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Accountable care: Carilion pharmacists blazing the trail

HCR/regulatory scorecard:
What is happening NOW!
Regulations for which comment periods have closed: DEA: Dispensing of controlled substances to residents of long-term care facilities CMS: Interim final rule on identification of backward-compatible version of adopted standard for e-prescribing and the Medicare Prescription Drug Program (NCPDP SCRIPT 10.6) FDA: Public meeting on Risk Evaluation and Mitigation Strategies (REMS) HHS: Proposed rule on modifications and enforcement rules under the Health Information Technology for Economic and Clinical Health (HITECH) Act IRS/Labor: Interim final rule on coverage of preventive services under Affordable Care Act Regulations recently finalized/other APhA comments: FDA REMS hearings: APhA attended two hearings held by FDA on the topic of Risk Mitigation and Evaluation Strategies (REMS), one that focused specifically on extended-release and long-acting opioids and another on the program in general (see articles in the pain management supplement mailed with this issue). Etc.: q MTM bill: The Medication Therapy Management (MTM) Expanded Benefits Act of 2010 (S. 3543) continues to attract attention in the Senate. Sponsored by Minnesota Democrats Kay R. Hagan and Al Franken, the bill is strongly supported by APhA. Members are encouraged to contact their senators. Sample messages are available to APhA members in the Legislative Action Center of Pharmacist.com. A Dear Colleague letter sent by the bill sponsors to other senators also can be accessed on the site. It highlights the importance of MTM and pharmacists clinical services, reading in part: The MTM Expanded Benefits Act would expand Continued on page 12 PHARMACY TODAY SEPTEMBER 2010 14

f accountable care organizations (ACOs) end up being the central organizing entity of a reformed health care system in the United States, the first draft of their history is being written now by pharmacists in southwestern Virginia. At the Carilion Clinic, one of the three ACO pilot sites, pharmacists are collaborating with other health professions and learning to use their skills and knowledge fully, bringing pharmacy technicians with them into direct patient care roles, and ultimately breaking down barriers between settings in a closed-loop pharmacy system. To fully realize what pharmacy can be in the context of an ACO, we have to be willing to rethink what the entire pharmacy model is, said L. David Harlow III, BPharm, Director of Pharmacy Operations at New River Valley Medical Center in Christiansburg, VA. Health care is a business, and the days of judging pharmacy productivity by doses dispensed and even interventions have got to be done away with. This is a new era in health care, and if we as a profession are to be relevant, its time to believe in what we can achieve and to be accountable for the outcomes patients have right alongside our partners in nursing, medicine, and other disciplines. Simply, we must do everything we can do and not just some of what we can do. As described in the June Hub, ACOs are a type of integrated delivery system in which risk is shared between payer and provider. By attaining quality goals, providers earn higher reimbursements. Carilion Clinics is the largest of the three CMS pilots, according to Mark McClellan, former FDA and CMS head who is now with the Engelberg Center for Health Care Reform at the Brookings Institution. McClellan noted that Carilion has 900 providers and 60,000 Medicare patients assigned to it, operates in a low competitive environment, and is a fully integrated system. The smallest of the three pilots, Arizonas Tucson Medical Center, has 80 providers and 10,000 Medicare patients, operates in a highly competitive environment, and has multiple independent provider groups. In the middle is Norton Healthcare of Louisville, KY, a mediumsize ACO with 400 providers and 30,000 Medicare patients.

Using all of our skills

In a health system the size of the Carilion Clinican organization that spent $55 million on an electronic medical record systemwhat does it mean to spend $10 million annually for pharmacists? It means a lot, Harlow said. The 100 pharmacists in the Carilion Clinic system are second only to physicians in total investment. Harlow added that pharmacists who often enter the profession with 8 to 10 years of education and training these daysare both grossly underused by the system and have expectations for themselves that are far too low. Theres a fair segment of pharmacists who dont perceive themselves as providers at a midlevel like a physician assistant or a nurse practitioner, Harlow said in an interview with Pharmacy Today. But in fact, a large part of the skill set that the new generation of doctors of pharmacy are being taught are in fact midlevel skills. Weve got to utilize those skills. For that to happen fully, Harlow believes, pharmacists need to be recognized as providers in the Medicare program. In the current reimbursement system, it would be a lot cleaner and a lot less messy to have [pharmacists] classified as providers in their own right, he said. These folks have earned that by the work that has been done over the last 20 years in bringing pharmacy forward to an all-doctoral program. In the future, the problem with not being a provider in Medicare circles is that rarely will a private insurer embrace something that Medicare does not, and if Medicare does embrace something, the private insurers will follow suit.

