Legislative and Regulatory Update Nancy A Alvarez PharmD BCPS FAPhA President 20172018 American Pharmacists Association MPA Sesquicentennial Meeting Oct 14 2017 Nancy A Alvarez declares no conflicts of interest real or apparent and no financial interests in any company product ID: 794478
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Expanding the Role of Pharmacists = Expanding Patient Access to CareLegislative and Regulatory Update
Nancy A. Alvarez, PharmD, BCPS, FAPhAPresident - 2017-2018American Pharmacists Association
MPA Sesquicentennial Meeting
Oct. 14, 2017
Slide2Nancy A. Alvarez 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 honorariaDisclosures2
Slide3At the completion of this activity, participants will be able to: Outline the details of federal provider status legislation and recent activity. Explain state-level opportunities that may increase patient access to pharmacists’ services. Describe how success at the federal and state level can impact pharmacists and their practice.Discuss ways to advocate and get involved. Learning Objectives3
Slide4At the federal level, the profession is advocating for legislative changes to which government program in effort to provide coverage for pharmacists’ services?MedicaidMedicare Part AMedicare Part BAffordable Care Act and the federal and state health exchanges Assessment Question #14
Slide5Provider status success at the federal, state and/ or private sector levels will:Better integrate the pharmacist into the patient’s health care team and help improve patient outcomesIncrease opportunities for pharmacists to contribute to more efficient and coordinated delivery of careIncrease patient access to health care and pharmacists’ opportunities to provide more patient care servicesAll of the aboveAssessment Question #25
Slide6Which of the following advocacy ideas would not be beneficial to the provider status effort?Pharmacists should reach out to members of Congress and their staff and invite them to their pharmacy practice.Develop an email campaign focused on disparaging other healthcare providers (e.g. physicians and nurses) and highlighting patients’ trust in the pharmacist.Write a letter to the editor or provide articles to local newspapers on pharmacists’ patient care services/ the value the pharmacists provide patients.Contribute to a political action committee (PAC) supporting federal provider status legislation.Assessment Question #36
Slide7We promote consumer access and coverage of pharmacists’ quality patient care services.What APhA Does7
Slide8Examples of pharmacists’ services that, in coordination with other health care team members, can help patients and their access to care: Chronic disease management and education: Helping patients improve the management of their condition(s) and optimize the benefits of their medications and health outcomes. Goal setting, monitoring, medication management services and coaching help improve conditions such as diabetes, cardiovascular disease, and respiratory diseaseMedication Management: Conducting a comprehensive review of a patient’s medications for appropriateness, effectiveness, safety, and adherence, and providing ongoing monitoring, as needed. Goal is to optimize medication use and health outcomes.
Pharmacists’ Services8
Slide9Examples of Pharmacists’ Services (cont’d): Health and wellness: Providing patients with annual and lifetime immunizations; blood pressure checks; cholesterol and glucose testing; weight management; tobacco cessation counseling; and other preventive servicesCare transition: Managing medications and coordinating information with other health care professionals to assist patients in transitioning smoothly between health care settings and prevent negative events like hospital readmissionsPharmacists’ Services
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Slide10Pathways to Provider RecognitionFederal Sector Social Security, Medicare Part B & D, CMMI, ACO Federal regulations (CMS, AHRQ, HRSA)State
MedicaidHealth insurance exchanges, state health plansExisting provider status &
collaborative practice
Private Payer
ACOs
Private or
employer-based insurers
Medical
homes
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Slide11*Information provided by National Alliance of State Pharmacy AssociationsWays to Optimize Pharmacists’ Value in States*11
Slide12State Level Changes12
Insurance Code
There is sometimes a list of professionals who are defined as health care providers for the purposes of the provisions in the insurance code
Challenge: A limited number of patients are covered by insurers who are held to these provisions (non-ERISA exempt plans)
Other Areas of State Laws
Pharmacy Practice Act
Business/Professional Code
