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September 6, 2012

The Power of Policy: Pathways to the Future

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

SOMETIMES, WHEN PEOPLE THINK of the word “policy,” they think of “red tape,” bureaucracy, or an arduous process. However, when I think about the word policy, a different connotation comes to mind. I think about how much has changed in our profession since I first became an ASHP member 35 years ago, and I reflect upon the policies that helped to get us here.

Clinical pharmacy practice, the entry-level doctor of pharmacy degree, specialization, pharmacists providing direct patient care in clinics and other ambulatory settings, collaborative practice agreements, barcode medication administration, electronic clinical information systems, and so many more advancements in our profession started with just one thought: How can we do things better? And, that thought, driven by policy turned into action, ultimately led to change.

At the root of all professional advancements and change are the policies that guide us there.

Change in pharmacy practice does not just happen. It is carefully crafted, nurtured and re-evaluated over and over – even after success.

Today, ASHP stands strong as an organization adaptable and responsive to the changing needs of our patients as well as the changing demands within health care as whole. And, it is all because of you, our members. You make this happen. Through ASHP’s professional policy process, our members do not just play a significant role in bringing new and innovative ideas to the forefront of pharmacy practice; they are the catalysts for our efforts.

In June, there were several groundbreaking policies that came before the ASHP House of Delegates for debate that will make similar strides for pharmacy practice, including policies related to pharmacist prescribing, board certification, and licensing and training of pharmacy technicians. All of these were inspired by the recommendations of ASHP’s Pharmacy Practice Model Initiative (PPMI). I’d like to share some thoughts about them with you.

While these policies concern different aspects of practice, they have one thing in common: a shared vision for the future of the profession in which pharmacists are essential members of every health care team, helping our patients with our deep and extensive knowledge about all aspects of medication therapy.

The policies regarding pharmacist prescribing puts this activity in context of the pharmacist’s role on the interprofessional team and clearly states that prescribing is a complex function that requires pharmacists to have specific skills and competencies. The policy regarding board certification addresses the growing demand for board-certified pharmacists and sets a new expectation that pharmacists should become certified by the Board of Pharmacy Specialties (BPS) if they practice in a specialty in which BPS offers certification.

And the policies regarding pharmacy technicians take a strong stand on requiring licensure, as well as specialized training for advanced roles. These technician positions are an outgrowth of ASHP’s Pharmacy Technician Initiative and should serve to strengthen ASHP’s advocacy for standards for training, certification, and licensure.

These are just a few examples of the forward-thinking policies that ASHP members have conceptualized and that were brought before the House of Delegates. Although some of these concepts might seem far-reaching to some of us today, it is easy to imagine that these ideas will one day be part of routine practice, and that a new set of future-oriented policies to advance the profession for the betterment of patients will be brought before future ASHP Houses of Delegates. We look forward to working with our members and our state affiliates in creating a future in which these policies are the standard operating procedure.

Please take a look at these summaries, and review the professional policies that were recently finalized by the ASHP House of Delegates:

Prescribing:

A) Pharmacist Prescribing in Interprofessional Patient Care

Defines pharmacist prescribing as patient assessment and the selection, initiation, monitoring, adjustment, and discontinuation of medication therapy pursuant to diagnosis of a medical disease or condition; further, The policy also advocates that health care organizations establish credentialing and privileging processes to ensure competency.

B) Qualifications and Competencies Required to Prescribe Medications

Affirms that prescribing is a collaborative process that, if performed collaboratively, requires that competent, interdependent professionals complement each others’ strengths at each step. The policy also suggests the creation of prescribing standards that would apply to all prescribers, and encourages research on the effectiveness of educational processes currently available.

Board Certification:

Board Certification for Pharmacists

This policy, recommended by the ASHP Section of Clinical Specialists and Scientists, supports the principle that pharmacists practicing in formally recognized specialty areas should become BPS certified in that specialty. Among other things, the policy also calls for BPS to prioritize recognition of new specialties in areas that have a sufficient number of PGY2 residencies and existing training programs.

Pharmacy Technicians: 

A) Licensure of Pharmacy Technicians 

Advocates for licensure of pharmacy technicians by state boards of pharmacy, as well as the development of uniform state laws and regulations and mandatory completion of an ASHP-accredited training program as a prerequisite to licensure.

