Dimmy Sokhal, PharmD 9/28/2016. Clinical Pharmacist, Hayat Pharmacy. Building Enhanced Services into Your Existing Medication Synchronization Program

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1 Building Enhanced Services into Your Existing Medication Synchronization Program Sponsored by Merck Dimmy Sokhal, PharmD Laura Patterson, PharmD Amina Abubakar, PharmD Dimmy Sokhal, PharmD Clinical Pharmacist, Hayat Pharmacy 1

2 Disclosure Dimmy Sokhal declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. Learning Objectives Illustrate how a proactive medication synchronization based workflow can positively affect the implementation of enhanced services Discuss at least three profit building patient care opportunities that are conducive to an appointment-based model pharmacy Devise a plan for incorporating enhanced services in the community pharmacy setting 2

3 Introduction Locally owned pharmacy in Milwaukee Dedicated to providing quality care to our patients Free delivery for our patients to their doorstep based on their convenience Simplify my Meds program Medication Therapy Management (MTM) program or medication check-up with pharmacist Shift to Patient-Centered Health Care Trending away from a fee-for- service or product model Inclination towards value-based reimbursement Reimbursement rates based on achievement of quality measures 3

4 Key Pharmacy Quality Measures Adherence: Proportion of Days Covered (PDC) 3 PDCs: Statins, Non-Insulin Diabetic Medications, Hypertension Drug Safety Use of High-Risk Medications in the Elderly Comprehensive Medication Review 2016: New full measure enters for Medicare and Medicaid Services. Part C and D Performance Data Star Ratings Measure List. Drug Coverage/PrescriptionDrugCovGenIn/PerformanceData.html. Accessed 08/05/14. Medication Synchronization (Med Sync) Creating a patient centered approach where patients medications are proactively aligned From: Multiple scripts Multiple refill dates Multiple store visits To: Multiple scripts Same refill date Single store visit 4

5 Transition From: Reactive and Transaction Based Model To: Proactive and Patient Centered Model Appointment based care Enhanced Clinical Performance Increased Revenue 5

6 Incremental Script Lift with Med Sync IMPROVING ADHERENCE Variables IMPACT Patients improve adherence 100 Average number of chronic disease state Rx per patient 4.65 Expected Rx fills for one month for average patients 465 Number of months of refills/year for nonadherent patients 7.4 Number of months of refills/year for adherent patients 10.9 Expected increase in Rx fills per year: adherent vs. nonadherent 1,628 Average retail cost per Rx $56 Expected revenue increase/year $91,140 Holdford D, Inocencio T. Adherence and Persistence Associated with an Appointment-Based Medication Synchronization Model. JAPhA. 2013; 53: Accessed March 9, Synchronization Program Workflow Simplify My Meds (SMM) Pharmacist and SMM Specialist work in central office Coordinate refills for patients every 30- or 90-days SMM coordinator at store organizes the adherence packaging for the patient SMM coordinator communicate any notifications of hospitalization or changes to SMM specialists Changes are updated in the system 6

7 Synchronization Program Workflow Monthly assessment of profile to identify and evaluate potential drug related problems: Drug interaction Therapeutic duplication Cost effectiveness opportunity Appropriate dosing Missing medication Synchronization Program Workflow SMM coordinators and specialist help identify members for the MTM team Recently discharged patient Non adherent patients Patients with low health literacy 7

8 Opportunity for Other Services At the time of monthly visit, the pharmacist has opportunity to: Evaluate immunization status for the patient Review obstacles or barriers for adherence to medications Address ongoing concerns/adverse effects Review appropriate administration technique for devices Offer a one on one meeting with a pharmacist Adherence rates % Patients Medication Possession Ratio (MPR) >80% Therapeutic Class Oral Statins ACE I/ARBs Antidiabetics Sync Status Enrolled 62% 56.5% 58% Sync Status Not enrolled 30% 28% 34% 8