Being “on the list” as a provider here may not have much of an impact on payment for services unless areas of the insurance code, Medicaid provisions, or state employee benefit provisions refer back to this language
Pharmacists can also be separately recognized as providers within Medicaid laws
Slide13Credentialing: The process by which an organization or institution obtains, verifies, and assesses an individual’s qualifications to provide patient care servicesPrivileging: Permission or authorization granted by a hospital or other health care institution or facility to a health professional (e.g., physician, pharmacist, nurse practitioner) to render specific diagnostic, procedural, or therapeutic servicesAdditional Training/ Certifications – E.g., for immunization administration, states require completion of a qualified training program Other Requirements Affecting Coverage13
Slide14Scope of PracticeCollaborative Practice AgreementsStatewide Protocols14
Slide15Practice of Pharmacy Collaborative Practice ProvisionsImmunization AuthorityOrder/ interpret labs, CLIA waived testsStatewide protocols to enhance public healthScope Components/ Opportunities15*Information provided by National Alliance of State Pharmacy Associations
Slide1616Statewide Protocols vs CPAs
CPAs
Negotiated between prescribers
&
pharmacists
Requires pharmacist to identify a collaborating prescriber
Could be patient-, disease state-, or patient population-specific
Services may be broad
& address
a variety of conditions
Care may or may not be protocol driven
Parameters are modifiable and negotiable between the
participating
providers
Statewide Protocols
Standardized for any willing and qualified pharmacist in the state
Pharmacist/pharmacy doesn’t need to find someone to sign off
Not patient-, pharmacist-, or provider-specific
Very focused service
Protocol-driven authority
Parameters are not modifiable by individual pharmacists
Slide17CPA ApplicationsChronic Disease ManagementAnticoagulationCardiovascular disease/hypertensionDiabetesOthersAcute Treatment – E.g. point of care testing, such as rapid strep testPublic Health – E.g. Naloxone17
Slide18Statewide ProtocolsNaloxoneImmunizationsSmoking CessationHormonal ContraceptivesTravel Medications18
Slide19Payment for Pharmacists’ Services19
Slide20Payment for Services*20*Information provided by National Alliance of State Pharmacy Associations
Slide21Pharmacy’s Federal Provider Status Efforts21
Slide2222Patient Access to Pharmacists’ Care Coalitionwww.PharmacistsCare.org
Slide23Patient Access to Pharmacists’ Care CoalitionBroad coalition of pharmacy organizations and stakeholders focused on regulatory and legislative actionCoalition seeking provider status for pharmacists including advocacy for:
Consumer/patient access & coverage for pharmacists’ patient care servicesPayers & policy makers to recognize pharmacists as health care providers who improve access, quality, & value of health careEnhanced inclusion of pharmacists as members of patient health care teamsAPhA serves on the PAPCC’s Steering Committee
&
has committed several million dollars to supporting the PAPCC, including a media campaign targeted to lawmakers.
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Slide24Nearly 40 organizations and growing!
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Patient Access to Pharmacists’ Care Coalition
Slide25H.R.592 / S.109Pharmacy and Medically Underserved Areas Enhancement ActRepresentatives Brett Guthrie (R-KY), G.K. Butterfield (D-NC), Tom Reed (R-NY), and Ron Kind (D-WI) introduced H.R. 592 on January 20, 2017126 Original Co-sponsorsSenators Chuck Grassley (R-IA), Sherrod Brown (D-OH), Susan Collins (R-ME) and Robert Casey (D-PA) introduced S. 109 on January 12, 201727 Original Co-sponsors Amends section 1861 of the Social Security Act to recognize pharmacists’ services within Medicare Part BThe entire Maine delegation is signed on to the bills! Federal Legislation
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No. of Cosponsors
H.R. 592 – 214
S. 109 – 45
Bipartisan
as of
October
9,
2017
Slide26H.R.592 / S.109 – Scope of ProposalPharmacists – State-licensed pharmacists with a B.S. Pharm. or Pharm. D. degree who may have additional training and certificates depending on state lawsServices – Services authorized under state pharmacy scope of practice lawsPatients – Services provided in/ for Medically Underserved Areas (MUA), Medically Underserved Populations (MUP), or Health Professional Shortage Areas (HPSA)Patient Access to Pharmacists’ Care Coalition26
No impact on state scope of practice
Slide27Are only a limited number of pharmacists eligible under H.R.592 / S.109?Patient Access to Pharmacists’ Care Coalition27
Slide28Patient Access to Pharmacists’ Care Coalition28Are only a limited number of pharmacists eligible under H.R.592 / S.109?
