simply don’t know where to begin. Don’t let this stop you. Decide today to do something about your financial future.

Provided courtesy of Pat Reding, CFPof Pro Advantage Services Inc., in Algona, Iowa. For more information, please call Pat Reding at 1-800-288-6669.

Putting all your eggs in one basket. Too many people invest everything in just one place. Try spreading your assets across multiple investments, and you’ll help to insulate them against the effects of economic ups and downs.

Registered representative of and securities offered through Berthel Fisher & Company Financial Services, Inc. Member NASD & SIPC .

Pro Advantage Services, Inc./Pharmacists Mutual is independent of Berthel Fisher & Company Financial Services Inc. Berthel Fisher & Company Financial Services, Inc. does not provide legal or tax advice. Before taking any action that would have tax consequences, consult with your tax and legal professionals. This article is for informational purposes only. It is not meant to be a recommendation or solicitation of any securities or market strategy.

Buying more home than you can afford. Interest-only loans, option adjustable-rate mortgages (option ARMs) and lease purchases still tantalize couples and families with small nest eggs, modest salaries and credit blemishes into taking on much more liability than they can bear. The result is often foreclosure. Speak to a professional to make sure the amount of home you purchase makes sense for you.

Making impulsive or emotional money decisions. A decision that feels good (or exciting) may not be appropriate for you financially.

Avoid spur-of-the-moment financial choices, and the influences that may trigger them. The next time you’re about to make a snap decision, stop and think. Will you lose the opportunity if you take a while to consider your next move? Consider and compare whenever possible.

Living above your means. In the acclaimed book The Millionaire Next Door, authors Thomas Stanley and William Danko found that most millionaires drive used American cars and shun a champagne-and-caviar lifestyle. It is the middle class that is generally seduced by big-debt, big-ticket luxury items … sometimes all the way into bankruptcy. Make wise decisions about money, take the time to consider big purchases, and be mindful of what effect they’ll have on finances down the road.

Avoiding all risk. Caution is good, but being extremely risk-averse (for example, refraining from investment and just putting your money in an FDIC-insured bank account) may cost you in terms Minnesota Pharmacist Fall 2011 n

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ACA: Reducing iatrogenic conditions Reprinted with permission from the Hub on Health Care Reform column in the September 2011 issue of Pharmacy Today (www.pharmacytoday.org). For more information about the Affordable Care Act and pharmacy’s role in shaping the outcomes of this law, access the Government Affairs section of APhA’s Web site, www.pharmacist.com.

Copyright © 2011, American Pharmacists Association. All rights reserved.

Moving to improve the quality of patient care, CMS is implementing Affordable Care Act (ACA) provisions that lead to financial incentives to reduce iatrogenic conditions such as hospital-acquired conditions.

ing our hands, saying, ‘Hey, look at me! Look at me! I can help!’ for a long time.” Lugo is 2011-12 Chair of the Section on Hospital and Institutional Practice in the APhA Academy of Pharmacy Practice & Management.

A June 6 final rule implementing section 2702 prohibits federal Medicaid payments to states for any amounts spent treating certain health care-acquired conditions (much like a Medicare version of the no-pay policy dating back to a 2008 final rule), and authorizes states to identify other provider-preventable conditions for which Medicaid payment will be prohibited. Although these regulations were effective on July 1, 2011, the agency delayed compliance action until July 1, 2012.

Community pharmacists also have a role to play, although they aren’t at any risk of payment penalties. Patients “may have acquired something in the hospital not knowing, go to the community setting, and have to be readmitted,” Bough said. Other scenarios out of the hospital include long-term care facilities, assisted living, and home health care, where pharmacists either deliver medications or work with patients in their home with nurses and nursing staff in home care or transitions of care, according to Bough.

The final rule identifies the preventable conditions for which Medicaid will no longer pay. Twenty-one states currently have nonpayment policies related to health care-acquired conditions. Under the Medicare policy, denied claims have saved $20 million per year.

More in ACA

“This isn’t new,” said Marcie Bough, Pharm.D., APhA Senior Director of Government Affairs, referring to CMS activity regarding iatrogenic conditions. She added that the financial impact of the June 6 final rule “isn’t direct on a pharmacy department within a hospital.” Instead, pharmacists can help with medication management to prevent and treat infections and be involved as their facility figures out best practices for addressing hospital-acquired conditions.

Hospital, community

“I think that institutions will look to pharmacists to play more of a pivotal role,” Amy M. Lugo, Pharm.D., BCPS, BC-ADM, Clinical Pharmacy Specialist, U.S. Department of Defense Pharmacoeconomic Center at Fort Sam Houston in Texas, told Pharmacy Today. “We’ve been standing there on the sidelines wav-

Pfizer seeks OTC version of Lipitor

Pfizer is pursuing an OTC version of atorvastatin (Lipitor) because the cholesterol medication — the world’s best-selling drug, with annual sales of $11 billion — loses patent protection in November, according to news reports.

In a New Drug Application for a statin to go OTC, a company would need to show certain information, according to LCDR Lisa Kubaska, Pharm.D., U.S. 14

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The Partnership for Patients: Better Care, Lower Costs initiative was announced on April 12. In the public-private initiative, the CMS Center for Medicare and Medicaid Innovation, established by section 3021, would set aside up to $1 billion to decrease preventable hospital “all-cause harm” incidents and preventable complications during transitions of care.

Rulemaking related to section 3008 of ACA, which reduces Medicaid hospital payments for hospital-acquired conditions and requires a study of expanding this payment policy to the Medicare program, has not been issued. The payment reduction is effective for discharges occurring during or after fiscal year 2015, and the report to Congress on the results of the study is due January 1, 2012.

—Diana Yap and Eleanor O’Neil Eleanor O’Neil was the 2011 APhA Intern in Political Journalism.

Public Health Service, who is an FDA spokesperson. This information would include determining the appropriate OTC target population for the product; providing label comprehension data; providing self-selection data, including information about each study participant’s lipid profile and medical history; providing actual use data; and providing data on safety and effectiveness.

Pfizer likely will have trouble gaining FDA approval for OTC atorvastatin;

the agency hasn’t approved OTC versions of other statins in the past, according to news reports. Asked if in that case, the company would consider a behind-thecounter (BTC) category for nonprescription atorvastatin, Pfizer replied in an e-mail statement: “We can confirm that we have strategic plans in place for Lipitor’s loss of exclusivity, but we don’t have any further comment at this time.”

OTC Version of Lipitor continued on page 15

feature OTC Version of Lipitor continued from page 14 Is BTC an option?

FDA itself has signaled that BTC may be an option for drugs that treat chronic conditions. At the Food and Drug Law Institute’s annual conference in Washington, DC, on April 5, FDA Center for Drug Evaluation and Research Director Janet Woodcock, MD, said that the so-called “third class,” or BTC category, would be the most effective way of making prescription drugs available on a nonprescription basis, “particularly to help treat chronic conditions,” reported an April 11 article in the Tan Sheet newsletter.

On November 14, 2007, FDA held a public hearing on the possibility of making certain medications available BTC. “FDA is continuing to evaluate under what circumstances it would be appropriate to approve a drug product for behindthe-counter use,” Kubaska told Pharmacy Today.

Asked if a BTC category would ever be a possibility for atorvastatin, Kubaska said that the two legal marketing venues for drugs are nonprescription and prescription and that BTC marketing “is not currently a legal marketing venue in the United States.”

BTC background

At the November 2007 FDA meeting, organized pharmacy supported the concept but the American Medical Association opposed it. In related December 2007 comments to FDA, APhA said that “a substantial body of evidence” showed that “certain prescription drugs can be safely made available without a prescription by requiring their storage behind the pharmacy counter and a substantive, clinical interaction with a pharmacist.”

Other countries with BTC-status drugs include Australia, Canada, France, New Zealand, United Kingdom (UK), Denmark, Germany, Italy, Netherlands, Sweden, and Switzerland, according to a March 2009 APhA Government Affairs Issue Brief on the matter. The Wall Street Journal reported on August 4 that

nonprescription simvastatin, another cholesterol drug, is sold BTC in UK pharmacies, “requiring interaction with pharmacists.”

Regulatory scorecard: What is happening NOW!

According to a special feature, “Risks, Benefits, and Issues in Creating a Behindthe-Counter Category of Medications,” in the January/February 2011 issue of the Journal of the American Pharmacists Association, BTC implementation “probably is feasible in the United States [but] the optimal model remains uncertain and various aspects of a program need to be prioritized and rigorously tested.”

o CMS: Comments were due by September 28 on a proposed rule to implement exchanges in which individuals and small businesses will be eligible to purchase private health insurance through competitive marketplaces created in each state under the Affordable Care Act, starting in 2014.

—Diana Yap

Proposed regulations receiving public comments:

Requests for information for which comment periods have closed:  CMS: Proposed rule on opportunities for alignment under Medicaid and Medicare.  CMS: Proposed rule affecting 2012 payment policies and rebates for services provided to Medicare beneficiaries in hospital outpatient settings and ambulatory surgical centers.  CMS: Proposed rule to update the 2012 physician fee schedule and other Part B payment policies.  FDA: Proposed rule to amend the Prescription Drug Marketing Act regulations by removing a requirement that the pedigree identify each prior sale or trade of a drug back to the manufacturer.  CMS: Information request related to a participant experience survey for the Center for Medicare and Medicaid Innovation Community-based Care Transitions Program.

Etc:  For a complete list of all the issues and regulations being monitored and acted on by APhA, access the Government Affairs section of pharmacist.com. Also, print readers of the Hub should know that hyperlinks to pharmacist.com, Federal Register notices, and other useful Web sites can be accessed in the online version of the Hub, located at www.pharmacytoday. org.

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MTM Update 2011: Patients, Pharmacists, Payers Seeing Positive Results

by Rita Tonkinson

It has been several years since the first actual steps to begin providing patients with comprehensive medication reviews – face-to-face meetings with pharmacists – resulting in medication management plans that are significantly changing outcomes. Medication Therapy Management Service (MTMS), as it was originally called, opened the door for pharmacists to move beyond dispensing toward scheduled one-on-one time with patients. Countless hours of time spent lobbying and educating legislators by the Minnesota Pharmacists Association (MPhA), the College of Pharmacy and many forwardthinking pharmacists have paid off. Particularly, billing for these services has come a long way since 2005. The history of national pharmacy organizations’, managed care organizations’, federal and local agencies’ and countless other stakeholders’ efforts would likely fill volumes. Our goal is a brief look at Minnesota and, primarily, MPhA’s efforts in advancing MTM to where it is today. This effort also included some case studies “from the trenches” that support the effectiveness of MTM. The work of Strand, Cipolle, et al., in the Pharmaceutical Care Project, brought to the profession the patient-centered philosophy necessary for the continued transformation of pharmacy practice.

