navigating the affordable care act health care reform & you€¦ · april 2013 c ti s ®...

Editor’s Note Accountable Care Organizations: The Future Is Here!

Case Studies Diabetes

www.PharmacyTimes.com

Health Care Reform & You Features • Directions in Pharmacy:

Navigating a New Map

• Tenets of Health Care Reform

• A Tidal Shift: Pharmacists and US Health Care Reform

• Fast Forward: Evolutionary Changes Ahead for Community Pharmacy

• Smartphones and Social Media: Transforming Health Care

N a v i g a t i N g t h e a f f o r d a b l e C a r e a C t™

Directions inPublished by

®

aPril 2013

®

Directions inIntroducIng

A New Supplement

Covers.indd 1 4/3/13 5:14 PM

Want to improve the U.S. Capitol’s approach to healthcare? Host a pharmacy tour for a Senator or Representative.

There is nothing like a pharmacy tour to show a member of Congress how: • Pharmacies help patients use medicines safely and stay healthy • Innovative pharmacy services do even more to improve patient health and

quality of life • Widely trusted and accessible, pharmacists are extremely valued by those in

greatest need • Pharmacy services improve healthcare affordability. Invest in your future. Contact NACDS’ Heidi Ecker at (703) 837-4121 or [email protected] today!

Capitol improvement.

nacds.org

AdTemplate.indd 2 4/3/13 7:13 PM

Directions in Pharmacy™ • April 2013 www.PharmacyTimes.com 1

6 Directions in Pharmacy: Navigating a New Map The impact of health care reform is changing the profession of pharma-cy dramatically with a refocus from “sick care” to “health care.” The new terrain promises big changes and new challenges for the profes-sion.Troy TrygsTAD, PhArmD, PhD, mBA

8 Directions in PharmacyWhy This Series and Why Now? Pharmacy Times presents a thought-provoking new series of supple-ments that underscores why phar-macists need to pay attention to the rapidly changing health care landscape.

9 Tenets of Health Care Reform: A Renaissance for Every Pharmacist These are the tenets pharmacists can embrace and incorporate into their daily practice.Troy TrygsTAD, PhArmD, PhD, mBA

10 A Tidal Shift: Pharmacists and US Health Care Reform Accountability and performance metrics are becoming a reality as pharmacists focus on quality of care. Pharmacists must anticipate and respond to the tidal shift.LAurA CrAnsTon, rPh, AnD sAmueL F.

sToLPe, PhArmD

12 Fast Forward: Evolutionary Changes Ahead for Community Pharmacy The growing trend of accountable care organizations gives pharma-cists the chance to make a greater impact on the health of their patients in a team approach that saves both dollars and lives. John K. mCguirK, mAeD, mBA

2 Publisher’s LetterPay Attention to the Changing MarketplacemiKe hennessy

4 Editor’s NoteAccountable Care Organi-zations: The Future Is Here! FreD m. eCKeL, rPh, ms

15 The Entrepreneurial PharmacistNiche Services and the Road Less Taken“it’s not enough to commit to change, you must commit to always changing”: a life rule that this phar-macist has embraced.sTeve ADKins, PhArmD

17 Career LadderTM Motivational Interviewing: Learning a New Skillnew ways of dealing with patients using evidence-based strategies can lead to greater adherence and greater job satisfaction.Jerry mCKee, PhArmD, ms, BCPP

18 TechnologySmartphones and Social Media: Transforming Health CareLeverage mobile technology to make the delivery of health care easier, low cost, and comfortable for the patient. BArBArA rAPChAK

22 Money Matters A Pharmacy on Every Corner or Prescription Drug Costs on Every Phone?Changes in purchase behavior have immediate and long-term effects on health care costs for both individu-als and employers.DAn PoLLArD, PhD, mBA

23 Case Studies: DiabetesCare Coordination in a New Health Care ModelAvoiding unnecessary utilization of hospitals, improving quality of care, and establishing continuous chronic disease management.sArAh KoKosA, PhArmD

24 ChatterACOs, the Affordable Care Act, and PharmacistsWhat pharmacy associations and industry experts are saying about how pharmacy should fit into the new landscape of health care.

CONTENTS April 2013 • Vol. 1, no. 1

FEATURES

DEPARTMENTS

™

Directions in

Pg 1 TOC_April.indd 1 4/4/13 12:41 PM

NEWS

W hen we decided to cre-ate a new supplement series that addressed the

new health care landscape and how the pharmacist fits into it, we knew that it was extremely important to take a deep dive. As the leading pharmacy journal in the industry, it was critical that we delved into this complex subject from a variety of per-spectives to give our readers the essential tools and key infor-mation they could use immediately.

While we define this new landscape within this special edition, we also want to provide pharma-cists with a road map to follow as the rap-idly changing scene moves fast forward. So, fittingly, we call this publica-tion “Directions in Pharmacy”—and with the guidance of our guest co-editor, Troy Trygstad, PharmD, PhD, MBA, and Editor-in-Chief Fred M. Eckel, RPh, MS, we will answer your questions as accountable care organizations (ACOs) proliferate and the Affordable Care Act (ACA) takes hold.

One of the many reasons it is so important for pharmacists to pay

very close attention to the chang-ing marketplace is what Fred Eckel points out in his Editor’s Note: “If you are not learning about ACOs and what is happening in your marketplace, you may wake up one morning and wonder what happened to your pharmacy’s busi-ness.” Rapid changes are happen-ing, and it is imperative that the

profession of pharma-cy as a whole is in the game.

Today, pharmacy associations are join-ing forces to fight for health provider status for pharmacists. We also know that ACOs are drawing in com-munity pharmacists across the nation. So, it is truly the time to organize as a profes-sion and marshal the

principles that hold the various segments of pharmacy together and to offer a united front.

Here, in Directions in Pharmacy , you’ll find “Tenets of Health Care Reform” that spell out what you, as a practicing pharmacist, need to take to heart and incorporate into your daily activities.

As our co-editors point out, not all of this is new to pharmacy—in fact, decades of discussion about

the role of pharmacists and how they should work with other health care professionals have passed—but, now, with the advent of ACOs and the ACA, it is time to take a seat at the table. There will be no sector in the health care industry that will go without disruption.

Included in this edition, you will also find thought-provoking articles and practical ones, such as The Entrepreneurial Pharmacist and Career LadderTM —both pro-vide real-world details about how to navigate the impact of health care reform.

Future editions will focus on other significant areas of con-cern—the coordination of care, health care costs, how technology is changing the way patients inter-act with their health care team, and what value-based, evidence-based strategies will mean for you.

Having the right skills to provide entrepreneurial solutions and pay-ing close attention to the market-place will help continually improve the value of the pharmacist.

Are you ready for the changes—and the challenges they bring? n

Thank you for reading!

Mike Hennessy Chairman/Chief Executive Officer

from the publisher& VIEWS

Pay Attention to the Changing Marketplace

There will be no sector in the health

care industry that will go without dis-

ruption.

2 www.PharmacyTimes.com Directions in Pharmacy™ • April 2013

editor’s note& VIEWS

Pg2_NewsMike.indd 2 4/3/13 5:17 PM

EDITOR-IN-CHIEF

Fred M. Eckel, RPh, MSProfessor Emeritus

Eshelman School of PharmacyUniversity of North Carolina at Chapel Hill

Past Executive DirectorNorth Carolina Association of Pharmacists

BOARD OF ADVISORS

Russel Allinson, RPh, MSChief Executive Officer/Chief Clinical Officer

Therigy, LLC

Donna M. Cestone, RPh Independent Consultant

Ed Cohen, PharmDSenior Director, Clinical Solutions

Walgreens

Stephen Eckel, PharmDAssistant Director of Pharmacy

University of North Carolina Hospitals Clinical Assistant Professor

Eshelman School of PharmacyUniversity of North Carolina at Chapel Hill

EditorPharmacy Times Health-System Edition

Deborah J. Faucette, RPh Independent Consultant

Donna M. Feudo, RPhProfessional Experience Program Director

Adjunct Clinical Assistant ProfessorErnest Mario School of Pharmacy

Rutgers, The State University of New Jersey

Tiziana M. Fox, PharmDSenior Director, Medical Information

Janssen Scientific Affairs, LLC

Steve Goodman, RPhPresident/FounderPMC Group, LLC

Rusty Hailey, PharmD, DPh, MBA, FAMCPSenior Vice President & President

Pharmaceutical Operations HealthSpring, Inc

Lisa M. Handley, PharmD Manager, Clinical Services

DRX

Richard J. HeineFormer Executive Director, Strategic Alliances

Employer Group Johnson & Johnson Health Care Systems

Susanne Hiland, PharmDSenior Director, Professional Relations and

Quality Improvement Walmart Health and Wellness

Daniel A. Hussar, PhD Remington Professor of Pharmacy Philadelphia College of Pharmacy

University of the Sciences in Philadelphia

Howard A. Kramer, RPhIndependent Consultant

George E. MacKinnon III, PhD, RPh, FASHPFounding Dean and Professor of Clinical &

Administrative SciencesCollege of PharmacyRoosevelt University

Harvey E. Maldow, RPh, MSIndependent Consultant

Michael A. Manolakis, PharmD, PhDAssistant Dean of Student DevelopmentWingate University School of Pharmacy

Sarah B. Matunis, RPhCorporate Clinical Coordinator

Clinical ServicesRite Aid Corporation

James C. McAllister III, MS, FASHPClinical Professor & Regional Experiential

Program CoordinatorUniversity of Florida College of Pharmacy

Chief Executive Officer InvictusRx, LLC

Michael E. McShea, RPhTrade Account Management

Eli Lilly

Scott A. Miller, PharmDDirector, Clinical Strategic Initiatives

Walgreens Specialty Pharmacy

Tom O’Connor, PharmD, MBA Associate Professor of Pharmacy

University of the Sciences in Philadelphia

Jason Reiser, RPh Merchandising Vice President, Health &

Family CareSam’s Club

Tom Rhoads, MBAChief Executive Officer

Parata Systems

Dain Rusk, RPhVice President/General Manager

Pharmacy OperationsSears Holdings Corporation-Kmart Pharmacy

Gregory J. Sciarra, RPh, MBADirector, Third Party Finance

CVS Caremark

David Trang, PharmD, MBAAssociate Professor of Pharmacy

Feik School of PhamacyUniversity of the Incarnate Word

BOARDADVISORY


EDITOR-In-CHIEF

Fred M. Eckel, RPh, MS

VICE PRESIDENT, GROUP EDITORIAL DIRECTORBea Riemschneider

SENIOR EDITORDaniel Weiss

ASSOCIATE EDITOREileen Oldfield

ASSOCIATE EDITOR/ONLINERandi Hernandez

PHARMACy LAW EDITORJoseph L. Fink III, BSPharm, JD

ASSOCIATE PUBLISHER Ashley Hennessy

SENIOR CREATIVE DIRECTOR: PRINT/DIGITALJennifer Lynn

DESIGNERJennifer Rittmann

SENIOR VICE PRESIDENT, CLINICAL AND SCIENTIFIC AFFAIRS

Jeff Prescott, PharmD, RPh

qUALITy ASSURANCE EDITORDavid Allikas

MARKETING & PARTNERSHIP MANAGER Elaine Chu

SALES & MARKETING COORDINATORGrace Rhee

ADVERTISInG REPRESEnTATIVESCarmel Burke-Bonesso

[email protected]