9 Refer patients who deny monthly appointment Simplify My Meds (SMM) team Medication Therapy Management (MTM) Team Refer patients who are noncompliant MTM-Comprehensive Medication Review & Assessment Intent is to work collaboratively with physicians Enhance therapeutic outcomes Aligning with evidence-based guidelines No therapeutic changes are made without healthcare prescriber approval 9

10 MTM Services at Hayat Home MTMs Pharmacists visit patient at their home Educate on importance of adherence Assist with tools for improving adherence Lifestyle education Training on appropriate administration of devices 8-10 Home MTMs/day MTM Services at Hayat Clinic MTMs Collaboration with clinics Work in collaboration with prescribers Assist with medication reconciliation Device training Evaluate issues with adherence Help set up goals for patients 10

11 MTM Services at Hayat MTMs Post Hospital Discharge Provide transitional care in collaboration with home health services Patient education on any medication related changes Assisting with follow-up with PCP post discharge Assisting with adherence Referrals for MTM services at Hayat Prescribers refer patients for MTM services at Hayat Local MA plan Staffing pharmacists Self-referral where patients or caregivers request MTM services 11

12 Hayat Pharmacy and Payers icare is a managed care organization that provides insurance benefits to dual eligible patients icare offers MTM services through OutcomesMTM Comprehensive medication reviews Targeted intervention program Hayat Pharmacy and Payers Hayat has performed 28% of icare s total completed CMR s for 2015 ~75% of all members referred to Hayat from icare have achieved a >80% PDC for the Star adherence measures In 2014 Hayat was only filling 3% of icare prescriptions In 2015 icare has increased its referrals to Hayat Hayat accounts for ~15% of total pharmacy claims for

13 MTM Services Payers Wisconsin Medicaid (Forward Health) covers MTM services for patients who meet eligibility criteria Billing for MTM services for Medicaid patients is done through Forward Health Portal Laura Patterson, PharmD Owner, Hale Center Clinical Pharmacy 13

14 Disclosure Laura Patterson declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. Becoming Clinical Free monthly diabetes classes Diabetes Self-Management Education accreditation MTM Immunizations Medication synchronization program 14

15 Rethinking Our Approach What programs or offerings do we currently have that are working well? In what ways can we grow this program? Are there services that could be combined to enhance our overall offering? Case Study: AB is a 68 year male enrolled in your pharmacy s medication synchronization program. He has Type 2 DM, HTN, and dyslipidemia. What immunizations is AB eligible to receive? 15

16 Immunizations Influenza Pneumonia PPSV23 PCV13 Tetanus Td Tdap Shingles Others? 16

17 ACIP Recommendations Ages Influenza Annually Td & Tdap Sub 1 dose of Td for Tdap; then Td every 10 years Ages 60+ Zoster Single dose regardless of past Zoster history Contraindicated in severe immunodeficiency Immunization Schedules. Centers for Disease Control and Prevention, Web. 29 August ACIP Pneumonia Summary Age 65+ Never received pneumonia vaccine Needs PCV13 and PPSV23 (at least 1 year apart) Administer PCV13 first Age 65+ Received PPSV23 at age <65 Administer PCV13 at least 1 year after PPSV23 Administer PPSV23 at least 1 year after PCV13 and 5 years after PPSV23 Age 65+ Received PPSV23 & PCV13 <65 Administer PPSV23 at least 5 years after last PPSV23 Immunization Schedules. Centers for Disease Control and Prevention, Web. 29 August

18 ACIP Pneumonia Summary Age Never received pneumonia vaccine Only indicated for adults with certain conditions See ACIP for full recommendations Immunization Schedules. Centers for Disease Control and Prevention, Web. 29 August Our Procedure Technician: Pulls chart, reviews immunizations Calls patient to review active med list Reviews immunization history with patient Schedules pick-up/vaccine appointment Patient arrives for appointment Pharmacist: Reviews immunization history with patient Administers needed vaccines Insert other services here! 18