Slide29Provider Status Effect on Pharmacy Practice29
Slide30Changes in workflowIncrease in pharmacist’s face-to-face time with patientsShift to appointment-based careChanges in facilitiesNeed for more private consultative areasNeed for access to electronic health recordsIncrease central-fill Provision of care off sitePotential Operational Changes 30
Slide31Changes in billing mechanismsMedical insurancePartnerships for bundle paymentsOutcomes based vs fee for serviceChanges in role of the pharmacistBuilding patient relationships/ engage patient in their care Increased collaborations/ team-based careEffective documentation for care deliveredAdditional training or verification of performance abilityPerformance appraisal system - meeting outcomes vs # of RxsLiability Potential Operational Changes 31
Slide32Profession’s Next Steps32
Slide33ConsiderationsTimeline Dependent on possible vehicle/ other health care reform legislationCost of the legislation/ Congressional Budget Office (CBO) Score PAPCC Strategy 33
Slide34Work with lead sponsors and committee leadership on next steps and timeline Continue to build co-sponsor support/ utilize full coalition grassrootsContinue discussions with administration Monitor activity in statesPAPCC Next Steps 34
Slide35Federal efforts is only one of our profession’s pathway to success Pharmacy-related associations and pharmacists’ progress in helping patients receive better coordinated care has been impressive at the state levelStates demonstrating impact pharmacists can have on patients and health care, including helping to fulfill needs of patients These efforts are valuable to our federal level efforts as well APhA will continue to work with others to make the case for increasing access to pharmacists’ patient care services 35Pharmacy’s Next Steps
Slide36Incorporate solutions to and offerings for policymakers & decision-makers’ concerns and what they valueE.g. transitions of care, movement towards coordinated care and new delivery models, address high cost items Take advantage of state laws and actionsE.g. individual Medicaid programs and health exchangesContinue to demonstrate value
quality, favorable patient outcomes, costHighlight evidence and continue researchAs robust as possible but don’t let the perfect be an enemyData is important but may not need to be in peer-reviewed literature
Pharmacy’s Next Steps
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Slide37Making the Case for Pharmacists’ Services37
Slide38Problems and OpportunitiesTotal health care spending in the United States was $3.4 trillion in 2016 and $75 billion in 1970.1Health care spending is projected to grow 5.6 percent per year, on average, and will account for nearly 20 percent of GDP by 2025.1The US spends almost $300 billion annually on medication problems including medication non-adherence.2Chronic diseases costs the US health care system $1.7 trillion annually (more than 75% of health care spending).3 1.Centers for Medicare and Medicaid Services, National Health Expenditures Projections 2016-2025.
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html2. New England Healthcare Institute. Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease. August 2009. http://www.nehi.net/publications/17-thinking-outside-the-pillbox-a-system-wide-approach-to-improving-patient-medication-adherence-for-chronic-disease/view3. Partnership to Fight Chronic Disease. 2009 Almanac of Chronic Disease. Available at: http://www.fightchronicdisease.org/resources/almanac-chronic-disease-0.Health Care Environment
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Slide39Percentage of Medicare Fee for Service Beneficiaries by Number of Chronic ConditionsCenters for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries,
Chartbook, 2012 Edition. Baltimore, MD. 2012.https://www.cbo.gov/sites/default/files/recurringdata/51302-2017-06-medicare.pdf39
Health Care Environment
Medicare enrollment is expected to grow from roughly
55 million in 2017 to 75 million by 2027.