B) Qualifications of Pharmacy Technicians in Advanced Roles 

Advocates that beyond completing an ASHP-accredited training program, certification and licensure, pharmacy technicians working in advanced roles should have additional training and should be required to demonstrate competencies specific to these tasks.

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Once these new policies take root and grow to become the norm across health care and the nation, imagine their impact on the practice of pharmacy and how they will give us new tools to enhance patient care. Further, imagine all the future creative enhancements in the care delivery process that they will set in motion. Think back to some of the policies approved by our House of Delegates in the past and what they have led us to achieve.

Then, begin using these new policies to create the future.

Innovations in Reimbursement

Betsy Bryant Shilliday, Pharm.D., CDE, CPP, right, speaks with a patient during the patient’s Annual Wellness Visit (AWV).

LAST APRIL, THE PHARMACY DIRECTOR of a large, multi-hospital health system in the Midwest phoned Gloria Sachdev, Pharm.D., clinical assistant professor of primary care at the Purdue University School of Pharmacy, West Lafayette, Ind.

Several administrators had bombarded the director with requests for additional clinical pharmacists. Faced with juggling the competing demands while securing adequate resources to support the costs—and with his organization in the midst of becoming an accountable care organization (ACO)—he turned to Dr. Sachdev, an authority on establishing sustainable clinical pharmacy models.

“No one had a firm idea of what services they needed, yet they all felt pressure to meet shifting quality-of-care measures,” said Dr. Sachdev. These included reducing 30-day readmission rates or boosting subpar performance measures which would be tied to how much money they could share from savings created by its ACO. And all of the petitioners knew that medication-related measures were intertwined with many of the health outcomes they wanted to influence.

“The question was wide open: Can pharmacists make an impact on some of these measures? The answer is yes,” said Dr. Sachdev.

Creating a Financially Sustainable Plan

After multiple meetings with the administrators and the pharmacy director, Dr. Sachdev helped the group identify what services each had in mind, which diseases and conditions needed the most attention, and the role pharmacists could play within the organization’s nascent accountable care model. Then, they hammered out a financially sustainable plan to expand pharmacist services.

Ultimately, two ambulatory care pharmacist positions were approved to focus on chronic disease management, transitions of care, and quality improvement. Both positions were designed to be billed “incident to” a physician’s care.

Gloria Sachdev, Pharm.D.

“Reimbursement for the pharmacists will cover a bit more than the cost of their services,” said to Dr. Sachdev. “It’s essentially a cost-neutral proposition.”  Getting the billing department involved and educating employees regarding billing opportunities for pharmacists early on was key to the group’s success.

When direct billing for pharmacist services isn’t available—which is usually the case in today’s health care environment—Dr. Sachdev noted that “in a pay-for-quality environment, if pharmacists can show that they can help a health system achieve quality measures of high priority, when the organization gets a large payment for attaining these measures, some of that money can be designated to pay the pharmacists’ salaries.”

“Pay-for-quality programs, such as ACOs, Patient-Centered Medical Homes (PCMHs), Medicare Part C (Medicare Advantage), etc., offer pharmacists new payment opportunities by implementing this indirect model of reimbursement,” she added.

Helping Patients Manage Their Medications

Elsewhere, pharmacists have put their own distinct imprint on direct patient care. The P3 (Patients, Pharmacists, Partnerships) program at the University of Maryland School of Pharmacy began as a diabetes management initiative, then broadened its scope considerably.

The P3 Program is a dynamic partnership that begins with the University of Maryland School of Pharmacy, and includes the Maryland Pharmacists Association, the American Pharmacists Association Foundation, the Maryland General Assembly, and the Maryland Department of Health and Mental Hygiene, Office of Chronic Disease Prevention.

The program contracts with six companies, including ASHP, to conduct medication management and preventive care for employees with chronic diseases such as diabetes, high blood pressure, and high cholesterol. Any employee covered under the employer’s health plan is eligible, and more than 400 are currently enrolled.

P3 pharmacists consult patients four to seven times annually. They assess each patient’s understanding of his or her illness and medication regime, emphasize the importance of medication adherence, and provide education about adverse effects and drug interactions. Pharmacists may also help patients set personal goals, coordinate referrals for lab tests and specialist visits, and administer pneumococcal and influenza vaccinations.