As early as 1992, there was legislator interest and the first bills were passed in 2004, creating a pilot program which later laid the ground work for the Minnesota Department of Human Services (DHS) to implement a program to pay pharmacists for providing medication therapy management services (MTM) to patients in the fee-for-service program in 2005. By 2007, 104 pharmacists had enrolled as MTMS providers with 228 paid initial encounters and 143 paid follow-up encounters. The total paid in 2007 was $32,365 or an average of $87 per encounter. Currently, legislators, carriers and others are seeing the financial benefits of providing patients with MTM services. Billings for MA and GAMC eligible MTM recipients are paid through Medicaid. In 2007, medical management industries also began developing plans to pay pharmacists for MTM services for private plan enrollees. Claims for enrollees of various commercial health care plans and selfinsured employers have this service paid through a vendor such as Outcomes Pharmaceutical Health Care® with Web access at www. getoutcomes.com.

A step-by-step MTM Tool Kit was developed in 2007 and offered online at MPhA.org to members. The MPhA MTM task force was responsible for directing resources toward supplying pharmacists with this tool. That year, during the American Pharmacists Month, a Pharmacists Care Campaign was launched to promote MTM through informing consumers of the value of this service. In 2008, MPhA petitioned for formal recognition of the MPhA Medication Therapy Management Academy. Numerous years saw expansion, small but significant, allowing more pharmacists to see more patients through expanded criteria allowed by DHS. A report, “Clinical and economic outcomes of medication therapy manage-

ment services: the Minnesota experience” provided by the Journal of the American Pharmacists Association (Vol. 48, No. 2/MarchApril 2008) stated, “The total health expenditure decreased from $11,965 to $8,197 per person (n = 186, P, 0.0001). The reduction in total annual health expenditures exceeded the cost of providing MTM services by more than 12 to 1.

It is impossible to credit all involved in the past number of years.

In addition, it should be noted that Minnesota Board of Pharmacy Executive Director Cody Wiberg, who while still at DHS before accepting the board position, was critical in supporting the initial pilot. Jarvis Jackson and Sara Drake both serve DHS in different capacities, but are pharmacists providing support from within the department and key in continuing the expansion of pharmacistrecognized services.

Results from the 2011 legislative session provided by MPhA’s lobbyist, Matthew Lemke, outline the MTM expansion: “Article 5, Sec. 30. MA and GAMC will now cover MTM services for a recipient taking three or more prescriptions (previously four) to treat or prevent one or more chronic conditions (previously two): or a recipient with a drug therapy problem that is identified by the commissioner or identified by a pharmacist and approved by the commissioner. Additionally, long-term care settings, group homes and facilities providing assisted living services would specifically be included. Current law excludes these settings. Skilled nursing facilities would be excluded under the change. The expansion of MTM is estimated to save the state approximately $107,000 in FY12-13 and $120,000 in FY14-15.”

What does MTM in Minnesota look like today?

MPhA’s Medication Therapy Management (MTM) Academy offers one-day symposiums to help pharmacists grow in their practice, and through certification, expand as MTM providers. This annual conference, usually offered in November, is in its third year in 2011.

In January 2008, the first APhA MTM Certificate program offered in Minnesota had 56 attendees. Four certification programs were offered in 2010 with 62 pharmacists certified. Thirty pharmacists attended the April 2011 seminar and more than 25 registered for the November 2011 meeting. Registration indicates a steady interest in becoming a certified MTM provider. Four Minnesota pharmacists were trained as faculty during the initial 2008 offering, allowing MPhA to continue to offer this certificate program using local expertise. Minnesota faculty includes MPhA members: Jodi Chaffin, R.Ph., director of pharmacy at Ely Bloomensen Community Hospital and Clinic, Ely, Minn.; Jeffrey Armon, Pharm.D., clinical pharmacist-cardiology, Medication Therapy Management, Instructor in Pharmacy Mayo College of Medicine, MTM Update 2011 continued on page 18 Minnesota Pharmacist Fall 2011 n

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feature MTM Update 2011 continued from page 17 Pharmacy Services, Mayo Clinic, Rochester, Minn.; Carrie Krieger, Pharm.D., medication therapy management pharmacist, Mayo Clinic Pharmacy Services, Mayo Clinic, Rochester, Minn.; and Julie Fike, Pharm.D, clinical pharmacist, specialization in MTM, Genoa Healthcare, Coon Rapids, Minn.

As criteria for payment, DHS requires pharmacists graduating prior to 1996 to complete this education to enroll and be paid as a provider. APhA’s Program was adapted to Minnesota’s needs by requiring additional case studies to satisfy state criteria. MPhA continues to offer these programs on demand at Twin City and Rochester locations. Each offering has attracted pharmacists from other states as well. The criteria, established for pharmacists by DHS, has been adopted by other health plans such as Twin Citiesbased Health Partners, who added MTM to their service offerings.

In Minnesota and elsewhere, more employers have incorporated MTM into their health benefits plans, industry sources indicate.

Eligibility varies based on market segments’ definition of eligibility.

To date, 20 states offer some type of MTM benefit.

“I have seen how unique every patient is and how every patient’s medication experience has been before he/she comes in for a consultation. In MTM, a patient sits down and talks one-on-one with a medication specialist. They get attention most have never received in their life concerning drugs that they are told to take daily. These same patients often hear negative reports about medications and receive mixed messages from multiple perscribers, family members, and various media sources – all of which can be very confusing and disconcerting,” said Chaffin.

According to Chaffin, pharmacists’ attitudes toward becoming certified have changed and interest is growing. Here are a few anonymous comments she mentioned from pharmacists who have completed the MPhA certificate training program: “I found out from this course that pharmacists really can make a difference to patients’ overall health and physicians are receptive to our services.”

“I learned that I am qualified to provide MTM.” “This workshop made me aware of the importance of asking openended questions.”

“I learned how important it is to document, document, document!”

What are the experiences of the pharmacists providing MTM today?

Following are case reports where patients profited emotionally because their unique needs were met, improved physically because their medication regimen was reviewed and changed and, finally, financially because medications were thoroughly reviewed and adjusted to fit their specific needs: An 87-year-old male patient came to the outpatient clinic for a medication therapy management consultation, provided by Armon.

“He came at the urging of his wife, who was concerned about his recent episodes of low blood pressure, dizziness, urinary incontinence and drenching sweats. She believed her husband’s problems 18

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may be medication-related given the many recent changes in his drug regimen. I suspected that the dizziness and hypotension the patient was experiencing were linked to the donepezil as well as the recently added carvedilol,” Armon said. He suspected the sweating and incontinence occurred because of the donepezil and midodrine used to treat hypotension. “I conferred with the patient’s cardiologist and primary physician and suggested to reduce the dose of carvedilol and discontinue midodrine and donepezil. I also recommended that the patient take his carvedilol with meals to reduce the dizziness.

“What the patient hoped to determine during his consultation was how his medications were working together and if they were in some way affecting him in an adverse way. However, sessions like this can also help to streamline a patient’s treatment and save them money.”

The most rewarding aspect of MTM services is patient satisfaction and relief that their medication questions are being answered.

“I have worked with MTM clients who have fallen through the cracks for diabetes care. Insurance plans cover patients with diabetes to see a certified diabetes educator or a dietitian. However, some are allowed one visit (which after seeing them in MTM, it is very clear that one visit is not enough). One patient said, ‘I’ve been to them and don’t want to go back.’ Patients fall through the cracks for a number of reasons: for not adequately testing their blood sugar, for not counting carbohydrates, for not understanding what is going on in their body, for not having a functioning meter.

These are long-term MTM clients, and I have seen them make changes in the way they take care of themselves because of the education during MTM visits and ongoing conversations when in the pharmacy,” Chaffin said. “For instance, with one patient, the first step was to facilitate getting a working meter, then educating on how to use it, coaching on using it regularly and keeping a record, reviewing the blood sugar record at the pharmacy, and encouraging that the record be taken to every provider visit. This first step was essential to the management of the patient’s diabetes medications.

MTM requires follow-up by the pharmacist and follow-up is easily facilitated when the patient gets their medications filled at the pharmacy where they have MTM. “One of my MTM cases revealed a client had been unintentionally ‘masking’ HTN with propranolol originally prescribed back in the 1970s (which was refilled by her doctor for all of these years, to be taken prn for anxiety). However, the client took propranolol before going to physician office visits because she was anxious about going; at the visits her blood pressure appeared to be well controlled.

However, she took the propranolol prn so when her blood pressure was taken at our pharmacy at her MTM visit, it was noted to be quite elevated and additional readings during the month showed high readings. The issue was that she took a blood pressure medication for anxiety (some docs did prescribe this way), but only took it as prn. In this case, MTM at her own pharmacy made it easy for her to stop in and get additional blood pressure readings to confirm HTN. She wasn’t nervous about coming to the pharmacy and did not take propranolol prior to the MTM visit. MTM resulted in her realizing she had HTN, in her understanding of the imporMTM Update 2011 continued on page 22

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2012 Medication Therapy Management program eligibility information available via

the Medicare Plan Finder

by Cynthia G. Tudor, Ph.D., Director, Medicare Drug Benefit and C & D Data Group

In addition to helping Medicare beneficiaries make informed decisions regarding health and prescription drug plans, CMS is committed to increasing beneficiaries’ awareness about Medication Therapy Management (MTM) programs. As part of this effort, Medicare beneficiaries will be able to view 2012 MTM program eligibility information via the Medicare Plan Finder (MPF) beginning this Fall during open enrollment. This memo provides a sample layout and a description to Part D sponsors about the information to be displayed.

Background

The Medicare Modernization Act established requirements for Part D sponsors regarding cost control and quality improvement, including requirements for MTM programs.1 Part D enrollees who have multiple chronic diseases, are taking multiple Part D drugs, and are likely to incur annual costs for covered Part D drugs that exceed a predetermined level are targeted for the MTM programs.2 Sponsors have some discretion to define their specific eligibility criteria. Annually, sponsors must submit a MTM program description to CMS for review and approval, including their program’s eligibility criteria, through the Health Plan Management System (HPMS) in the MTM Program Submission Module.

Certain changes to a Part D sponsor’s approved MTM program during the program year or prior to the start of the upcoming program year may be allowed by CMS. This policy can be found at: www.cms.gov > Medicare > Prescription Drug Contracting > Medication Therapy Management. All proposed changes must be submitted to CMS for review and approval prior to the implementation of requested changes. Sponsors may request changes to their CY 2011 and/ or 2012 MTM programs during the next update window, which is between September 1 and 10, 2011.

MTM Program Eligibility Information Posted on the MPF

Beginning in October, the MPF will display 2012 MTM program eligibility information for use during this Fall’s open enrollment period. The information will be displayed on the “Your Plan Results” page for Medicare Advantage Prescription Drug Plans (MA-PDs) and stand-alone Prescription Drug Plans (PDPs) through a link labeled View Plan Medication Therapy Management (MTM) Program Eligibility Information. The link will bring the beneficiaries to an Excel spreadsheet on the CMS Web site. See the following page for a mock-up of the information that will be displayed. The table will be populated using the eligibility criteria information from sponsors’ CMS-approved 2012 MTM programs from the HPMS MTM Program Submission Module, including programs approved during the September update window. A document and glossary will also be included to describe to beneficiaries how to use the table. Advocates and Medicare beneficiaries can sort the information to view the MTM program eligibility requirements for available drug plans. They can also look for programs available for their specific health conditions or drug utilization. Advocates and beneficiaries will be encouraged to contact each drug plan for more details about their MTM program and if they may qualify for it. We are exploring other ways to integrate this information into the MPF in the future.