Anthony Costella [email protected]

Chris Hennessy [email protected]

Susan Levey [email protected]

DIGITAL ADVERTISINGJohn Hydrusko

[email protected]

MAIN NUMBER: 609-716-7777

OPERATIOnS & FInAnCE

CONTROLLERJonathan Fisher, CPA

ASSISTANT CONTROLLERLeah Babitz, CPA

ACCOUNTANT: Amy Wheeler

CORPORATE

CHAIRMAN/CHIEF EXECUTIVE OFFICERMike Hennessy

CHIEF OPERATING OFFICERTighe Blazier

CHIEF FINANCIAL OFFICERNeil Glasser, CPA/CFE

EXECUTIVE VICE PRESIDENT, EXECUTIVE DIRECTOR OF EDUCATION

Judy V. Lum, MPA

SENIOR DIRECTOR OF EDUCATIONDavid Heckard

VICE PRESIDENT/EXECUTIVE CREATIVE DIRECTORJeff Brown

SCIENTIFIC DIRECTOR Elena Beyzarov, PharmD

EXECUTIVE ASSISTANT: Teresa Fallon-Yandoli

PUBLISHING STAFF

Pharmacy Times (ISSN 0003-0627, USPS 0808-740) is published monthly as a registered trademark of Pharmacy & Healthcare Communications, LLC, 666 Plainsboro Road, Suite 300, Plainsboro, NJ 08536. Copyright © 2013. All rights reserved. Periodical post-age paid at Plainsboro, NJ, and additional mailing offices. Pharmacy & Healthcare Communications, 666 Plainsboro Road, Suite 300, Plainsboro, NJ 08536. Phone: 609-716-7777. Fax: 609-716-4747. Send all subscription inquiries or requests and all address changes to: Pharmacy Times, 666 Plainsboro Road, Suite 300, Plainsboro, NJ 08536. Include most recent mailing label and allow 6 weeks for any changes to be implemented. Subscription rates: Individual $109/year; retired/student pharmacists (with documentation): $58/ year; Institution $201/year. Individual outside the US $224/year; Institution outside the US $316/year payable in US funds. Please al low 4 to 6 weeks for receipt of first issue. PoStm ASte R: Send address changes to: Pharmacy Times, 666 Plainsboro Road, Suite 300, Plainsboro, NJ 08536. Canada Post Publications mail Agreement Number 40813549. Canada Postmaster: Send address changes to: Pharmacy & Healthcare Communications, LLC, Po Box 456, Niagara Falls, oN L2e 6S8. Articles are accepted for publication with the understanding that they are contributed solely to this publication and will be of interest to pharmacists. Published articles reflect the view of the author, and not necessarily that of Pharmacy Times. Guidelines for authors are available by writing to Pharmacy Times at 666 Plainsboro Road, Suite 300, Plainsboro, NJ 08536, or by calling the editor (609-716-7777). Reprints available in quantity: Contact John Burke, Pharmacy Times, [email protected] (609-716-7777). Contents may not be reproduced without permission of the publisher. microfilm copies of articles available through University microfilms Inter national, 300 N. Zeeb Road, Ann Arbor, mI 48106.

Opinions expressed by authors, contributors, and advertisers are their own and not necessarily those of Pharmacy & Healthcare C ommunications, LLC, the editorial staff, or any member of the editorial advisory board. Pharmacy & Healthcare Communications, LLC, is not responsible for accuracy of dosages given in articles printed herein. The appearance of advertisements in this journal is not a warranty, endorsement, or a pproval of the products or services advertised or of their effectiveness, quality, or safety. Pharmacy & Healthcare Communications, LLC, disclaims resp onsibility for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements.

Directions in™

Pg3_EditBoard.indd 3 4/3/13 5:17 PM

NEWS

What role will accountable care organizations (ACOs) play in the evolution of

health care in this country and even in the practice of pharmacy? It’s a question I have been asking myself since the presidential elec-tion. For the last few years, there has been a lot of press concern-ing the Medicare Shared Savings Program and the resulting ACOs. Recently, Health and Human Services Secretary Kathleen Sebelius announced 106 new ACOs, which included a diverse cross-section of physician-led organizations. Many of these new ACOs serve fewer than 10,000 beneficiaries. Additionally, about 20% include community health centers, rural health centers, and critical access hospitals.

I share these facts to help you realize that these new organizations will become part of the health care system in many communities—and can offer opportunities for many pharmacists who know what types of drug-related services these group need, and know how to market to these new entities. ACOs are being promoted to assure care coordina-tion across the health care con-tinuum as well as to save health care costs. Pharmacy has been suggesting

that poor drug therapy manage-ment is a problem and pharmacists can play a vital role in improving care and reducing costs. Although pharmacists are not mandated to be part of an ACO, they are widely recognized as important players because drug nonadherence and drug therapy misadventures are expensive. When drug therapy is managed well, savings occur. Therefore, most ACOs will be look-ing to pharmacists to help them. If you are not learning about ACOs and what is happening in your marketplace, you may wake up one morn-ing and wonder what happened to your phar-macy’s business.

What should you focus on if you want to get involved with an ACO? Since the ACO is an integrated patient care model based on a pay-for-performance reimbursement model, quality of care becomes more important than quantity of care. It is not how many prescriptions you fill that matters, but how well the patient does on the medicine dispensed. For many pharmacists this will be a paradigm shift. How would your role as a pharmacist change if you were paid on patient outcomes? That’s how you will need to think if you want to get involved with an ACO.

It probably means that you will spend more time talking to the patient and less time on handling the prescription drug. It will prob-ably mean that you will have to be linked better electronically to the other providers who are also

taking care of the patient. Today, all health professionals can survive practicing in a silo and too many still do. But that approach will not work in a successful ACO. True interdisciplinary practice will be required. Pharmacists will also have to learn to collaborate with phar-macists in other practice settings to

make the patient’s care transition seamless.

Some of these new approaches will happen easily, but some many require major effort on your part to get ready. Pharmacy school curriculums are being reworked to prepare students to practice effectively as mem-bers of a health team. Interdisciplinary educa-

tion is now being stressed in all health profession schools. To stay competitive with these new gradu-ates, you will also need these skills.

Pharmacy organizations will be affected as this new model grows. Many organizations were started to help pharmacists practice in unique settings. Now that collaboration across settings is required, these organizations will also have to learn to collaborate. That should be good for the profession.

The profession is changing and ACOs may be a big driver of that change. But whether ACOs grow, as I expect they will, or not—health care reform is happening. Pharmacy Times plans to help keep you aware of these important changes and how you can be a player in them with this special series (please see page 8). Welcome to the future! n

Editor’s notE& VIEWS

Accountable Care Organizations: The Future Is Here!

Mr. Eckel is a professor emeritus at the Eshelman School of Pharmacy, University of North Carolina at Chapel Hill. He is past executive director of the North Carolina Association of Pharmacists.

Fred M. Eckel, rPh, Ms Pharmacy Times Editor-in-Chief

CARE TO COMMENT ON THIS TOPIC? Go to www.Pharmacy Times.com to comment on the April issue at Editor’s Note.

MorE on @ www.

PharMaCy tiMEs.CoM


How would your role as a pharmacist change if you were paid on patient out-

comes?

Opportunities Abound for Pharmacists Who Can Offer New Services and Save Costs

Pg4_EditNote.indd 4 4/4/13 12:47 PM

• Over 80 free activities to choose from

• Online and live regional meetings• Webinars, case studies, print activities

Make Pharmacy Times Office of CPE your destination to find a

comprehensive selection of pharmacy continuing education activities

Sign up today at PharmacyTimes.com/continuing-education

Pharmacy Times Office of Continuing Professional Education (CPE) is accredited by the Accreditation Council for Pharmacy Education (ACPE)

as a provider of continuing pharmacy education.

The most outlets to access CE at home and on the go

Print, web, iPad, mobile

PT_CPE.indd 6 3/5/13 12:28 PMROB_April.indd 104 4/3/13 2:29 PM

Both the profession itself and the health care system at large had mixed reactions about the re-visioning of pharmacy and its new curricular focus on clinical, patient-focused care delivery versus the product-focused approach.

The nature of this new approach and, more importantly, its new set of profes-

sional and implied practice expectations, harkened back to the earlier part of that decade and the beginnings of the “phar-maceutical care” movement. Visionaries lauded this paradigm shift; employers rued their new payroll increases and staff short-ages, and pragmatists rolled their eyes. I was myself skeptical, not of the intrinsic merit of the new principles of practice, but rather in my faith that the marketplace could generate demand for these new skill-sets and expectations.

It took me all of 4 weeks upon gradua-tion from pharmacy school to find myself in a graduate program in health econom-ics, assigned to an advisor who had an unflinching belief in the abilities of a phar-macist to provide cognitive services and the unrealized demand in the marketplace for pharmacist services of all types and

in all settings. I begrudgingly went along with it. I’ve now had the privilege and experience of more than a decade of work in helping to build a set of programs and initiatives that are exploring and testing real-world, market-driven application of pharmacist services in all settings of care.

