Federal Pharmacy 2016: Senior Leaders Perspective

Federal Pharmacy 2016: Senior Leaders Perspective CPE Information and Disclosures Mr. Ron Nosek, Dr. George Jones, COL John Spain and RADM Pamela Schweitzer declare 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 honoraria. Ron Nosek, Department of Veterans Affairs George Jones Jr, Defense Health Agency COL John Spain, U.S. Army RADM Pam Schweitzer, U.S. Public Health Service March 4, 2016 The American Pharmacist Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. CPE Information Target Audience: Pharmacists & Technicians] ACPE#: 0202-0000-16-082-L04-P/T Activity Type: Knowledge-based Learning Objectives 1. Discuss two current issues that affect federal pharmacy. 2. Describe how the Defense Health Agency is improving medication safety and effectiveness by offering medication therapy management to its beneficiaries. 3. Explain how the Veterans Health Administration s clinical pharmacy program is expanding the role of pharmacists and provide an update of the PhARMD Project. Self-Assessment Question 1 1. The Veterans Health Administration provides care to over 8.9 million Veterans annually from 1,600 medical care sites. True or False Self-Assessment Question 2 2. DoD Pharmacy is implementing a Congressionally directed Medication Therapy Management pilot in: a.) Patient Centered Medical Home based care model b.) A Military Treatment Facility and civilian care based care model c.) A civilian care based care model d.) All of the above 1

Self-Assessment Question 3 3. Priorities of the Army Medical Department include: a.) Readiness and Health b.) Healthcare Delivery c.) Force Development d.) Take Care of Soldiers, Civilians and Families e.) All of the above Self Assessment Question 4 4. What opportunities are there for pharmacists to strengthen the healthcare system infrastructure? a.) Strategize on ways to fill gaps in healthcare delivery b.) Pharmacist Provider status c.) Alignment of clinical values across healthcare teams, and a shift to patient-centered goals within care delivery. d.) All of the above Federal Pharmacy 2016: Senior Leaders Perspective Ron Nosek Deputy Chief Consultant, VA PBM National Director, VA Meds by Mail Program Veterans Health Administration Overview and Key Initiatives in VA VHA and PBM CMOP Clinical Pharmacy Programs The PhARMD Project Academic Detailing VA Pharmacy Residencies March 4, 2016 Veterans Health Administration Over 1,600 sites of care including: 167 VA Medical Centers Over 1,000 Community-Based Outpatient Clinics (CBOCs) 300 Vet Centers (Readjustment Counseling), 70 Mobile Vet Centers Outreach and mobile medical clinics serve the most remote rural Veterans all tethered to one of our medical centers Provides health care services to 8.9 million Veterans each year 92.4 M OP appointments annually 16,801 Average Operating Beds 707.4 K Admissions 312 K surgeries annually Pharmacy Services Approximately 8,500 Pharmacists; 600 Residents/Fellows; 4,500 Technicians 223 outpatient pharmacies; 7 mail order pharmacies 146 M Rx s (271 M 30-day Eqv) annually (80% filled by mail) $3.7 billion in drug cost Pharmacy Benefits Management VA operates a world-class pharmacy benefits management program with demonstrated excellence in several key areas including: Clinical pharmacy practice (profession benchmark) Top Pharmacy Residency Training Programs Pharmacy automation (innovator) Medication safety (national and international reputation) Formulary management (sustained superior performance in access, cost and quality over the past decade) 2

CMOP Overview Workload 117 million Rx s (80% of all OP Rx s filled in VA) 320,000 packages mailed/day $3.18 billion ($12.7 million/day) Low volume products Goal to increase # of line items carried by CMOP (>1,700 added) Products >10 Rx s/month across VA Specialty Pharmacy (GL-CMOP) Centralized approach through CMOP; reduce burden on VAMCs Focus on products with wholesale restrictions Dispensing ~40 line items and 35,600 Rx s CMOP Overview Naloxone Kits Nasal kits and commercially available auto injector Dispensed ~17,000 kits in FY2015 Over 100 documented reversals Non VA partnerships Indian Health (43 of 78 sites actively transmitting) FY 2015 workload approx. 481,500/year Veterans Tracking the delivery of their medication using MyHealtheVet An average of 3,000 Veterans track the delivery of their medication every work day 180,000 Veterans have signed up for email notification that their medication package has been mailed 917,000 emails have been sent to Veterans J.D. Power 2015 Mail Order Pharmacy Study Clinical Pharmacy Practice in VA Clinical Pharmacists are Essential Providers of Comprehensive Medication Management Services Over 3,185 (47%) Clinical Pharmacists with a Scope of Practice (SOP) Movement to Practice-Area Based SOPs Credentialing of Clinical Pharmacists with a SOP in a similar manner to the LIP SOP Oversight and Evaluation of the Quality of Care Professional Practice Evaluations(OPPE and FPPE) Process Redefined VHA Policy to Support Practice Change Clinical Pharmacy Practice Initiatives Hepatitis C Treatment in VA Approximately 140,000 Veterans in VA care with chronic Hepatitis C infection making it the largest single HCV provider in the U.S. VA has had a comprehensive National Viral Hepatitis Program since 2001 and is a leader in the U.S. in HCV screening, care, and treatment. VA has treated over 26,000 Veterans with the new interferon free direct acting antivirals in FY 2015 and over 35,000 since January 2014. VA has screened 68% of Veterans born within the 1945-1965 cohort, a group which the CDC and USPSTF recommend one-time screening. (This is substantially higher than the 40% screening rate nationally in this cohort) Also have systems in place at the VISN level to address gaps in testing and access to care. These teams have worked successfully to ramp up VA treatment capacity resulting in as many as 1,500 new treatment starts per week Hep C drug treatment was over $1.2 billion in FY2015 3

