1. 1. THE PHARMACIST FOOTPRINT WHERE PHARMACY, DIABETES, AND PUBLIC HEALTH CROSS PATHS PRESENTED BY KINBO LEE PRECEPTOR DR. LORI HALL
2. 2. CONTENTS 1.Drug Update: Sodium Glucose Transport subtype 2 (SGLT-2) Inhibitors 2.Legislation and Policy 3.The Pharmacy Value Proposition 4.The Healthcare Paradigm Shift 5.Summary
3. 3. DRUG UPDATE: SGLT-2 INHIBITORS
4. 4. SGLT-2 INHIBITORS 1. Canagliflozin (Invokana) FDA approval in March 2013 2. Dapagliflozin (Farxiga) FDA approval on January 2014 3. Empagliflozin (Jardiance) FDA approval in August 2014
5. 5. SGLT-2 INHIBITORS MECHANISM OF ACTION
6. 6. SGLT-2 INHIBITORS DRUG COMPARISON Biguanides Sulfonylureas Thiazolidinediones Dipeptidyl Peptidase IV Inhibitor Glucagon- Like Peptide-1 Agonist SGLT-2 Inhibitors Efficacy (HbA1c) High (1-1.5% decrease) High High Moderate High Moderate Hypoglycemia Risk Low Moderate Low Low Low Low Weight Neutral / Loss Gain Gain Neutral Loss Loss Side Effects GI (diarrhea, cramping), vitamin B12 deficiency, lactic acidosis Hypoglycemia Edema, heart failure, bone fractures Angioedema (rare), urticaria GI (nausea, vomiting, diarrhea), increased HR Genitourinary infections, polyuria, dizziness, hypotension Cost Low Low Low High High High
7. 7. SGLT-2 INHIBITORS INVOKANA COMMERCIAL
8. 8. FDA OFFICE OF PRESCRIPTION DRUG PROMOTION (OPDP) 1. Maintains the FDA Bad Ad program with CME/CE e-learning course available 2. Raise awareness about misleading prescription drug promotion and provide an easy way to report this activity 3. Common violations include: Omitting or downplaying risk Overstating the effectiveness Promoting uses not addressed in approved labeling Misleading drug comparisons
9. 9. LEGISLATION AND POLICY
10. 10. LEGISLATION AND POLICY National Governors Association (NGA) Mission is to share best practices, speak with a collective voice on national policy, and develop innovative solutions to improve state government Founded in 1908 with membership consisting of governors of the 55 states, territories, and commonwealths Identifies priority issues and deal collectively with matters of public policy and governance at the state and national level
11. 11. LEGISLATION AND POLICY NGA REPORT
12. 12. LEGISLATION AND POLICY NGA REPORT RECOGNIZES THAT: 1. The level of education required to practice shifted from a bachelor of science (B.S.) to a doctor of pharmacy (PharmD) 2. Core competencies include toxicology, pathophysiology, pharmaceutical chemistry, pharmacology, disease treatments, and laboratory training externships also incorporated into programs. 3. Licensure requires passing of the North American Pharmacist Licensure Examination (NAPLEX) and a another exam (e.g. Multistate Pharmacy Jurisprudence Examination) to test pharmacy jurisprudence knowledge 4. Pharmacists can become board certified in six specialties: nutrition support, nuclear pharmacy, pharmacotherapy, oncology, psychiatric pharmacy, and ambulatory care
13. 13. LEGISLATION AND POLICY NGA REPORT FOUR PRIMARY DOMAINS: 1. Ensuring appropriate medication therapy and outcomes 2. Dispensing medications and devices 3. Engaging in health promotion and disease prevention 4. Engaging in health systems management
14. 14. LEGISLATION AND POLICY US. CONGRESS
15. 15. LEGISLATION AND POLICY US. CONGRESS
16. 16. THE PHARMACY VALUE PROPOSITION
17. 17. THE PHARMACIST VALUE PROPOSITION 1. Increase access to care 2. Increase quality of and satisfaction with care 3. Reduce costs
18. 18. THE PHARMACIST VALUE PROPOSITION
19. 19. THE PHARMACIST VALUE PROPOSITION
20. 20. THE PHARMACIST VALUE PROPOSITION