We appreciate your continued cooperation in administering the Medicare drug benefit. Questions regarding Part D MTM programs should be sent via email to partd_mtm@cms.hhs.gov.

References 1 MMA 2003, under title 42 CFR Part 423, Subpart D 2 § 423.153(d)(1) Medicare Plan Finder continued on page 20 Minnesota Pharmacist Fall 2011 n

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Sample Layout View Plan Medication Therapy Management (MTM) Program Eligibility Information

If you’re in a Medicare drug plan and have complex health needs, a Medication Therapy Management (MTM) program can help you and your doctor make sure your medications are working to improve your health.

You’ll get a review of all your medications with a pharmacist or other health professional, who’ll talk with you about how to get the most from the drugs you take. You will be able to talk about any problems you may be having and ask questions about your medications. You’ll also get a summary of this discussion to help you talk with your doctors, pharmacists, and other providers.

MTM programs are no cost to you. We encourage you to take advantage of this valuable program if you qualify.

You May Qualify for an MTM Program

You may qualify if you’re in a Medicare drug plan and meet these 3 requirements: 1. Have at least 2 chronic health conditions, and 2. Take at least 3 medications, and 3. Use medications that cost more than $3,100 for the year combined (your costs and your plan’s costs).

Contact each drug plan for details about their MTM program and if you may qualify for it. (https://www.medicare.gov/find-a-plan)

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The Minnesota Pharmacists Foundation works to create a strong future for pharmacy by investing in pharmacists of tomorrow. The Foundation backs this commitment by providing annual scholarships to pharmacy students attending the University of Minnesota campuses in Duluth and Minneapolis.

Visit our page on Facebook or the MPhA site to learn more about how you can help us achieve our goals!

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Accountability Increases Ability

By Diane Ciotta

“Are you working hard or hardly working?”

This question often gets a chuckle. Unfortunately, it’s less humorous as it has become increasingly more difficult to find hard-working help. Many employers are challenged daily by the frustration of lackadaisical attitudes of their personnel, which is seemingly contagious and complicated by the expense of constant turnover.

One corporation in particular was crippled with what could be called a stress-leave epidemic. It began when one sales executive complained to his/her Human Resources Department that he/she was under too much pressure to reach sales goals and consequently his/her doctor recommended this person take some time off for health reasons. The company policy granted six weeks, which coincidentally (and conveniently) started the week before Thanksgiving and ended just after the New Year. This person’s absence increased the responsibilities of the other team members to serve that employee’s current customers, which in turn resulted in a domino effect of more so-called necessary stress-leave cases.

As if the impact of this cancerous situation wasn’t bad enough … every position was required to be held and in each case, entire commissions were paid to the original sales person! To add insult to injury, the first offender of this crisis invited all of his/her co-workers to a holiday party that admittedly was planned as a result of not working, as it provided adequate time to prepare for such an affair.

The company’s policy could be considered problematic, but in legitimate situations and when not abused, the benefit opportunity is quite generous. It’s the misuse of plan that is extremely disturbing and the lack of conscience on the part of the abusers that is inexcusable.

The most puzzling factor in this scenario is that considering the current state of the economy and the unemployment rate at an all-time high, it would seem that people should be grateful to be employed and therefore perform above and beyond the call of duty to maximize their earnings and secure their position. Instead, the opposite is often true ­— many choose to hardly work and some even find ways to work the system and essentially not work at all.

Can accountability really be taught? Granted, a small child can certainly learn to take responsibility for his/her own actions through positive example and consistent discipline. On the other hand, a person of working age needs encouragement as opposed to training.

Effectively motivating employees to be more accountable stimulates an optimistic focus on both results and attitude. There are several ways to establish a comfortable, non-complacent environment, including: 1. Focus on coaching vs. managing. Too often management operates by means of intimidation rather than motivation.

Just as customers are more inclined to buy from people they like, employees will typically work harder for a boss

they respect more than fear. Coaching is the art of showing, not just telling. In addition to building better employer/ employee relationships, learned skills encourage a more committed focus than just dictated tasks.

2. Set challenging, yet attainable expectations. Being stretched promotes growth but being overwhelmed causes anxiety. Finding a balance between requiring responsibilities that are progressive without being incredulous will enhance accountability and confidence.

3. Provide incentives for productive activity in addition to end results. Rewards given for reaching a goal or completing a duty are great, but there are benefits to recognizing effort as well as accomplishment. To acknowledge a positive action through incentives is a subliminal way of encouraging productive behavior. Activity becomes habit and affirmative results increase conviction.

4. Dedicate time in department meetings to recognize excellence. Team meetings typically cover “housekeeping items” that could be easily communicated through email. Instead, using this forum as an environment to edify activity rather than to cover mundane information offers a terrific opportunity to recognize accomplishment in areas of attitude and activity. The impact is two-fold. To hear praise is terrific but to be praised in front of associates is awesome, while it subconsciously raises the expectation bar.

5. Commit to replacing complacent behavior. Neither party is doing the other a favor by hanging on to something that’s not a good fit. In many cases, a decision to terminate an inadequate performer results in a better outcome for both people where the terminated employee finds something more appropriate for their professional needs and the employer fills their position with someone much more qualified for the requirements of the position. It’s a winwin situation.

There is no advantage in the association between an unfulfilled employee and/or a discontent employer. As the saying goes, “If it ain’t good for everybody it ain’t good for nobody!” In an effort to gain a mutually beneficial working relationship, commit to being accountable, then encourage and expect accountability and take the necessary action when either is missing from the equation. The result will offer a return on investment for both parties.

Diane Ciotta is the founder of The Keynote Effect, where she presents a passionate message of accountability and encourages activities to conquer complacency. As a professional speaker with more than 20 years of sales training experience, she is also co-author of the book, “Pushing to the Front,” with Brian Tracy. For more information, please visit www. thekeynoteeffect.com, e-mail di@thekeynoteeffect.com or call 732-6727942.

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Feature MTM Update 2011 continued from page 18 tance of controlling HTN and in her willingness to visit her physician as recommended. She was prescribed the HTN medication I recommended to her PCP to be taken on a scheduled basis. I followed up with getting her new HTN medication filled and she continues to get regular blood pressure readings at the pharmacy.”

When asked if she see trends in working with patients, Chaffin said not in working with patients, but in keeping much better records of visits with patients.

“A trend that I do see is increased documentation/verification/confirmation/evaluation of MTM resulting in benefits as seen by insurance companies. Getoutcomes.com states on their Web site that program evaluation results of more than 100,000 members (from a program in a state other than Minnesota) resulted on average, in more than $600 per member in overall cost savings annually. PharmMD, a Tennessee-based comprehensive MTM company, published its 2011 Industry Trend Report stating that ‘MTM continues to have high satisfaction ratings with 94 percent of customers stating they would recommend the service to a friend and 89 percent of customers stating that pharmacists offered help that could not be obtained from anyone else.’ The report also states that several health plans saved more than $30 million from MTM programs.

The PharmMD report further stated: “MTM has seen tremendous growth across many industries and stands poised to gain an even louder voice in the broader care management market, if the quality of services in MTM programs continue to improve.”

Nearly 20 years of history, encapsulated into a few short paragraphs, does not give justice to the efforts driven by MPhA to bring this valuable service to those in Minnesota who need it the most. The case studies tell the story – patient satisfaction is the headline. Pharmacist satisfaction is close behind. Of course, being paid and acknowledged as medication experts has been long-awaited. Making a significant impact in the health of patients – what could be more fulfilling? And, to begin to be recognized as efficient and valuable players in the overall health care picture – one might say – it looks like progress is being made.

“Efforts like this one are perfect examples of why there is a state pharmacy association,” said Julie K. Johnson, Pharm.D., executive vice president and CEO, Minnesota Pharmacists Association. “And why,” she added, “All pharmacists should be members.”

Rita Tonkinson is a contracted staff writer for the association, who provides insightful looks into the field of pharmacy for our readers.

Pharmacy Time Capsules By: Dennis B. Worthen, Lloyd Scholar, Lloyd Library and Museum, Cincinnati, OH

2011 (Fourth Quarter) 1986—Twenty-five years ago:

Food and Drug Administration approval of the first monoclonal antibody drug, Muronomab-CD3 (also known as Orthoclone OKT3), for treatment of transplant rejection.

Total health care expenses for a population of approximately 244 million were approximately $477 billion.

Average prescription price was $14.36 and the average number of new and refill prescriptions filled per year was 29,100 according to the Lilly Digest.

1961—Fifty Years Ago:

Pharmacist Donald Hedgpeth and the Northern California Pharmaceutical Association indicted for violation of the Sherman Anti-trust Act for the development of a pricing schedule that incorporated a professional fee.

Amitriptyline HCl (Elavil) was introduced in the US by Merck Sharp & Dohme.

Total health care expenses for a population of approximately 189 million were approximately $29 billion.

Average prescription price was $3.25 and the average number of new and refill prescriptions filled per year was 15,100 according to the Lilly Digest.

1936—Seventy-five Years Ago:

Johnstown, PA was hit with a devastating flood on St. Patrick’s Day. Initial reports were that 27 out of 34 drug stores were destroyed. Pharmacists and manufacturers rushed aid to the city to assure that essential medicines were available.

1886—One hundred twenty-five years ago:

The Brooklyn College of Pharmacy was formed in 1886.

Renamed, it is now the Arnold and Marie Schwartz College of Pharmacy and Health Sciences of Long Island University.

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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Minnesota Pharmacist Fall 2011 n

Feature

The Changing Landscape For Vaccine Administration Managing vaccine storage and delivery at the pharmacy

By Kevin O’Donnell and Patrick McGrath Pharmacist administered vaccination is a growing trend at independent and chain pharmacy operations. During the H1N1 scare of 2009, the last of the 50 states passed laws allowing pharmacists to administer vaccines.

When pharmacists are involved with vaccines, inoculation rates are usually higher. Patients are becoming more comfortable with receiving vaccines from sources other than their primary care physician.

Pharmacists can improve the efficacy of the vaccines they administer by maintaining refrigerator temperatures, careful handling and documenting temperature records. State regulators require that records be maintained and will look for it upon inspection. With everything a pharmacist must track and be responsible for, temperature record collection is often overlooked or taken for granted.

Accidents and power outages are a regular part of the pharmacy environment. Using simple procedures and intelligent equipment, pharmacists can easily ensure that the vaccines they administer have been stored at the proper temperatures in the pharmacy.

