2011 Midyear Clinical Meeting New Orleans, Louisiana. Educational Session Abstract

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1 MCS-1 Title: Securing and managing prior authorizations for high-cost infusions in a large integrated health system Purpose: Medications administered by intravenous infusion commonly include chemotherapy, and biological products, which are among the most expensive medications on the market. As a result, most payers require that a prior authorization be issued as a condition of reimbursement for these medications. A number of challenges exist for hospital based infusion clinics in ensuring that each infusion has been appropriately reviewed, and approved by the patient s payer. This case describes how these challenges were addressed in a large, integrated healthcare delivery system that includes twenty-two hospitals that offer infusion services and nine infusion clinics. Methods: The corporate department of pharmacy services identified that the infusion clinics had no standardized process to ensure that prior authorizations and/or alternative financial arrangements had been secured prior to administering the infusion. Quantifying the amount of missed revenue presented a challenge as hospitals use a single denial code for all types of charges that are denied on the basis of not having a prior authorization in place. A representative from the finance department worked with the department to manually review denials to estimate that the system was losing approximately $1,000,000 annually because prior authorizations were not secured prior to administering the medication. A small workgroup was developed that included pharmacists, infusion clinic managers, finance managers, and patient assistance coordinators to formulate a plan to control this process across the system. It was recommended by this workgroup to hire a small team of pharmacy technicians to work with payers, referring providers, patient account services representatives, and patient assistance coordinators to ensure that financial arrangements were made prior to administering the medication to patients. The administration and operations committee with decision rights to hire this staff held a meeting every other month. In order to expedite approval of these positions, the workgroup met with all stakeholders prior to the committee meeting to describe the problem and proposed solution, as well as to collect statements of support to provide to the committee members. The workgroup addressed the concerns of the committee, and the committee approved two pharmacy technician employees to manage prior authorizations for the health system s infusion clinics. Results: One pharmacy technician was hired to establish the process of reviewing the infusion clinic schedules, medication orders, and patient payer information, and to ensure that financial arrangements are made prior to the scheduled date of infusion. Once the process was established, a second pharmacy technician was hired to assist in the workload. Since the inception of this service, the health system has secured prior authorizations for nearly $1,800,000 in medication charges in 9 infusion clinics. The medications that most commonly require prior authorization include infliximab, immune globulin, and zoledronic acid, and these medications represent approximately 64% of the prior authorizations secured. Conclusion: Establishing a prior authorization management service and hiring dedicated pharmacy technician staff to coordinate with all stakeholders to ensure that financial arrangements are made prior to administering highcost medications resulted in a favorable return on investment. Future goals for this service include increased

2 coordination with patient assistance programs, and exploring prior authorization requirements for lowercost medications. Learning Objectives: 1. Describe the challenges associated with hospital-based infusion clinics in securing and managing prior authorizations for high-cost infused medications. 2. Describe one strategy for approaching health-system leadership to add employees to manage prior authorizations. 3. List the medications that commonly require prior authorizations. Self-Assessment Questions: 1. (True or False) When payers deny a claim for a high-cost infused medication, there is a distinct code that is used to identify the medication and the reason for denial. 2. (True or False) Zoledronic acid, immune globulin, and infliximab generally require prior authorization by most payers. 3. (True or False) Once secured, prior authorizations are always approved for the duration of therapy. Answers: 1. (F); 2. (T); 3. (F) Primary Author: Tina Aramaki, PharmD, Corporate Director of Pharmacy Services, Intermountain Healthcare Contact Information: 36 South State Street, 17th Floor, Salt Lake City, UT 84111, tina.aramaki@imail.org Second Author: Melissa S. Duke, PharmD, MS, Clinical Pharmacy Manager, Intermountain Healthcare Contact Information: 36 South State Street, 17th Floor, Salt Lake City, UT 84111, missy.duke@imail.org Third Author: Richard Iverson, PMP, Pharmacy Services Project Manager, Intermountain Healthcare Contact Information: 36 South State Street, 17th Floor, Salt Lake City, UT 84111, richard.iverson@imail.org

