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March 22, 2016

Hospital Pharmacies Cope with Surge in Drug Prices

WHEN THE STAFF AT BAYSTATE HEALTH in Massachusetts observed an alarming series of price increases for the vasodilator drug nitroprusside last year, the integrated health system took a strong step in response.

“Over a period of time during 2015, we just basically booted nitroprusside out of the building,” said Gary Kerr, chief pharmacy officer for the health system.

Nitroprusside and an inotropic drug, isoproterenol, sold by Valeant Pharmaceuticals International, Inc., were among the medications discussed during a December 9 Senate Special Committee on Aging hearing that examined sudden price spikes affecting off-patent drug products.

Valeant’s website states that the company markets more than 200 prescription drug products. The company has made headlines and angered legislators by purchasing the rights to older drugs and then dramatically increasing their prices.

“We’re very acutely aware of drug prices,” Kerr said. “Part of our modus operandi here has always been to manage our drug utilization, our drug selection, and our budgets as thoughtfully as we can.”

He said the “dramatic and sudden” increase in the price of nitroprusside was debated in a series of pharmacy and therapeutics committee meetings last year, with active input from three surgical departments and the emergency department physicians.

Kerr said the group compared normalized treatment costs for nitroprusside and two alternative drugs—clevidipine and nicardipine—and ultimately decided to drop nitroprusside from the formulary.

The new treatment cost for nitroprusside would be 8 to about 60 times the cost for the alternative drugs’ vials or premixed injection, according to Kerr’s figures.

Kerr said the health system’s physicians supported the formulary decision even though it meant changes to patient care.

“There are some nuances with the drugs and their indications, but the docs are very, very cooperative with us. They know that the . . . drug formulary is a critical management tool for us,” Kerr said.

Joel Melroy, manager of adult inpatient pharmacy services for Medical University of South Carolina (MUSC) Hospital Authority, similarly emphasized pharmacy’s role in managing drug costs.

“We, as pharmacists, are in the business of ensuring that our patients have the best therapy and the most cost-effective therapy to the patient, to the hospital, and to the payer,” Melroy said.

Melroy said last year’s increases in the price of nitroprusside, a relatively low-use drug, weren’t a major issue for the health system. But the increased cost of isoproterenol was a problem.

Melroy said the pharmacy team analyzed where and how the drug was being used in the hospital and concluded that stocking smaller vials of the drug would blunt the price increase.

“We’ve tried to soften the impact as much as we can by doing what we can—which is actually very little—to decrease the cost that the hospital and the health system is actually incurring,” he said.

Jerome Wohleb, director of pharmacy services at Bryan Medical Center in Lincoln, Nebraska, said the pharmacy previously prepared i.v. bags with isoproterenol for use as needed in the cardiology service and the intensive care unit.

“Now, we don’t mix it up until [it’s time] to hang it, which means a physician says, ‘I’ve got to have it,’ ” Wohleb said.

To similarly minimize the waste of nitroprusside, he said, “We’ve tried to reduce the sizes of our mixed products and watched how we are administering it.”

Wohleb emphasized that the problem of price increases affects “substantially more” than just the two Valeant drugs.

He said the price for the 20 most costly drugs purchased by the hospital in the past 18 months has increased by 11%, on average, or about $2 million. For workhorse drugs that are widely used throughout the hospital, such as analgesics, anesthesia drugs, and surgical drugs, the cost increases over 18 months have ranged from 126% to 5,000%.

Wohleb said his medical center “really is counting on the pharmacy to be a solution” to the problem of high drug costs.

“What we’ve done here to counter this change is to really beef up our clinical services, and try to work collaboratively with physicians, and target some of our expensive drugs so that we can appropriately use drugs that are needed,” Wohleb said. He said an active therapeutic interchange program is a big part of that effort.

Jason Mills, pharmacy supply chain manager for MUSC Hospital Authority, noted that there are drawbacks to changing long-established medication therapy for reasons other than clinical benefit.