Some weeks ago, I saw a job opening posted on our local pharmacist associa-tion’s website for a “clinical pharmacist” position embedded in a practice in a very rural part of North Carolina. While I had seen and been involved with pharmacists being embedded in primary care practices in many geographies in North Carolina, I had never seen one in our market that wasn’t associated with (aka subsidized by) either academia or my own employ-er, Community Care of North Carolina (CCNC), particularly in a rural area with

Troy Trygstad, PharmD, PhD, MBA

The Impact of Health Reform on Pharmacy Promises Changes and Challenges for the Profession

feature

When I entered pharmacy school in 1998, the pro-fession was at a training

crossroads manifested by a dra-matic shift in program tracks away from the bachelor of pharmacy degree to the doctor of pharmacy degree.


Directions in PharmacyNavigating a New Map

Troy Trygstad, PharmD, PhD, MBA

Pg6_RoadMap.indd 6 4/4/13 9:43 AM

its economy of scale challenges. I should note that the North Carolina market does not maintain Kaiser Permanente–like sys-tems, and maintains almost exclusively a fee-for-service payer mix.

Curious, I called my local pharmacist “on the ground” in that area and inquired about the position. “How is this position being funded?” I asked. The response was illuminating: “Our health system is growing its accountable care organiza-tion (ACO) presence and the position is being funded by the health system to that end. They have 2 young and progressive physicians who are excited about having a pharmacist in the practice and focus-ing on patient outcomes and total cost of care.” I grinned from ear to ear. The shift is happening!

Wake-Up Call #2Not too long ago, CCNC was asked by our state legislature to figure out how to incorporate community pharmacy activi-ties into the CCNC Medical Home model of care. In essence, they were asking us to be thinking more along the lines of “Medical Neighborhood.” We scraped together whatever funding we could find and launched 10 pilot sites of all types and foci in the community, ranging from

behavioral health to specialty pharmacy to traditional dispensing pharmacy to a site embedded within a senior center.

Five of the sites were traditional com-munity pharmacies with revenue models nearly completely dependent on reim-bursement for product versus services. We were been pleasantly surprised by the reaction to the program within the local communities of care, in particular, the level to which the primary care practices in these communities have been very sup-portive.

I think it can best be summed up by an e-mail from one of the physician direc-tors: “… (This Pharmacy)... is literally a godsend for too many patients to count …one of our (other) physicians remarked recently they do so much for our patients that he worried that they could not stay in business...(with continued reimbursement reductions)...”.

Not only were many practices will-ing to work with their local community pharmacy within this model, we had more than 100 pharmacies that the practices themselves identified as desirable col-laborators—and they would be willing to work hand-in-hand with them to optimize medication use for their patients. That e-mail, in combination with the recent Walgreens’ announcement of its 3 ACO endeavors and the ACO job posting, have convinced me that the times truly are a-changin’.

Historical PerspectiveCalls for professional sea change have been around for a while, regardless of what your role is in the health care system. Take the example of the “medical home model” in which primary care physicians are meant to be quarterbacks who orches-trate a patient’s care across many pro-vider types and continuums through their practices’ efforts. The model’s principles, according to all of the major primary care associations, include: whole-person orien-tation (versus a disease-centric approach), coordination of activity across licensure and setting, focusing on quality and safe-ty, all made possible through a payment mechanism (payment reform).

Sound familiar? Here are the prin-ciples of “pharmaceutical care,” brought to us by Hepler and Strand in 1990: “The patient is the primary beneficiary…achieving definite therapeutic outcomes.” Refined by the American Socieity of

Health ASHP in 1993 and then best described in the following preamble from the American Pharmacists Association Board of Trustees in 1995 (my empha-sis): “Pharmaceutical Care is a patient-centered, outcomes oriented pharmacy practice that requires the pharmacist to work in concert with the patient and the patient’s other healthcare providers to promote health, to prevent disease, and to assess, monitor, initiate, and modify medication use to assure that drug therapy regimens are safe and effective. The goal of Pharmaceutical Care is to optimize the patient’s health-related quality of life, and achieve positive clinical outcomes, within realistic economic expenditures.”

Yet it has taken 2 decades for pharma-ceutical care—or whatever you want to call it—to finally develop a marketplace. If you think ours has been a long journey, just ask medical home proponents. That movement started way back in 1967 with the American Academy of Pediatrics. Ironically, the first known published notion of the principles surrounding phar-maceutical care are found in the excerpts of a speech given by Brodie in 1973, not too long after the notion of the medical home was born. Why has it taken this long for both ideas to take root?

Why Now?The answer is Arithmetic. Because of a mix of price inflation, technological advances, and the aging baby boomers, the percentage of our gross domestic product (GDP) consumed by health care has risen from 9.8% of GDP in 1985 to 16.8% of GDP in 2010—and it is projected by the Congressional Budget Office (CBO) to be fully 25% of our economic output by 2037. That is an unsustainable trend and we are close to reaching an inflection point.

Reasonable people can argue that we have already reached that point, and that it was this escalating trend that was at least partially responsible for the Affordable Care Act (ACA) coming to pass—despite gargantuan structural and status quo barri-ers to health reform. But if health reform is viewed in its more generic sense, nobody can argue that it would not have come to pass eventually.

Health Care Versus ButterA look back in history gives us a view into the future. The economic model and


ABoUt tHe AUtHorTroy Trygstad, PharmD, MBA, PhD, is the direc -tor of the Network Pharmacist Program and Pharmacy Projects for Community Care of North Carolina (CCNC), a parent organization of 14 regional care management networks. These net -works bring together medical practices, county health departments, hospital systems, and mental health providers to integrate care delivery for Medicaid, Medicare, private plans, employers, and the uninsured. CCNC and its networks are responsible for developing and evaluating accountable care systems in North Carolina.

Under his direction at CCNC, the Network Pharmacist program has grown to include phar -macists who are involved in a number of diverse activities ranging from patient-level medication reconciliation to practice-level e-prescribing facilitation to network-level management of pharmacy benefits. Dr. Trygstad also plays an integral role in health information technology adoption and proliferation with CCNC practices and across the state, leading electronic prescrib -ing adoption efforts as well as the development and deployment of a statewide medication management platform. He has been involved in novel adherence implementations as well as the development of adherence technologies that use administrative claims data to predict, inter -vene, and triage adherence interventions and coaching opportunities. Dr. Trygstad received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical out -comes and policy from the University of North Carolina.

He is co-editor of the Pharmacy Times series on Directions in Pharmacy.

Pg6_RoadMap.indd 7 4/3/13 5:19 PM

political context around the term “Guns vs Butter” is borne out of the dilemma of warring countries, popularized as a term in World War II. As the layperson’s version goes—you can spend money on guns (meant to imply military spend-ing) or butter (a metaphor for everything unrelated to military spending)—to win the war. If you spend too much on guns, the war machine grinds to a halt because you don’t have the necessary goods and services of daily living and you lose the war on the home front. If you spend too much on butter, you lose the war on the battlefront. Well, it seems that our new battle in a globalized economy is in many ways centered around, or at least largely affected by, the Health Care versus Butter dilemma—if not for reasons of our cost to produce goods and services, then for reasons of consumer choice.

That same CBO report described the likely effect of consumerism on health care purchasing behavior over the next few decades in the following way: “Instead, over time, people will try to limit their spending for health care in order to maintain their consumption of other goods and services.” Why? Because people, when given the choice and being subject to price sensitivity, will choose transportation, telecommunications, food, and housing over health care as health care consumes more and more of our spending on personal consumption. So, regardless of the ACA, change was coming.

Paradigm ShiftMuch of that change can best be described as a re-focus from “sick care,” wherein most of our collective spend and effort is in reaction to sickness or a major event such as a heart attack, to “health care” that provides care proactively to avoid sick-ness and events in the first place. Without this paradigm shift, the only way to con-tain costs is by reducing reimbursement (cost per unit), a strategy that pharmacy is all too familiar with. The latter focuses on fewer costly units, particularly those of the preventable kind. Indeed, most ACOs or entities engaged in bundling, shared savings, or other pay-for-performance arrangements have keyed in on prevent-able hospital admissions, readmissions, emergency department (ED) visits, and total cost of care.

This new emphasis represents enor-mous opportunity for the profession and

practice of pharmacy when one considers that our primary defense against kid-ney failure, amputations, blindness (all emanating from diabetes), heart attacks, strokes, mental health crisis, and even dis-ease related to smoking is well-informed and optimized medication use. Our well-aged, fee-for-service system is under attack—and no sector of the health care industry will go without disruption this time around.

From Silos to SystemsNow that the health care system is gradu-ally tying quality and prevention to reim-bursement, we are starting to see the natural evolution away from work flows and output related to producing more units within silos of care and to workflows and output related to preventing units by coordinating the provision of care across licensure and setting.

For pharmacy, this is actually pro-ducing a paradoxical effect, wherein the use of more of 1 type of unit (more medication fills) has a preventive effect, on balance, on the use of costly and avoidable units (hospital and ED vis-its). With respect to CCNC’s Medical Home model, patients who are engaged with their medical home, on average, have 15% to 60% fewer hospitalizations (depending on the complexity of their disease mix and age of the population) than patients not enrolled in a medi-cal home, with 19% to 26% fewer ED visits. Their medication use, however, was 8% to 39% higher, with much of that owed to increased adherence, per-sistence, and fewer instances of under-treatment.

CCNC’s Medical Home model has placed a strong emphasis on engaging the “medical neighborhood” and its many providers, including community pharma-cy, home health, long-term care, behav-ioral health, and a host of other ancillary service providers including chaplain and other nontraditional, community-based care team members. This strategy and subsequent findings are not unique to CCNC, and similar experiences are pop-ping up all over the country as innova-tion takes hold. While a great deal of uncertainty remains as to where all of this effort will eventually land, what is certain is that the 5-decades-old pharmacy busi-ness model will tested in the very near future. n


feature

Directions In PharmacyTM

Our co-editors for Directions in Pharmacy are Troy Trygstad, PharmD, MBA, PhD, direc-tor of the Network Pharmacist Program and Pharmacy Projects for

Community Care of North Carolina, and Fred M. Eckel, editor-in-chief of Pharmacy Times.

2013 is likely to be the “year of inflec -tion” for pharmacy. We are reaching a breaking point with budgetary constraints at the local, state, and federal government levels. Businesses are standing up and say -ing, “We’ve had enough!” And investments in health information technology is now advancing cross-setting and panel-based, longitudinal care at a breathtaking pace.

