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May 7, 2018

Provider Status and Opioids Legislation Update

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

I WOULD LIKE TO UPDATE YOU on ASHP’s ongoing efforts to advocate for passage of legislation that would recognize pharmacists as patient care providers in the Medicare program, as well as legislative efforts related to the opioid epidemic.

As the 115th Congress begins to shift focus to the November elections, opportunities for healthcare legislation are limited. We anticipate that any healthcare-related legislation will be mainly focused on the opioid epidemic. As a lead member of the Patient Access to Pharmacists’ Care Coalition, ASHP is working to determine ways in which provider status language might be addressed in the pending opioid bills. However, given that the focus of these bills is mainly on opioids, our efforts for now may need to shift to articulating how pharmacists can play important roles in helping to solve this major public health problem.

Efforts to obtain provider status are part of ASHP’s larger vision that medication use will be optimal, safe, and effective for all people all of the time. Our intent is to enhance our members’ ability to provide care as part of the interprofessional patient care team.

As states look to expand their scope of practice laws to promote the direct patient care roles of pharmacists, ASHP is supporting state-level efforts of our members and working at the federal level to include these direct patient care roles in Medicare. We also want to make sure our members are well-positioned to align their efforts with Medicare modernization, which is now focused on moving toward value-based models that align payment with quality and outcomes. ASHP members are in an excellent position to lead efforts to optimize medication therapy through value-based models, and ASHP will be there to make sure that Congress, Medicare and Medicaid, states, and others understand the many advanced practice models our members are engaged in as well as the direct patient care roles they play.

As we continue to work with Congress, states, and public and private payers to recognize pharmacists as patient care providers, we will keep you apprised of these activities and our many advocacy efforts on your behalf — addressing persistent drug shortages, rising drug costs, and threats to the 340B Drug Pricing Program, as a few examples.

Thank you for your support and your continued engagement as we work together to help our patients achieve optimal medication therapy outcomes and to advance pharmacy practice.

Sincerely,

Paul

January 13, 2017

Provider Status Bill Reintroduced in Senate with Strong Bipartisan Support

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

IT IS WITH GREAT PLEASURE that I can announce that on Thursday evening, Senators Charles Grassley (R-Iowa), Robert Casey (D-Pa.), and Sherrod Brown (D-Ohio), along with 24 other original co-sponsors, reintroduced the Pharmacy and Medically Underserved Areas Enhancement Act (S. 109). This legislation is the same as last year’s provider status bill, with the exception of the new bill number, S. 109. This is significant not only because of the quick timing of the reintroduction, but also because of the high number of Senators who have signed on as original co-sponsors. The Patient Access to Pharmacists’ Care Coalition (PAPCC), in which ASHP serves on the steering committee, set a goal late last year of introducing the new bill in 2017 with 20 co-sponsors. We are pleased to see that this goal was not only met but exceeded.

On the House side we expect reintroduction soon. Our lead sponsor to the House bill, Rep. Brett Guthrie (R-Ky.), has been leading the charge and will reintroduce the bill with the same bill number as last Congress, H.R. 592. Again, the language will be same as last year. We expect the House bill to be reintroduced with approximately 90 co-sponsors.

We are greatly encouraged to see the momentum from last session carry over to the new 115th Congress, and we remain steadfast in our commitment to passing this important legislation. As a lead member of the PAPCC, ASHP will be working diligently to help facilitate passage of the legislation, most likely as part of a larger Medicare package later this year. In fact, early discussions between the PAPCC and key congressional staff are already occurring, as we seek to position the legislation to be a part of a larger Medicare bill.

I will continue to update you on the progress on provider status as new developments arise. Thank you so much for being a member of ASHP. It’s because of you that we are the premier organization in pharmacy.

Sincerely,

Paul

November 16, 2016

ASHP’s Role with the New Congress and Administration

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

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

AS ANOTHER ELECTION SEASON comes to a close and we look ahead to the new administration and the 115th Congress in 2017, ASHP is again positioning itself as a credible resource to policymakers on issues impacting the profession of pharmacy and public health. While elections create change among those in government, ASHP’s public policy priorities remain the same: advancing provider status legislation, protecting the 340B program, and working with both sides of the aisle and with the administration to address the growing problem of skyrocketing drug prices and their impact on our patients and the healthcare system.

Over the last few years ASHP has increased its presence in Washington by spearheading legislative efforts aimed at curbing drug shortages and ensuring safer compounding practices. These are issues that impact all Americans regardless of political affiliation, and ASHP input was instrumental in developing policy solutions.

The new landscape on Capitol Hill and at the White House is an opportunity for ASHP to forge new partnerships, educate new stakeholders, and highlight ASHP’s expertise in public health issues. Healthcare legislation will once again be back on the agenda, and issues related to Medicare and Medicaid are likely to be in play. As we look ahead to advancing provider status, 2017 may provide legislative vehicles that could include pharmacists as providers in the Medicare program.

ASHP remains committed to working with the new administration and the new Congress to address our public policy goals. Currently we are planning outreach efforts to the Trump transition team and will begin educating the freshman congressional class on how ASHP members improve the health and wellness of their patients by ensuring safe and effective medication use and advancing healthcare. Although change in Washington is inevitable, ASHP stands firm on its commitment to its members and the public at large.

We look forward to continuing to engage you and represent your professional interests in 2017 and beyond. Thanks so much for being a member of ASHP, and for everything you do for your patients.

Sincerely,
Paul

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)

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