The PhARMD Project Pharmacists Achieve Results with Medications Documentation A clinical reminder dialog template that allows pharmacists to document the spectrum of clinical pharmacy services that are provided to patients by pharmacists within the VA. PhARMD Project Tool: How Does it Work? A health factor was created for each of the clinical pharmacy interventions in the tool using standardized nomenclature and these health factors are exported into the regional and corporate data warehouses CPPO has developed the ability to retrieve these clinical pharmacy health factors (HF) for each intervention logged by the clinical pharmacist at the local medical center The PhARMD tool contains interventions commonly seen in different settings Original tool focuses on the ambulatory setting Version 7.0 includes interventions in the acute care setting; released at the end of FY15 PhARMD Project Focus on Interventions PhARMD Project Results CPPO PhARMD Reporting SharePoint available with data for all participating sites Summary and interventions breakdowns Important in describing role of the pharmacist Provides information related to types of patients and their therapeutic goals identified by pharmacists Provides granularity as to number of patients who achieved therapeutic targets Academic Detailing Implementation in Veterans Health Administration Multi faceted Approach: Academic Detailing, Audit Feedback and Practice Facilitation In-person educational outreach Information is provided interactively so the academic detailer can: Understand where the provider is coming from in terms of knowledge, attitudes, and behavior personal motivations for practice Modify the interaction to meet the needs of the provider Engage the provider by acknowledging their expertise and learning together rather than teaching Uses balanced evidence-based information and tools Delivered by a healthcare professional specially skilled in empathic persuasive communication Over time, the educator and provider develop a trusted and useful relationship As of March 2015, VHA mandated implementation of Academic Detailing in every Veteran Integrated Service Network to be provided by Clinical Pharmacy Specialists Insomnia Pharmacotherapy Dashboard Academic Detailing VISN Implementation Statistics as of September 2015 6 VISNs have fully implemented AD 14 VISNs are in progress of implementation 2 VISNs pending decision on waiver OEND Distribution Report Topics Covered During AD Visits (FY15 Q1-3) Topic Total Visits Pain/Opioid Use 1171 OEND 638 Benzo in the Elderly 194 PTSD 194 Testosterone 141 AUD 51 Insomnia 43 Hepatitis C 35 Depression 25 Dual Care 18 Refractory Schizophrenia 13 Coalition Building 12 Other 39 4

OEND Academic Detailing Campaign Resource Center Reversal & Status Report Kit Prescription Fills by State (12/10/15) Reported Reversals by State (12/10/15) VA Residency Program Overview Total number of programs: 236 PGY-1: 157 PGY-2: 79 PGY-1 Residents: 441 PGY-2 Residents: 159 Mental Health, Ambulatory Care, Internal Medicine, Oncology, Geriatrics, Pain Management/Palliative Care, Critical Care, Emergency Medicine, Infectious Disease, Pharmacy Admin, Informatics Fellows: 5 (Infectious Disease and Cardiology) 700 600 500 400 300 200 100 0 Growth of VA Pharmacy Residencies Number of VA Funded Resident Positions 5