Pharmacy Times presents a series of sup-plements on navigating health care reform, the role of pharmacy, and the impact of the ACA—and it is meant to be provocative, interesting, and most important, informative. We will compel readers to question their belief in the status quo and assist in the formation of new and “disruptive thought” as we all prepare for what will likely come to pass.

Health Reform and YouIn this first supplement, the focus is on the impact of health reform, not in terms of the ACA, but in terms of the important tenets of system change that were coming, regardless of the ACA, spurred by the economic realities of our health system over the next 20 years.

Here are some of the other major themes we will address in Directions in Pharmacy: �Care Coordination: Who, What, When,

Where, and How?��Health reform means collaborating

with multiple different provider types in multiple different settings. How will this change the practice of pharmacy and are you ready?

��Plugged In: Health Information Technology or Bust

��HITECH and other influences have dramat-ically increased investment in electronic health solutions. Will this dramatically change how we practice, or will it be busi -ness as usual?

Providing Value: Ignore It at Your Own Risk

� The system is moving to value-based reimbursement. Pharmacy practice must change to meet this unstoppable trend.

Pg6_RoadMap.indd 8 4/4/13 9:51 AM


feature

Troy Trygstad, PharmD, PhD, MBA Co-Editor, Directions in Pharmacy

Regardless of how the Affordable Care Act is implemented in the coming months and years, these are the general tenets of Health Care Reform as we view them. The editors believe that pharmacists would do well to incorporate these tenets into their

daily practice in order to maximize their role within the 21st-century health care team. We encourage you to embrace these tenets, regardless of your role within the health care system or the setting in which you practice. The Directions in Pharmacy series of supplements has been designed to help pharmacists better understand the nature and magnitude of changes underway throughout the entirety of the health care system. We hope that you find these them interesting and helpful.

The Tenets• Reduced Cost Shifting and Increased Sharing of Risk with Providers• Increased Focus on Prevention• Increased Accountability• Increased Cross-Setting and Inter-Entity Collaboration• Increased Capture, Exchange, and Application of Data

The Results• Patient-Centered Medical Home• The “Health Home”• The “Medical Neighborhood”• The Accountable Care Organization• Global Payment and Quality Contracting• Shared Savings Contracting• A Renaissance of the Pharmaceutical Care Movement?

Tenets of Health Care Reform:A Renaissance for Every Pharmacist

Pg9_TenetsHealth.indd 9 4/4/13 9:54 AM

Our care delivery system has been vili-fied for its fragmentation, inaccessibility, and waste, while simultaneously praised

for its innovation, skilled workforce, and resourcefulness. The changing landscape is full of both challenges and oppor-tunities for pharmacy, which will only increase in the next 12 to 24 months as the hard work of fully implementing the provisions of the Patient Protection and Affordable Care Act (ACA) continues.

A Tidal ShiftAs pharmacists, we must anticipate and respond to the tidal shift with-in the health care marketplace as a

result of the ACA rollout. Federal and state governments, payers, and provid-ers are increasingly reframing health care issues in terms of value, rather than strictly in terms of cost. This is reflected throughout the provisions of the ACA, with emphasis and incentives on improved quality and performance measurement serving as drivers of a new paradigm.

Providers and payers are rewarded for assuming population health risks and lowering overall costs while maintaining or improving quality. Emerging delivery models such as accountable care orga-nizations (ACOs), and penal programs such as the Centers for Medicare & Medicaid Services (CMS) Readmissions Reduction Program, share common ele-ments of care coordination requirements and data-driven quality measurement.

Pharmacy needs to answer these ques-tions regarding our integration into the post-ACA environment:

• What are the real implications and opportunities for pharmacists within the short and medium terms?

• How can we best position ourselves to play a meaningful role in driving improvements in patient care within the evolving system?

In order for pharmacy as a profes-sion—and pharmacists as individual practitioners—to deepen their collective contributions, there are several key steps that we should take.

Focusing on Value, Not VolumeThe ACA includes several mechanisms that will lead to a substantial num-ber of previously uninsured individu-als becoming covered. A March 2010 Congressional Budget Office report indicated that the ACA will increase the number of insured non-elderly Americans from 83% to 94% by 2019. For elderly patients, the gradual closing of the Medicare Part D donut hole by 2020 will increase patient access and the use of pharmacies. The challenge lies in how we handle the increased vol-ume of patients within our health care system—both at the primary care level with the shortage of physicians, and as pharmacists with the increase in the pre-scription volume. First, it is necessary to recognize that the emerging system is trending to reward value over volume.

Laura Cranston, RPh, and Samuel F. Stolpe, PharmD

feature

The American health care landscape is shifting—and the pharmacy profes-

sion must shift with it. Health care delivery in the United States is both nuanced and enigmatic.


A Tidal ShiftPharmacists and US Health Care Reform

Laura Cranston, RPh Samuel F. Stolpe, PharmD

The Impact of Health Reform on Pharmacy Promises Changes and Challenges for Pharmacists

Pg10LandScape.indd 10 4/4/13 10:06 AM

As a profession, how do we ensure that there is value within the medication use system? Defining that value is critically important.

Measuring Value in Health CareValue in today’s health care system is measured through performance metrics. The National Quality Forum has nearly 700 endorsed measures that are used across health care settings. Each year, it reviews hundreds more for recom-mendation to various agencies within the Department of Health and Human Services. Pharmacy is far from exempt from performance measurement. The CMS has adopted several Pharmacy Quality Alliance measures generated using prescription claims data to cal-culate star ratings for Medicare D and Medicare Advantage plans.

As pharmacists, are you aware of the development of performance metrics that apply specifically to medication use and medication therapy management (MTM) services? Do you know how medication adherence is measured? Are you aware there are measures that look at how many comprehensive medica-tion reviews are completed within the Medicare program for beneficiaries that qualify for an MTM benefit within their plan?

These measures will begin to shape how pharmacy practice continues to evolve. They are not only used by gov-ernment agencies. In fact, some employ-ers are already using performance met-rics on appropriate medication use as an integral part of the way they evaluate the performance of both the pharma-cies they run and the pharmacists they employ.

With the health care system, value is measured for nearly all providers. Doctors, hospitals, nursing homes, home health care agencies, dentists, and oth-ers are all directly measured. There are websites dedicated to public reporting of the performance of doctors, hospitals, nursing homes, and more. Pharmacies and pharmacists have thus far existed outside of this paradigm, but are unlike-ly to be able to do so for much longer. While it may yet be several years before pharmacies’ performance is publicly reported, as it is with other providers, the movement exists for performance to

be measured across pharmacy providers in today’s environment.

The Meaning of Accountability for Pharmacists Within the health care system, account-ability is moving front and center. Accountability for outcomes and perfor-mance as well as incentives for meeting certain high levels of quality care is becoming a reality. This accountability is being driven from many angles—by payers, employers, and also the federal government.

For pharmacists, however, there is a key step that we need to achieve before we can have direct accountability for our services and actions. This is a major rationale behind the collective effort amid national and state-based pharmacy organizations to pursue the recognition of pharmacists as health care providers as defined by the Social Security Act.

Why Become Providers?If we truly want to optimize value in our health care spending, Medicare must include pharmacists’ clinical services that are provided in collaboration with physicians and other providers on the health care team. Recognition of phar-macists’ clinical services in the non-physician part of Medicare Part B would help to improve patient outcomes and assist physicians and other providers in effectively addressing the complex health care needs of patients.

This provider listing is not only used within Medicare Part B, but also by ACOs, state Medicaid programs, and other payers to determine payment poli-cies and services covered. Achieving direct provider recognition of pharmacists would be a giant step forward in terms of being able not only to provide the clinical services that pharmacy has been offering, but also being able to be directly compen-sated for these services as well.

The change in provider status needs to accompany an accountability mind-set. That accountability extends beyond the 15-minute window when our patients are our customers. Pharmacists must take responsibility for their panel of patients, and think carefully about their contributions to managing the health of individuals and populations. Managing medication therapy includes taking responsibility for medication adherence,

talking with patients about their therapy, addressing medication concerns, and making connections with patients who are not coming into the pharmacy when they should be.

Narrowing of Networks: Quality Means MarketabilityPharmacies that ignore the trend lines now run the risk of being increasingly cut out of the game. The narrowing of provider networks is already a promi-nent feature of the emerging health care landscape. Cost cutting within employ-er-based plans, increasingly managed care–heavy Medicaid programs, and the naturally narrower options within ACOs and Patient-Centered Medical Homes are becoming more pronounced features of the landscape. Within phar-macy, we see this paradigm unfolding as well.

Plans and payers have created pre-ferred pharmacies—and they are a very prevalent reality in 2013. While the nar-rowing of preferred pharmacy networks to date has not been based on quality, we are seeing those dialogues beginning to take place in the market. Once qual-ity becomes the determinant in creating networks based on performance against clinical measures, it will become the focal point in maintaining a pharmacy’s marketability. Individual pharmacists, pharmacies, and the profession as a whole must include a focus on quality to remain viable within the new health care landscape. n


About the AuthorsLaura Cranston, RPh, serves as the executive director of the Pharmacy Quality Alliance, which is a multi-stakeholder organization established in April 2006 to improve the quality of medication management and use across health care settings with the goal of improving patients’ health through a collaborative process to develop and implement performance measures and recognize examples of exceptional pharmacy quality. Prior to her current position, Laura served as the executive director for the Institute for the Advancement of Community Pharmacy, an organization whose mission was to advance the practice of both independent and chain community pharmacy in the United States.

Samuel F. Stolpe, PharmD, is associate director of quality initiatives at the Pharmacy Quality Alliance and an adjunct faculty member at Howard University. Dr. Stolpe collaborates on a number of research and demonstration projects exploring expanded roles for community pharmacists. He plays a key role in developing and implementing intervention strategies that improve medication-based performance metrics.

Pg10LandScape.indd 11 4/3/13 5:26 PM

Service lines of the traditional sec-tors—such as community pharmacy, health-system pharmacy, and

large chain pharmacy—will begin to blur. The rate of evolution will also

escalate in 2013 and beyond while health care reform continues, driven primarily by continued implementation of provisions of the Affordable Care Act (ACA).

John K. McGuirk, MAEd, MBA

Accountable Care Organi-zations Allow Pharmacists to Make a Greater Impact

feature

A longtime student of health care reform and the Affordable Care Act (ACA), John K. McGuirk, MAEd, MBA, is vice president, business development, for Smart Insurance Company, a Cleveland, Ohio–based company providing

innovative insurance products to the senior mar -ketplace.