“The drugs in the Valeant catalog are staples. They’re old drugs. They’ve got the proof that the evidence-based practice is there. It’s really hard to drive practice change when you’ve got decades of proof that this agent is effective,” Mills said.

Such changes also affect the implementation of order sets and various parts of the medication-use process.

“We heavily use barcode scanning on different phases of our distribution process,” Melroy said. That means, he said, that whenever MUSC’s pharmacy distributes a drug product that has a different National Drug Code number than a previously distributed product, “there is a lot behind the scenes that has to happen” to ensure the change is recognized by the order sets that specify the drug.

Mills said the same issues arise when the hospital makes purchasing changes in response to drug shortages. But he said there’s often less mystery associated with shortages than with price increases.

“With a shortage, you’re kind of dealing with a fixed timeline. Typically, you reach out to the manufacturers, and they give you an estimate as to when the product in question is going to get back into the supply chain or if it’s been discontinued outright. So you have a little more clarity,” Mills said.

Kerr said that in the past, Baystate took little notice of the weekly reports on drug price changes from the health system’s wholesaler.

“We’re paying attention right now,” Kerr said. “You’ve got to have an infrastructure, and you’ve got to have people committed to this. . . . This is something you’ve got to manage every week, if not every day.”

A statement posted on Valeant’s website in response to the December 9 Senate hearing explains that because most hospitals use small amounts of isoproterenol and nitroprusside, the price increase “has had a limited impact on the average hospital’s cost.” The company also stated that it is working with “the small number of hospitals who use a large volume of the drugs” to provide “significant volume discounts.”

Erin R. Fox, director of the drug information service for University of Utah Health Care, testified during the Senate hearing that she had called Valeant to negotiate price concessions for isoproterenol and nitroprusside.

“Each time I called, I was referred back to my wholesaler for the purchase price,” she said. “Each time, the answer was, ‘Talk to your distributor.’ ”

–By Kate Traynor, reprinted with permission from AJHP (February 15, 2016; volume 73, pages 182, 184)

 

 

 

March 18, 2016

Residency Match Day 2016

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

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

CONGRATULATIONS TO ALL who matched during the first of two residency Matches! For those who did not match in the First Match, please plan to participate in the Second Match, as there are still a number of unfilled positions at excellent programs for you to take advantage of.

The Match this year was another great success, with 3,940 individuals matching with residency programs. The number of residency programs continues to grow, with another 322 residency positions added to the 2016 Match. It is ASHP’s explicit goal to continue to work with residency programs and the profession to increase the number of residency positions in the years to come.

It is fantastic to see the growing interest in residency training as well as the demand for residency-trained pharmacists. Residency training has been a powerful way to help position pharmacists as knowledgeable and credible leaders on the patient care team. It has also helped pharmacists take on even greater responsibility for medication therapy management and overall patient care.

I am still amazed when I reflect on the vision that leaders like ASHP’s former CEO Dr. Joseph A. Oddis had for the profession when ASHP created the concept of residency training more than 50 years ago. I believe it is safe to say that residency training was a major driver in the evolution and advancement of pharmacy as a clinical and patient-oriented profession. We should all be thankful to those early ASHP leaders who acted on their vision for the profession many decades before residency training was in such high demand.

I know that all of you as new PGY1 and PGY2 residents will take every opportunity offered to you during this exciting and very rigorous year of training that you are about to embark on. The experience will likely be among the more challenging in your career; however, the fruits of your labor will pay great dividends in terms of the outcomes you are able to help your patients achieve and the contributions you will make as a vital member of the interprofessional team. Further, the leadership and interpersonal skills you will gain during your training will help you to be not only a leader in the profession, but also a strong advocate of the patients you serve.

