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1/11/2018 1 ASHP Update: Current Issues in Pharmacy Practice

Julie L. Webb, R.Ph. Senior Vice President Office of Professional Development

Disclosure Statement

• I have no conflict of interest or financial

disclosures relative to this presentation

Pharmacists’ Objectives

• Explain the pharmacy profession’s efforts in pursuing

provider status at the national level

• Describe the areas of focus for ASHP related to opioid
• veruse
• Describe the tenants of the Standardize for Safety

Initiative

• Discuss the market place information on the pharmacy

workforce, growth in residency training programs, and BPS credentialing and how the Practice Advancement Initiative (PAI) can impact future pharmacy practice

• Summarize the emerging roles of pharmacy technicians

Technicians’ Objectives

• Explain how provider status impacts pharmacy

technicians’ role in the profession

• Discuss the trend of opioid use in the United States over

the last decade

• Describe the tenants of the Standardize for Safety

Initiative

• Summarize the current marketplace of the pharmacy

workforce as it relates to credentialing

• Describe the emerging roles for technicians based on

the impact of the Practice Advancement Initiative (PAI)

Current Issue Topics

• Provider Status
• Opioid Overuse
• Standardize 4 Safety
• Workforce Issues/Opportunities
• Question & Answer

Provider Status is About Patients

Achieving provider status is about giving patients access to care that improves: Patient safety Healthcare quality Outcomes Decreases costs

1/11/2018 2 Why is provider status important for pharmacists?

• Pharmacists are not recognized under the Social

Security Act as health care providers

• New payment systems emphasize quality and
• utcomes

– Accountable Care Organizations – Medical Homes

• Social Security Act determines eligibility

Who Has Provider Status?

• Physicians
• Nurse practitioners
• Physician assistants
• Certified nurse

midwives

• Psychologists
• Clinical social workers
• Certified nurse

anesthetists

• Speech-language

pathologists

• Audiologists
• Registered dietitians
• Physical therapists

Access to Primary Health Care

• Growing number of Medicare beneficiaries
• Increasing patients with one or more chronic

conditions

• Newly covered patients via Affordable Care Act
• Projected shortage of physicians

– Projected shortfalls in primary care range between 14,900 and 35,600 physicians by 2025 – If currently underserved populations utilized health care at the same rate as the rest of the population, up to an additional 96,000 physicians would have been needed in 2014

Source: AAMC Center for Workforce Studies, April 2016 Analysis Source: AAMC Center for Workforce Studies, June 2010 Analysis

Projected Physician Shortage

Focus on Medically Underserved Communities

• Help meet unmet healthcare needs

– Increase patients’ access to care – Improve quality – Decrease costs

• Strategy follows similar successful paths taken

by other healthcare professionals to gain provider status

Patient Access to Pharmacists’ Care Coalition (PAPCC)

• Formed January 2014
• Organizations representing patients,

pharmacists, pharmacies and other interested stakeholders

• Drafted legislation in 2014 and 2015
• Facilitated reintroduction of H.R. 592 and S. 109

bills in 2017

1/11/2018 3

Multi-Stakeholder, Interdisciplinary

Healthcare Distribution Management Association Healthcare Leadership Council Hematology/Oncology Pharmacy Association International Academy of Compounding Pharmacists Kroger League of United Latin American Citizens McKesson National Alliance of State Pharmacy Associations National Association of Chain Drug Stores National Center for Farmworker Health National Community Pharmacists Association Albertson’s LLC and New Albertson’s Inc. American Association of Colleges of Pharmacy American Pharmacists Association American Society of Consultant Pharmacists American Society of Health- System Pharmacists AmerisourceBergen Association of Clinicians for the Underserved BI-LO Pharmacy Cardinal Health CVS Health Food Marketing Institute fred’s Pharmacy Fruth Pharmacy National Consumers League National Patient Advocate Foundation National Pharmaceutical Association National Rural Health Association Omnicell Pediatric Pharmacy Advocacy Group Rite Aid Pharmacy Safeway SUPERVALU Pharmacies Target Thrifty White Pharmacy Walgreens WalMart Winn-Dixie Pharmacy

PAPCC Objectives

• Mission: To develop and help enact a federal

policy proposal that would enable Medicare beneficiary access to, and payment for, Medicare Part B services by state-licensed pharmacists in medically underserved communities

• Primary Goal: To improve medically underserved

seniors’ access to pharmacists’ services consistent with state scope of practice laws and regulations

• Increases access to healthcare for patients in

medically underserved areas

• Promotes cost-effective healthcare by increasing
• pportunities for early interventions
• Allows pharmacists to provide services

authorized by state scope of practice

The Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592/S. 109) The Pharmacy and Medically Underserved Areas Enhancement Act (Continued)