In recent years, the practice of pharmacy has come back to its roots of individualized and personal prescription care. But in upcoming years, the evolution of the pharmacy industry will

likely take giant leaps and lurches.


Fast Forward Evolutionary Changes Ahead for Community Pharmacy

Pg12_FastForward.indd 12 4/3/13 5:26 PM

As health care reform unfolds on both the national and state fronts, the mar-ketplace will transform into a landscape unlike anything previously seen within our industry. It will bring great opportu-nity for pharmacies, but will also bring its share of challenges.

The Congressional Budget Office projects that 32 million more people will have health coverage by 2019. This will mean an influx of new phar-macy patients or existing patients who gain coverage. However, state-by-state implementation of Medicaid expansion and public health care exchanges will create a complex patchwork that will yield a proliferation of state-based and regional payers and new prescription plans. And while this state-based patch-work may be well suited to small chains and independent pharmacies, it will be a serious challenge for many large regional and national pharmacy compa-nies to manage.

Under these new benefit plans, phar-macies will likely see more narrowed networks and similar, or potentially even slightly lower, blended reimbursement rates. However, there may be some new and expanding opportunities to gain revenue through professional service fees. Overall, pharma-cies can expect more patients, and thus more gross revenue, but it is anticipated that reim-bursement rates will put more downward pres-sure on margins.

The Rise of Preferred NetworksWith the projected increase in the num-ber and types of pharmacy benefits being offered, participation in preferred networks is a must for long-term sus-tainability. These narrowed networks are a great opportunity for pharmacies to retain patients, and even gain new patients as network managers divide lives between fewer providers. In fact, the industry is already seeing evidence of a growing popularity of preferred pharmacies.

According to a study by Drug Channels Institute chief executive offi-

cer Adam J. Fein, PhD, for 2013, 44% of Medicare Part D beneficiaries chose a plan that financially rewards them for using a preferred pharmacy.

“Beneficiaries are seeing lower copays and potentially seeing lower out-of-pocket costs through preferred networks, which ultimately drive them to preferred pharmacies,” says Smart Insurance Company chief executive officer Pritpal Virdee. “Layer on top of that the fact that the mandatory main-tenance of certain drugs will continue to rise and pharmacies are sure to have a complex road to navigate due to the fast-changing health care landscape.”

Lines Are BlurringAs the industry continues to evolve, lines of distinction between many tra-ditional sectors of pharmacy—com-munity, managed care, health system, and chain drug pharmacies—are fast blurring. Pharmacy providers within these traditional sectors are beginning to aggressively explore opportunities to grow and excel outside their usual scope.

RxAlly is a great example of a nontraditional alliance that even 5 years ago might have been unthinkable: a large chain and indepen-dent pharmacies coming together behind similar goals with 1 focus. With more than 12,000 inde-pendent pharmacies and 8000 Walgreens locations, RxAlly is the preferred net-work for the SmartD Rx Medicare Prescription Drug Plan.

In a recent presentation at the annual American Society of Health-System Pharmacists conference, presenters Anthony Zappa, PharmD, MBA, Steve Rough, MS, BSPharm, and Scott Knoer, PharmD, MS, pointed out that phar-macy leaders will need to begin looking beyond the traditional business models for their organizations to remain suc-cessful. Having the skills to provide entrepreneurial solutions will help con-tinually improve the value the pharmacy brings to an organization.

At the same time, pharmacy benefit managers (PBMs) and mail order phar-macies are no longer alone in launching and operating care management pro-

grams with a national scope. To gain a greater share of chronic and specialty pharmacy patients, heighten the pro-file of their improving dedication to integrating more clinical practice, and potentially build new revenue sources, large chain pharmacies are providing bedside medication delivery programs, expanding specialty pharmacy opera-tions, and building strong patient care management programs.

With PBMs as the largest sector in the specialty pharmacy market, and many health systems moving to out-patient pharmacy, specialty pharmacy,


The industry is already see-ing evidence of a growing popularity of preferred phar-macies.

Understand the changing health care reform land-scape in your state and region

Prepare for an onslaught of new payers, benefit plans, and patients

Learn more about preferred networks and what they mean to your business

Evaluate in-store technol-ogy for multidisciplinary clinical connectivity

Pharmacy leaders need to look beyond traditional business models to remain successful

Expand your role as a trusted advisor and a commu-nity leader

Tips to Be Prepared for the Changing Landscape


and even mail order to control costs, independent and community-based pharmacies must continue to compete vigorously to maintain patients and pre-scriptions. As competition grows, com-munity pharmacies will need to vie for every specialty prescription.

Focus on Collaborative CareOver time, networked pharmacies have proven their ability to help reduce over-all health care costs and decrease patient hospitalizations. Indeed, the growing popularity of accountable care organi-zations (ACOs) and collaborative care networks has afforded pharmacists the oppor-tunity to make an even greater impact on posi-tive patient outcomes through a heightened leadership role as a mem-ber of a multidisciplinary care team to further man-age whole-patient care.

For example, Walgreens has devel-oped an innovative ACO model with pharmacists serving as an integral part of patients’ care teams, and is uniquely positioned to help meet the triple aim of improving patient outcomes and satis-faction while lowering health care costs. “Walgreens pharmacists and Take Care Clinic nurse practitioners are the most accessible health care providers in thou-sands of communities nationwide,” said Jeffrey Kang, MD, Walgreens senior vice president of pharmacy, health, and wellness services. “By offering greater access to important, preventive services such as immunizations, health testing, medication therapy management, and various forms of patient counseling, among many others, our clinicians are working with hospitals, health systems, and physician groups to deliver integrat-ed care that can benefit patients, payers, and the health care system at large.”

And the popularity of ACOs is growing. A November 2012 study by management consulting firm Oliver Wyman found that 25 to 31 million US patients currently receive their care through ACOs, including 2.4 million in Medicare ACO programs and 15 mil-lion non-Medicare patients in Medicare-

oriented ACOs. Furthermore, 45% of Americans live in a locale served by at least 1 ACO. The study goes on to state that ACOs, little known only 2 years ago, are poised to offer a competi-tive threat to traditional fee-for-service medicine.

With these changes, it is imperative that community pharmacies position themselves as a collaborative partner. Technically, community pharmacy will be pressed to have the right platform of connectivity beyond just a clinical collaboration. Pharmacists must devise an IT systems solution that ensures a

formal charting of health care information and greater connectivity with other health care provid-ers to ensure a 1-view medical chart.

RxAlly chairman and chief executive officer Bruce T. Roberts says that another challenge facing pharmacies is measuring and demon-strating the clinical and economic value that they bring to the system—get-ting our system to fairly compensate them based

on the value. “At RxAlly, we are lever-aging our tools, resources, and analyt-ics—and the collective commitment of our individual pharmacies—to measure performance, hold pharmacies account-able for demonstrating performance, and hold payers accountable for pro-viding patients with access to pharma-cist delivered services, shown by data to improve health and reduce overall costs,” he said.

A Trusted AdvisorWhile these evolutionary changes are encouraging pharmacists to practice and operate differently, fortunately, phar-macists will also have the opportunity to continue building on their role as trusted advisors. Patients will be looking for advice as they navigate the complexi-ties of the ACA and the expansion of Medicaid, and as they wade through the intricacies of public exchanges while they choose a drug plan that helps them manage their personal prescription care. “Pharmacists have the unique opportu-nity to assume a much more meaning-

ful role in people’s health care,” says Roberts. “They are among the most accessible health care providers, can enhance the patient experience, and are at a key intersection in health care to assist in coordination of care.”

A January 2013 survey commis-sioned by Smart Insurance Company validates that Medicare beneficiaries not only value the advice of pharma-cists, they seek them out as trusted advisors, and as a result, are more loyal to those pharmacies. “The survey find-ings validated our brand promise as a company,” says Virdee. “But it also shows that there is an economic value for pharmacists to be advisors and a part of a preferred network. We know that counsel and partnership by pharmacists that helps beneficiaries effectively treat their health issues in an economically efficient way is appreciated by benefi-ciaries.”

While it is true that the community pharmacy’s role in the fast-changing health care landscape is evolving, there is reason to be optimistic. The effects of the projected new patients with health care coverage will be unprecedented—and it will offer pharmacists the oppor-tunity to continue being patient advo-cates while building business at the same time. n

ACOs, little known only 2 years ago, are poised to offer a competitive threat to tradi-tional fee-for-service medicine.


feature

TAbleT exTrA

Download the Pharmacy Times iPad App Today!

AbouT The AuThorMr. McGuirk earned his bachelors of science in psychology, masters in education and masters in business administration with a concurrent post-graduate equivalency in public health from the University of Alabama at Birmingham.

Prior to joining Smart Insurance Company, he spent 7 years with Walgreen Co in the specialty pharmacy division and managed market sales, government segment. His experi -ence includes more than 20 years with infusion, specialty, community, and retail pharmacy com-panies, as well as several years in disease and condition management and medical publishing. Throughout his career, he has remained dedi -cated to building payer and provider initiatives that improve equal access to increasingly effi -cient and innovative health care and therapies through social marketing campaigns, health and wellness, preventive care/disease prevention and community-based harm reduction pro-grams, and innovative plan design.


Do the statements above describe you and your practice? If not, chances are you have a very

negative opinion of the rapidly chang-ing landscape in health care. One of my pharmacy school professors made an extremely prophetic statement: “It’s not enough to commit to change, you must commit to always changing.” In our efforts to keep pace with the changes ahead, we must embrace change and be willing to take the road less taken.

As the baby boomers age, health care and medication costs continue to rise. In order to manage these patients both clinically and fiscally, numerous niche pharmacy services continue to surface. These services include, but are not limited to, medication therapy man-agement, adherence programs, immu-nizations, diabetes care, blood pres-sure monitoring, smoking cessation, lipid monitoring, asthma management,

weight and osteoporosis management, HIV/AIDS services, mental health ser-vices, anticoagulation monitoring, and cancer awareness education. These ser-vices allow us to move our profession away from the traditional drug curator role and toward the desired role of health care provider.

ChangesSeveral years ago, we made a conscious effort at our pharmacy to try to tackle some of the most difficult patients. The majority of these patients have no fewer than a half dozen disease states with at least as many medications. Many live in adult care homes, while others are ambu-lant in the community. We offer special compliance packaging, on-site pharmacy consulting, and medication delivery. We also provide similar services to both mental health and HIV facilities in the area.