Current Issues in DoD Pharmacy Operations DoD Pharmacy Enterprise Dr. George E. Jones, Jr. Chief, Pharmacy Operations Division Defense Health Agency Learning Objectives An overview of the Defense Health Agency and the DoD Pharmacy Enterprise Support Activity Awareness of the DoD Pharmacy implementation of a Medication Therapy Management pilot project Military Health System Modernization Creating a more globally integrated health system built on our battlefield successes Driving enterprise-wide shared services; standardized clinical and business processes that produce better health and better health care Implementing future-oriented strategies to create a better, stronger, more relevant medical force DHA Pharmacy Ops Division: Supporting the DoD Pharmacy Enterprise The DHA Pharmacy Operations Division has responsibility for corporate management and compliance oversight of enterprise-wide pharmacy initiatives enabling DoD pharmacy benefit delivery in support of the MHS. Pharmacy Enterprise Support Activity - Guided by Pharmacy Work Group Medically Ready Force Ready Medical Force 34. Medically Ready Force Ready Medical Force 35 DoD Pharmacy: Delivering! Pharmacy Shared Services from Initial to Full Operating Capability 2013 15 Service Consultants/DHA Pharmacy Staff Pharmacy Work Group Exceeded Every Target Integrated Operational Framework Dynamic Collaboration to Address Mission Opportunities Tasked to implement Congressionally directed Medication Therapy Management pilot program Assess MTM delivery and results in three practice settings Develop / track metrics to describe value to patient outcome Delivering Today Positioned to Build on the Excellence MTM in DoD Pharmacy A Pilot Program NDAA 2015 Section 726 Medication Therapy Management Pilot Program program to evaluate the feasibility and desirability of including medication therapy management as part of the TRICARE program. Elements: 1+ chronic condition; 1+ prescribed medication Focus improve use and outcome of medication(s) Metrics to measure the effect of MTM 6

MTM Pilot Implementation Pilot directed in NDAA 2015 Section 726 2 year pilot Determine if MTM is feasible and desirable for deployment DoD wide Directed MTM Pilot Sites Location Type 1 Patients enrolled in PCMH Location Type 2 Patients using MTF pharmacies but receiving medical care outside the MTF Location Type 3 Patients receiving purchased sector care and using Retail or Mail (non MTF) MTM Pilot Implementation, cont. Issuing a Request for Proposal (1 st QTR CY2016) Mechanism to enable adding staff to deliver MTM Implementing purchased sector care location Measurement and Analytics support Leverage Existing Medication Optimization Patient Centered Medical Home efforts Reports developed by DHA and provided to Services Capabilities of current pharmacy contract partner Initiate Pilot Program 3 rd QTR CY2016 OVERALL GOAL Improve Medication Use; Meet Report to Congress Requirements Key Points An overview of the Defense Health Agency and the DoD Pharmacy Enterprise Support Activity Awareness of the DoD Pharmacy implementation of a Medication Therapy Management pilot project Federal Pharmacy 2016: Senior Leaders Perspective COL John Spain U.S. Army Pharmacy Consultant and USA MEDCOM Pharmacy Program Manager Office of the Army Surgeon General March 4, 2016 Outline TSG 44: Intent, Priorities, Future Environment Army Pharmacy Strategic Plan Top 3 Interaction at Dispensing Clinical Pharmacy Expansion Recapture Looking Forward Clinical Pharmacy Value Proposition Specialty Medications Engagement DOD Federal Pharmacy Industry Comments/Questions/Discussion TSG: Intent and Priorities TSG 44 - LTG Nadja West Primary mission: Support the warfighter Priorities Readiness and Health Healthcare Delivery Force Development Take Care of Soldiers, Civilians and Families 7

TSG: How I View the Future Health Care Environment Characteristics: Paradigm shift in care-delivery model (i.e. phone, internet, group visits, genetically tailored treatment) Super empowered healthcare consumers Continued rising costs reaching a potential breaking point Increasing focus on patient behavior Integrated information technology systems Health Service Challenges: Super empowered healthcare consumers Fiscal constraints Data saturation Patient compliance Strategic Plan (FY13-16) SP: Bottoms up - iterative review - living document (SP Group >JFPS review >field review >final >revision >publish[jan16] >interim[apr16]) 1. Readiness: visibility of non-deployable medication, polypharmacy high risk 2. Stewardship: perpetual inventory, E-Rx, contract compliance, reverse distribution 3. Quality Care: polypharmacy, secret shopper, staffing model 4. Innovation/Standardization: automation, metrics, privilege/credentials 5. Service Excellence: customer feedback 6. People: job/skill expectations, certification, training opportunity Top 3 #1: Interaction at Dispensing Interaction at Dispensing Pharmacy Expansion in the Army Medical Home Recapture Everyone contributes to achieving Service Excellence objective MOE : >87.5% of patients rate pharmacy services as very good/ excellent #2: Expansion in the AMH #3: Recapture Purchases Brand to generic compliance ~ 93% National contract compliance ~ 88% Select Brand Prescriptions Acute Maintenance Patients Expanding formularies Increasing co-pays 8

Looking Forward Value Proposition Clinical Financial Readiness Specialty Medications Value Proposition Clinical measures: predictive modeling outcomes assessment Financial measures: RVU generation Patient care time (direct & indirect) Readiness measures: # high risk Polypharmacy # non deployable medication use Financial Clinical Readiness Value Proposition Clinical Value Proposition Financial RVU generation Patient care time (direct & indirect) Value Proposition Readiness Specialty Medications Medical Readiness Assessment Tool Polypharmacy Report 9

