Pharmacy Practice Opportunities in Tennessee Lucy Adkins, PharmD Director of Pharmacy Practice Initiatives TENNESSEE LEGISLATIVE INITIATIVES Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -2- Micah Cost, PharmD, MS 1
Collaborative Pharmacy Practice SB 1992 by Overbey, McNally, Haile, Crowe, Yager (HB 2139 by Shepard, Ramsey, Sexton) Pharmacy, Pharmacists - As introduced, authorizes collaborative pharmacy practice. - Amends TCA Title 63, Chapter 10; Title 63, Chapter 6 and Title 63, Chapter 9. Passed in 2014 Public Chapter 832 Effective July 1, 2014 Link to Law: http://www.tn.gov/sos/acts/108/pub/pc0832.pdf Collaborative Pharmacy Practice Rules Effective February 20, 2017 Link to Rules: http://share.tn.gov/sos/rules_filings/11-14-16.pdf Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -3- What Is Collaborative Pharmacy Practice? Tennessee Code Annotated 63-10-204 - Definitions "Collaborative pharmacy practice" is the practice of pharmacy whereby one (1) or more licensed pharmacists licensed in this state, jointly and voluntarily work with one (1) or more prescribers licensed in this state, under a collaborative pharmacy practice agreement to provide patient care services, to achieve optimal medication use and desired patient outcomes "Collaborative pharmacy practice agreement" is a written and signed agreement entered into voluntarily between one (1) or more licensed pharmacists in this state, and one (1) or more prescribers licensed in this state, each of whom is in active practice in this state providing patient care services in this state, that provides for collaborative pharmacy practice, as defined by law; (A) "Practice of pharmacy" (vii) Provision of patient care services and activities pursuant to a collaborative pharmacy practice agreement; (B) Nothing in this chapter authorizes a pharmacist to order laboratory tests or prescribe any prescription drugs except pursuant to a medical order by the attending prescriber for each patient or pursuant to a collaborative pharmacy practice agreement jointly agreed upon by a pharmacist or pharmacists and a prescriber or prescribers; provided, that pharmacists are authorized to conduct and assist patients with tests approved for home use. Pharmacists may convey orders for laboratory tests when authorized by the attending prescriber and may prescribe prescription drugs when required to carry out a medical order or perform activities pursuant to a collaborative pharmacy practice agreement when authorized by the attending prescriber Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -4- Micah Cost, PharmD, MS 2
What Is Collaborative Pharmacy Practice? Who can enter into a CPPA: CPPA can be between pharmacist(s) and prescriber(s) OR pharmacist(s) and the chief medical officer, medical director, or a designated physician in an organized medical group Scope defined: CPPA must define the nature and scope of patient care services to be provided by the pharmacist Authority: The prescriber or prescribers entering into the agreement retain the ultimate authority regarding scope of services provided by pharmacists Communication Required: Any patient care services provided by a pharmacist(s) must be documented or communicated to the prescriber(s) within three (3) business days Employment of Pharmacist(s) for CPPA: An individual TN-licensed prescriber or one (1) or more TN-licensed prescribers in an organized medical group may employ pharmacists for the purpose of providing patient care services pursuant to a CPPA. Employment of Physicians for CPPA: No retail pharmacy may employ a prescriber for maintaining, establishing or entering into a CPPA with a patient. A pharmacy or pharmacist may employ a physician or licensed medical practitioner for quality assurance reviews. Supervision of mid-level prescribers: The supervising physician who has primary responsibility for supervising the APN or PA, must also approve and sign the CPPA. Services of mid-level prescribers must be included in the routine services delivered by the supervising physician in the physician's medical practice. Maintenance of CPPA: Pharmacists and authorizing prescribers shall maintain a copy of the written CPPA on file at their places of practice. Review of CPPA: CPPAs shall be reviewed and renewed biennially (at a minimum). Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -5- Provider Recognition And Reimbursement Through MCOs HB 0450 by Terry, Sexton C / SB 0461 by Bell, Haile, Crowe Effective July 1, 2017 Link to Public Chapter 82: http://publications.tnsosfiles.com/acts/110/pub/pc0082.pdf Bill Provisions: This legislation adds pharmacists as providers of care in existing state insurance code. This legislation will provide a pathway for pharmacists who are acting within the scope of their license or certification under state law to be credentialed with managed health insurance issuers and enable them to participate, receive referrals, and be reimbursed for covered services or indemnification. This legislation will create a mechanism for pharmacists to participate as members of the larger health care team, resulting in increased communication, collaboration, and patient referrals, as appropriate, to physicians and other health care providers for further assessment, management, and treatment. Managed Health Insurance Issuers shall retain the authority to include providers or classes of providers only to the extent necessary to meet the needs of the managed health insurance issuer's plan and its enrollees and limit referrals and establish any other measure designed to maintain quality and control costs consistent with the responsibilities of the plan. Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -6- Micah Cost, PharmD, MS 3