Slide40Problems and OpportunitiesNearly 70 percent of Americans are on at least one prescription drug, and more than 50 percent take two.1In 2016, there were more than 4 billion prescriptions filled at US outpatient pharmacies – an average of more than 12 prescriptions/person.2Almost 50% of people prescribed medications for chronic diseases do not take their medications correctly.3Pharmacists with their education and training (including more medication education than other providers) can help improve these statisticsHealth Care Environment
Nearly 7 in 10 Americans Take Prescription Drugs, Mayo Clinic, Olmsted Medical Center Find, http://newsnetwork.mayoclinic.org/discussion/nearly-7-in-10-americans-take-prescription-drugs-mayo-clinic-olmsted-medical-center-find Kaiser Family Foundation. http://kff.org/other/state-indicator/retail-rx-drugs-per-capita/
Sabaté
E, editor. , ed. Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization; 2003.
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Slide41Health Care Access is a National Problem41
Slide42Growing Support for Pharmacists’ Value
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Slide43Independent report released on May 2014; available at http://avalerehealth.net/
Report explores pharmacists services currently being provided and their contribution to health/ health care systemIdentified the most recent U.S. research articles and focused on four pharmacist services and one care delivery arrangement:
Medication management; medication reconciliation; preventive services; counseling; and collaborative care models
Research / Evidence
Pharmacy Organization Value of Pharmacy Project
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Slide44Patients Benefit from Medication-Related Services; examples include:Evidence Supporting Value
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Slide45Support for Pharmacy45Issued January 2015
Slide4646On January 17, 2017 CMS’s Center for Medicaid and CHIP Services (CMCS) Issued an “Information Bulletin” to statesEncourages state flexibility to facilitate timely access to drug therapy by expanding the scope of pharmacy practice “CMCS encourages states to consider using these methods to promote access particularly to those drugs that can help address priority public health issues” “These practices can facilitate easier access to medically necessary and time-sensitive drugs for Medicaid beneficiaries”
Support for Pharmacy
Slide47APhA Advocacy ResourcesAPhA: PharmacistsProvideCare.comJoin the Campaign!State-specific informationFact SheetsMaking the caseInfographics
Public opinion pollsScope of practiceStudent Tool KitSupporter EngagementMonthly NewslettersLetters to Members of CongressAdvocacy AlertsMessaging
E.g., FAQ
Social Media efforts - videos
Pharmacists’ Involvement Needed!
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Slide48Messaging, stories and profiles highlighting pharmacists’ servicesSHARE YOUR STORY! Show you care about your patients. Identifying other health care providers supportive of pharmacistsYou don’t have to go to Washington DC to make a difference!!www.pharmacistsprovidecare.com
APhA Provider Status Activities48
Slide49At the federal level, the profession is advocating for legislative changes to which government program in effort to provide coverage for pharmacists’ services?MedicaidMedicare Part AMedicare Part BAffordable Care Act and the federal and state health exchangesAssessment Question #149
Slide50Provider status success at the federal, state and/ or private sector levels will:Better integrate the pharmacist into the patient’s health care team and help improve patient outcomesIncrease opportunities for pharmacists to contribute to more efficient and coordinated delivery of careIncrease patient access to health care and pharmacists’ opportunities to provide more patient care servicesAll of the aboveAssessment Question #250
Slide51Which of the following advocacy ideas would not be beneficial to the provider status effort?Pharmacists should reach out to members of Congress and their staff and invite them to their pharmacy practice.Develop an email campaign focused on disparaging other healthcare providers (e.g. physicians and nurses) and highlighting patients’ trust in the pharmacist.Write a letter to the editor or provide articles to local newspapers on pharmacists’ patient care services/ the value the pharmacists provide patients.Contribute to a political action committee (PAC) supporting federal provider status legislation.Assessment Question #351
Slide52Discussion & Questions
For more information on
APhA’s
provider status activities
Visit
www.pharmacistsprovidecare.com
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