DOD Pharmacy Engagement Federal Pharmacy Engagement DOD/VA Pharmacy Value Collaboration Pharmacy MTM handoff in patient transition from DOD to VA Aligning GS grades and position responsibilities Institutionalizing dispensing interaction based on Indian Health Service practices Industry Engagement MTFs need access to specialty medications through DAPAs Opportunities for partnering can capitalize on shared goals in improving adherence and health Standardization and interoperability provide win-win-win prospects Federal Pharmacy 2016: Senior Leaders Perspective RADM Pam Schweitzer, Assistant Surgeon General Chief Professional Officer for Pharmacy U.S. Public Health Service March 4, 2016 PHS Pharmacists by Agency (1266 Commissioned Corps 2/15/2016) IHS 554 CMS 35 FDA 406 CDC 21 BOP 155 NIH 11 SAMHSA 6 HRSA 15 AHRQ 1 OS 15 Coast Guard 16 DOD TMA 10 ICE 20 Collaboration - Stronger together Indian Health Pharmacy meetings: Oklahoma, Northern Tier, Quad (Arizona) Bureau of Prisons Denver Subject Matter Expert (SME) teams Chronic diseases, immunizations, geriatrics, wellness, pain management/opioids, provider status/mtm/cpa s External Liaisons to organizations, schools of pharmacy Cross-category (other USPHS disciplines) collaboration Tobacco Cessation, Women s support group, Wellness (early stages) 10

Ongoing You can do what I cannot do. I can do what you cannot do. Together we can do great things. Mother Teresa Limited distribution drug products Health information technology connecting health, interoperability Federal Pharmacy House of Delegates Introduced two new business items: NBI #9 - Medication Assisted Treatment (MAT) NBI #10 - Opioid Overdose Prevention U.S. Surgeon General Initiatives New National Adult Immunization Plan - released Surgeon General s Opioids campaign coming soon Tobacco cessation training program Rx for Change RX for Change: Tobacco Cessation Intervention for Clinicians (Five A Model) RX for Change: Basic Tobacco Intervention Program for busy clinicians and non-clinicians (Ask-Advise- Refer) National Adult Immunization Plan National Adult Immunization Plan (NAIP) Goals Goal 1: Strengthen the adult immunization infrastructure. Goal 2: Improve access to adult vaccines. Goal 3: Increase community demand for adult immunizations. Goal 4: Foster innovation in adult vaccine development and vaccination-related technologies. http://www.hhs.gov/nvpo/national-adult-immunizationplan/index.html 11

Recommended vaccines The CDC and its Advisory Committee on Immunization Practices (ACIP) currently recommend 13 different vaccines for adults age 18 and older to prevent a host of diseases: Includes: vaccines that are universally recommended (e.g., influenza) recommended for certain age groups (e.g., human papilloma virus [HPV]), targeted to individuals with specific risk factors (e.g., hepatitis A and B). catch-up vaccinations for those adults who never initiated or did not complete a multi-dose series when vaccination was first recommended during childhood. Medical Reserve Corps National Network of Networks Mission: Engage volunteers to strengthen public health, reduce vulnerability and disaster risk, build resiliency, and improve community preparedness, response and recovery capabilities Keys to success: Dedicated volunteers and leaders Supportive housing organizations Strong partnerships http://www.naccho.org/topics/emergency/mrc/networkprofile Mt Kilimanjaro Key Points Mission first Support our federal delegates (house of delegates) Smoking cessation training Develop strategies to improve adult vaccinations Your health is important! Answer to Self-Assessment Question 1 1. The Veterans Health Administration provides care to over 8.9 million Veterans annually from 1,600 medical care sites. True 12

Answer to Self-Assessment Question 2 2. DoD Pharmacy is implementing a Congressionally directed Medication Therapy Management pilot in: a.) Patient Centered Medical Home based care model b.) A Military Treatment Facility and civilian care based care model c.) A civilian care based care model d.) All of the above Answer to Self-Assessment Question 3 3. Priorities of the Army Medical Department include: a.) Readiness and Health b.) Healthcare Delivery c.) Force Development d.) Take Care of Soldiers, Civilians and Families e.) All of the above Answer to Self Assessment Question 4 4. What opportunities are there for pharmacists to strengthen the healthcare system infrastructure? a.) Strategize on ways to fill gaps in healthcare delivery b.) Pharmacist Provider status c.) Alignment of clinical values across healthcare teams, and a shift to patient-centered goals within care delivery. d.) All of the above Closing Remarks Ron Nosek Ron.nosek@va.gov Dr. George E. Jones, Jr. George.e.jones48.civ@mail.mil COL John Spain John.spain1.mil@mail.mil RADM Pamela Schweitzer Pamela.Schweitzer@cms.hhs.gov 13