Legislative Pathways to Advance Practice: National and Local Efforts

Gina D. Moore, PharmD, MBAAssistant Dean for Clinical and Professional Affairs

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Gina Moore has no conflicts of interest to disclose

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Objectives Outline health policy trends influencing

pharmacy practice Describe national legislative initiatives affecting

pharmacy Describe legislative initiatives in Colorado

affecting pharmacy practice Apply this information to advocacy efforts in your

practice setting

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Health Policy Trends

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US Healthcare Trends1

» Expenditures far higher than other developed countries, yet health outcomes are not better

» 31st among developed nations for life expectancy

» The only industrialized nation that does not guarantee health insurance

» Increasing enrollments in public insurance programs

US Prescription Drug Spending increased 13% in 20142

» Newer cancer and MS treatments

» Price increases in branded medicines

» New hepatitis C treatments

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HEALTH POLICY TRENDS

1Berwick D, Nolan, T, Whittington J. The triple aim: care, health, and costs. Health Aff 2008;27:759-769.2IMS Data. Available at: http://www.reuters.com/article/us-health-spending-medicine-idUSKBN0N508I20150414 (accessed 1/4/2016)

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https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html (accessed 1/4/2016)

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https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-12-21.html (accessed 1/4/2015)

Accountable Care Organizations (ACOs)» ACO Investment Models

» Advance Payment ACO Model

» Medicare Health Care Quality Demonstration

» Physician Group Practice Transition Demonstration

» Program of All-Inclusive Care for the Elderly (PACE)

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CMS INNOVATION MODELS

Bundled Payments for Care Improvement (BCPI) - 4 models1. Acute care hospital stays only

2. Bundled payments for acute care plus post-acute care

3. Post-acute care only

4. Prospective bundled payment for acute hospital stays only

Disease-specific models (Joint Replacement, Oncology) Others

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EPISODE-BASED PAYMENT INITIATIVES

Comprehensive Primary Care Initiative Graduate Nurse Education Coordinated Care Comprehensive Quality Improvement Strategies

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PRIMARY CARE TRANSFORMATIONS

Pharmacy Society of Wisconsin

» “Retooling the pharmacist’s role in improving health outcomes and reducing health care costs”

» $4.2M

» Program goals:

Integrate community pharmacists into clinical care teams (expand Wisconsin Pharmacy Quality Collaborative)

MTM services – diabetes, HF, asthma, geriatrics

Goals: improve adherence, improve disease outcomes, decrease ADRs and complications

Plan to train 1200 pharmacists over 3 years

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INNOVATION AWARDS INVOLVING PHARMACY (PARTIAL LIST)

University of Southern California

» “Integrating clinical pharmacy services in safety-net clinics”

» $12M

» Program goals:

Enhance medication safety

Reduce overall health costs

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INNOVATION AWARDS INVOLVING PHARMACY (PARTIAL LIST)

North Carolina Community Care Networks

» “Optimizing the Medical Neighborhood: Transforming Care Coordination through the North Carolina Community Pharmacy Enhanced Services Network”

» $15.1M

» Community pharmacists to deliver medication management services to patients with at least one chronic condition and have 80% of their meds filled at a specific pharmacy

» Goals: ↓ hospital readmissions and ED visits

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INNOVATION AWARDS INVOLVING PHARMACY (PARTIAL LIST)

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Value-based Insurance Design (V-BID) Traditional Cost-Sharing Approaches

» Consumers may more out-of-pocket without regard to the type of care/service

» Decreased medication adherence rates, particularly in lower income groups/chronic diseases1

Value-Based Insurance Design» Reduced consumer cost for evidence-based services

» Improved adherence with no net increase in total expenditures

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CONSUMER INITIATIVES

1Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. JAMA 2007;298(1):61-69

Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE)1

» Eliminated cost-sharing for secondary preventative medications post – MI (β-blockers, ACEI, ARB, statins)

» Increased adherence, fewer CV events, 70% reduction in total health care spending

V-BID Model Test for MA Plans» To begin 1/1/17 in 7 states (AZ, IN, IA, MA, OR, PA, TN); continue for 5 years

» Plans may alter benefit and design structure in regard to treatment for 7 chronic diseases (DM, COPD, CHF, CVA, HTN, CAD, mood disorders)

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CONSUMER INITIATIVES

1Choudry NK, Avorn J, Glynn RJ, et al. Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) Trial. Full coverage for preventive medications after myocardial infarction. N Engl J Med 2001:365(22):2008-2097.