In its 2009 report the state of the world’s vaccines and immunizations, the World Health Organization (WHO) described vaccines as “one of the most powerful and cost-effective of all health interventions. It prevents debilitating illness and disability, and saves millions of lives every year. Vaccines have the power . . . to . . . save . . . lives.”1 Vaccines, according to the WHO, are ranked second only to clean water for the prevention of disease and improvement of all human life.

In the U.S., a child can receive a dozen or more shots and be vaccinated against 23 diseases before the age of 18. The most recently published recommended immunization schedule furnished by The Centers for Disease Control and Prevention (CDC) states that the cost to immunize a child in the U.S. through adulthood is $1,195 for males and $1,483 for females.2 A vaccination administrator will typically hold between $5,000 and $15,000 of vaccine inventory in a refrigerator at any one time.3 The fragile nature of vaccines requires that they must be stored at proper temperatures. To maintain their efficacy, most vaccines require refrigeration, while some must remain frozen. All vaccines must be protected from heat. The CDC also estimates that between 15-35% of all vaccines distributed in the U.S. become unusable and are wasted as a result of temperature spoilage.4 The proper procurement, storage and administration of vaccines is essential for maintaining both the social value and economic value of these drugs.

Under New Administration

Pharmacists regulated by individual states’ laws have been administering vaccines to patients for many years. It was only in October of 2009 that the state of Maine passed a law to become the last

of the 50 states to allow pharmacists to administer vaccines.5 Advancements in the training of pharmacists initiated by the American Pharmacy Association (APhA) in 1996 accelerated the practice when they published the Pharmacy-Based Immunization Delivery Program, which was endorsed by the CDC.6 By 2006, 43 states had laws on the books allowing registered pharmacists to provide immunizations. The H1N1 pandemic influenza scare of 2009 motivated the few remaining states to enact legislation removing legal hurdles to allow pharmacists in all 50 states to administer vaccines.7 The nationwide shift in vaccine administration by pharmacists received additional legislative endorsement when the Patient Protection and Affordable Care Act was signed into law on March 23, 2010 as part of the Healthcare Initiative created by President Obama. Under PPACA, which became effective September 23, 2011, “children 0 -18 years that are enrolled in new group or individual private health plans will be eligible to receive vaccines recommended by the CDC Advisory Committee on Immunization Practices (ACIP) prior to September 2009 without any costsharing requirements when provided by an in-network provider.”

Essentially, this means that co-payments or deductibles will no longer be accepted for the administration of vaccines for preventive care.

Conventional wisdom holds that this economic pressure on primary care physicians and pediatricians will discourage them from administering vaccines. At the 2011 APhA conference in Seattle, Wash., the association’s president, Harold Godwin, stated that he believes this will increase the flow of patients to pharmacists for vaccinations, and that pharmacy owners should work with local physicians to facilitate information sharing to complete patient history files.

Studies Show Pharmacists are Qualified

Each year, nearly 90,000 Americans die of infections that can be prevented by vaccination, such as influenza, pneumococcal disease, and hepatitis B, according to the ACIP. Influenza and pneumonia together are the fifth leading cause of American deaths.8 A study published in 2004 in the journal Vaccine compared influenza vaccination rates in states where pharmacists were authorized to administer vaccines versus states where they were not.

Researchers reviewed and compared data from 1995, when only nine states allowed pharmacists to vaccinate patients, with data from 1999, when the number of states had grown to 30. The Managing Vaccine Storage continued on page 24 Minnesota Pharmacist Fall 2011 n

23

Feature Managing Vaccine Storage continued from page 23 research concluded that states allowing pharmacists to provide immunizations had significantly more people in all age groups who were immunized against influenza than in states that did not.

Among patients ages 18 to 64, states allowing pharmacist administration of vaccines had a 5% increase in vaccination rates between 1995 and 1999. And for patients age 65 years and older, influenza vaccination rates were significantly higher in states allowing pharmacist vaccination (10.7%, compared with 3.5% in states without authorization).9 This demonstrates that making vaccines more accessible to the general population through pharmacists results in a higher vaccination rate. The time-strapped American consumer is often influenced by convenience. The administration of vaccines at a local pharmacy without the need, time or costs associated with scheduling a doctor’s appointment is a tempting convenience indeed — just one more thing to add to the list of things to get while at the pharmacy. This model can be leveraged to improve vaccination rates for conditions other than influenza.

Are Pharmacists Ready for This New Responsibility?

Properly trained pharmacists are taking proactive steps to improve their potential for success. It is proposed that the standard concern of pharmacists is centered around the procedures for injecting the patient and informing them of potential side-effects while not enough emphasis is placed on the processes for receiving vaccines, storing them at proper temperature levels, and reporting their administration to physicians or state registries. Pharmacists may be experienced with managing tablet-style drug inventories, but the physical fragility of temperature-sensitive vaccines carries additional responsibilities. If they are stored or administered at temperatures that are too high or too low, efficacy can be negatively affected and the patient may be inadequately protected.

Managing Temperature-Sensitive Vaccines at the Pharmacy Level

Vaccines have great social value allowing for an improved quality of life by preventing debilitating diseases. They carry a high inventory value because of their typically high cost per dose, making temperature management a critical component to inventory, cost and patient well-being. Improperly stored vaccines can lose their efficacy. They must be maintained at required temperatures as determined by the manufacturer’s stability studies, up to the point of administration to the patient. For these reasons, pharmacists are encouraged to be trained on proper vaccine storage and handling procedures and be equipped to execute appropriate measures to ensure that proper temperature conditions are maintained during storage and administration. Prior to administering vaccines, a pharmacist will receive certification training from a state approved agency. However, in some cases they may not be fully trained to handle temperature management.

24

Minnesota Pharmacist Fall 2011 n

Good and Best Practices

The CDC has clearly indicated that proper handling and storage of vaccines is paramount. An organization’s basic quality management plan should ensure that each receiving location identifies an individual as the primary vaccine inventory person, and another as the secondary/backup person. They should be responsible for receiving, storing and handling all vaccines. They should maintain an inventory log documenting the vaccines received. This should include the drug name, date received, lot number, expiration date and arrival condition — including temperature. When receiving vaccines, it is important to inspect the product to ensure the temperature has been maintained, and the product should be stored according to its recommended label conditions immediately upon arrival. This is in accordance with the CDC Vaccine Handling and Storage Tool Kit, an on-line tool that can be found at www2a.cdc. gov/vaccines/ed/shtoolkit/. The guide goes on to state that if vaccines arrive without a temperature monitor device or data logger or the temperature appears to be above or below that which is listed on the manufacturer’s storage label, the supplier and/or the manufacturer should be contacted. These vaccines should be quarantined or segregated and kept in the cold-chain but clearly marked so as not to be mistakenly used until it is determined if they are acceptable for use or if they are to be returned for replacement.

When storing vaccines, the CDC recommends the use of a unit with separate refrigerator and freezer space. Vaccines should be placed into “breathable plastic mesh baskets” on the middle shelves (never on doors, in drawers/bins or against walls). Separate vaccines by bin and label them according to the vaccine within.

Refrigerators or freezers used to store vaccines should not contain food or beverages. It is recommended to place bottles with water on door shelves to stabilize internal temperatures.10 Refrigerator temperatures must be maintained between 2º and 8º C (35ºF and 46ºF). Vaccines efficacy will decrease if they are exposed to temperatures beyond their allowable range. Diminishing efficacy is not necessarily a linear process. Often degradation is accelerated over time as the result of excessive temperature exposure or after multiple exposures to temperatures outside the recommended storage condition.

Managing Vaccine Storage continued on page 25

Feature Managing Vaccine Storage continued from page 24 The CDC advocates the use of a mercury bulb thermometer or a digital thermometer inside a vaccine storage unit and manually recording the storage equipment or facility twice a day at a minimum. However, not only can such devices and processes be inaccurate, but they fail to document an elapsed history of temperature exposure. Continuous monitoring of the internal temperature of the storage unit is considered a best practice. This is most reliably achieved through the use of an electronic temperature-monitoring device. It is important to have an accurate, calibrated device that can provide the high and low temperatures observed each day as well as alert the user to situations when the temperature has gone beyond the required range. The WHO, for example, recommends the use of a 30-day device (such as the Fridge-tag®).11 This device will record and display high and low temperature data for the preceding 30 days. It will also provide a visual indicator if temperatures have exceeded a specified range, and if so, for how long. Such a device may be helpful to pharmacies that are closed overnight and need visibility of temperatures when no one is present.

administration to the patient, it may not stop the very disease it is meant to prevent.

Kevin O’Donnell is a senior partner at Exelsius Cold Chain Management – U.S. He serves as chair for the International Air Transport Association (IATA) Time & Temperature Task Force, is a member of the USP Expert Committee on Packaging, Storage and Distribution, and is a temporary advisor to the WHO. He blogs at www.coolerheadsblog.com. He can be reached at kevin.odonnell@exelsius.us.

Patrick McGrath is general manager, Berlinger USA LLC. He has an MBA fromTemple University, is a long-standing member of the Parental Drug Association and is serving as a temporary member of a CDC advisory committee.

References

The CDC recommends every pharmacy have an emergency vaccine retrieval and storage plan. Facilities should be equipped with a back-up generator, or an uninterrupted power supply or an approved alternate or off-site storage location. In the event of a power outage, emergency plans need to be in place and practiced well before they need to be implemented. It is important to have an emergency call-tree readily accessible for managing vaccine inventory and escalation procedures. Portable insulated coolers and preconditioned refrigerants will help if vaccines need to be moved to a new location. In the absence of a back-up generator or uninterrupted power source, it is important to keep the refrigerator and freezer doors closed and to rely on a continuous temperature monitoring device for information on inventory viability. Should temperatures go outside of the required range it is important to contact the manufacturer with the maximum temperature recorded and total time out of temperature. Only the manufacturer of a vaccine can determine the proper dispensation of a product that may have been compromised due to exposure to high or low temperatures.

1 WHO, UNICEF, World Bank. State of the world’s vaccines and immunization, 3rd ed. Geneva,World Health Organization, 2009.

Changing U.S. laws and shifting payment policies ensure that pharmacists will play a growing role in the administration of vaccines in the future. This increased access to vaccines among the U.S. population will result in lower costs and will benefit patients and society by preventing or potentially iradicating diseases. It is important for all involved within the vaccine supply chain that this paradigm shift is recognized and actively planned for and that appropriate records of temperature conditions in storage and transportation are maintained. States’ boards of pharmacy requiring certification for vaccine administration by pharmacists can improve patient outcomes by including training on proper handling and storing of vaccines.

Continuous temperature monitoring and proper management of vaccine storage facilities at the pharmacy level decreases wastage, lowers costs and improves patient outcomes.

8 Spikoff, Martin. Should Pharmacists Be Allowed To Vaccinate Their Patients?, Managed Care Digest, January, 2008.

2 Recommended Immunization Schedules for Persons Aged 0 Through 18 Years - United States, 2009, Centers for Disease Control and Prevention, January 9, 2009. MMWR 2008; 57(51&52).

