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PharmacyPracticeAdvancement:PolicyInfluencesattheNationalLevel

C.EDWINWEBB,PHARM.D.,M.P.H.

FERRISSTATEUNIVERSITYSPRINGSEMINAR

MAY16,2017

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Disclosure• Ihavenoactualorpotentialconflictsofinterestinrelationtothisactivity.

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LearningObjectives• Recognizeopportunitiesforpharmacypracticeadvancementpresentedbynationalshiftsinpaymentpolicyandbenefitdesigntoreward“valueandoutcomes”ratherthan“volume”ofhealthcareservices.• Definethekeyprinciplesofpatient-centeredandteam-basedcarethatfacilitateimprovedclinical,economic,andqualityoutcomesfromtheuseofmedications.• Explaintheemergingnationaltrendsinstandardizeddirectpatientcareprocessesforpharmacistsandtheirpotentialtosupportcontemporarypracticeadvancement.

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“AssumedTruths”inHealthCareReformPaymentReform:â FFSandá “bundles”,quality/outcomesincentives

Patient-centeredness(e.g.,fromboomerstomillennials)Healthcareteams,PCMH’s,andACO’s

Risksharing– oneandtwo-sided

Proactiveanalysisofandcareforpopulations

Technologyinnovationsandadaptations◦ precisionmedicine◦ pharmacogenomics◦ clinicaldecisionsupportusingevidence-basedstandards◦ health-IT– shifttointeroperability

MACRA2015– gamechangerformedicine18thtimeisacharm:MACRArepealsthe1997sustainablegrowthrateforPartBpaymentsReplacestheSGRwithanewpaymentmethodmeanttomovephysiciansandsomeotherproviderstowardalternativepaymentmodels(APMs)MACRAcreatestwoavailabletracks◦MIPS:“fee-for-serviceplusqualitylink”◦ APMs:accountablecareorganizationorotherrisk-bearingorganization

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Whatispatient-centeredcare?“Theexperience(totheextenttheinformed,individualpatientdesiresit)oftransparency,individualization,recognition,respect,dignity,andchoiceinallmatters,withoutexception,relatedtoone’sperson,circumstances,andrelationshipsinhealthcare.”

DonaldBerwick,M.D.FormerCMSAdministratorPresident,InstituteforHealthcareImprovementHealthAffairs,August2009

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Anyrecent“significant”experienceasa“real”patient?

StopandReflect

•Whatwasitlike?•Didyoufeel:•Fullyinformedaboutyourdiagnosisandcareplan?•Includedindiscussions/decisionsaboutyourcare?•Empowered/expectedtoquestionanddiscuss?•Respected/valuedasanindividual?•Partoftheteam’sstructure/activities?

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Whatisteam-basedcare?

“Thehealthcarewewanttoprovideforthepeopleweserve—safe,high-quality,accessible,person-centered—mustbeateameffort.Nosinglehealthprofessioncanachievethisgoalalone.”

CarolA.Aschenbrener,M.D.ThenExecutiveVicePresident

AssociationofAmericanMedicalColleges- 2011

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IOMPaper“TeamMembers”

PamelaH.MitchellUniversityofWashington

MatthewK.WyniaAmericanMedicalAssociation

SallyOkunPatientsLikeMe

C.EdwinWebbAmericanCollegeofClinicalPharmacy

RobynGoldenRushUniversityMedicalCenter

BobMcNellisAmericanAcademyofPhysicianAssistants(former)

AgencyforHealthcareQualityandResearch

IsabelleVonKohorn,InstituteofMedicine(former)ValerieRohrbach,InstituteofMedicine

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IOMDiscussionPaper2012:Aframingdefinition

Team-basedhealthcareistheprovisionofhealthservicestoindividuals,families,and/ortheircommunitiesbyatleasttwohealthproviderswhoworkcollaborativelywithpatientsandtheircaregivers—totheextentpreferredbyeachpatient—toaccomplishsharedgoalswithinandacrosssettingstoachievecoordinated,high-qualitycare.