National Legislative Initiatives

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H.R. 592/S. 314 (Pharmacy and Medically Underserved Areas Enhancement Act)

Overview:» Amends the SSA – Medicare Part B

» Reimbursable pharmacist-provided services to Medicare beneficiaries in medically underserved communities

Medically Underserved Areas (MUAs) Medically Underserved Populations (MUPs) Health Professional Shortage Areas (HPSAs)

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NATIONAL PROVIDER STATUS LEGISLATION

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H.R. 592/S. 314 (Pharmacy and Medically Underserved Areas Enhancement Act)

Key Points» Increases access to care and improves quality

» Does not expand pharmacist scope of practice beyond that permitted by the state

» Reimbursed at 85% of physician fee schedule (consistent with NP and PA reimbursement)

Cosponsor Count: H.R.592 – 262; S.314 – 39 Awaiting CBO score

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NATIONAL PROVIDER STATUS LEGISLATION

Federal » Social Security Act

» Medicare Part B & D

» CMMI

» Federal Agencies (CMS, AHRQ, HRSA)

State» Medicaid

» State Health Plans

» Other provider status statutes, collaborative practice agreements

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POTENTIAL PATHWAYS TO PHARMACIST PROVIDER STATUS

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https://www.pharmacist.com/naspa-finds-state-level-provider-status-widespread-not-necessarily-linked-payment (accessed 1/4/2016)

State Provider Status Examples

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Allows ALL LICENSED PHARMACISTS to:

» Administer drugs and biologics ordered by a prescriber

» Provide consultation, training, education about drug therapy and disease management

» Furnish self-administered hormonal contraception pursuant to a statewide protocol

» Furnish travel medications recommended by the CDC (not requiring a diagnosis)

» Furnish nicotine replacement products for smoking cessation pursuant to a statewide protocol

» Provide immunizations to patients age 3 and older

» Order and interpret tests for monitoring the efficacy and toxicity of drug therapy, in collaboration with a PCP or prescriber

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CALIFORNIA – SENATE BILL 493 (2013)

Establishes Advanced Practice Pharmacist (APP) recognition and allows APPs to:

» Perform patient assessments

» Order and interpret drug therapy-related tests, in coordination with PCP

» Refer patients to other healthcare providers

» Initiate, adjust, and discontinue drug therapy pursuant to an order from treating prescriber

» Participate in the evaluation and management of diseases in collaboration with other healthcare providers

APP Requirements (two out of three needed)» Board Certification

» Post graduate residency

» One year of experience working under a CPA or protocol

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CALIFORNIA – SENATE BILL 493 (2013)

Requires commercial and private health care plans to enroll pharmacists in provider networks

Mandates payment for services provided within the pharmacist’s scope of practice

Established advisory group to determine policies for implementation

Credentialing

» Entities with existing internal or delegated credentialing to start January 2016

» Workgroup to determine credentialing for community clinics and pharmacies in 2017

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WASHINGTON – SB 5557 (2015)

Permits health insurers to provide reimbursement for clinical pharmacy services

Authorizes the Oregon Health Authority to collaborate with the Oregon Board of Pharmacy to establish statewide protocols

Allows pharmacist prescribing/dispensing of hormonal contraception

Allows pharmacists to immunize patients 7 years and older

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OREGON – HB 2028 (2015)

Statewide Protocols Standardized for any willing and

qualified pharmacist

Does not require the pharmacist(s) to identify a collaborating prescriber

Not patient- or provider-specific

Not modifiable by individual pharmacists

Usually developed by a state agency

Collaborative Practice Agreements Agreed upon between prescriber(s)

and pharmacist(s)

Generally ordered on an individual patient basis (required in CO)

Care is evidence-based and protocol driven

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Statewide Protocols vs. Collaborative Practice Agreements

(Proposed Regulation) Allows pharmacist to prescribe/dispense self-administered hormonal contraception

» Oral

» Transdermal

» Vaginal

» Depot injection

Pharmacist must review patient answers to self-screening tool and assess BP

Pharmacist must ensure patient understanding and provide appropriate counseling

Contraceptive choice based on United States Medical Eligibility Criteria for Contraceptive Use (USMEC) developed by the CDC

Pharmacist must notify patient’s PCP or enter information into a shared EMR

Pharmacists must complete a minimum of one hour of approved CE or participate in SOP curriculum on or after 2014

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SELF-ADMINISTERED HORMONAL CONTRACEPTION PROTOCOL - CA

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Available at: http://www.oregon.gov/pharmacy/Imports/ContraceptivePrescribing/MECCorrespondingToORQuestionnaire11.2015.pdf (accessed 1/4/2016)

COLORADO PROVIDER STATUS LEGISLATION

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Colorado Provider Status Task force convened by Deans from CU and Regis in

2014 Expanded to include representatives from RxPlus,

SBOP, managed care, CPS, chains, FQHCs, and schools

Committed funds to hire a pharmacist on a consulting basis to focus on efforts

Bill sponsor identified Bill draft received 12/22/15

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Colorado Provider Status – Bill Highlights Modeled after Washington legislation “Collaborative Pharmacy Practice Agreements”

» Colorado insurance statute includes pharmacists as licensed healthcare providers, so not specifically addressed as such in this bill

Allows pharmacists to be reimbursed directly by health insurance providers for chronic disease management

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Colorado Provider Status – Next Steps Stay involved Contact your local legislator(s) once the bill is

introduced

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Provider Status – Potential Impacts Shift to appointment-based care Need for access to EMRs Need for private consultation areas Need to keep abreast of billing opportunities Need to build relationships with providers Need to document patient interactions and outcomes Increased liability premiums?

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Questions?38

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