The Future of Pharmacy??? M. Lynn Crismon, Pharm.D. Dean Doluisio Chair, & Behrens Professor College of Pharmacy The University of Texas at Austin

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1 The Future of Pharmacy??? M. Lynn Crismon, Pharm.D. Dean Doluisio Chair, & Behrens Professor College of Pharmacy The University of Texas at Austin February 25, 2011

2 Disclosure During the past 12 months, Dr. Crismon through The University of Texas at Austin has been the recipient of grant funding from Eli Lilly & Company, Shire Pharmaceuticals, the Texas Health & Human Services Commission, the Texas Department of State Health Services, and the Seton Family of Hospitals.

3 Why do we need healthcare transformation?

4 Why? Let s not underestimate the economic imperative for practice model reform Current US healthcare system is not sustainable ASHP Pharmacy Practice Model Summit 2010.

5

6 Why? About 75 of every health care dollar is spent on chronic diseases Total of $1.7 trillion annually Pharmacy Health Care Reform Coalition 2008

7 Why? The US health care system incurs more than $177 billion annually in mostly avoidable health care costs to treat adverse events from inappropriate medication use. ASHP Policy Analysis, January 2011

8 The definition of insanity is doing the same thing over and over again and expecting a different result. Albert Einstein

9

10 Characteristics of Optimal Future Healthcare Quality care Patient safety Outcomes driven Fiscally responsible

11 Payment Methods Fee-for-service Cost: McAllen versus El Paso 400% variation in practice Pay for Performance Payment related to practice guidelines and appropriate use Non-payment related to improper use Currently insufficient numbers of guidelines Few based on adequate data Kübler-Ross Death and Dying of FFS - Adapted from Arthur Garson, MD

12 Inadequacies of Fee-for- Service Current fee-for-service system does not reimburse adequately for beneficial activities such as chronic disease management, preventive counseling, and care coordination. Shields MC, et al. Health Affairs 2011.

13 Relevance to Pharmacy Fighting for higher dispensing fees is a losing battle Professional fee plus - Need to advocate for reimbursement based upon outcomes Patient adherence Adherence with approved guidelines HgA1c levels Cholesterol & LDLs Blood pressure Decline in hospitalization rates

14 The Importance of Adherence Drugs don t work in patients who don t take them. Former Surgeon General Dr. C. Everett Koop

15 Nonadherence Results in: 10-25% of all hospital and nursing home admissions 20% of unintentional pregnancies 3 times as many physician visits $2,000 more in costs per year per nonadherent patient 33-69% of all medication related hospitalizations Center for Health Transformation 2010

16 Pharmacist Service Types Medication Therapy Management Problem solving focus Adherence focus Collaborative Drug Therapy Management (CDTM) Assume responsibility for managing chronic diseases in collaboration with physicians Patient outcomes focused 46 states have CDTM legislation

17 Elements of a Chronic Disease Management Program Evidence-driven Guidelines Evidence-Based Planned Care Practice Design Patient Education Expert Care Information Appointment Self- Management Roles Follow-up Behavior Change Psychosocial Support Patient Participation Education Decision Support Reminders Outcomes Consultation Feedback Care Planning Adapted from Katon, W. et al., Gen Hosp Psychiatry, 19: , 1997.

18 Reimbursement Approach Per patient per year reimbursement Based upon disease state(s) Comorbidity Risk factors Base reimbursement plus bonuses based upon outcomes Demands integration of pharmacist services with other provider service systems

19 Other Pharmacist Services Enhancing patient self care Wellness services Immunizations Nutritional counseling Lifestyle management Specialty services Home infusion Hormonal replacement therapy Pain management etc.

20 ASHP Pharmacy Practice Model Initiative Major Themes Move pharmacist closer to the patient Responsibility for safe use of medications and assuring quality Well-developed technician workforce Wide-spread use of technology Slide courtesy of Diane Ginsburg

21 What is an Accountable Care Organization? (ACO) An ACO is a group of providers who are jointly held accountable for achieving measured quality improvements and reductions in the rate of spending growth. McClellan M. Health Affairs 2010

22 The Healthcare System Integration of physicians, hospitals, clinics Accountable Care Organizations, etc. Healthcare professionals must interact in a system with other providers, hospitals and clinics Pharmacists must demand to be included in these systems Savings shared among provider, ACO, & payer

23 ACOs & Medical Homes The Medicare Payment Advisory Commission: A Medicare medical home s responsibility for patient medication reviews should be coordinated with a pharmacist. Medicare Payment Advisory Commission. Report to the Congress: Reforming the Delivery System. Washington, DC, June 2008.