3 CDC Vaccine Price List, http://www.cdc.gov/vaccines/programs/ vfc/cdc-vac-price 4 ibid.

5 Egarvary, Alex. Maine Legislature Approves Pharmacist Immunization, Pharmacist.com. 24 June, 2009.

6 Terrie, Yvette C., RPh, Vaccinations: The Expanding Role of Pharmacists, Pharmacy Times, January 2010.

7 Hogue, Michael, D., et.al., Pharmacist Involvement with Immunizations: A Decade of Professional Advancement, Journal of the American Pharmacist, March/April 2006, Vol. 46 No. 2.

9 ibid.

10 Chojnacky, M., Miller, W., Ripple D., and Strouse, G. Thermal Analysis of Refrigeration Systems Used for Vaccine Storage (NISTIR 7656). November 2009.

11 Kartoglu, U., Erida Nelaj, E., Maire, D., Improving temperature monitoring in the vaccine cold chain at the periphery: An intervention study using a 30-day electronic refrigerator

Proper planning, training and temperature management will improve a facility’s ability to demonstrate that vaccines have been handled correctly. After all, if the vaccine’s efficacy, potency, safety or quality is compromised due to temperature excursions prior to Minnesota Pharmacist Fall 2011 n

25

Pharmacist and Technician Workforce

2011 Minnesota Pharmacist Compensation and Labor Survey

By Jon C. Schommer, Ph.D.; Akeem Yusuf, B.Pharm; Ronald S. Hadsall, Ph.D.; Tom A. Larson, Pharm.D; Stephen W. Schondelmeyer, Ph.D.; Donald L. Uden, Pharm.D.

The University of Minnesota, College of Pharmacy, Department of Pharmaceutical Care & Health Systems provided funding for this study. Our sincere thanks to the many pharmacists who responded to a survey that asked about personal information and took about 15 minutes to complete. It is only through their efforts that this report is possible.

Study Purpose and Methods

The purpose of this study was to describe Minnesota pharmacistsâ&#x20AC;&#x2122; demographic characteristics and compensation at their primary place of employment for 2011. A random sample of 454 pharmacists with active Minnesota pharmacist licenses and residing in Minnesota was selected from pharmacist records kept by the Minnesota State Board of Pharmacy. In July 2011, each sample member was mailed a cover letter, a postage paid return envelope, and a questionnaire that asked about his or her salary, benefits, and demographic characteristics. Three weeks after the initial mailing, another survey form and postage paid return envelope were mailed to non-responders.

Of the 429 deliverable surveys, a total of 201 (46.9 percent) pharmacists responded. Only pharmacists who reported they were actively practicing pharmacy in Minnesota for at least an average of 30 hours per week were included for data analysis. Thus, a total of 113 respondents met our inclusion criteria for this report.

Respondents were categorized as working in one of three regions of the state: (1) Twin Cities Metropolitan Area, (2) Other Urban Areas with Populations Greater than 75,000 (Duluth, Rochester, St. Cloud, Moorhead/Fargo), and (3) Small Urban/Rural Areas.

For each category, descriptive statistics for demographic characteristics, hourly wages at their primary place of employment, and benefits at their primary place of employment were computed. In addition, wage information was further categorized by practice setting [independent, chain (11 or more units under common ownership), hospital, or other], position (management or staff), and gender (male or female).

During the time of the 2011 survey, both the state of Minnesota and overall United States economies were still recovering from an economic recession that began in 2008. Thus, for the 2011 survey, we asked questions about pharmacist unemployment, and also about (1) layoffs, (2) mandatory reductions in hours, (3) early retirement incentives, and (4) restructuring of work schedules for both pharmacists and technicians.

Results

Table 1 contains a summary regarding demographic characteristics of respondents who were actively practicing pharmacy in Minnesota for at least 30 hours per week. Overall, pharmacist practice settings were hospital (40 percent), chain (35 percent), other (18 percent), and independent (7 percent). Forty-two percent of these respondents held a management level position and 58 percent held staff positions. The average age of these respondents was 42 years and they also reported an average of 17 years in practice. Gender distribution was 56 percent female and 44 percent male. Overall, pharmacists reported working an average of 41 hours per week and devoted an average of 53 percent of their time to dispensing activities with the other 47 percent devoted to patient care services, business/organization management, research, education, or other activities not described in the other categories. Fifty-two percent of the respondents reported that a B.S. in Pharmacy was their entry level practice degree.

Table 2 summarizes hourly wage information for selected categories of respondents. Results are reported as average dollar amounts (dollars per hour) for each respondentâ&#x20AC;&#x2122;s primary place of employment.

Income from other jobs, overtime, bonuses, profit sharing, or other earnings are not included in this table. Thus, Table 2 should be viewed as presenting information about gross base earnings reported on a per hour basis. Such reimbursement does not include other sources of income and does not reflect the value of fringe benefits that most pharmacists receive.

Results presented in Table 2 show that, on average, Minnesota pharmacists, who were working at least 30 hours per week, reported an hourly wage of $58.15 for 2011. In comparison, the average hourly wages for Minnesota pharmacists were $56.18 in 2009, $53.38 in 2007, $48.30 in 2005, $43.90 in 2003, $38.77 in 2001, and $30.81 in 1999 (see Figure 1). Thus, from 1999 to 2001 hourly wages increased by 26 percent (from $30.81 to $38.77), between 2001 and 2003 hourly wages increased 13 percent (from $38.77 to $43.90), between 2003 and 2005 hourly wages increased 10 percent (from $43.90 to $48.30), between 2005 and 2007 hourly wages increased 10.5 percent (from $48.30 to $53.38), between 2007 and 2009 hourly wages increased 5 percent (from $53.38 to $56.18), and between 2009 and 2011 hourly wages increased 3.5 percent (from $56.18 to $58.15). It should be noted that these hourly wages are not adjusted for inflation.

Compensation and Labor Survey continued on page 27

26

Minnesota Pharmacist Fall 2011 n

Pharmacist and Technician Workforce Compensation and Labor Survey continued from page 26 Table 1: Demographic Characteristics

Characteristic

Twin Cities Metropolitan Area (N=60)

Other Urban Area with Population Greater than 75,000 (N=14)

Small Urban or Rural Area (N =39)

Overall (N= 113)

Practice Setting

N = 60

N = 14

N = 39

N = 113

Independent

4%

0%

13%

7%

Chain

30%

21%

49%

35%

Hospital Other a

43%

64%

26%

40%

22%

14%

13%

18%

Position

N = 60

N = 14

N = 39

N = 113

Management b

35%

43%

51%

42%

Staff

65%

57%

49%

58%

Age

N = 60

N = 14

N = 39

N = 113

(in years, mean +/- s.d)

43 +/- 11

39 +/- 11

43 +/- 11

42 +/- 11

Gender

N = 59

N = 14

N = 39

N = 112

Female

59%

43%

56%

56%

Male

41%

57%

44%

44%

Degree

N = 60

N = 14

N = 39

N = 113

B.S. Pharm Other c

52%

43%

62%

54%

48%

57%

38%

46%

# years practice

N = 60

N = 14

N = 39

N = 113

(in years, mean +/- s.d.)

17 +/- 12

16 +/- 11

17 +/- 12

17 +/- 12

Hours worked/week

N = 60

N = 14

N = 39

N = 113

(hrs per wk, mean +/- s.d.)

41 +/- 8

44 +/- 13

41 +/- 5

41 +/- 8

% time devoted to Dispensing Activitiesd

N = 60

N = 12

N = 39

N = 111

(%, mean +/- s.d.)

48% +/- 37

35% +/- 35

66% +/- 24

53% +/- 34

a Other includes clinic, mail service, long term care, home health/infusion, pharmacy benefit administration, academia, or other non-licensed pharmacy organization. b Management includes partner, executive officer, manager, director, assistant manager, supervisor, or other non-staff role. c Other signifies a Pharm.D. as the entry-level degree. d Dispensing was defined as: â&#x20AC;&#x153;preparing, distributing, and administering medication products, including associated consultation, interacting with patients about selection of over-the-counter products, and interactions with other professionals during the medication dispensing process.â&#x20AC;?

Note: Some of the percentages may not total 100% due to rounding. Ns may not total 113 due to item non-response.

Table 3 presents the distribution for responses relating to fringe benefits. The percentages given in the table reflect the proportion of respondents who answered that they did receive a particular benefit either partially or fully paid by their employer. Rather than listing benefit types from the most common to the least common benefit, we instead listed them based on the following groupings: Insurance benefits, Savings/Retirement benefits, Vacation/Leave benefits, Professional benefits, and Other Miscellaneous benefits.

Effects of the 2011 Economy on the Pharmacy Workforce

Out of the 201 respondents to our survey, our findings showed that only 3.0 percent reported that they were unemployed, which was

significantly less than the Minnesota unemployment rate (7.2%) and U.S. unemployment rate (9.1%) during the same time period.

Of respondents who were unemployed, only 33 percent reported that they were seeking employment.

Results for questions related to (1) layoffs, (2) mandatory reductions in hours, (3) early retirement incentives, and (4) restructuring of work schedules for both pharmacists and technicians showed that 37 percent of respondents reported restructuring of pharmacist work schedules at their workplace to save labor costs, followed by mandatory reductions in pharmacist hours (16%), early retirement Compensation and Labor Survey continued on page 28 Minnesota Pharmacist Fall 2011 n

27

Pharmacist and Technician Workforce Compensation and Labor Survey continued from page 27 Table 2: Hourly Wagea Information for Respondents Categorized by Practice, Position, Region, and Gender

Region N = 110b Practice and Positionc Category

Twin Cities Metro Area N = 58

Gender N = 109b

Other Urban Area with Population >75,000 N = 14

Small Urban or Rural Area N = 38

Male N = 49

Overall N = 110b Female N = 60

Independent, Management

*

*

*

*

55.35

55.35

Independent, Staff

52.00

*

53.75

52.00

55.50

53.17

Chain, Management

62.11

65.17

60.31

60.98

61.76

61.37

Chain, Staff

58.28

58.12

58.42

58.36

58.29

58.33

Hospital, Management

62.98

66.33

57.37

62.32

61.40

61.86

Hospital, Staff

57.54

59.56

52.87

57.58

57.15

57.16

Otherd, Management

*

60.00

54.85

58.00

54.17

54.72

Otherd,

54.89

*

55.06

56.51

53.78

54.92

58.17

61.27

56.96

58.63

57.85

58.15

Staff

OVERALL (all respondents)

a Results are reported as average dollar amount (dollars per hour) for respondentsâ&#x20AC;&#x2122; primary place of employment. Data are not reported for cells with fewer than 2 respondents. b Ns do not total 113 due to item non-response. c Management includes owner, partner, executive officer, manager, director, assistant manager, supervisor, or other non-staff role. d Other includes clinic, mail service, long term care, home health/infusion, pharmacy benefit administration, academia, or other non-licensed pharmacy organization.

incentives for pharmacists (7%), and pharmacist layoffs (5%).

