9/4/2015. Prescription for the Future: Pharmacists Influencing Positive Health Outcomes. Disclosure(s) Objectives

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1 Prescription for the Future: Pharmacists Influencing Positive Health Outcomes Daniel E. Buffington, PharmD, MBA, FAPhA Clinical Pharmacology Services, Inc. Tampa, FL Disclosure(s) Daniel E. Buffington, PharmD, MBA declares no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. Objectives Assess the changing pharmacy practice landscape Outline factors driving the expansion of pharmacists practice roles Identify innovative pharmacists services and future pharmacy practice models Apply principles to influence positive health outcomes 1

2 Clinical Practice Clinical Pharmacology Services, Inc. Tampa, Florida Daniel E. Buffington, PharmD, MBA Clinical Pharmacology Services 6285 E. Fowler Ave Tampa, FL Office Fax Scope of Services Drug Information Health Information Technology Pharmacists Services Clinical Trials Forensic Pharmacology Clinic Consultation (MTM) Practice Model Education Medical Practice Model 2

3 Harms & Hospital Readmissions Related to ADE Goals: To reduce hospital and treatment related harms To improve the quality of care Partnership for Patients (P4P) Hospital Engagement Networks (s) 26 s Hospitals / Facilities Nearly all hospitals in the US To improve health outcomes To reduce hospital readmissions To improve the costs and management of care Harms & Hospital Readmissions Related to ADE CMM I Pharmacists? 3 Targeted ADE: 1. Anticoagulants 2. Diabetic/Hypoglycemic 3. Opiates Collect and Report Data Demonstrate significant reductions in harm PfP (Network of hospitals and health-systems) 3

4 Pharmacy Practice Landscape Pharmacists and Pharmacy Integration Into the Health Care Delivery Model Pharmacy Practice Landscape Evolution of education & training Specialization & Board Certification Expanding scope of practice Strong support for pharmacists services within the literature Integration into medical reimbursement models Growth & Expanding Opportunities for All Pharmacy Team Members Pharmacists Pharmacy Technicians 4

5 Transition Practice Focus Pharmacists professional activities and practice roles have evolved to focus on ensuring patient safety and improved health outcomes Pharmacology & Science Medication Focused MTM & Patient Care Clinical Pharmacy Practice (Expanding Focus) Patient Care Information Product Pharmacists Services MTM Progression of Intensity Patient Education Drug Regimen Review Problem Intervention Physical Assessment Adherence Persistence Disease Management Medication Management Minimal focus Triage-minded Short term nature Instantaneous Episodic Multi-focused Multi-relationship Repetitive Accountability Total Picture Drug/Patient/Disease Model 5

6 Pharmacists Patient Care Process (JCPP, May 2014) CPP_Pharmacists_Patient_Care_Process.pdfd Medical Billing Process for MTM Point of Care * Non-Insurance New Patient, initial 15 min Established Patient, initial 15 min additional 15 min Invoice CMS 1500 * Insurance Outpatient Inpatient Patient (Employer) CMS 1500 UB-04 Insurance Pharmacists Reimbursement Current Procedural Terminology (CPT) Codes Medication Therapy Management (99605, 99606, 99607) Evaluation & Management (E&M) Transitions of Care Complex Care Coordination Laboratory Codes Device Education Discharge Counseling Fee-For-Service Contract services Medicare Part-D MTM (?) 6

7 Institute of Medicine (IOM) 1999 Publication from the Institute of Medicine Health care in the United States, is not as safe as it should be or could be At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could be prevented Many of these problems involve drug related problems Prepared a comprehensive strategy for reducing preventable medical errors Provides a challenge to reduce the percent of medical errors by 50% within 5 years of report Comprehensive View - Systems, Education, Practitioners, etc. The pharmacist has become an essential resource and thus access to his or her expertise must be possible at all times. Institute of Medicine, 2009 US Hospital Readmissions One out of three hospital readmissions are medication related issues or complications. NEHI Issue Brief, October 2012 Improving Medication Adherence and Reducing Readmissions Frankl SE, et al. Am J Med 1991 Jun;90(6):