IOMDiscussionPaper2012:NecessaryPrinciplesofHigh-PerformingTeams• SharedGoals

• Clear(Distinct)Roles

• MutualTrust

• EffectiveCommunication

• MeasureableProcessesandOutcomes

IOMDiscussionPaper2012:Necessaryvaluesofsuccessfulteammembers

• Honesty

• Discipline

• Creativity

• Humility

• Curiosity

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So???…..whatdoesallthishavetodowith“real”pharmacypractice?

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MTMDefined:Profession’sConsensus2005

“MTMisaserviceorgroupofservicesthatoptimizetherapeuticoutcomesforindividualpatients.MTMservicesincludemedicationtherapyreviews,pharmacotherapyconsults,anticoagulationmanagement,immunizations,healthandwellnessprogramsandmanyotherclinicalservices.PharmacistsprovideMTMtohelppatientsgetthebestbenefitsfromtheirmedicationsbyactivelymanagingdrugtherapyandbyidentifying,preventingandresolvingmedication-relatedproblems.”

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MTMDefined:CMS,MedicarePartDMTMgenerallyreferstoactivitiesintendedtooptimizetherapeuticoutcomesbyensuringthatpatientsaretakingtheirmedicationssafelyandasprescribed,addressinganybarrierstotheirdoingso,andbringinganymedicationissuestotheattentionofthetreatingphysician.

Under423.153(d),aPartDsponsormustestablishanMTMprogramthat:◦ EnsurescoveredPartDdrugsareusedtooptimizetherapeuticoutcomesthroughimprovedmedicationuse,

◦ Reducestheriskofadverseevents,◦ Isdevelopedincooperationwithlicensedandpracticingpharmacistsandphysicians,◦ Maybefurnishedbypharmacistsorotherqualifiedproviders.

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CMSperspectiveonPartDMTM- ~2015“EvidencesuggeststhattheMTMservicescurrentlyofferedbyPartDplansfallshortoftheirpotentialtoimprovequalityandreduceunnecessarymedicalexpenditures,mostlikelyduetomisalignedfinancialincentivesandregulatoryconstraints.CompetitivemarketdynamicsandPartDprogramrequirementsandmetricsmayincentivizeinvestmentintheseactivitiesonlyatalevelnecessarytomeettheminimumcompliancestandards.”

“Currently,PartDstatutoryandregulatoryMTMprovisionsrequireuniformserviceofferingstoenrolleeswhomeettheplan’sprogramcriteria,basedonnumbersofmedicationsandchronicconditionsandexpectedannualprescriptiondrugcosts.Thesecriteriabothover-identifyandunder-identifybeneficiarieswhoareeitherexperiencingorat-riskofexperiencingmedication-relatedissuesandcouldbenefitfromMTMinterventions.”

“TheresultisthatPartDMTMprogramsmaynotincludethelevelofresourcesnorthetypeofactivitiesthatcouldhavethegreatestpositiveeffectonbeneficiaryoutcomes.”

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PCPCCdefinescomprehensivemedicationmanagement(CMM)- 2012ThePCPCCguidedefinescomprehensivemedicationmanagementinthePCMH

IncludedinAHRQ’sInnovationCenter-QualityToolkit

2ndRevisionwithAppendixA-GuidelinesforPracticeandGuidelinesforDocumentation

PCPCCResourceGuide:IntegratingComprehensiveMedicationManagementtoOptimizePatientOutcomeshttp://www.pcpcc.net/files/medmanagement.pdf

CMMDefined:PCPCCComprehensivemedicationmanagementisdefinedas thestandardofcarethatensureseachpatient’smedications(whethertheyareprescription,nonprescription, alternative,traditional,vitamins,ornutritionalsupplements)areindividuallyassessedtodeterminethateach medicationisappropriateforthepatient,effectivefor themedicalcondition,safegiventhecomorbiditiesand othermedicationsbeingtaken,andabletobetakenby thepatientasintended.

Comprehensivemedication managementincludesanindividualizedcareplanthat achievestheintendedgoalsoftherapywithappropriate follow-uptodetermineactualpatientoutcomes.Thisall occursbecausethepatientunderstands,agreeswith, andactivelyparticipatesinthetreatmentregimen,thus optimizingeachpatient’smedicationexperienceand clinicaloutcomes.