24 Baylor Health Care System Creating ACO that includes pharmacists by building on existing chronic disease management programs, medical homes, and health information technology infrastructure Focused on improving health care quality and reducing costs Establishing shared savings programs with private payers Starting by January 1, 2012 ASHP Policy Analysis, January 2011

25 8 Core Principles (Based upon Baylor Model) Build on existing programs Identify high-need patients Develop and expand medical homes Collaborate with other health systems, hospitals, physician groups, and health care providers Identify patient outcomes data currently collected and expand data collection and analysis Create an integrated medical record for inpatient and ambulatory care Create a personal health record for patients Work with private insurers to add patients under the ACO ASHP Policy Analysis, January 2011

26 Walgreen s Northwestern University Collaboration Formed an ACO relationship with Northwestern Medical Center beginning January 2011 Pharmacist integrated into system 1,500 patients enrolled Conversation with Kermit Crawford, RPh, President of Pharmacy Services, Walgreen s, February 2011

27 Electronic Medical Records (EMR) Pharmacist must have access to EMR Pharmacist services must be integrated into EMR Allows team based care without pharmacist being in the physician office Decision logic trees need to be integrated into EMR

28 Guideline Driven Care Pharmacist services must be guideline driven Guidelines must be evidence based Care must be integrated into EMR e.g., Screen goes red if deviate from guideline Adapted from A. Garson

29 Tort Reform Caps on damages i.e., pain and suffering Decrease frivolous cases Plaintiff penalties for filing frivolous cases Plaintiff pays defense legal fees for frivolous cases

30 Possible Eventual Healthcare System Two tiered Virtually like every other country Single safety net public system Outcomes reported from other countries largely based upon public systems Private system Largely employer driven insurance plans Insurance pools for self employed and small employers Boutique healthcare for the wealthy Patients can move from private system to public system and vice versa Both systems outcomes driven Acknowledgement: Arthur Garson, MD

31 Effects on Pharmacy Education ACPE Accreditation Standards 2007 Requires experiential education throughout PharmD program Increased emphasis on ambulatory care Increased emphasis on assessment & outcomes based education

32 UTCOP Curriculum Implemented Fall 2009 Integrated pharmacotherapy modules Problem based pharmacotherapy labs Professional development convocation every semester P1-P3 Increased emphasis on patient selfcare and nonprescription treatment Increased emphasis on problem solving, communication skills, and ethical decision making

33 Experiential Education P1 & P2 Years P1: Care and respect for the elderly (CARE) P2: Supervised patient counseling experiences Communications labs Healthcare ethics labs Patient assessment labs Case based pharmacotherapy labs Patient self care counseling Community pharmacy based Clinical skills lab All P2 students immunization certified

34 Experiential Education P3 Year Introductory institutional pharmacy experience Summer between P2 & P3 years Introductory community pharmacy experience All P3 students certified in APhA MTM program Case based pharmacotherapy labs In addition, 200 hours of internship outside of curriculum required before P4 year

35 Experiential Education P4 Year 42 weeks in length (7 X 6 weeks) Community pharmacy rotation Hospital pharmacy rotation Acute care rotation Ambulatory care rotation Must be interprofessional Must utilize patient medical record Disease management focus 2 selective rotations (patient care focus) Elective rotation

36 Milestone Exams End of P1 and P2 years Formative assessment End of P3 year High stakes exam MUST PASS! P4 exams Clinical care Community pharmacy Hospital pharmacy

37 Advanced & Specialized Skills Development PharmD prepares an individual for entry into the general practice of pharmacy What is needed to develop advanced or specialized skills? Specialty practice Management Research

38 Factors Driving Change Residency Programs in ASHP Accreditation Process ( ) as of 9/27/10 PGY2 Specialized Clinical PGY1 Pharmacy Practice Hospital

39 Why should you be a change leader? Lead change that you believe in versus being forced to accept the change of others. ASHP Pharmacy Practice Model Summit 2010.

40 Attitudes Toward Change Late Majority (35%) Early Adopters (10%) Innovators (5%) Early Majority (35%) Resistors (15%)

41 Performance Lewin s Force Field Change Model Forces Against Change Refreezing Structure Rewards Measures Forces Against Change Moving Forces for Change Forces for Change Unfreezing Creating a Need Overcoming Resistance Mobilizing Commitment Time

42 Managing Large Scale Change Organizational Assessment Sustained Reinforcement/Results Using Appropriate Project Strategy Aligning Systems & Structures Keeping Initiative Alive & Visible Metrics/Evaluation Determining Where You Are vs Where You Need To Be Developing the Vision Developing the Strategy Strategic Change Initiative Organizational Effectiveness Leading The Change The Change Initiative Launching the Initiative Aligning Sponsorship Establishing an Effective Team Spotlighting the Shared Need Sharing the Vision J. McCracken UT Dallas Building Internal Commitment Influencing Key Stakeholders Keeping an Effective Change Team Communicating the Project Managing Conflict

43 Arlyn Kloesel Endowment for Excellence in Pharmacy Practice

44

45 Questions?

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