Please know that regardless of where you practice — whether in an ambulatory clinic, hospital, or other patient care setting — ASHP is your professional home as a patient care provider. Also, as a resident, please plan to continue to read and contribute to AJHP Residents Edition. ASHP is the only organization with this exceptional peer-reviewed platform for pharmacy residents, and its success is fully attributed to you and the great work you will be doing as a resident. Please also make sure to stay involved in the ASHP New Practitioners Forum, which provides a multitude of resources and opportunities for you to be involved in ASHP.

Again, congratulations to all of you, and good luck in your residency. I look forward to seeing you at the ASHP Midyear Clinical Meeting in Las Vegas in December!

Paul

 

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March 17, 2016

Medicare Project Helps Put Pharmacists in Primary Care

AN ONGOING MEDICARE demonstration program with a medication management component shows some hope of reducing healthcare costs through the use of team-based primary care services.

An analysis of first-year data from the Comprehensive Primary Care Initiative (CPCI), which started in the fall of 2012 and runs through this year, found that the cost savings to Medicare nearly equaled the $141 million in care-management incentives paid to the participating practice sites.

A report commissioned last year by the Centers for Medicare and Medicaid Services (CMS) called this finding “promising,” since savings weren’t expected during the program’s first year. But the report noted that the cost offsets varied by region and urged caution in interpreting the initial data.

Nearly 100 CPCI sites have implemented comprehensive medication management services.

The CPCI includes about 500 primary care practices in seven geographic regions. Each participating site receives per-member-per-month (PMPM) payments from CMS and other payers and may be eligible for additional shared-savings incentives.

Among the initiative’s requirements are that all participating sites implement one or more primary care strategies—comprehensive medication management, integrated behavioral health services, or patient self-management support services—as part of CPCI’s focus on population health.

Sites are encouraged, but not required, to implement all three of these strategies by the end of the demonstration project, according to CMS.

The most recent data from CMS indicate that nearly 100 CPCI sites have implemented comprehensive medication management services and 74 practices have brought at least one pharmacist onto the healthcare team to provide the services.

Katherine O’Neal

Katherine O’Neal

Clinical pharmacist Katherine O’Neal of OU Physicians, an internal medicine clinic affiliated with the University of Oklahoma School of Community Medicine in Tulsa, is one of those pharmacists.

“I am completely integrated into the clinic,” O’Neal said. “I do medication reconciliation and daily prescription reviews and medication monitoring for all medications prescribed in our clinic, and I provide support for medication use and self-management.”

She also works to resolve medication-related issues that occur during transitions in care and sees patients by referral to help them control chronic conditions such as diabetes, hypertension, chronic obstructive pulmonary disease, and dyslipidemia.

O’Neal is the internal medicine clinic’s only pharmacist and is onsite 4.5 days per week. Her position is funded through the University of Oklahoma College of Pharmacy, where she holds the titles assistant professor and adjunct associate professor.

Nearly a quarter of the pharmacists working at CPCI sites are funded through an academic appointment, according to CMS. About half have been directly hired by the practice group, and 14% work under contract. Other sources fund the remainder of the positions.

According to CMS, all of the CPCI sites that focus on medication management provide medication reconciliation services, and most also address medication coordination during care transitions and medication review and assessment. Nearly half have collaborative drug therapy management agreements in place.

Jessica Binz, director of clinical pharmacy education at the University of Arkansas for Medical Sciences—West Family Medical Center in Fort Smith, said her practice site participates in several quality initiatives, including CPCI.

The new payment mechanisms… are going to open up tremendous opportunities for pharmacists.

Binz practices under a collaborative drug therapy management agreement—known in Arkansas as a “written protocol”—and also works closely on medication-related issues with the transitions-of-care team.

“I do smoking cessation and medication management for smoking cessation as well,” Binz said. “We have an interdisciplinary team that works with patients that are interested in stopping smoking.”

Binz said the smoking-cessation program started last October and is going well. She said one of the positive trends is that her patients, many of whom have “issues with transportation,” find ways to get to their follow-up appointments.