8 Deaths Related to Drug Therapy (2009) 19,551 Deaths 1 14% Increase Fold Increase Since Institute of Safe Medicine Practice Medication Safety Alert Newsletter: Community/Ambulatory Care Edition Volume 9, Issue 6: June 2010 Pharmaceuticals are the most common medical intervention, and their potential for both help and harm is enormous. Ensuring that the American people get the most benefit from advances in pharmacology is a critical component of improving the national health care system. The Institute of Medicine (IOM) The Institute of Academy of Sciences. Informing the future: Critical issues in health. Fourth edition, page Deaths Related to Drug Therapy 125, % Increase % Increase % Increase or 6.25 Fold Higher , Medicine Practice Safety Alert Newsletter: Community/Ambulatory 1. Institute of Safe Medication Care Edition Volume 9, Issue 6: June National Pharmaceutical Council and American Hospital Association. 8

9 US Health Care Spend on Prescription Medications and Related Problems (2009) Medications Spent on drug therapy problems created by prescription medications. Institute of Safe Medicine Practice Medication Safety Alert Newsletter: Community/Ambulatory Care Edition Volume 9, Issue 6: June 2010 U.S. Health Care System Is In Crisis Innovative Services and Health Care Solutions Medication Therapy Management Specialty Practice Roles o Antimicrobial Stewardship o Medication Safety o Transitions of Care o Specialty Pharmacy & Care Coordination o Pharmacogenetics o Pharmacoeconomics & Predictive Modeling o Vaccinations o Electronic Health Records & Audits Health Information Technology 9

10 Innovative MTM Case Studies 018 Evaluation of Medication Therapy Management Services for Patients with Cardiovascular Disease in a Self-insured Employer Health Plan Managed Care Clinical Interventions Cardiovascular disease (CVD) Major cause of mortality Highest total t expenditures among major diseases Objective Implement MTM services for patients with CVD Outcomes All cause medical and total expenditures decreased ROI was $1.67 per $1 in MTM Cost Improved treatment goals (i.e., blood pressure, BMI) Evaluation of Medication Therapy Management Services for Patients with Cardiovascular Disease in a Self-Insured Employer Health Plan Wittayanukorn et al., J Manag Care Pharm. 2013;19(5):

11 Impact of a Medicare MTM Program: Evaluating Clinical and Economic Outcomes MTM delivery to Medicare Part-D patients Pharmacists Interventions Optimizing medication regimens Patient education Coordination of laboratory tests MTM & Care Coordination Outcomes 14% reduction in risk of mortality 3% reduction in the risk of hospitalizations 17% increased rate for ED visits Impact of Medicare MTM Program: Evaluating Clinical and Economic Outcomes. Hui et al., AJMC A Reengineered Hospital Discharge Program to Decrease Rehospitalization Transitions in Care Pharmacy and Nursing collaborative intervention Arrange follow up appointments Confirm medication reconciliation Conduct patient education Follow up call 2 4 days after discharge to reinforce discharge plan and review medications Outcomes Lower rates of rehospitalization within 30 days of discharge A reengineered Hospital Discharge Program to Decrease Rehospitalization. Jack et al., Annals of Internal Medicine. 2009;150: Role of Pharmacist Counseling in Preventing Adverse Drug Events After Hospitalization Transitions in Care Pharmacist Intervention Counseling at discharge Follow up telephone call 3 5 days after discharge Clarify medication regimen, reviewing indications, directions, potential side effects Screening for barriers to adherence, early side effects Outcome Lower rate of preventable adverse drug events 30 days after hospital discharge Role of Pharmacist Counseling In Preventing Adverse Drug Events After Hospitalization. Schnipper et al., Arch Intern Med. 2006;13(5):

12 Antimicrobial Stewardship Program IDSA/SHEA 2007 Guidelines Hospitals implementing a Pharmacy lead Antimicrobial Stewardship Program (ASP) show: Decrease in antimicrobial use (22-36%) Annual savings of $200,000 $900,000 Average antimicrobial cost reductions of 15% Clin Infect Dis 2007;44: The Power of Anonymous Work in and Age of Relentless Self Promotion For some individuals, we perform better given the more attention we receive (i.e., Benefit & Rewards). Yet many Invisibles - skilled professionals whose role is critical and technically focused it s the opposite: the better they do their jobs the more they disappear. In fact, it s only when something goes wrong that they are noticed. What has been lost amid the noise of self-promotion today is that not everyone can, or should, or even wants to be in the spotlight. Invisibles share a core of common traits: deep ambivalence toward recognition meticulous commitment toward their craft 2014 David Zweig Portfolio Hardcover, June 12, 2014 relish behind-the-scenes responsibility strong correlation with business success and personal fulfillment 12