PCPCCResourceGuide:IntegratingComprehensiveMedicationManagementtoOptimizePatientOutcomeshttp://www.pcpcc.net/files/medmanagement.pdf

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“ProviderStatus”An“experiencedcontrarian’s”viewpointWewouldhavehadtolooklongandhardtofindamore“tone-deaf”termforthemajorissueathandforpharmacists- effectivecoverage/paymentforpharmacists’patientcareservices- inrelationshiptothecurrentpolicyanddeliverysystemissuesjustoutlined– butthingsmaybestartingtochangeabit.

Tosucceed,theeffortmustbegroundedinacommitmenttopatients’care,outcomesandquality,nottoourownprofessional“status”…..itcan’tbeaboutUS!

Asanisolatedgoal,achieving“providerstatus”guaranteestheprofessionverylittle(seeMurawski andIves,AJHP2011,JAPhA 2013)

Asan“integrated”partofbroaderpracticechange andpaymentpolicychange,itcanhelppositionpharmaciststoactuallybemeaningfulandeffective“providers”

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RelevantExistingApproachesSection1861oftheSSA– the“holygrail”◦ Physician“definition”vs.physician“services”◦ Non-physician“providers”◦ StatutefocusesFIRSTontheservicescovered(PAIDFOR!!!)bythePartBbenefit,followingby“qualifications”description

NPsandPAs CSWPTServices Ph.D.PsychologistOTServices CRNA

UltimateIrony– a“providerofservices”means“….ahospital,criticalaccesshospital,skillednursingfacility,comprehensiveoutpatientrehabilitationfacility,homehealthagency,hospiceprogram,or,forpurposesofsection1814(g) andsection1835(e),afund.”

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RelevantExistingApproachesState-based– IsitCDTM,“mid-level”or“providerstatus”?◦ NorthCarolina(2000)– “clinicalpharmacistpractitioner”◦ JointRegulatoryoversightbyBOP&BOM◦ Differentiatedtrainingandcredentialingrequirements◦ Protocolrequirements

◦ NewMexico(1993)– “pharmacistclinician”◦ Primarily“prescriptiveauthority”initiative◦ Requiresdiagnosticandphysicalassessmenttrainingequivalenttoaphysician’sassistant(includedinrevisedPharm.D.curriculum)

◦ Directsupervisionofasinglephysician◦ Policysupportoutsideofpharmacyduetoconcernsaboutaccessto“primarycare”

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RelevantExistingApproachesCalifornia’s“Solution”(2013)– alesson?◦ Amendsthe“businessandprofessionalcode”todesignateallpharmacistsashealthcareproviders◦ Someprogressivemodificationstogeneralscopeofpractice◦ Establishes“advancedpracticepharmacist”◦ Education,trainingand/orspecialistcertificationrequirementsbeyondlicensure◦ Expandedscopeofpractice,notlimitedtoapharmacysetting◦ Regulatoryframeworknowessentiallycomplete

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So…whatarewestillmissing…?Withverylimitedexceptions,healthinsurancecoverageandpaymentpoliciesdon’texplicitlyincludemedicationmanagementservicesasadefinedbenefit fordiscreetPAYMENT!Aclearlydefined“what”deliveredusingaconsistentandstandardizedprocessofcareMorecompleteunderstandingthatcurrent trendsinpaymentpolicywillincreasethe“valueovervolume”challengeforALLproviders…andthefuture isnolongerfaraway

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ProcessofDirectPatientCare:Towardstandardizationandalignment….

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Pharmacyorganizations’harmonizationefforts:EnhancedstandardizationandprofessionalscopeofCPA/CDTMregulationsatthestatelevel;Recommendedguidelinesforthedevelopmentanduseof“statewideprotocols”(SWP’s)toimproveaccesstoproductsandcareservicesthataddressimportantpublichealthissuesthatmostpharmacistsareabletoprovide;Strivingforgreaterprecisionandrigorinterminologyreflectingpharmacists’patientcarepracticeactivities;

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Doyouknowthisman?