Regarding technicians, 36 percent of respondents reported restructuring of technician work schedules, followed by mandatory reductions in hours (21%), layoffs (5%), and early retirement incentives (2%).

Figure 1: Hourly Wages for Minnesota Pharmacists, Actively Practicing for at Least 30 Hours Per Week

(1999, 2001, 2003, 2005, 2007, 2009, 2011)

Final Comments

The results are part of a series of surveys designed to help assess the economic and practice environments of practicing pharmacists in Minnesota. Findings for the years 1999 to present are available from the corresponding author upon request (schom010@umn.edu). Longitudinal analysis of these data has contributed to our understanding of how the supply and demand for pharmacists fluctuate over time as pharmacy education and practice environments continue to evolve.

Also, the results can be used for making hourly wage and benefit comparisons among different groups of pharmacists in Minnesota.

Jon C. Schommer, Ph.D. is Professor and Director of Graduate Studies at the College of Pharmacy, University of Minnesota.

Compensation and Labor Survey continued on page 29 28

Minnesota Pharmacist Fall 2011 n

Note: Hourly wages are not adjusted for inflation.

Pharmacist and Technician Workforce Compensation and Labor Survey continued from page 28 Table 3: Distribution of Fringe Benefits

Type of Fringe Benefit

Twin Cities Metropolitan Area (N=60)

Other Urban Area with Population Greater than 75,000 (N=14)

Small Urban or Rural Area (N = 39)

Overall (N=113)

Health Insurance – Self

95%

100%

100%

97%

Health Insurance – Spouse

90%

100%

92%

92%

Health Insurance – Dependents

92%

93%

92%

92%

Dental Insurance

92%

71%

87%

88%

Life Insurance

92%

79%

90%

89%

Disability Insurance

83%

64%

77%

79%

Malpractice Insurance

33%

36%

39%

35%

Tax Sheltered Savings (e.g. 401K)

92%

93%

80%

88%

Pension Plan

60%

50%

21%

45%

Stock Purchase Options

20%

29%

36%

27%

Maternity/Paternal Leave

73%

86%

72%

74%

Non-paid Leave

62%

79%

69%

66%

Paid Professional Leave

32%

50%

26%

32%

Sick Leave

72%

86%

72%

74%

Paid Vacation

90%

100%

100%

95%

Paid Personal Days

67%

36%

54%

58%

Paid Association Dues

22%

7%

13%

17%

Paid License Fee

13%

0%

21%

14%

Professional Attire Allowance

5%

14%

8%

7%

Paid Meeting or Seminar Fee

32%

57%

21%

31%

Tuition Remissions

42%

64%

8%

33%

Parking Allowance

7%

7%

0%

4%

Employment Travel (e.g. mileage)

40%

29%

44%

40%

Child Care Allowance/Service

7%

7%

3%

5%

Shift Differential

48%

57%

15%

38%

Job Sharing

2%

0%

0%

1%

Flexible Schedule

35%

21%

39%

35%

Discounts on Personal Purchases

53%

36%

62%

54%

Discounts on Prescriptions

25%

29%

36%

29%

Company Car

2%

0%

0%

1%

Expense Account

7%

0%

0%

4%

Flexible Spending Accounts

73%

71%

74%

74%

Results are reported as proportion of respondents who answered “yes” to having the benefit partially or fully paid by their employer. For information about definitions of the benefits listed in this table, contact the corresponding author, Jon Schommer, at schom010@umn.edu.

Akeem Yusuf, B.Pharm. is a Ph.D. Candidate in the Social and Administrative Pharmacy graduate program, College of Pharmacy, University of Minnesota.

Ronald S. Hadsall, Ph.D. is Professor at the College of Pharmacy, University of Minnesota.

Tom A. Larson, Pharm.D. is Professor and Associate Dean at the College of Pharmacy, University of Minnesota.

Stephen W. Schondelmeyer, Ph.D. is Professor, CMC Endowed Chair in Pharmaceutical Management and Economics, Director of the PRIME Institute, and Department Chair at the College of Pharmacy, University of Minnesota.

Donald L. Uden, Pharm.D. is Professor at the College of Pharmacy, University of Minnesota.

Minnesota Pharmacist Fall 2011 n

29

Feature

The MPhA Readership Survey Identifies Strengths and Weaknesses of Various MPhA Publications In late summer 2011, MPhA sent emails to approximately 960 members (representing all members for whom we have valid email addresses), asking them to complete an online survey about MPhA communication vehicles. More than 100 members responded to the survey, representing enough members to give us a good sample size of our members. Because members had to complete the survey electronically, the responses may be skewed somewhat toward those members who are most comfortable with working in an online environment.

The results show strong member interest in MPhA publications, but most especially with the Minnesota Pharmacist magazine. More than half of all respondents indicated that they “always” read the magazine, with almost 21% saying they “often” read it, and about 18% saying they read it “sometimes.” Compared with many other professional associations, these are very strong numbers.

When asked about the types of material that are most and least interesting, respondents indicated the highest interest in articles about practice issues in the Minnesota Pharmacist; 92% told us those articles were either very or somewhat interesting. Articles about event updates, legal issue updates, and in-depth information also rated highly. Members also indicated that interest in the MPhA E-news is strong, with approximately 87% saying the e-newsletter is very or somewhat interesting. However, a few of the comments showed that members are less interested in the weekly Pharmacy News Flash (because that newsletter didn’t begin until after our survey was written, we didn’t ask about it specifically in this survey). CAPS, our monthly fax/email newsletter, also had a good showing, with 85% saying it is very or somewhat interesting.

Members gave the Minnesota Pharmacist generally good ratings for readability, visual appeal, clarity of content, and informativeness. More than 73% say that the quarterly frequency is just about right. A few members indicated that they would prefer to receive the magazine electronically, but just as many urged us to continue printing it. As a result, the MPhA Editorial Advisory Board will likely give members the ability to opt in for electronic delivery.

One area where MPhA needs to do more work is in giving members good reasons to use our Web site. Less than 30% of respondents (and these are likely to be the members most comfortable with working online) say they use the Web site at least a few times per month — and 11% of members say they never use the site.

The most common reasons that members have used the site are to look up information about an event (66%), to renew membership (63%), and/or to register for an event (61%).

30

Minnesota Pharmacist Fall 2011 n

We plan to put a copy of the full survey results on the MPhA Web site. We also plan to follow up in the future with mailed surveys (or perhaps a survey in a future issue of the Minnesota Pharmacist) to continue to gather feedback from our members. Our goal is to provide the information that our members want and need!

Feature

Health Mart Healthy Living Tour provides free health screenings at Brainerd, Crosby and White Bear Lake Health Mart Pharmacies

A pharmacist conducts a screening on the Health Mart Pharmacy tour at Range Drug

Three Health Mart pharmacies offered free health screenings to more than 70 patrons at recent events as a part of the Health Mart Healthy Living Tour.

On August 17, the tour made stops at GuidePoint Health Mart Pharmacy in Brainerd, Minn., and Range Drug Health Mart Pharmacy in Crosby, Minn. On August 18, the Tour headed south for a stop at White Bear Health Mart Pharmacy. This national mobile health campaign is designed to help identify people who are at risk for diabetes and to encourage those already affected by the disease to better manage their condition with personalized support from community pharmacists.

For Health Mart pharmacists, the events are indicative of Health Mart’s effort to help independent pharmacies attract new customers and maximize the value of existing customers through market-

ing support. Aboard the 40-foot mobile screening unit, tour staff are capable of conducting more than 35 screenings per visit, measuring blood pressure, blood glucose, total cholesterol and hemoglobin A1C levels.

Co-sponsored by Bayer Diabetes Care and Novo Nordisk, the Health Mart Healthy Living Tour will visit more than 100 pharmacies and screen thousands of Americans along the way. The tour aims to raise awareness of the growing diabetes epidemic—the disease affects approximately 25.8 million Americans.

A pharmacist conducts a screening on the Health Mart Pharmacy tour in White Bear Lake, Minn.

For information about becoming a Health Mart, visit http://www. becomeahealthmart.com.

Minnesota Pharmacist Fall 2011 n

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Student Perspective

Never Let A Disaster Go to Waste: Opportunities Presented by the Swine Flu Epidemic for Innovation in Global Public Health Emergency Response Delford Ilara Doherty, Pharm.D. and M.P.H. Candidate, 2010; University of Minnesota College of Pharmacy and School of Public Health Background

The ongoing Swine flu epidemic is another fierce reminder of our universal incapacity to respond to a global disaster. While researchers strive to understand the epidemiology of the recent outbreak of the H1N1 virus with the aim of devising a formidable response, politicians and pundits use the opportunity to push their political agendas, some spewing hate while others play the blame game. Throughout this saga, only a few actually stopped to think about the enormous opportunity presented by this swine flu outbreak.

The most humbling aspect of this outbreak is that it emphasizes the reality of our common destiny, not as individual nations, peoples or races, but as a global network of nations interconnected and bound by a common fate – our desire to survive as a civilization.

Consider the series of events that followed the swine flu outbreak on April 24, 2009. Within 24 hours of the World Health Organization (WHO) alert, the outbreak became a media frenzy resulting in a massive outpouring of, sometimes credible but mostly terrifying, information to the public. In a matter of days Mexican farmers were blamed for the genesis of “swine” flu (H1N1), and across the border in the United States conservative pundits seized the opportunity to pursue their fear mongering, stigmatizing Mexicans and illegal immigrants, calling them mules used in what they saw as a bioterrorist attack on the U.S. Within a week there were laboratory-confirmed cases across Austria, Canada, Germany, Israel, Netherlands, New Zealand, Spain, Switzerland and the United Kingdom. Meanwhile, across the globe nations quavered and most responded appropriately while others, ill-prepared, reacted illogically. For example, Egypt called for the slaughter of more than 300,000 pigs at a time when millions suffer from starvation across the world — while other nations like Ghana banned the importation of pork. In both cases, the nations reacted without preemptive evidence and took actions that were adverse to their national economies and to our universal interest. Subsequently, other nations responded by overreacting in a claim to protect their individual interests and citizenry, but in doing so took steps that severely infringed on individual liberties.

This was the case in China, where Mexican citizens and Canadian students were “detained” or “quarantined” without due process.

Within 10 days the outbreak, despite our best efforts, had spread 32

Minnesota Pharmacist Fall 2011 n

to 16 countries with more than 658 reported cases. This is not an attempt to trivialize the efforts of those working hard on the frontlines to prevent a global pandemic, nor is it an attempt to castigate current policies. The intention is to instigate innovation by highlighting recent facts. In 10 days the outbreak effectively exposed our global vulnerability, erupted our deepest fears and, most importantly, illuminated the acute need for an all-inclusive approach to global emergency response.

Our public health preparedness can only be as strong as our weakest link. The exclusionist mentality of the past in which nations look out solely for their own interest is archaic, unethical and unsustainable. No single nation can afford to act alone. There is a moral imperative for the cultivation of innovative ideas that will evolve into a blueprint for global public health emergency response. This essay highlights major pathways to developing the framework of the blueprint.