• H.R. 592

– Introduced January 12, 2017 – Rep. Brett Guthrie lead sponsor (R-KY) – Introduced with 107

• riginal cosponsors

– Maintained bill number from last year – Currently 241 cosponsors

• S. 109

– Introduced January 12, 2017 – Sen. Grassley lead sponsor – Introduced with 26 cosponsors – Currently 51 senators cosponsoring bill

• Services
• Managing chronic diseases
• Medication management
• Manage care as patients

transition from hospital to home

• Health and wellness testing
• Administering

immunizations

• Overall impact:
• Improved health outcomes
• Reduced hospital

readmissions

• Reduced emergency

department visits

The Pharmacy and Medically Underserved Areas Enhancement Act

How Does Provider Status Impact Pharmacy Technicians?

• As the clinical role of pharmacists grows, more

will need to be done on the pharmacy operations side

• The role of pharmacy technicians could be

elevated due to provider status

• Would expect a robust demand for pharmacy

technicians going forward

1/11/2018 4 State Provider Status

• ASHP will work with state affiliates to

move state legislation to recognize pharmacists as providers

• Expanding state scope of practice so

pharmacists can practice at the top of their license

Specific State Affiliate and Individual Actions

• Write to your senators and representative
• Recruit individual health system support of

H.R. 592/S. 109

• Solicit other state-level health profession
• rganizations support of H.R. 592/S. 109:
• Visit elected officials/staff in Washington DC or

district offices

Assessment

ASHP is part of the Patient Access to Pharmacists’ Care Coalition whose goal is to improve medically underserved seniors’ access to pharmacists’ services consistent with state scope of practice laws and regulations

• True
• False

Assessment

ASHP is part of the Patient Access to Pharmacists’ Care Coalition who's goal is to improve medically underserved seniors’ access to pharmacists’ services consistent with state scope of practice laws and regulations

• True
• False

OPIOID ABUSE EPIDEMIC

Opioid Abuse Epidemic

• Opioid prescriptions have increased 175% in

past 20 years

• ED visits due to nonmedical use of opioids more

than doubled between 2006 and 2010

• National Institute on Drug Abuse (NIDA)

estimates overall cost of opioid abuse is $700 billion annually

1/11/2018 5

Opioid Abuse Epidemic: Congress

• S. 524 – Comprehensive Addiction and

Recovery Act (CARA)

• Became law 07/22/2016
• Naloxone availability
• Amends the Controlled Substances Act to permit partial fills
• f Schedule II prescriptions when permitted under state law
• VA to expand its Opioid Safety Initiative to include all VA

medical facilities

• FDA to refer new drug applications for opioids to an advisory

committee before approval

• Creation of a public–private task force on pain management

within two years (pharmacists included)

Opioid Abuse Epidemic: ASHP Activity

• ASHP participated in White House meeting on

prescription drug abuse in May

– Coordinated by the Office of National Drug Control Policy – First in a series of meetings with healthcare provider and patient advocacy groups to work to expand access to opioid treatment, prevention, and recovery resources

Opioid Abuse Epidemic: ASHP Activity

• Multiple meetings on Capitol Hill to educate on the role
• f the pharmacist in pain management
• Have collaborated with or are currently working with:
• NACDS
• NCPA
• NABP
• NGA
• Pain Care Forum (PhRMA)
• Pew Trusts
• AMA
• APhA
• ASA
• CDC
• FDA

Three Main Areas of Focus for ASHP

• Education

– Members, interprofessional – Webinars, major meetings – Pharmacy school curriculums – Specialty traineeships – Inventory diversion prevention

• Patient-Specific Pain Plan

– Tailored to a specific patient – May be acute or chronic – Needs to be interprofessional (the role of the pharmacist)

• Regulatory/Advocacy

– Interoperable PDMP’s and mandatory usage – Lock-in pharmacy – Partial fills – Appropriate quantity prescribing – Development of abuse- deterrent formulations

ASHP continues to…

• Work with CDC, CMS, FDA and other pertinent agencies

and public health groups (including NABP) to promote pharmacists’ concerns and roles in this arena

• Develop resources and education to support the federal

initiatives

• Work with state legislatures and boards of pharmacy as

they develop and implement related laws and regulations

• Reach out to our members

Assessment

• ASHP is focused to which of the following

activities related to opioid overuse?

• A. Education
• B. Patient-specific pain plan
• C. Regulatory issues
• D. All of the above

1/11/2018 6

Assessment

• ASHP is focused to which of the following

activities related to opioid overuse?