Consults occur at wellness clinics, at community pharmacies, or at an employer’s premises. All P3 pharmacists receive training in medication therapy management, chronic disease management, and self-management coaching and must have completed an Accredited Council for Pharmacy Education-level Diabetes Certficate program, be a certified diabetes educator, or be a Board-certified Pharmacotherapy Specialist.

“We bill the employer every month based on the number of visits and pay the pharmacists who saw the patient,” said Dawn Shojai, Pharm.D., assistant director of P3.

The results are telling: Since January 2009, P3 participants have experienced statistically significant improvements in outcomes for all clinical endpoints, including hemoglobin A1c levels, blood pressure, and LDL cholesterol levels.

The numbers also compare favorably to national and statewide indicators, according to Dr. Shojai. For example, 83 percent of P3 participants had HbA1c levels under 8 percent, compared with 62.3 percent and 64 percent of patients enrolled in national and Maryland commercial plans, respectively, according to data from the 2011 HEDIS (Healthcare Effectiveness Data and Information Set). On average, employers saved about $1,500 per employee annually.

Dr. Shojai continues to push hard for recognition of P3 by Maryland’s Medicaid program, which she expects to occur eventually. “Most of the battles have been to convince people that paying for pharmacists, while expensive, will save money and lives,” she said.

Annual Wellness Visits: A New Kind of Patient Care

Farther south, pharmacists in North Carolina are mining a section of the Affordable Care Act (ACA) and hauling out a steady new revenue source. The ACA established Medicare coverage for annual wellness visits (AWV), but Medicare doesn’t stipulate who must conduct the visit except to say that the clinician must be a licensed health professional.

“This is a completely new avenue for pharmacists to generate revenue by seeing Medicare patients and earning direct reimbursement at a higher service level,” said Betsy Bryant Shilliday, Pharm.D., CDE, CPP, associate clinical professor at the University of North Carolina at Chapel Hill School of Medicine and Eshelman School of Pharmacy.

“Across the board, this is a different type of visit than pharmacists are used to providing. It’s a big deal,” she said. Patients seem to think so, too. Appointment slots fill up weeks in advance. “It’s a service patients want, and that means I am generating income, too,” Dr. Shilliday added.

Reimbursement varies by region, but rates are uniformly higher than for nurse visits, and the service isn’t subject to the usual 20 percent copayment, said Dr. Shilliday, who details the visit requirements on the Section of Ambulatory Care Practitioners portion of the ASHP website.

The practice of pharmacists conducting AWVs is not yet widespread, but Dr. Shilliday predicts steady growth as health systems realize that this represents a practical and profitable way to mitigate the shortage of primary care providers. Ultimately, it is up to pharmacists to identify these kinds of opportunities, according to Dr. Shilliday. “We need to step outside our comfort zone of practice to embrace innovative opportunities, expand our scope of practice, and assume new responsibilities” she said.

Bearing the Burden of Proof 

Mary Ann Kliethermes, Pharm.D., vice chair of ambulatory and associate professor at the Chicago College of Pharmacy, Midwestern University, in Downers Grove, Ill., agrees that in the current health care landscape, pharmacists bear the burden to prove their worth. Her own experience is a case in point. Dr. Kliethermes works part-time in an internal medicine office of a large, multi-site physician group in the Chicago suburbs. Until recently, her main responsibility had been counseling patients who were on anticoagulation therapy. She and the one other pharmacist in the office, however, envisioned much more.

Mary Ann Kliethermes, Pharm.D.

Over six months, they assembled a detailed business plan to broaden medication management services and projected the potential clinical and financial gains. They supported their case with data that showed, among other things, how pharmacist-directed medication management greatly reduced drug-related hospital readmission rates. By fortunate coincidence, the physician group had decided to adopt a patient-centered medical home model, necessitating a closer look at clinical outcomes. The result: Two pharmacists were added to their staff and a third is under consideration.

Their approach embraced the reality of the newer models to which health organizations must hew, and which tie reimbursement to quality and cost reduction, said Dr. Kliethermes, who co-edited, Building a Successful Ambulatory Care Practice, recently published by ASHP.

“We offered a total business package, justified our skills, and showed how we could help the practice meet its goals,” she said. “It is up to the health organization to decide how to allocate its resources, but it is up to pharmacists to show how they can improve outcomes.”

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