Provisions for Innovation

We are at a juncture in our history in which we must seize the opportunity to act to unite our efforts in order to prepare ourselves for unknown threats which may be lurking in the future.

With the gloom of natural disasters, bioterrorism, swine flu, severe acute respiratory syndrome (SARS), avian flu and a myriad of infectious diseases afflicting many in the underdeveloped world, we now have a mandate to conduct an overhaul of our international public health system in order to build our global capacity to respond to future threats. The following three provisions represent a possible pathway to innovation.

The first provision involves using the expertise and authority of WHO to build the global infrastructure to respond to global health threats from infectious diseases and bioterrorism. Building infrastructure would include the strategic placement of laboratories, the stockpiling of vaccines and medications and developing a model response plan based on unique regional and national capacities. This can be taken a step further by recruiting nations that can pledge personnel – health care, paramilitary, police, researchers – who will form a first response team that can be mobilized in a global emergency.

Never Let a Disaster Go to Waste continues on page 33

Never Let a Disaster Go to Waste continued from page 32 The second provision involves global investment and the exchange of intangible resources. The premise of this step depends on the hope that wealthy nations understand the imperative for global inter-reliance and the ethical responsibility they have to assist less fortunate and underdeveloped nations in building capacity to respond to local disasters. Under this provision a fund will be created to allocate funds across the globe in order to train researchers and health professionals, develop mechanisms for the exchange of epidemiological and other data and exchange ideas about processes.

Eventually, this initiative would evolve into a global forum where proactive and prevention strategies would be developed, along with global response policies with the aim of both standardizing and expediting response processes.

The most vital provision of this blueprint is that of advocacy. There is an acute lack of scientists, researchers and health professionals in advocacy. Scientists have generally relegated advocacy to the realm of politicians and pundits who may not have the technical background in order to fully appreciate the outcomes of scientific findings. Furthermore, scientists and health professionals, especially those in underdeveloped nations, have abdicated leadership and advocacy to function in traditional roles, underestimating the political landscape. For trends to move toward innovation for global emergency preparedness, there is a need for scientists and researchers to become better advocates in order to inform policymakers and taxpayers about the inherent and ethically justifiable need for global engagement and international investment in building global capacity to respond to disasters. It is a moral imperative and a strategic necessity for the WHO and other international advocacy organizations to create the means â&#x20AC;&#x201C; through funding, training and workforce development â&#x20AC;&#x201C; for scientists, researchers and health professionals to be proactive and become leaders in advocacy.

The Way Forward:

It is by no means obvious that these provisions necessarily herald a trend. For example, while there is much discussion of and support for a Model Emergency Response Act in the United States and other industrialized nations, underdeveloped nations are still limited due to several factors such as political instability, poor infrastructure and an almost nonexistent public health system. The provisions in this essay identify these limitations and provide illustrative ideas to address components that can be influenced by external factors such as funding, the focus on building strategic regional rather than national infrastructure, workforce development, etc. The key message, then, is that these provisions can be met incrementally.

With predictions of a possible more virulent strain of the H1N1 returning in the fall, advocates and policymakers have the attention of the public that provides the impetus for a mandate to act quickly and act now. This is not a proposal for a global one-size-fits-all blueprint in which industrialized nations control and dictate the agenda. Rather, this is an array of recommendations for global preparedness with the first step being the unequivocal empowerment of the WHO to use its platform and leadership in order to move forward in achieving the multipronged provisions presented here.

is imminent. This threat should launch a realization among the political community in industrialized nations regarding potential threats to their individual interests. This reawakening should shift the focus from personal and proprietary protections on the part of nations to a global approach that encompasses resource allocations, transformative policies that reflect ethical principles, global security and the building of global capacity to both prevent and respond to an emergency. There is a moral imperative for this.

As opposed to a global approach in dealing with the threat of a pandemic, most nations have taken exclusionist steps in only protecting their individual interests. In this global economy where nations exist in a kaleidoscope of markets that are interdependent on resources and share common economic ambitions, it is crucial for nations to collectively engage in meaningfully securing our universal health and safety.

While these provisions have their limitations, this essay does not seek to address those possible impediments, nor does it take them for granted. The purpose of this essay is to assert an illustrative pathway to an innovative global initiative that will improve preparedness, standardize and strengthen response to global health emergencies in order to protect our collective interests as a global community. We must either seize this opportunity to unite and strive, or continue on our current path to a potential peril. This is not an ideology; it is a call to action.

Del Doherty is a fourth-year Pharm.D. & MPH candidate at the University of Minnesota College of Pharmacy.

After surviving civil war in his homeland Sierra Leone, Del moved to Gambia in 1999 where he completed high school. In 2002 he moved to U.S. to attend Wartburg College in Waverly, Iowa and earned his undergraduate degree in biochemistry and biology. He is currently in the final year of the doctor of pharmacy (Pharm.D.) and masterâ&#x20AC;&#x2122;s of public health (MPH) programs at the University of Minnesota College of Pharmacy and School of Public Health. His academic interests include health care policy, clinical outcomes evaluation and global health policy. His extracurricular interests include reading, writing, debating politics and policies, and playing soccer or a game of Scrabble.

Conclusion:

In addition to the advent of global warming and climate change, and the recent rise in the potential for bioterrorism as a threat to the major cities of the world, the potential for a global pandemic Minnesota Pharmacist Fall 2011 n

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Student Perspective

K2 is it really synthetic marijuana?

By Laura Palombi, Class of 2012, student at the College of Pharmacy in Duluth, MPSA’s Vice-President of Community Outreach

Many of us have heard of K2, misleadingly labeled as “synthetic marijuana,” but are unaware of what a significant problem this product has become in our communities. Synthetic Cannabinoid Products (SCPs) include “K2,” “Spice,” “Genie,” Blaze,” and “Dream” among other terms. These products are marketed as herbal incense but when smoked they produce psychoactive effects that are often similar to marijuana.1 They can also be injected, inhaled from pipes, drunk as a tea, or rolled in joints. SCPs are easy to obtain using the Internet and are also available for purchase at retail outlets and some gas stations; they are usually sold in small, silvery bags of dried leaves.2

What are the psychoactive effects of Synthetic Cannabinoid Products?

How do Synthetic Cannabinoid Products work?

What are the physical effects of Synthetic Cannabinoid Products?

The active constituent of marijuana is ∆ 9-tetra-hydrocannabinol (∆ 9-THC), which exerts its psychological effects by interacting with the cannabinoid receptors (CB1 and CB2) in the brain.3 Since the cannabinoid receptors were discovered, researchers have started to synthesize a variety of chemical compounds that modulate these receptors and have discovered JWH018, the most common compound used in SCPs. Since JWH-018 was first discovered, a number of new synthetic cannabinoid products (JWH-073, JWH-019 and JWH-250) have been synthesized. These chemicals are added to SCPs in various amounts; each “batch” is different, making the psychological and physical effects varied and unpredictable.

• Euphoria • Memory changes • Irritability • Anxiety • Visual perception changes • Auditory perception changes • Paranoid thoughts

• Seizures

• Tachycardia • Palpitations • Appetite changes • Blackouts • Restlessness

K2 continued on page 35 34

Minnesota Pharmacist Fall 2011 n

Student Perspective K2 continued from page 34 What’s the problem with Synthetic Cannabinoid Products?

Most users of K2 and other SCPs assume that a marijuana-like drug will cause a marijuana-like high. According to users, medical professionals and law enforcement officials, however, the effects of SCPs are much more potent than those of traditional THC marijuana and many of their effects are the opposite of what would be expected with a traditional marijuana high. According to users of SCPs, its most prominent effects include anxiety, paranoia and even “psychotic” feelings.4 It is likely that SCPs such as JWH-018 can precipitate psychosis in those with psychiatric risk factors.5 Emergency rooms across the state are seeing increasing numbers of SCP users who present with very severe agitation, dangerously elevated heart rates, panic and anxiety attacks, disorientation and significant hallucinations. The stimulant effects of SCPs like K2 stand in contrast to the mellowing effect that users seek in a synthetic marijuana product. According to Stacey Bangh, Pharm.D., Clinical Supervisor at the Minnesota Poison Control Center6, “we have seen a lot of patients having the opposite effects as marijuana when they present to the ER: agitated, tachycardic, several with seizures.”

According to Dr. Bangh, their treatment often requires “benzos and time, as well as keeping them safe.”

Resources for Pharmacists: Minnesota Poison Control Center Hotline: 1-800-222-1222 Open 24 hours, 7 days a week Poison emergency and information calls are answered by nationally Certified Specialists in the Poison Information (CSPI). They answer poison related questions and provide first aid advice and treatment recommendations to the general public and health care professionals throughout the state. The service is provided via a national toll-free telephone number accessible by both voice and TTY and is available 24 hours a day, 365 days a year. Interpretive services are also available in most languages.

National Drug and Alcohol Treatment Referral Routing Service: 1-800-662-HELP Open 24 hours, 7 days a week

Poison control centers across the nation are seeing a sharp increase in the number of emergency calls related to K2. As an example, 2,915 calls were made to the two major poison control centers (AAPCC and NPDS) in 2010. As of September 30, 2011, more than 5,000 calls were made to the poison centers, confirming that the frightening effects of K2 are escalating across the country.

The use of SCPs including K2 is well-established in Minnesota.

The Minnesota Poison Control Center saw an increase from 28 exposures in the year 2010 to 116 through mid-October of 20117.

Although it is not surprising that Hennepin County had the greatest number of exposures reported to the Minnesota Poison Control Center in 2009-2011 (25 exposures), St. Louis County’s secondplace rank (13 exposures) ahead of even Ramsey County (12 exposures) is noteworthy.

Law enforcement officials across the state are quite familiar with K2 and its unpredictable effects. Adam Wright, Narcotics Officer for the Boundary Waters Drug Task Force in Northeastern Minnesota, believes that the effects of K2 are “worse than that of regular THC marijuana.” According to Officer Wright, “People that we deal with are almost in a hallucinational phase. The effects are certainly that of THC marijuana but it appears that the euphoric stages are much worse.” Duluth Community Policing Officer Rob Hakala describes being on two calls where K2 users were hallucinating: “One was a woman who was attacking cars as she felt they were the reason she could not find her house. Second was a woman who cut off all of her hair to get the ‘bugs’ out. Not known if the K2 was mixed with other drugs on this call but both were using K2 prior to the incidents.”

Although the SCBs K2 and Spice (JWH-018 and related compounds) have been banned in other parts of the world, they remained uncontrolled at the federal level in the United States until March 1, 2011 when the DEA used its emergency scheduling power to schedule five synthetic cannabinoids (JWH-018, JWH-073, CP-47, 497, JWH-200 and cannabicyclohexanol) in the schedule 1 list of controlled substances.

Who is using synthetic cannabinoid products?