All of the Medicare beneficiaries in the practice—about 650 people—are considered part of the CPCI population, Binz said. Overall, according to CMS, the CPCI practice sites are responsible for the care of about 2.7 million patients, including more than 400,000 Medicare and Medicaid beneficiaries.

F. Alison Gray

F. Alison Gray

F. Alison Gray, ambulatory care pharmacist at the Little Rock Family Practice Clinic in Arkansas, said she was initially brought into the CPCI-participating clinic to help patients reduce their medication costs, mostly by increasing the use of generics and ensuring that prescribing is aligned with each patient’s pharmacy plan.

After she found that the healthcare team was already doing a good job of keeping drug costs down, she turned her focus to warfarin management because it is “fairly straightforward” to implement and manage.

“Once I got that off the ground, then I moved on to diabetes education, which is really my passion,” said Gray, who worked with the clinic’s dietitian to develop a diabetes education program for patients.

“We have individual and group visits as well as a monthly support group that we have put together. And so far, it’s been pretty successful. We’ve seen some pretty good outcomes with patients,” Gray said.

Gray said she will be evaluating diabetes outcomes measures for CPCI. For warfarin-management patients, she is collecting data on their International Normalized Ratio (INR) values and examining whether patients are having their INR checked regularly.

Outcomes measures like these may help practice sites qualify for incentive payments from insurance programs that participate in the CPCI.

CMS initially identified 31 payers that covered a substantial portion of the practice sites’ patients, agreed to contribute to PMPM payments, and, in some cases, offered pay-for-performance bonuses or other incentives to improve population health.

Marie Smith, assistant dean for practice and public policy at the University of Connecticut School of Pharmacy in Storrs, said the multipayer participation is an unusual cornerstone of the CPCI.

Smith explained that it’s difficult for practice sites to disrupt their processes to participate in individual initiatives by different payers. She said having payers working in concert, as they do in the CPCI, minimizes this problem.

But she said it’s the PMPM payments, which largely come from CMS, that have really boosted the CPCI by providing start-up funds for sites to hire the pharmacists and other staff needed to meet the program’s milestones. She contrasted that strategy to shared-savings incentives, which are generally paid out only after outcomes have been assessed and long after the care is delivered.

Smith spent six months during 2013 on faculty leave at the CMS Innovation Center, where she focused on creating a road map for the integration of clinical pharmacy services into CPCI practice sites. She said the near-universal existence of state collaborative practice laws in 2012 gave CMS staff the confidence that pharmacists would be able to work effectively under the CPCI model without running afoul of scope-of-practice regulations.

CMS’s implementation guidance for CPCI participants recommends that practices focusing on medication management include a clinical pharmacist on the healthcare team. According to CMS, the pharmacist should be involved in patient care either directly or by performing chart reviews and making therapy recommendations.

The pharmacist should also help the practice identify patients who are at high risk for poor health outcomes and would benefit from medication management. And, according to CMS, the pharmacist should participate in care team meetings and help develop processes to improve medication use and safety.

“It’s an exciting time to be in primary care because there’s so much experimentation going on,” Smith said. “The new payment mechanisms, I think, are going to open up tremendous opportunities for pharmacists.”

–By Kate Traynor, reprinted with permission from AJHP (March 15, 2016; volume 73, pages 346, 349, 350)

March 7, 2016

2+2 Curriculum Ensures Broad Patient Care Experience

Filed under: Current Issue,Feature Stories,Managers,Students,Uncategorized — Tags: , , , , , — Kathy Biesecker @ 7:01 pm

Touro pharmacy students worked with patients during the Harlem Healthy Soul Festival in September 2015.

A NON-TRADITIONAL “2+2” CURRICULUM at the Touro School of Pharmacy in Harlem, N.Y., is paying big dividends for students and their future employers. Founded in 2008, Touro has differentiated itself by requiring students to spend twice the amount of typical time in clinical rotations during their four-year Pharm.D. experience.

Traditional “3+1” pharmacy programs designate a single year for clinical rotations after three years of coursework.