3 MCS-37 Title: Driving cost reduction initiatives though clinical decision support Purpose: In response to state healthcare budget cuts resulting from current economic crisis, the hospital s senior administration requested the Department of Pharmacy to provide strategies for pharmaceutical expense reduction for FY2010. Pharmacy departmental leadership goals were to create additional initiatives preventing FTE and OTPS cuts. Implementation of a Therapeutic Interchange Program (TIP) was deemed to provide an opportunity for approximately $1M in expense reduction specifically targeting the with HMG CoA Reductase Inhibitor class. A targeted interchange success rate of 80% created an operational challenge for this large tertiary healthcare system. Proposed interchange solutions necessitated a quick, seamless, and non-interruptive paradigm. This case describes the management challenges and implementation solution chosen to the meet fiscal target deadline in a 2,275 bed hospital system. Methods: A pharmacy task force (comprised of a pharmacy director, numerous clinical pharmacists, and an informatics pharmacy manager) was created to design and implement a Therapeutic Interchange Program (TIP). Policies and processes to support TIP were designed and approved in This program focused on selecting preferred agent(s) in select therapeutic classes and interchanging orders for preferred formulary alternatives via the computerized prescriber order entry system (CPOE). Successful process implementation required establishing a systemic driver for a large, system-wide change. This included the design of clinical decision support and medical logic modules incorporated into the workflow of users of the CPOE system. This decision support provides prescribers with defaulted equivalent doses of the preferred therapeutic agent, while taking into account parameters such as concomitant treatments, drug interactions, and accepted indications. Concomitantly, substantial educational efforts were developed for clinicians across all sites and clinical roles. Results: Successful adoption of TIP statin conversion resulted in a 90% reduction in doses dispensed for nonpreferred statins. Post-implementation comparative benchmarking data reveals a seven percentage point reduction in case utilization rate for atorvastatin, placing the target hospital in the lower third of institution resource consumption within a peer group of similar hospitals. Support from medical leadership was imperative in driving the successful and sustained program goals. Conclusion: Clinical decision support through CPOE systems present an ideal vehicle for driving formulary management decisions with several advantages. Electronic therapeutic interchange precluded the need for added staff work load, decreased electronic work-around, enhanced non-formulary management, and enforced a complete conversion for a large number of prescribers. Learning Objectives: 1. Critique organizational culture and behavior that may require you to select and apply a different solution at your practice setting. 2. Analyze comparative data to illustrate end goals and opportunities for systems improvement to key stakeholders. 3. Predict barriers in change management that may place hurdles in reaching target timelines. Self-Assessment Questions: 1. (True or False) The most effective method for implementing therapeutic interchange at this site was through decentralized staff-based interchange.

4 2. (True or False) On-going data analysis provided additional system improvement opportunities that would have been unrecognized. 3. (True or False) Communication in this case study proved to be an inconsequential barrier to adoption. Answers: 1. (F); 2. (T); 3. (F) Primary Author: Ruchi Tiwari, PharmD, MS, Pharmacy CPOE Manager, New York Presbyterian Hospital Contact Information: 622 West 168th Street, Department of Pharmacy, New York, NY 10032, Second Author: Lindsay Hovestreydt, PharmD, BCPS, Clinical Pharmacy Manager, New York Presbyterian Contact Information: 622 West 168th Street, Department of Pharmacy, New York, NY 10032,