19 Case Study: AB is a 68 year male enrolled in your pharmacy s medication synchronization program. He has Type 2 DM, HTN, and dyslipidemia. Upon reviewing his immunization history your pharmacy technician finds that AB has not yet had a flu shot this year. She also finds that 6 years ago AB received PPSV23, and 2 years ago he received PCV13. She finds no record of shingles vaccine or of his tetanus immunization history. What immunizations is AB eligible to receive? Immunizations Influenza Pneumonia PPSV23 Tetanus Tdap Shingles 19

20 Amina Abubakar, PharmD, AAHIVP CEO, RxClinic Pharmacy Disclosure Amina Abubakar declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. 20

21 Practice Sites: Rx Clinic Pharmacy #1 Independent Community Pharmacy Point-of-Care Testing Rapid Flu BHRT Diabetes Screening BP Cholesterol HIV HepC Pharmacogenetics' Testing with MTM MTM / CIPAs Diabetes Education Program URAC Accredited Specialty Pharmacy DME Practice Sites: Rx Clinic Pharmacy #2 Ballantyne Family Medicine Collaborative Practice Agreement Annual Wellness Visits Chronic Care Management Pain Management BHRT HIV Specialty Pharmacist Travel Health & Immunizations Clinic Pharmacogenetics' Testing with MTM Cash Model Insurance Model 21

22 Cycle of Workflow Medication Reconciliation Coordinate Pick up Needs Assessment Assign Death Date Create Sync Date Assign Workflow Date Call Patients 7 Days Out Med Sync Calls Assess Adherence Medications not being filled Medications discontinued Assess Adverse Effects Side effects Assess Need for Up Solutions DME Immunizations MTMs Adherence Packaging POCT Pharmacogenetics' Testing Compounding 22

23 How to Implement Technicians Into the Workflow Assess Workflow Find challenges Determine time of most volume Reconstruct Workflow Create med sync process Train staff to identify patients Identify Technician Easily Trained Ambitious Train Technician Provide questionnaire and when to refer to pharmacist What are Up Solutions and how does that make us more money? 23

24 Immunizations Immunization Avg Cost ($)/vaccine Potential Immunization Revenue Average Reimbursement ($) Profit/ Immunization ($) # Projected to administer Total Profit Influenza $12.00 $30.00 $ $7200 Herpes Zoster $ $ $ $2,000 Pneumococcal $75.00 $95.00 $ $1,500 Tdap $45.00 $64.00 $ $1,900 Hep B $50.00 $ $ $ Meningococcal $55.00 $ $ $ Total Profit $13,530 MTMs Service Monthly Revenue Yearly Revenue Mirixa $50 X 10 Cases = $500 $500 X 12 = $6,000 Outcomes $60 X 25 Cases = $1,500 $1,500 X 12 =$18,400 PHARMACeHOME $50 X 60 Cases = $3000 $3000 X 12 =$36,000 Total Income $5,000 $60,000 24

25 POCT POCT CPT Code Cost Reimbursement Price Influenza Ag detection Influenza assay w/optic 87449; modifier QW 87804; modifier QW $13.15 $16.36 $ Strep Throat 87880; modifier QW $1.30 $16.36 $59 96 HIV 86803; modifier QW 86703; modifier QW $14.45 $12.58 $19.43 $40 65 HCV 86803; modifier QW $19.98 $19.47 $40 65 Pharmacogenetics Business Plan Example cash model: wholesale= $250 Suggested retail $399 Profit ~ $150 Goal 5/month = $10,000/year Insurance Model: Treat like DME by collecting all supporting documents and doing prior Auth Educate patients and market to physicians **Best Practice: Must engage medical providers in order to create a dependency to collaborate with your pharmacy **Talk to your software vendors about integrating results (in the mean time use allergy fields for the flagged medications. 25

26 Questions? Dimmy Sokhal, PharmD Laura Patterson, PharmD Amina Abubakar, PharmD 26