K2 is an emerging drug of abuse in people of all ages, but especially young persons, because of the ease of use in which it is obtained over the Internet: “There are an increasing number of Web sites where users can order Spice blends or pure JWH compounds without age restriction or any type of control.”8 Studies have shown that K2 has been used by nearly one in ten college students; it was “particularly common among males and early college students.”9 K2 continued on page 36 Minnesota Pharmacist Fall 2011 n

35

Student Perspective K2 continued from page 35 According to law enforcement officials in St. Louis county, synthetic cannabinoids are being used by individuals who normally would not experiment with street drugs.

How can we test for synthetic cannabinoid use?

Much of the popularity of synthetic cannabinoids comes from the fact that their use is not detectable in standard toxicology tests, thus allowing SCP users to escape detection.10 A new method of testing for SCB metabolites in urine using liquid chromatography-tandem mass spectrometry (LC-MS-MS) has been developed and validated. This method, which has “high sensitivity and reproducibility,” may gain popularity in the analysis of forensic urine specimens for the detection of K2 abuse.11 Another LC-MSMS method has been developed to test whole blood samples for SCBs including JWH-018, JWH-073, JWH-019 and JWH-250.12 Although few laboratories throughout the state are able to perform LC-MS-MS testing, some Health systems, including St. Luke’s Hospital and Essentia health in Duluth, are able to send their samples to specialized laboratories to obtain K2 screening results.

The composition of synthetic cannabinoid products is changed repeatedly over time “as a reaction to prohibition and prosecution of resellers” and because of this, “neither the reseller nor the consumer of these mixtures can predict the actual content of the ‘incense’ products.”13 As long as there is no generic definition in the controlled substances legislation, “further designer cannabinoids will appear on the market as soon as the next legal step has been taken.”14 As new cannabinoids will continue to appear in the future, a continuous monitoring of these products is required.

About the author: Laura Palombi is a fourth-year student at the University of Minnesota College of Pharmacy, Duluth, and is a member of the Minnesota Public Health Association.

References 1. Castellanos, D, Singh, S, Thornton, G, Avila, M, and Moreno, M. “Synthetic Cannabinoid Use: A Case Series of Adolescents.”

Journal of Adolescent Health, 49 (2011): 347-349.

2. DEA Drug Fact Sheet: K2. http://www.justice.gov/dea/pubs/ abuse/drug_data_sheets/K2_Spice.pdf Accessed October 30, 2011.

3. ElSohly, M, Gul, M, ElSohly, K, Murphy, T, Madgula, V, Khan, S. “Liquid Chromatography – Tandem Mass Spectrometry Analysis of Urine Specimens for K2 (JWH-018) Metabolites.”

Journal of Analytical Toxicology, 2011: 35.

4. Schneir, A, Cullen, J, and Ly, Binh. “‘Spice’ Girls: Synthetic 36

Minnesota Pharmacist Fall 2011 n

Cannabinoid Intoxication.” Journal of Emergency Medicine, 40 (3): 296-299.

5. Every-Palmer, S. “Synthetic cannabinoid JWH-018 and psychosis: An explorative study.” Drug and Alcohol Dependence, 117 (2011): 152-157 6. Bangh, Stacey, Pharm.D., DABAT, Clinical Supervisor at The Minnesota Poison Control Center. Interview on October 28, 2011.

7. Bangh, Stacey, Pharm.D., DABAT, Clinical Supervisor at The Minnesota Poison Control Center. Interview on October 28, 2011.

8. Fattore, L, Fratta, W. “Beyond THC: The New Generation of Cannabinoid Designer Drugs.” Front Behav Neurosci, 2011: 5(60) 9. Hu, X, Primack, B, Barnett, T, Cook, R. “College students and use of K2: an emerging drug of abuse among young persons.”

Substance Abuse Treatment, Prevention and Policy, 2011; 6(16).

10. Hoecker, C. “Designer drugs of abuse in children and adolescents.” 2011 UpToDate, accessed 10/10/11.

11. ElSohly, M, Gul, W, ElSohly, K, Murphy, T, Madgula, V, Khan, S. “Liquid Chromatography – Tandem Mass Spectrometry Analysis of Urine Specimens for K2 (JWH-018) Metabolites.”

Journal of Analytical Toxicology, 2011(35).

12. Kacinko, S, Xu, A, Homan, J, McMullin M, Warrington D, Logan B. “Development and validation of a liquid chromatography-tandem mass spectrometry method for the identification and quantification of JWH-018, JWH-073, JWH-019, and JWH-250 in human whole blood.” J Anal Toxicol, 2011; 35(7): 386-93.

13. Dresen, S, Ferreiros, N, Putz, M, Westphal, F, Zimmerman, R, Auwarter, V. “Monitoring of herbal mixtures potentially containing synthetic cannabinoids as psychoactive compounds.” J Mass Spectrom, 2010, 45(10): 1186-94.

Student Perspective

The Use of the

Minnesota Immunization Information Connection in an Institutional Setting Ann Brigl and Brittany Payeur, third year pharmacy students at the University of Minnesota Brittany Payeur (left) and Ann Brigl (right)

How many institutional pharmacists have heard of the Minnesota Immunization Information Connection? The Minnesota Immunization Information Connection, referred to as MIIC, is a comprehensive Web-based application managed by the Minnesota Department of Health (MDH), used to capture immunization histories for Minnesota residents. This service, provided at no cost to health care providers or patients, consolidates disparate immunization records into a single source, thereby giving providers a tool to ensure proper immunization administration by assessing which vaccinations are currently appropriate for a patient. This includes reminders when vaccinations are due and alerts when an immunization has been missed. It details when each immunization was given, as well as the lot number of the vaccine and the provider information. Patients using facilities that participate in MIIC are automatically included in the system when they are immunized, unless they choose to opt-out of participating.

Pharmacists can register for two levels of use. One option is full access, which means that they can look up immunization information on a patient and they can enter information into the system if they administer a vaccine to a patient. The second option is for “read only” access, which means they can check a patient’s immunization status, but cannot enter or change any information.

Almost all Minnesota hospitals provide data to MIIC, but practitioners do not consistently use it to look up immunization histories for their patients. It is advisable to verify the patient’s immunizations in MIIC whenever a patient presents at an emergency department or clinic setting to avoid possible duplicate immunizations and to save time and money for the provider. It is a simple process for an organization to enroll for participation in MIIC. The Minnesota Immunization Data Sharing Law (Minn.

Stat. §144.3351) allows health care providers to enter immunization into MIIC without patient consent. Sites can either enroll as a cohort, with one representative in charge of the log-on information for its users or a site can enroll separately. Either way, it is necessary to contact the regional MIIC coordinator to enroll. A list of MIIC regional coordinators can be found at http://www.health.state. mn.us/divs/idepc/immunize/registry/map.html. To participate in MIIC, providers are required to sign a MIIC user agreement, which states that confidentiality and security will be maintained, patients will be given the opportunity to opt out of the program, and MIIC will be allowed to monitor their use of the system.

Acknowledgements: Steve Mandt, Pharm.D., and Kim Gulliver, Senior Planning Analyst for MIIC

MIIC is a valuable service provided by the Minnesota Department of Health. It is currently underutilized in hospital settings, and therefore, its full potential has yet to be seen. The use of the system helps facilitate cost savings, ensure proper resource utilization, and provide overall better patient care. It is easy to use, as well as being simple to enroll and obtain access. Its use by institutional pharmacists should be encouraged.

Other Immunization Resources: immunize.org The Immunization Action Coalition is the best place to find comprehensive and complete information. flusafe.org Minnesota Department of Health’s resources on vaccinating staff and protecting patients.

One drawback for institutional use has been the need to integrate MIIC with the existing electronic health record (EHR) system, such as EPIC. One way to overcome this obstacle or facilitate a transition to using MIIC would be for a group of pharmacists working at that facility to register as a cohort, allowing them to access MIIC on any Web browser. This way access to MIIC is limited, but is still always available to key pharmacy personnel.

Minnesota Pharmacist Fall 2011 n

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MPha award nomination form Please provide a letter of support for each award nominee describing in detail the reasons for the MPhA Awards Committee to consider your nominee. Include specific examples and/or details. Attach your nomination letter and any supporting documents to this form, including a current CV of nominee if possible. Nominations that do not include adequate information will not be considered until missing information is submitted. Nominators will be notified when nominations are received by the MPhA office and if additional information is required. Please see the MPhA Web site for additional award information and forms: www.mpha.org.

Harold R. Popp Award

Sponsored by MPhA, the Popp Award recognizes one pharmacist annually for outstanding services to the profession of pharmacy. This is the highest honor bestowed by the association.

Nominee’s Name: _________________________________________ Workplace: ________________________________

bowl of hygeia award

Sponsored by Pfizer, the Bowl of Hygeia recognizes pharmacists who possess outstanding records of civic leadership in their own communities, from which their specific identification as a pharmacist reflects well on the profession.

Nominee’s Name: _________________________________________ Workplace: ________________________________

distinguished young pharmacist award

Sponsored by Pharmacists Mutual Companies, the Distinguished Young Pharmacist Award recognizes a young pharmacist within his/ her first ten years of practice who has distinguished himself/herself in the field of pharmacy. This pharmacist is also a participant in national pharmacy associations, professional programs, state association activities and/or community service.

Nominee’s Name: _________________________________________ Workplace: ________________________________

excellence in Innovation award

Sponsored by Upsher-Smith Laboratories, Inc., the Excellence in Innovation Award recognizes innovative pharmacy practice resulting in improved patient care.

Nominee’s Name: _________________________________________ Workplace: ________________________________

Pharmacy Technician award

Presented by MPhA, the Pharmacy Technician Award recognizes a pharmacy technician in any practice setting who demonstrates leadership in their work and in their community. This includes demonstrating professionalism by participation in pharmacy association, professional programs and/or community service, promoting teamwork within the pharmacy, providing leadership and serving as a role model for coworkers, developing or assisting development of efficient safe procedures that support the provision of pharmaceutical care.

Nominee’s Name: _________________________________________ Workplace: ________________________________ Nominator’s information:

Recognizing members who are an inspiration to the field of pharmacy!

Name (please print): __________________________________________________________________________ Phone: ____________________________ E-mail: ______________________________________________ Address:_________________________________________________________________________________ City: ______________________________________________ state: _________ Zip: _________________

Please return all nominations by March 15, 2012 to the MPhA office.

38

Minnesota Pharmacist Fall 2011 n

Partnership Join the

Full Name (Mr/Ms/Dr): ________________________________________________ Address: ____________________________________________________________ City: __________________________________ State: ________ Zip: ___________

Phone: _________________________ Preferred Fax: _________________________ Preferred E-mail: ______________________________________________________ Birth Date: ___________________________

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Business Name: ________________________________________________________ Business Address: _______________________________________________________ City: ______________________________________ State: _______ Zip: ___________ Business Phone: ____________________________

I am applying as (choose one): With the exception of Associate Members, you must have completed pharmacist educational requirements.

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Mail or fax back to: Minnesota Pharmacists Association • 1000 Westgate Drive, Suite 252 • St. Paul, MN 55114 651.290.2266 fax • 800.451.8349 mn • 651-697-1771 metro

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