Medication Therapy Management in Medicaid HB 0628 by Kumar, Terry, Ragan, Brooks K, Holsclaw (SB 0398 by Haile, Overbey) Implementation in progress. Pilot program begins January 1, 2018. Link to Public Chapter 363: http://publications.tnsosfiles.com/acts/110/pub/pc0363.pdf Program Design: TennCare Position: The State believes that pharmacist-led MTM services will enhance the effectiveness of the PCMH and health home programs, improve health outcomes and quality of care, and could potentially drive cost savings over time. Structure: Health home and PCMH providers may enter into collaborative practice agreements with qualified pharmacists to provide MTM services to TennCare members with high levels of clinical risk who may benefit from these services. MTM will engage pharmacists as part of the extended care team for these enrollees and increase collaboration between pharmacists and primary care providers. Patient Eligibility: High-risk TennCare beneficiaries enrolled in Tennessee s PCMH and health home programs (approx. 300,000 eligible enrollees) Qualifications for Pharmacist Participation: Qualified Tennessee-licensed pharmacists may provide MTM services to eligible TennCare patients in collaboration (under collaborative pharmacy practice agreements) with prescribers, patients, caregivers, and other healthcare providers. Pharmacist Enrollment as Providers: TennCare, or its managed care organizations, may enroll individual pharmacists as providers under their Medicaid provider program for the purposes of reimbursement for the MTM in Medicaid pilot program. Outcomes and Savings Measured: Requires that any cost savings realized by TennCare through this MTM in Medicaid pilot program be prioritized for use in expanding the administration of the MTM in Medicaid pilot program according to overall impact on cost-effectiveness and medical outcomes. Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -7- MTM in Medicaid Pilot Program Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -8- Micah Cost, PharmD, MS 4
RECENT TPA INITIATIVES Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -9- CDC/TDH Grant Program 5 Year Program Providing Funding and Support for: Training/Credentialing of up to 100 pharmacist providers in diabetes and hypertension management services Provision of diabetes and hypertension management services to at least one patient at each practice site AADE Accreditation of 100 pharmacy practice sites in diabetes management Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -10- Micah Cost, PharmD, MS 5
CPF Grant Program TPA has been awarded a grant from the Community Pharmacy Foundation (CPF) to explore the role of community pharmacists in providing Annual Wellness Visits (AWV), Initial Preventive Physical Exams (IPPE), and Chronic Care Management (CCM) services incident to a provider. Practice Model: This grant integrates a community pharmacist in a provider s office, with successful implementation of a collaborative pharmacy practice agreement (CPPA) and delivery of pharmacist-provided patient care services, in order to demonstrate how pharmacists can improve access and health outcomes for patients, as well as establish a blueprint for this model for care and potential new revenue stream for prescribers and community pharmacists. Primary components of this project: Create a model for integration of a community pharmacist into a prescriber s office; Develop and implement a CPPA between the community pharmacist and the prescriber to allow for the delivery of patient care services; Deliver yearly AWV and/or IPPE services; Deliver CCM services to enrolled patients on a monthly basis; and Create a detailed implementation guide for CPF with tools and resources to assist community pharmacists in providing services through this model of care. Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -11- Chronic Care Management In 2015, the Centers for Medicare and Medicaid Services (CMS) began paying providers for CCM services CCM is a time based, predominantly non-face-to-face, service provided to patients in between office visits Mainly telephonic, but can be over email or a patient portal CCM is essentially a per member per month (PBPM) payment Billed monthly if enough clinical staff time is spent providing/triaging care to enrolled patients Clinical staff may include a pharmacist Billing allows for general supervision under incident to billing rules, thus physicians have an opportunity to outsource this service to pharmacists Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -12- Micah Cost, PharmD, MS 6
The Expanding Role Of The Pharmacy Technician Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -13- FEDERAL LEGISLATIVE INITIATIVES Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -14- Micah Cost, PharmD, MS 7
Federal Legislation: H.R. 592 and S. 109 Pharmacy and Medically Underserved Areas Enhancement Act H.R. 592: Representatives Brett Guthrie (R-KY) and G.K. Butterfield (D- NC), Todd Young (R-IN) and Ron Kind (D-WI) re-introduced legislation on January 20, 2017 206 total House supporters (6 TN Reps) S. 109: Senators Chuck Grassley (R-IA), Sherrod Brown (D-OH), Robert Casey (D-PA), and Mark Kirk (R-IL) introduced the Senate version on January 12, 2017 43 total Senate supporters (0 TN Sens) Summary: Amends section 1861(s)(2) of the Social Security Act to recognize pharmacists services within Medicare Part B Covered pharmacists services under Medicare Part B: State-Specific: Services are limited to those that the pharmacist is legally authorized to perform in the State in which the individual performs such services Structure of Services: Services include those which would otherwise be covered under this part if furnished by a physician, or as an incident to a physician's services Increased Patient Access: Services would be provided in a setting located in a health professional shortage area, medically underserved area, or medically underserved population. Payment: Pharmacists payment for services would be equal to 80 percent of the lesser of the actual charge or 85 percent of the fee schedule amount provided under section 1848 if such services had been furnished by physician. Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -15- Medically Health Underserved Professional Shortage Areas/Populations - TN - TN http://www.tn.gov/health/article/federal-shortage-areas Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -16- Micah Cost, PharmD, MS 8
tnpharmacists www.tnpharm.org @TNPharmacists Copyright 2017, Tennessee Pharmacists Association. All rights reserved. -17- Micah Cost, PharmD, MS 9