Niche Services and the Road Less TakenSteve Adkins, PharmD

Pharmacists Can Embrace New Technology and New Ways to Provide Care for Their Patients

The International Pharmaceutical Federation states that community

pharmacists should:1. Be experts in pharmaceutical

care, pharmacotherapy, and health promotion

2. Be professional communi-cators with patients, other health care providers, and decision makers

3. Deliver good quality in prod-ucts, services, and communi-cation

4. Document their actions and make descriptions and publi-cations available


the entrepreneurial pharmaCist

The Entrepreneurial Pharmacist

Pg15_Entrepreneurial.indd 15 4/4/13 10:10 AM

http://en.wikipedia.org/wiki/International_Pharmaceutical_Federation

http://en.wikipedia.org/wiki/International_Pharmaceutical_Federation

http://en.wikipedia.org/wiki/Pharmaceutical_care

http://en.wikipedia.org/wiki/Pharmaceutical_care

http://en.wikipedia.org/wiki/Pharmacotherapy

http://en.wikipedia.org/wiki/Health_promotion

http://en.wikipedia.org/wiki/Patient

http://en.wikipedia.org/wiki/Healthcare_provider

http://en.wikipedia.org/wiki/Communication

http://en.wikipedia.org/wiki/Communication

Our pharmacy is also certified by each of the major clozapine registries, and we coordinate: Obtaining lab values for close to

100 patients Screening those lab values to

ensure that there has been no sig-nificant drop in white blood cell count (WBC) or absolute neutro-phil count (ANC)

Either faxing or entering those val-ues into the online registry

Then, assuming there’s been no significant drop in WBC or ANC, dispense in 7-, 14-, or 28-day incre-ments (per protocol) to ensure the patient’s safety

We also coordinate care with our adherence program for patients outside of these facilities to decrease hospitaliza-tions, improve outcomes, and enable these adults to both preserve their independence and prevent a costly transition to assisted or skilled care.

Medication Adherence Programs WorkWe often get the question, “What is medication adherence and why is it so important?” Medication adherence means medications are:

• Taken at the right time of day • Taken with or without food • Taken completely and refilled appro-

priately• Stored correctly Many of us don’t like having to take

medicine, especially not multiple medi-cations daily, but how often do we actu-ally consider the problems that nonad-herence can cause? Nonadherence to medication can lead to many problems, including an increase in cost to both the patient and insurer, and lead to a decline in the patient’s overall health.

Poor adherence may give a patient’s physician the false impression that the current medication regimen is not working appropriately, causing the physician to add unneces-sary medications to the cur-rent regimen. Studies have shown that taking medication with less than 80% accuracy (referred to as medi-cation possession ratio, or MPR) leads to expensive hospital visits, increased

admissions to nursing homes and rehabilitation centers, and poor overall outcomes. However, with our program we report these issues to the patient’s provider to ensure the best outcomes.

With this adherence pro-gram we offer the follow-ing:

• Medication reviews• Synchronized medication refills coor-

dinated with the patient (not auto-refills)

• Special compliance packaging • eHealth Technology—to be added in

the near future

Medication ReviewsAt our reviews, we offer a simple 30- minute consultation with one of our phar-macists to arm our patients with the tools they need to improve compliance. We provide them with a comprehensive list of their medications, including:

• What they are used for• How and when they should be taken • If they should be taken with or with-

out food• How they can affect other medical

conditions • How they may interact with other

medications • Suggestions for less expensive medi-

cations

Synchronized Medication RefillsWe offer this service for numerous rea-sons. Synchronization helps the phar-macist and loved ones to quickly access noncompliance issues and enables the

pharmacist to see a patient’s entire medication regimen, rather than rely on a technician or a computer to check for interactions or duplication in therapy.

Special PackagingAs the number of medica-tions increases, a patient’s ability to remain adher-ent becomes exponentially more difficult. Another way that we offer sup-

port to our patients is with our special packaging program. Rather than having medications dispensed in a vial or bottle, a patient’s medications are packaged in a

special card that makes it very easy to see if a dose has been missed.

TechnologyMore than 50% of the population now has a smartphone. Health Park Pharmacy is in the pro-cess of interfacing with a smartphone application that will do the following:

• Prompt you with a phone call when-ever it is time for you to take your medication

• Verify that you are taking the cor-rect medication with RFID/bar-code verification

• Allow you to report any adverse effects to your doctor or pharmacist immediately

• Enable your pharmacist to monitor how well you are taking your medi-cations

• Allow our pharmacists to make a clinical intervention using Face- Time, Skype, or a home visit if a patient’s MPR drops below accept-able values

This service will most likely cost about $100 to $150 per month. That cost is significantly less than the cost of a hos-pital admission ($25,000+), emergency department visit ($5000 to $10,000), or the cost of a skilled nursing facil-ity (~$7000 per month). With all of these tools, our pharmacy team can help patients maintain independence and live a longer, healthier life.

It’s not easy, but services like these will continue to push our profession for-ward and away from commoditization. n

“It’s not enough to com-mit to change, you must com-mit to always changing.”

We made a conscious effort at our phar-macy to try to tackle some of the most diffi-cult patients.

AbouT The AuThoRSteve Adkins, PharmD, is co-owner of Health Park Pharmacy in Raleigh, North Carolina. He has a passion for patient care and mHealth. Over the last 10 years, he has provided one-on-one advice to his patients to improve their health by working with physicians to provide the best plan for each individual. He was inspired to become a pharmacist by Don Deaton and Linda Deaton Adkins. They encouraged him to take a job as a delivery driver at his hometown pharmacy in Danville, Virginia, and it was there that he felt the impact this business had on his com -munity. As a result of these experiences, his goal as a community pharmacist has been to educate patients to improve their health. He hopes to utilize mHealth to take medication adherence and patient care to the next level.


the entrepreneurial PhARMAciST

Pg15_Entrepreneurial.indd 16 4/4/13 10:12 AM

Effective communication with patients and clinical colleagues is a fundamental aspect of a phar-

macist’s practice. With the patients I work with, those with severe and persis-tent mental illnesses, behavioral changes such as tobacco cessation, exercising, proper nutrition, and medication adher-ence would often bring about profound changes in their well-being—if the patient would simply adopt these changes. Getting to that point is often a significant barrier and a source of frustration, as repeated attempts to engage patients to change end in failure.

Convincing a physician or administra-tor to make a clinical policy change, a formulary addition, or a practice change can be just as challenging. The day-to-day challenge of being ineffective can lead

to long-term frustration, cynicism, and professional burnout.

Our health care training has often led us to believe that physicians, pharmacists, and nurses are at the pinnacle of the health care team. As “all-knowing,” they simply have the task of pointing out to patients what they are doing wrong and what they need to do differently to improve their health and well-being.

It is becoming increasingly clear that dictating directives to patients is a highly ineffective strategy. I like to think of it as “The ‘60s are over and Vince Lombardi is dead!” Commanding patients what to do unilaterally, fear and intimidation tac-tics (“If you do not lose weight you will develop diabetes, hypertension, joint disease, etc”), and giving pointed advice without permission are strategies that are doomed to fail. Further, it will add to the clinician’s frustration regarding their rela-tive inability to be successful in changing a patient’s behavior and health outcomes.

Motivational interviewing (MI) is an evidence-based strategy that is includ-ed in the Substance Abuse and Mental Health Services Administration’s listing of effective patient care programs. MI incorporates strategies of understanding

the patient where they are—via active listening, empathy, respect, and collabo-ration with the patient on developing and achieving incremental goals. MI is not an intuitive process. On the contrary, it often runs counter to our training as health care providers as being “all-knowing.”

Effective implementation of MI tech-niques requires basic training and skills development, then repeated practice. Ongoing feedback via trained supervision has been found to best assure that the principles of MI are adhered to over time.

MI uses active listening skills to iden-tify what motivates a patient. The issue becomes one of “What is the patient motivated for?” instead of “Why isn’t the patient motivated?” MI is based on the concept that people are more often “stuck” versus totally opposed to change. As health care providers, pharmacists are in a unique position to positively influ-ence someone’s motivation via applying the techniques of MI.

Quite simply, MI is the effective use of open-ended questions to identify where the patient is in relationship to consid-ering a change in behavior. There are suggested to be 6 stages in the change continuum—pre-contemplation, contem-plation, preparation, action, maintenance, and relapse. As the primary experts on themselves, patients are in the unique position of taking action to help them-selves. Empowering the patient to see the world from this perspective can help him or her to begin to take action.

The cardinal rule of MI—using the acronym RULE (offered up by Miller, Rollnick, and Butler, 2009)—is to Resist the righting reflex (ie, telling the patient what to do or being judgmental), Understand your patient’s motivation, Listen to your patient, and Empower your patient.

Initially, the use of MI may feel cum-bersome and may take more time versus the old unilateral advice giving prac-tices. In time, with continued practice and coaching, the skills will become more entrenched. It may always be difficult for some of us to remain neutral and non-judgmental, and to refrain from respond-ing to poor decision making by patients. Transferring the responsibility for success from the provider to the well-informed and change-ready patient can be an effec-tive tool for the pharmacist—and can lead to enhanced professional satisfaction. n

Motivational Interviewing Jerry McKee, PharmD, MS, BCPP


CAREER LADDERTM

Learning a New Skill

For a case study on motivational interviewing, go to www.pharmacy times.com

MoRE @ www.

phARMAcy TiMEs.coM

Jerry McKee, PharmD, MS, BCCP, is associate director of Behavioral Health Pharmacy Programs Community Care of North Carolina.

Pg17_CareerLadder_V2.indd 17 4/3/13 5:31 PM

Technology

While not a replacement for a double blind clinical trial, the PatientsLikeMe study was able to use a novel algorithm to reduce bias in an open label, real-world situation to improve the statistical power of the study, making the patient data obtained from social media mean-ingful.

In another ongoing study at Rex Cancer Center in Raleigh, North Carolina, patients with chronic phase chronic myeloid leukemia are using smartphones to track and manage adherence while monitoring outcomes associated with oral cancer drugs to enable early intervention.2 Outcome

data is being collected using The M.D. Anderson Symptom Inventory, a multi-symptom, patient-reported measure for clinical and research use.