21. 21. THE PHARMACY VALUE PROPOSITION Kennedy Pharmacy Innovation Center Established at the University of South Carolina in 2010 Fosters creativity and innovation by connecting passionate, forward-thinking individuals Develops and supports entrepreneurial programs, and exploration of new sustainable business models Transforms pharmacy practice into viable, effective patient-centered care models by providing tools, resources, and relationships
22. 22. THE PHARMACY VALUE PROPOSITION Collaborative Patient-Centered Medical Home (PCMH) Case Objective: Develop and evaluate sustainable business model for pharmacists providing comprehensive medication management Focus: Patients with diabetes, lipid disorders, hypertension, congestive heart failure, obesity, and polypharmacy Location: Palmetto Primary Care Physicians, Charleston, SC Time: November 1, 2013 October 31, 2014 Value Proposition: Revenue, Quality, Satisfaction, Cost Avoidance, Provider Productivity, and ROI
23. 23. THE PHARMACY VALUE PROPOSITION (CONT.) Key Activities Obtain and evaluate patient history Assess/manage medication therapeutic regimens of chronic conditions within treatment guidelines Provide patient counseling on medications, nutrition, lifestyle, and medication self-management Conduct limited physical examinations per guidelines for management of medication regimens Order diagnostic tests and medical devices to support chronic disease management
24. 24. THE PHARMACY VALUE PROPOSITION (CONT.) Revenue Streams Comprehensive Medication Management Incident to Annual Wellness Visit Chronic Care Management Transitional Care Management Pay for Performance
25. 25. THE PHARMACY VALUE PROPOSITION (CONT.)
26. 26. THE PHARMACY VALUE PROPOSITION (CONT.)
27. 27. THE PHARMACY VALUE PROPOSITION (CONT.)
28. 28. THE PHARMACY VALUE PROPOSITION (CONT.)
29. 29. THE PHARMACY VALUE PROPOSITION (CONT.)
30. 30. THE PHARMACY VALUE PROPOSITION (CONT.)
31. 31. THE PHARMACY VALUE PROPOSITION (CONT.)
32. 32. THE HEALTHCARE PARADIGM SHIFT
33. 33. THE HEALTHCARE PARADIGM SHIFT 1. Better coordination of health care among providers 2. Payment incentives for the coordination of care 3. Use of quality metrics to reward performance 4. Health care providers responsible for outcomes, not just the provision of service 5. Report cards to guide consumer decision-making
34. 34. THE HEALTHCARE PARADIGM SHIFT
35. 35. THE HEALTHCARE PARADIGM SHIFT
36. 36. THE HEALTHCARE PARADIGM SHIFT NGA Center for Best Practices: Delivery System Reform 1. Care coordination and disease management (e.g. Accountable Care Organizations) 2. Payment reform (e.g. CMS, private payers, state Medicaid) 3. Quality improvement and measurement (e.g. AHRQ) 4. Prevention and primary care efforts (e.g. immunizations, blood pressure/diabetes screening)
37. 37. THE HEALTHCARE PARADIGM SHIFT The Pharmacists Role in Team-Based Care Settings Medication management, especially complex cases Chronic disease management Care transitions Medicare Wellness Visits Drug therapy consultations Drug information Meeting with pharmaceutical representatives Examples here and here
38. 38. THE HEALTHCARE PARADIGM SHIFT AN EXAMPLE Centers for Medicare & Medicaid Services (CMS) ACO Initiatives 1. The Pioneer ACO Model 2. The Medicare Shared Savings Program
39. 39. SUMMARY 1. The healthcare system is shifting from volume-based to value-based payment models 2. The mission of the pharmacist is to provide pharmaceutical care, which is the provision of medication-related care for the purpose of achieving definite outcomes that improve patients quality of life 3. Pharmacists are among the most accessible and trusted health care professionals 4. Barriers exist in federal and state laws that limit the pharmacists scope of practice
40. 40. QUESTIONS?