5 MCS-35 Title: Implementation of an outpatient specialty pharmacy clinical practice model in an academic medical center: a decade of experience Purpose: Specialty pharmaceuticals are agents that are usually high cost and used to treat complex medical conditions. These drugs may require significant clinical monitoring of laboratory results and adverse effects, and may require risk evaluation and mitigation strategies (REMS). Outpatient pharmacy departments in academic medical centers typically dispense a small percentage of specialty medications which may result in lost revenue for the medical center. Moreover, patient care is fragmented and difficult to coordinate since medications may be obtained from multiple pharmacies that do not have access to medical records. The purpose of this case study is to illustrate the opportunity to improve coordination of care and increase revenue from specialty pharmaceuticals by implementing an outpatient specialty pharmacy clinical practice model in an academic medical center. Methods: A total of 2 full-time equivalent clinical pharmacists were assigned to four outpatient specialty clinics. The Liver Clinic was the first to implement the model in 2003, followed by, Gastroenterology (2007), Rheumatology (2008), and Multiple Sclerosis (2010). Clinics were selected based on the need for therapeutic drug management including better coordination between the specialty clinic and the on-site outpatient pharmacy In each clinic, the clinical pharmacist performed some or all of the following functions: 1) review the therapeutic appropriateness of the specialty medication(s) for the medical condition in question, 2) initiate and complete the prior authorization process 3) provide patient education of adverse effects, disease state and demonstrate self-administration techniques if an injectable agent was prescribed and 4) monitor for laboratory abnormalities and adverse effects, and if applicable, manage the REMS program for the specialty medication. The clinical pharmacist provided a list of pharmacies from which the patient could obtain their prescription(s). If the patient chose the on-site outpatient pharmacy, the prescription was referred to the outpatient specialty pharmacy staff. Functions performed include insurance benefit eligibility, verification of prior authorization, coordination of delivery options, and refill management. The medication was picked up by the patient at the on-site pharmacy or by the clinical pharmacist who delivered it to the clinic during the patient s appointment. Refills were picked up by the patient or mailed to the patient s home. Results: Prior to implementing the specialty clinical practice model in 2002, 191 specialty prescriptions representing $203,909 in revenue were dispensed for patients from the four specialty clinics. By 2011, following the interventions and coordination of care by clinical pharmacists, 1,656 specialty prescriptions were dispensed representing $3,665,546 (annualized). Each time the model was implemented, prescriptions dispensed by the on-site pharmacy increased the subsequent year from 35 to 383 for the Liver clinic and 84 to 207 for the MS clinic. Biological agents that were prescribed in the GI and Rheumatology clinic and dispensed from the on-site pharmacy increased from 155 to 360 in 2008 and to 670 in Clinical and dispensing functions were integrated with constant communication via medical center documentation systems. Conclusion: A specialty pharmacy clinical practice model was effective in increasing prescription capture and revenue for specialty pharmaceuticals by the on-site outpatient pharmacy. Integration of the clinical, dispensing, education, and support functions helped to facilitate coordination of care. This model may be replicated in other medical centers with specialty outpatient clinics and on-site pharmacies. Learning Objectives: 1. Define key characteristics of specialty pharmaceutical agents that may be prescribed in specialty medical clinics.

6 2. Review the challenges the prescriber, pharmacist, and patient face with specialty pharmacy services. 3. Discuss methods for improving continuity of care and specialty pharmacy revenue at an academic medical center by utilizing clinical pharmacists to act as liaisons between the on-site outpatient pharmacy and specialty medical clinics. Self-Assessment Questions: 1. (True or False) Specialty pharmaceutical agents are usually dispensed by an on-site outpatient pharmacy. 2. (True or False) REMS requirements may be associated with specialty pharmaceutical agents. 3. (True or False) Utilizing clinical pharmacists may be a viable option to improving prescription volume and revenue at an outpatient medical center pharmacy. Answers: 1. (F); 2. (T); 3. (T) Primary Author: JoAnn Stubbings, BSPharm, MHCA, Manager, Research and Public Policy, University of Illinois at Chicago College of Pharmacy Contact Information: 840 South Wood Street, MC 884, Chicago, IL 60611, jstubbin@uic.edu Second Author: Juliana Chan, PharmD, Assistant Director of Pharmacy Clinical Services, University of Illinois at Chicago College of Pharmacy Contact Information: 833 S. Wood Street, MC 886, Chicago, IL 60611, jchan@uic.edu