These are 2 examples of how cell-phones and social media are being used to collect and aggregate data to supplement and transform more traditional sources

Barbara Rapchak, founder, eMedonline In April 2011, the social networking website PatientsLikeMe

revealed the results of their patient-initiated observational study regarding the use of lithium carbonate in the treatment of amyo -

trophic lateral sclerosis. It was the first time a social network had been used to evaluate a treatment in a patient population in real time. Significantly, it refuted an earlier published study claiming that lithium carbonate slowed the progression of the disease. 1


Transforming Health Care

Smartphones and Social Media

Pg18_Tech.indd 18 4/4/13 10:30 AM

of medical information. The rising cost of health care and complexity of pre-scribed therapies require new approach-es to obtaining information in order to engage patients and manage disease in real time. Patient-centric, technology-enabled approaches have significant time and cost advantages, and can add value to the medical knowledge base.

Personalization and ValueThe sociology of patient care and how patients value the experience are impor-tant considerations in health care deliv-ery today. Value differentiation occurs on the experiential side, not the technical side. Air travel is a good example of this. Travelers in first class, business class, and coach all arrive at the same time. All of the differential value to the traveler is in the experience.

The more personalized the experi-ence, the greater the perceived value. There is a great opportunity to drive the personalization of the health care experi-ence using technology and social media. Greater personalization and perceived value lead to positive behavior change and ultimately better health based on the health belief model. If the behavior has an effect that is perceived to be personal, relevant, and valuable, then it is more likely to be adopted.

Pharmacists have the opportunity to play an important role in personalizing the health care experience, adding value along the way. One good example of this is in initiatives to reduce hospital readmis-sions. Faced with large penalties for high readmission rates, hospitals are focusing on medication reconciliation and adher-

ence to help patients transition from the hospital to the next source of care.

Pharmacists—armed with mobile health technologies that can be used to facilitate adherence with medica-tion regimens, monitor vital signs, and send reminders and alerts about critical follow-up within the first 30 days post-hospitalization—have been successful in reducing readmissions.

At Nyack Hospital in Nyack, New York, for example, pharmacists gave congestive heart failure and pneumonia patients smartphones to help man-age dosing regimens and monitor medication adher-ence upon discharge. They saw readmissions drop from 26.7% to zero.3 This was in a population with signifi-cant comorbidity and poly-pharmacy—up to 27 dosing events per day.

Barnes-Jewish Hospital in St. Louis, Missouri, found that readmissions large-ly stem from almost half of discharged patients failing to fill their prescriptions.4 New technology and new full-time phar-macists at the hospital gave patients the ability to fill prescriptions at their bed-side, resulting in 40% of patients now leaving with their medication.

Other opportunities for technology-enabled pharmacy programs exist in improving the experience in health plans. In 2012, the Centers for Medicare & Medicaid Services added medication adherence to their Five Star Quality Rating System for Medicare Advantage

Plans, providing health plans an added incentive to measure and capture adher-ence among covered members.5

A technology-enabled pharmacy pro-gram can be a key factor in better care coordination. Aetna built in a financial incentive of $2 to $3 per patient per month to primary care doctors across its network if practices meet certain stan-dards for care coordination. Other insur-ers including Blue Cross Blue Shield (BCBS) of Florida, Anthem BCBS, and Empire BCBS are offering similar pro-grams.6

Patient-Driven, Participatory Change Social media has the potential to impact the provider-patient relationship akin to what Facebook, Twitter, and LinkedIn have done for relationships among friends, family, and business colleagues. In addition to fostering one-on-one rela-tionships, social media and mobile tech-nologies leverage the power of crowds, facilitating patient-driven, participatory, organic change.

The potential and wonder for technolo-gies like smartphones and social media in the field of health care are clear. But so is the “dis-connect” between what can be and what is. Max Lugavere, founding host for Al Gore’s Current TV, put the question bluntly—“If there really is so much potential, why is the current state of health care, at the

patient level, such an uninspired mess?”7

Hospitals are complex decision-mak-ing settings. When dealing with the kinds of records that involve count-less variables where even the slight-est overlooked nuance can have huge consequences, the need to move beyond what Lugavere calls “the MS-DOS-like abyss” is clear. Around 25% of medication errors included in the 2006 Pharmacopeia MEDMARX involved computer technology as a contributing cause. Issues cited included alert fatigue, screen fragmentation, and terminology confusion.8

Much can be done in terms of user


Patient-centric, technology-enabled approaches have significant time and cost advantages…

About the AuthorBarbara Rapchak is an experienced health care technology and business executive with specific expertise in behavior informatics—studying how people use technology to enhance the health care experience. She is the founder of eMedonline, a patented software-as-service platform for mobile medication therapy management that improves adherence and facilitates care transition and disease management, resulting in reduced health care costs for providers and payers, and enhanced drug use for pharmaceutical manufac -turers and specialty pharmacies.

The technology is uniquely built on Ms. Rapchak’s extensive research in medication adherence and behavioral informatics. It has been shown to deliver 98% compliance and clinically significant improve -ments in self-efficacy in numerous clinical trials funded by the National Institutes of Health (NIH) and indus -try. It has also reduced hospital readmissions in a pilot study, engaging the patient, facilitating care transi -tion, and supporting meaningful use. Ms. Rapchak has managed complex technology development proj -ects and is experienced in providing clinical research services and expertise to companies and institutions conducting health informatics research and clinical trials. She has led sponsored research and technology development for the NIH, collaborating with hospitals, universities, major corporations, and government agencies on a wide range of health care projects. Her expertise includes technology development, research design, protocol development, and clinical monitoring. She is a member of the Scientific Review Panel for NIH, and supports entrepreneurism in the private sector by participating as a mentor to student interns and a guest lecturer to academia. She received her bachelor of science degree from Notre Dame.

Pg18_Tech.indd 19 4/4/13 10:31 AM

Technology

interaction and interface design to improve usability and link disparate sys-tems to connect what have previously been silos of data, adding significantly

to knowledge value. Innovative mHealth platforms are now being combined with medical interface terminologies to allow mobile technologies to become fully integrated with clinical systems, work flow, and knowl-edge. Leveraging the best that mobile technology has to offer can make it easier to deliver treatment in a low-cost setting out-side of the acute environ-ment in the emergency department or hospital, making it more comfort-able for the patient.

The Patient as an Untapped Resource The medical field by definition is social, involving interaction between people. It is also dependent on information. Social media and mobile technologies bring people and information together in a

way that fosters a rich environment for the practice of medicine and health care.

The ready access to virtually unlim-ited information from various media is revolu-tionizing the exchange of medical informa-tion and the interaction among stakeholders in the health care experi-ence. Armed with more data than ever before, patients are in a bet-ter position to chal-lenge treatment plans and weigh options. Physicians and pharma-cists are in a better posi-tion to have the medical information that they

need instantly at their fingertips with a few keystrokes.

The challenge becomes how to use this information in a meaningful way. Are we up to the challenge? n

Armed with more data than ever before, patients are in a better position to challenge treat-ment plans and weigh options.

®

The

iPad Edition

Scan here to download App

A Unique

Interact

ive Exper

ience

Download the March edition and enjoy all the

iPad extras!

Your favorite pharmacy journal, reimagined

for the iPad.Explore multimedia resources,

exclusive articles, and CE lessons at your fingertips.

Download the free app today.

Pg18_Tech.indd 20 4/4/13 10:31 AM

Directions in Pharmacy™ is published by Intel-lisphere, LLC, a leading provider of health care publishing, research, information, and educa-tion. Operating within both traditional and digital media channels, Intellisphere serves the needs of health care professionals through an extensive suite of magazines, journals, e-mail databases, websites, events, and personal meetings.

Intellisphere reaches more than half a million health care professionals through Cardiology Re-view, Pharmacy Times, Specialty Pharmacy Times, The American Journal of Managed Care, The American Journal of Pharmacy Benefits, HCPLive.com, Oncology & Biotech News, Onc- Live, Contemporary Oncology, Oncology Nursing News, Targeted Therapy News, and The Interna-tional Journal of Targeted Therapies in Cancer.

A Health Care Information Leader

12_CoversAd.indd 12 4/3/13 5:13 PM

Shopping is everywhere in the United States. Just look around and you will see price check

apps, extreme couponing, daily deals, and location-based coupons. Shopping has become the national pastime, with bragging rights going to those who can grab the best deal. Shopping is every-where—until you buy a prescription drug.

The CatchMost would-be shoppers purchase pre-scription drugs using insurance from their employer. Here’s the catch: most employer-sponsored prescription drug plans share costs between the employer and the individual using fixed copays.1 While simple in some respects, copays provide individuals with little indica-tion of the actual cost of the drug. Copays usually result in either the indi-vidual or the employer paying the vast majority of the drug cost.

For example, the monthly copay for a generic drug such as atorvastatin 10 mg may be $15. With the actual cost of the drug at $14, the individual is paying 100% of the cost.2 In another example, the monthly copay for a brand drug such as Abilify 10 mg may be $65. The actual cost is $684 and the employer pays $620.3 The split is in the other direction, with the individual paying

less than 10%. To add to the confusion, the cost-sharing tiers are determined by a lengthy formulary document which includes fine print on further restric-tions such as prior authorization, step therapy, and quantity limits. Even though the patient purchases the drug at the pharmacy, they have very little idea of the actual cost.

For many people, getting a prescrip-tion boils down to 2 things: Which Pharmacy? and “The Surprise.”

Which Pharmacy? This is the big question from the physician when he/she is e-prescribing the prescription. As patients are not shoppers, this boils down to a question of convenience. The pharmacy situated most conveniently between the physician’s office and the patient’s home gets the business. As a result, pharmacies have pursued an extensive strategy of geographic con-venience to put a pharmacy on every corner.

The Surprise. Most people, including physicians, do not know what drugs cost.4,5 When a patient goes to pick up a drug-cost is often a surprise. Did I get the $15 or the $65 drug this time?

Consumer-Directed Health CareEmployers are moving rapidly to con-sumer-directed health plans (19% of plans in 2012) to shed cost and to make their employees more price sen-sitive. As people start spending their own money through high-deductible plans or higher copays, individuals start shopping. Shopping requires answers to more than just “Which Pharmacy?” and doesn’t work so well when there is a surprise on cost.

Here are some common shopping questions starting to be asked about prescription drugs:

What’s the difference between the drug being prescribed and its therapeu-tic alternatives? How much am I will-ing to spend for the convenience of a once-a-day medication versus a twice-a-day medication? Is this strength/form being prescribed available on a $4 generic formulary?