31Photocopyright2012- DreamWorksStudios

“Roles”vs.ResponsibilitiesSomequotesfromtheLindaStrandKeynoteatACCP2012:

“‘Linda,whenwhatyoudolookslikepatientcare,soundslikepatientcareandispatientcare,thenIwillpayyouforpatientcare.’”

(BCBSMinnesotaexecutive– circa1995)

“Eachofusdevelopedourownclinicalactivities,whichwedefinearoundourselves,basedonourspecialintereststhatemphasizeourstrengths,deliveredonourpreferredtimetable.Thatisnotapatientcareservice- thatisahobby.”

(Onthe“earlyhistory”ofclinicalpharmacy)

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Responsibilitiesof“Providers”Aphilosophygroundedinanethicalframeworkthatputspatients/familiesatthecenterofone’spractice

Clinicalperformancethatisevidence-based,continuouslyaccessible,andrigorouslyconsistentinitsprocessofcare

Aprocessofcarethatisstandards-based,recognizable,andunderstoodbypatientsandtheteam

Apracticeinfrastructurethatassuresavailability/exchangeofessentialclinicaldata,unfailingdocumentationofcare,measuresresults,andvalidatesvaluesufficienttojustifypayment

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WhatSuccessMustLookLikeinaPharmacist’sDirectPatientCarePracticeTheservicecanbedescribedsimplyandintermsofwhatitcandoforthepatientTheservicehasanethicalandfiducialfoundationTheserviceisbasedonstandards ofpracticesothatitcanbedeliveredconsistently-- onepractitionertothenext-- andfromonepatienttothenextTheserviceintegrateswiththeotherprovidersonthehealthcareteam,usingalignedandconsistentterminology,philosophy,standardizedcareprocesses,andquality/outcomeemphasisTheservicegeneratesmeasureable,reproducibleresultsthatdemonstratevaluetoothersTheserviceispaidforasotherdirectpatientcareispaidfor(increasinglyincludingemergingvalue-basedpaymentmodels)

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Inthefinalanalysis,“providers”must…befullyaccountableforthecareandservicestheyprovide,particularlyintermsofqualityandoutcomes;…becommittedtoandfocusedonthepatients/familywhohavegiventhempermission tocomeintotheirlives;…delivercareandservicesinthecontextofandalignmentwithnationalhealthpolicygoalsandobjectives;and…OWN andACCOMPLISH THEWORKthatisthecore oftheirparticularexpertise….whilenotaddingworktotheothercliniciansonthecareteam.

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Get The MedicationsRight!

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SupplementalResourcesforContinuingProfessionalDevelopment• KaiserFamilyFoundation(www.kff.org)• ExcellentdatasourceonMedicarepolicies,trends,expenditures

•NationalCommitteeonQualityAssurance(www.ncqa.org)• KeyorganizationinhealthsystemqualitymetricsdevelopmentandapplicationbyMedicare/privatepayers

• HealthAffairs(www.healthaffairs.org)• Leadingnationalhealthpolicyjournalcoveringthewidestrangeofhealthpolicy,deliverysystem,andpaymentissues.

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Questions?

Pre-Test1.TheannouncedgoalsoftheCentersforMedicareandMedicaidServices(CMS)toshiftthevastmajorityofitspaymentstructureforphysicians’andotherproviders’servicestowardquality/value-basedperformanceareintendedtooccuroverthenext:

A. 6-12monthsB. 2-3years(correct)C. 5-10yearsD. 2decades

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Pre-Test2.Whichofthefollowingisnot consideredanessentialprincipleofhigh-performinghealthcareteams?

A. Financialaccountability(correct)

B. EffectivecommunicationsC. SharedgoalsD. Clearroles

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Pre-Test3.Whichofthefollowingelementsofapharmacist’sstate-authorizedscopeofpracticewilllikelybeimpactedbycurrentnationaltrendsindeliverysystemandpaymentpolicyreforms?

A. FrequencyoflicensurerenewalB. RequirednumberofhoursofACPE-

approvedcontinuingeducationactivitiesC. Structureandefficiencyofcollaborative

practiceagreementsandclinicalprotocols(correct)

D. Increasesinthepharmacist-to-technicianratioallowedunderstateregulations

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