13 Malcolm Gladwell 2000 The moment of critical mass, the threshold, the boiling point. The tipping point refers to that dramatic moment when something unique becomes common Ideas, products, messages, and behaviors can behave like viruses. Presents perspectives into why change so often happens as quickly and as unexpectedly as it does Law of the Few - Explores the 80/20 rule 80% of the work is done by 20% of the people Connectors - social networking hubs Mavens information specialists & idea generators Salesman persuaders, charismatic, negotiators Stickiness Factor the impactful message, memorable The Power of Context the conditions and environment need to be optimal Examines the factors that contribute to high levels of success. Contrast Opportunities vs Legacy that lead to critical success. Speculates on trends of the very successful across different sectors and businesses, eventually resolving that it the duration and level of preparation you put into your career. Refers to the 10,000 hour rule. Includes training, preparation, practice, and refinement of your skills in order to be ready for that moment of opportunity. Concludes with opinion that success is ultimately impacted by your advantages in life, inherited traits (family, culture, etc.) and your drive to aggressively prepare your self and to be observant of career opportunities. Malcolm Gladwell 2008 Future of Pharmacy Practice Models Profession & Practice Reboot Old Model Can Only Evolve So Far Future Practice Model 13

14 Practice Model Repair Prior Model or Build New Model Traditional Pharmacy Model (Practice Settings & Process) Medical Practice Model Design or Integration (Practice Settings & Process) Specialty Practice Model & Role Product Management & Administrative Functions Innovative Clinical Support Services Prototypes or Models to Emulate? Group Practice Primary Care Multispecialty Consult Service Allied Health Medical Specialty Private Practice Practice Model? 14

15 Pharmacy Practice - Inpatient Cont tract Management Radiology Department Service Billing Pharmacy Department Service Billing Cont tract Management Labs X-Rays Radiology Group Practice Medications Pharmacists Group Practice Electronic Documentation Platforms Electronic Health Record (EHR) Electronic Medical Record (EMR) Personal Health Record (PHR) National Health Care System Goals Pharmacist s services (MTM) support the national health care Triple Aim goals embodied in health care reform principles 1. Better Health for the Population 2. Better Health for Individuals 3. Lowered Cost Through Improvement It is imperative for pharmacists to achieve inclusion into the Medicare Part-B clinical service payment infrastructure for both current and future models. 15

16 Messaging Resources & Campaign ADS REPORTS INFO GRAPHICS COMMERCIALS (VIDEOS) CASE STUDIES ECONOMIC & ROI DATA Next Steps for the Profession Medicare Part-B Eligible Providers Status (Pharmacist Reimbursement) Electronic Health Records (EHR) Practice Model Development Media & Messaging Patient & Family Engagement Payer engagement (Standard Health Care Benefit) Pharmacist Physical Assessment Financial Benefits & ROI of MTM Evolution of Pharmacist Services AMA CPT Codes Electronic Health Records MTM Medicare Part-B Eligible Provider Status Developing Advanced Practice Models SOLUTION: Optimize the utilization of Pharmacists and MTM into the interdisciplinary care process models 16

17 Evolving Payer Engagement Strategic Planning Federal (CMS) State (Medicaid ) Commercial Integration into an Equitable Professional Payment Model for Clinical Services Fee-For-Service Future Bundled Payment Models Return-on-Investment (ROI) Depends on the ability to define an existing baseline or benchmark to utilize for calculating change / improvement Assists payers in deciding to include include MTM in the standard cope of benefits The greater the ROI the more support and effort payers will put into ensuring patient access and reimbursement for pharmacists services. 17

18 Expanding Roles to Support Optimal Health Outcomes 1. Medical literature supports pharmacists' med management improves health outcomes 2. Medication reconciliation reduces treatment discrepancies i and decreases utilization 3. Improve vaccination rates 4. Collaborative care models increases physician efficiency Avalere Health, LLC (May 2014) H.R. 592 / S.B th Congress To amend title XVIII of the Social Security Act to provide for coverage under the Medicare program of pharmacist services 18

19 018 Legislative Support House of Representatives Current Sponsors 435 Representatives (Total) Over 23% House Representatives Support the bill Contact Information: Daniel E. Buffington, PharmD, MBA, FAPhA Practice Director & CEO Clinical Pharmacology Services, Inc E. Fowler Ave Tampa, FL Office danbuffington@cpshealth.com cpshealth.com 19

20 Questions & Answers 20