Set Expectations For Prospective Discharge Med Review and Hand Off To Care Coordinators Discharge Side

Medical Home Or Primary Care Establish Collaborative Relationships Site-Specific Relationship Or Pharmacist

Set Expectations For PTA Med Review Inside Collaborative Practice Agreements And In-House Privilege Admissions Side

Carilions closed-loop pharmacy system

MTM eligibility to seniors with any chronic condition that accounts for high spending in our health care system, such as heart failure and diabetes. Currently, only 12.9% of Part D beneficiaries are eligible under the MTM criteria requiring multiple chronic conditions. The bill also ensures access to MTM for seniors at a pharmacy or with a qualified health care provider of their choice. To ensure pharmacists and health care providers are able to provide MTM to seniors, this bill ensures they are appropriately reimbursed for their time and service. Finally, this bill would establish standards for data collection to evaluate and improve the Part D MTM benefit. q Methamphetamine bill: The House Energy and Commerce Committee on July 28 passed the Combat Methamphetamine Enhancement Act of 2009 (H.R. 2923). The bill now goes to the House Judiciary Committee for its consideration. Introduced by Bart Gordon (D-TN), the bill would require retailers of certain chemical products used in manufacturing methamphetamine, including pharmacies, to self-certify that they are compliant with certain requirements, prohibit distributors of listed chemical products from selling such products to individuals not registered with DEA; require the Attorney General to develop a list of all self-certified individuals and make it publicly available on the DEA website; and impose civil penalties for negligent failure to self-certify as required in the bill. q DEA National Drug Takeback Day: On September 25 from 10:00 am to 2:00 pm, DEA plans to assist state and local authorities by coordinating a National Drug Takeback Day. The collection of unused prescription drugs will be in conjunction with state Attorneys General and local law enforcement authorities. The collection sites will be established and staffed by duly sworn state and local officers. DEA has established local points of contact in its field divisions, is providing collection boxes, and will collect and destroy the material at the conclusion of the program. q For a complete list of all the issues and regulations being monitored and acted on by APhA, access the Government Affairs section of Pharmacist.com. Also, print readers of the Hub should know that hyperlinks to Pharmacist.com, Federal Register notices, and other useful websites can be accessed in the online version of the Hub, located at www.pharmacytoday.org.
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Empowering technicians
Its not just pharmacists Harlow thinks are underused. We use technicians in our emergency department for medication reconciliation, Harlow said, noting the importance of this process in reducing readmissions. Its not cost-effective for me to take a pharmacist and put them in a place where all theyre doing is recording data. And neither is it cost-effective with a nurse. However, I can take a pharmacy technician who knows the medicines, knows the typical strengths they come in, what the colors are, and let them do an interview with a patient. If they need to, they call the patients physician to make sure the dose is correct, or call a community pharmacy to see what doses [the patients] are on. To be honest with you, my pharmacy technicians were terrified when I told them they would be doing that, Harlow said with a chuckle. Having a little faith in them and now a year laterthey are very satisfied with that direct patient contact. Its increased their job satisfaction enormously. And they feel likeand they are in fact making a real difference. how pharmacists fit into an ACO, he said. To begin with, pharmacists have to see themselves as providers of care and capable of providing direct patient care, be that in the hospital or in the local pharmacy, Harlow explained. That needs to happen yesterday. ACOs are about everyone in the organization playing to their respective strengths to gain efficiency everywhere possible, because the ultimate goals are savings and outcomes. As a previous owner of a pharmacy and employee of a large chain, I understand full well the challenge presented by the retail workflow, and retail organizations have to overcome that, Harlow continued. With the help of ACO insurers, your day [doesnt have to] be about adjudication; insurers have a stake in this shared savings an ACO can accomplish. Retail and institutions have got to find a way to communicate better, and in a computer world that should be attainable. My hospital patient will come to your pharmacy with a med list that will be different than it was a week ago, and if we are going to keep them out of the hospital, you need that information so you can support that in the MTM programs at the retail level ... Correspondingly, when that patient arrives at my hospital, my clinicians need to know what you have done in your MTM cliniceven if it failedand what the patients current profile looks like.
L. Michael Posey, BPharm, and Oriana Pawlyk, 2010 APhA Intern in Political Journalism

Closing the loop

With a clean medication list on admission, Harlow and his colleagues can effectively implement a closed-loop pharmacy service (see figure on page 12) that ultimately improves patient outcomes and lowers the total cost of care. This is the key to understanding

riana Pawlyk, APhAs 2010 Intern in Political Journalism, and Today Editor L. Michael Posey, BPharm, attended a presentation at the National Press Club in Washington, DC, on June 30. Pawlyk, now a junior at Miami University in Oxford, OH, was at APhA headquarters for 8 weeks. Under a program sponsored by the Institute on Political Journalism and the Fund for American Studies, she wrote articles for the print and online versions of the Hub, assisted with research for the Whats in the Bottle? series, participated in staff meetings and discussions, and interfaced with staff in Government Affairs and other APhA departments. A Chicago native, Pawlyk is on track to graduate in May 2012 with a double major in journalism and English literature.
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provides readers with practical information on health care reform issues, what APhA is doing to keep pharmacists important role front and center with decision makers, and simple ways for pharmacists to participate in the processes that will determine the structure, function, and processes of a reformed