Touro’s “2+2” curriculum, modeled on medical school education, offers two years of classroom instruction followed by two years of clinical experience. The expanded exposure to real-world practice creates more opportunities for students to impress potential employers and helps them narrow their postgraduate and professional options.

“The additional rotations helped me discover my professional interests, fine-tune my career plans, and ultimately decide that I wanted to pursue an academic career,” said Emmanuel Knight, Pharm.D., a 2015 Touro graduate and now an academic fellow at the school.

“And if you make an impact at a clinical site, they’re more likely to consider you for residencies, fellowships, and jobs.”

Pharmacy Immersion Helps Chart Professional Paths

During the two-year clinical component, students complete six-week rotations at affiliate sites to learn first-hand about areas such as ambulatory care, general medicine, and institutional and community pharmacy practice. To pack the equivalent of six semesters of coursework into just four terms, Touro’s semesters last 19 weeks instead of the usual 13 to 15 weeks.

Tova Berman

Tova Berman

Tova Berman, a third-year pharmacy student, noted that the early immersion in fieldwork allowed her to map out a professional path with greater confidence.

“By starting my clinical rotations in my P3 year, I have been able to think about my future pharmacy career in much more concrete terms,” said Berman. “Also, while classroom learning is an extremely important component of our education, experiencing hands-on clinical work at an early stage has helped bring the material to life. I see it for myself on a daily basis: various illnesses, medication management, and how pharmacists play an integral role in patient care.”

Touro stresses that every clinical rotation is an opportunity for a potential employer or residency program to assess a student, according to Ronnie Moore, Pharm.D., assistant dean of clinical affairs and associate professor at Touro. The augmented rotation timetable also gives students a chance to repeat rotations at desired clinical sites.

“The extra time that students spend on rotation gives the staff at those sites a good gauge on students’ individual capabilities,” Dr. Moore said, adding that the amount of information that students retain grows exponentially in an actual practice setting.

Ronnie Moore, Pharm.D., assistant dean of clinical affairs and associate professor at Touro.

Ronnie Moore, Pharm.D.

By the second half of their third year, he added, most students are already honing in on a particular practice area. They also still have plenty of time left to choose additional rotations that best prepare them to meet their goals.

That was true for Touro alumnus Michelle Friedman, Pharm.D. When Dr. Friedman began pharmacy school, she had intended to become a community pharmacist. But during her second year of clinical work, she gravitated toward clinical pharmacy. After graduation and two years of residency, Dr. Friedman became a clinical faculty member at Touro and a preceptor at Kingsbrook Jewish Medical Center, Brooklyn, N.Y., for students who are completing their internal medicine rotations.

“My early rotations opened my eyes to new experiences and helped me decide what I wanted to do,” she said. “What I’m doing today is the best of both worlds for me because I love teaching, and I love clinical pharmacy.”

A Commitment to Public Health, Service

Organizations that hire Touro graduates say they, too, benefit from students’ additional clinical exposure.

“The Touro student we hired had already completed multiple rotations with us,” said Hinnah Farooqi, Pharm.D., director of pharmacy at Harlem Hospital Center. “She became familiar with our staff and our work environment, which shortened her training time and helped her become readily accepted as a colleague.”

Touro students participated in the American Hearth Association Heart and Stroke Walk in September 2015.

Another facet of Touro’s hands-on ethos is the school’s curricular obligation to public health and community service.

“We strongly believe that a student’s education is greatly enhanced when it reaches beyond the four walls of the school into the surrounding community,” said Dr. Moore.

For instance, among their various service work commitments, Berman assisted at an immunization clinic at a local senior center.

Dr. Friedman and fellow students spoke to Staten Island high schoolers about drug abuse, and Dr. Knight helped to set up a volunteer program in which residents at a long-term care facility were transported to and from concerts and religious services.

“We had many opportunities to do those types of things during our last two years when we didn’t have to focus on coursework,” he said. “It allowed me to give something back to the community.”

–By Steve Frandzel

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