Which pharmacy has a better price? Does its $4 program have extra fees? Does mail order make more sense? Is there a drive through or do I need to park and bring my kids inside?

Should I buy through the plan? What about purchasing outside the plan with a prescription discount cards or on a $4 generic plan? Should I use a manufac-turer coupon or free samples?

A new class of mobile solutions is emerging to help consumers answer these questions and eliminate the cost surprise. With drug cost information accessible from your phone, individu-als can start shopping. Changes in pur-chase behavior have immediate and long-term effects on health care costs for both individuals and employers. A single shopping decision to switch to a lower-cost drug can result in health care savings of more than $1000 a year for multiple years.

We are a society of shoppers, so let’s empower individuals with information and put their shopping skills to work to lower health care costs. n

MATTERSMONEY

A Pharmacy on Every Corner or Prescription Drug Costs on Every Phone?Dan Pollard, PhD, MBA

Dan Pollard, PhD, MBA


ABouT THE AuTHoRDan Pollard, PhD, MBA, founded myDrugCosts with the vision to help individuals make cost-informed decisions about prescription drugs. Prior to myDrugCosts, Dr. Pollard spent 14 years in health care software product management driving innovation at health care IT companies such as Allscripts, Misys Healthcare, and MDeverywhere. Dr. Pollard earned his PhD in medical informatics as a National Library of Medicine fellow at Duke University. He also has an MBA from the Fuqua School of Business.

MoRE @ www.

PHARMACy TiMES.CoM

For references, go to www .PharmacyTimes.com/ publications/issue.

Pg22_MoneyMatters.indd 22 4/3/13 5:35 PM


Care Coordination in a New Health Care Model

Case studies diabetes

improving Outcomes for Patients with diabetes

It has been widely accepted that seri-ous medical errors and miscommu-nications often occur as our patients

shift from one health care setting to another. Resources, time, and money are spent caring for patients, and can increase exponentially when a break-down in the flow of information takes place in an unorganized health care environment, especially when in the form of readmissions.

For example, imagine we have a patient with uncontrolled diabetes and low health literacy. We’ll call him AB. Over the years, AB has passed incon-sistently through urgent care facilities, primary care offices, emergency depart-ments (EDs), and pharmacies. He and his providers have dabbled with the gamut of therapies, yet his A1C remains above 10 and complications with his

kidneys, eyes, and nerves have set in. He is often lost to follow-up, and reap-pears in the system, usually the ED, only when symptoms become unbear-able. AB is typically noncompliant with medications and unable to provide an accurate home medication list. He is admitted, treated, released, and the cycle repeats.

Many have questioned how we, as a system, can intervene to promote better health outcomes for this patient. How can we avoid unnecessary utilization of hospitals, improve quality of care, and establish continuous chronic disease management?

One area of focus, as advocated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is coordination of care surrounding hos-pital admissions and discharges. Several

models have been developed, which are currently undergoing research to assess impact, and they incorporate distinct elements. Simply stated, coordination

and communication com-pose much of the founda-tion.

Now, imagine we have a new health care model where patients are encased within a team. This team may include a nurse care manager, pri-mary care provider, spe-cialists, pharmacist, social worker, hospital, and any other entities involved in

the patient’s care. In this model, the team encircles the patient continuously as he makes his journey through the health system, and are in constant com-munication along the way. Let’s apply this to our patient, and map out his new course.

AB presents to the ED due to uncon-trolled blood sugar. He is unable to provide the hospital with a complete list of his medications. He is subse-quently admitted, and while beginning his treatment, is visited by his nurse care manager, who engages AB and ini-tiates the care coordination process. She facilitates the gathering of his medica-tion list from his various providers and pharmacy claims, while simultaneously assessing potential education and social needs and communicating with the hos-pital staff.

The medication lists are passed on to the team pharmacist, who reviews and reconciles them to ensure that a com-plete and accurate list is communicated back to the hospital. The pharmacist is also surveying for potential hurdles,

Sarah Kokosa, PharmD

We are headed down a path of change in several aspects of health care today.

Pg23_CaseDiabetes.indd 23 4/3/13 5:36 PM


case studies diabetes

such as high-risk medications, potential cost-saving opportunities, and evidence of noncompliance or educational needs. When discharge is planned, the hospital provides instructions to AB, both ver-bally and written, including an updated medication list.

Once he arrives home, AB is again visited by his nurse care manager. She has a lengthy discussion with him about his condition, and provides edu-cation on self-management. She then assists AB with scheduling a follow-up appointment with a primary care provider (PCP), who will become his “medical home.” Importantly, the nurse also evaluates his home medication use while reviewing the discharge instruc-tions and discharge medication list with AB. These additional lists are compiled along with pharmacy claims and pro-vider lists, and again sent to the team pharmacist, who troubleshoots discrep-ancies, performs a complete medica-tion review, and ensures all relevant information and recommendations are communicated to the PCP.

AB’s nurse continues to follow up with him periodically via telephone, ensuring he made it to his PCP appoint-ment, and providing additional educa-

tion throughout the transition period. During his PCP appointment, diabe-

tes and pharmacist recommendations are addressed, labs are drawn, his chart is updated, and a follow-up appoint-ment is made. The initial steps to re-establishing chronic care have begun. Prescriptions are e-prescribed to the pharmacy and a complete medication list is provided to AB at the conclusion of his visit.

AB’s nurse care manager continues to follow up with him, ensuring he makes it to appointments, follows any new PCP instructions, and provides reinforcement, encouragement, and empowerment. She may even follow him long term if there is a perceived need. Then, if AB is not readmitted to the hospital within a set period of time, he has successfully traversed the transitional care process and is on his way to improved health outcomes.

Is this model of transitional care pos-sible? Absolutely! In fact, a model quite similar to this—in which a clinical phar-macist plays a crucial role among the coordinated care team—is already estab-lished and under investigation in states such as North Carolina. Are we detecting medication-related problems? Yes, many,

and they are being resolved while focus-ing on additional methods of prevention.

We are headed down a path of change in several aspects of health care today. While it may seem a daunting new venture, at times, it’s also exciting! We are infinitely optimistic and confident that we are uncovering the answers to improving quality of care and promot-ing better outcomes in a more efficient manner to create a brighter and healthier future for our patients. n

About the AuthorSarah Kokosa, PharmD, received her doctor of pharmacy degree in 2007 from Albany College of Pharmacy, in Albany, New York. Ms. Kokosa has been working with AccessCare since 2010, and currently serves as an ambulatory care clinical pharmacist for Sampson and Wayne Counties in North Carolina. In Sampson County, she is embed -ded within Clinton Medical Clinic, a 16-provider primary practice, where she has developed clinical pharmacy services with a focus on diabetes, hyper -tension, and lipid management, along with general medication therapy management (MTM) services. She has also worked with the AccessCare team in Sampson County to develop and implement a medication reconciliation and transitional care program with the local hospital, Sampson Regional Medical Center. In Wayne County, Sarah aids the nursing team with MTM for both transitional and chronic care patients, and is also involved with recent efforts to enhance the care team’s role within the local hospital.

“ Pharmacists are perfectly positioned and trained to maximize the benefits of the drug spend to obtain the most savings and boost revenues to the ACO,” said APhA senior vice president of government affairs Brian Gallagher, BSPharm, JD.

Using medications properly in an ACO environment, 9/7/12, APhA

“ It will not make any sense for any ACO to be created that won’t have pharmacy at the table,” said Health Affairs editor-in-chief Susan Dentzer.

Speech at the Opening General Session of the 2013 APhA Annual Meeting & Exposition

on March 2, 2013.

“ Supporters of the 2010 health law are look -ing to draft sports teams, pharmacies and political ground operations for their biggest marketing campaign yet: persuading mil -lions of uninsured, hard-to-reach and skepti-

cal Americans to sign up for health plans this fall.”

Wall Street Journal, States Gear Up to Pitch Health Plans,

2/12/13

“ NACDS has no higher pri -ority in 2013 than helping NACDS members implement healthcare reform, advocat-ing before the government throughout the implementa -tion, and helping to commu -nicate the important contri -butions of pharmacy to this effort—all for benefit of the patients whom you serve. ”

Pharmacies Again at Center of Health Insurance Rollout, 2/14/13, NACDS

“ The Walgreens ACOs created new partnerships with pharmacists and primary care providers,

and we are pleased that pharmacists are tak-ing an active part in this effort to improve the nation’s health care system,” Jonathan Blum, CMS acting principal deputy administrator and director, Center for Medicare.Walgreens forms three new ACOs, 1/22/13

chatter: acOs, the affordable care act, and Pharmacists

0

5

10

15

20

25

30

35

40

Esse

ntial

Very I

mporta

nt

Som

ewhat

importa

nt

Not Im

portant

Unsure

31% 6% 0% 25% 38%

How important is it for pharmacies to join an account-able care organization (ACO) in the next 36 months?

feature

Pg23_CaseDiabetes.indd 24 4/3/13 5:36 PM

Join our growing community o f Pharmacists!

Uson !

Facebook.com/PharmacyTimesFind us at:

• Get Facebook-exclusive content, including multimedia links and “Pet Peeve Fridays”

• Interact with your peers by discussing issues that pharmacists face every day

• Access new content daily and discuss pharmacy issues

• Suggest journal topics and give us your feedback

facebook_ad_0213.indd 1 4/3/13 1:39 PM

Today’s health care models require providers to collaborate and be accountable for achieving quality care. Leaders in local communities are restructuring their approaches to health care challenges, such as hospital readmission rates and care for chronic diseases. As a community pharmacist, you have a lot to offer. You know your patients and have watched their families grow and change. Medication use is central to many of the issues facing health care in our communities. Reach out and talk to the leaders who will shape health care in your community, such as local hospitals and physician groups. Listen to their needs and plans for these new models of care. Share with those providers how community pharmacists can play an integral role in making new efforts succeed. The National Community Pharmacists Association will continue to support you and to work with federal and state policymakers to ensure a level playing field. Community pharmacists have an important role to play!

Follow us on Twitter @commpharmacy | www.ncpanet.org

Independentpharmacists

looking forward

AdTemplate.indd 1 4/3/13 7:12 PM

navigating the affordable care act health care reform & you€¦ · april 2013 c ti s ®...

Documents