• A. Education
• B. Patient-specific pain plan
• C. Regulatory issues
• D. All of the above

https://www.ashp.org/Pharmacy-Practice/Standardize-4- Safety-Initiative

Statement of the Problem

• Currently, no national consensus for standard

concentrations of IV medications (continuous, intermittent, etc)

• Patients are transferred between patient care areas

– Within each hospital – Within same city – Within same state – Out of state

• Each time a patient needs an IV medication, there is

potential for error if a concentration different from the previous patient care area is used

• Often vulnerable patient populations involved

– Critically ill – Pediatric, neonate – Geriatric

Standardize 4 Safety

• Standardize 4 Safety is the first national,

interprofessional effort to standardize medication concentrations in order to reduce errors and improve transitions of care

• Standardize 4 Safety is creating, testing,

publicizing, and supporting the adoption of these national standardized medication concentrations

• Key partners include AAMI, PPAG, and ISMP

Status of S4S – Half-way Point

Done In process Not started (2018) Phase One, V 1.01 adult continuous Phase Two, V 1.02 adult continuous Intermittent IV meds Phase One, V 1.01 Cmpd oral liquids Phase Two, V 1.02 cmpd

• ral liquids

PCA’s, epidurals Phase One, pediatric continuous Phase One, standard doses

• ral liquids

What You Can Do

• START TALKING!!!!
• Be a champion, cheerleader, sponsor
• Don’t just get buy-in, take ownership
• Remember to take an interprofessional

approach

• Start talking to the informatics team now
• Everyone can make a difference
• Resources: IPI, Bainbridge Health, ASHP,

eBroselow, new potential tools in the pipeline

1/11/2018 7 PHARMACY WORKFORCE How many pharmacists are there?

According to HRSA Bureau of Health Care Professions, there are currently 286,400 pharmacists:

• 63% work in retail settings
• 23.1% work in hospitals
• 13.9% work in other settings*

* Managed care, pharmacy education, long term care, home care, consulting, industry, wholesale, associations, GPOs, trade groups, publishers, office practices, etc

For the 2014 National Pharmacists Workforce Study, pharmacists:

• 44.1% work in indep, chain, mass merch, or supermarket

pharmacies

• 29.4% work in hospitals
• 16.7% work in other patient care practices*
• 7.5% work in other settings (industry and non-patient care)

* Defined as HMOs, clinic pharmacies, mail service, nuclear, home care, long term care

2014 National Pharmacists Workforce Survey

Pharmacists Practicing in U.S. Hospitals

42,708 46,906 48,637 49,995 49,045 50,349 55,474 56,327 54,512 57,154 51,724 64,225 61,031 56,213

10,000 20,000 30,000 40,000 50,000 60,000 70,000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Pharmacist FTEs

Year

Source: ASHP national survey of pharmacy practice in hospital settings – 2002-2015

What does the future hold?

Pharmacist supply and demand by 2020

• 50,000

100,000 150,000 200,000 250,000 300,000 350,000 400,000 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

SUPPLY DEMAND Supply drivers: More graduates Baby boomers retire Demand drivers: Prescription volume Changing roles Technicians Technology Health Care Reform

Assumptions: includes only known new schools, BLS projection on demand

Supply drivers: Baby boomers Delayed retirement Fewer part timers More graduates Demand drivers: Slower economy

Pharmacy Practice Initiative

• 2010 PPMI Consensus Conference
• 2014 Ambulatory Care PPMI Conference
• PPMI = Practice Advancement Initiative
• Enhancing roles for technicians
• Moving pharmacists closer to the patients
• Credentialing opportunities

ASHP Credentialing Initiatives

• Residency training
• BPS exam preparation
• BPS recertification resources
• Professional certificates

1/11/2018 8

Percentage of Graduates Seeking Residency

Year Graduates Participants in PGY1 Match Percentage of Grads in Match 2006 10,199 1,356 13% 2007 10,282 1,898 19% 2008 11,127 2,092 19% 2009 11,516 2,501 22% 2010 11,487 2,898 25% 2011 12,346 3,257 26% 2012 13,163 3,706 28% 2013 13,207 3,933 30% 2014 13,838 4,142 30% 2015 13,994 4,358 31% 2016 14,556 4,864 33% 2017* 5,160

500 1000 1500 2000 2500

ASHP Accredited Pharmacy Residency Program Growth

Hospital Pharmacy Practice PGY1 Clinical Specialized PGY2

2,238 1,861

1900 2092 2508 2915 3277 3706 3933 4142 4358 4609 1162 4913 1045 1612 1769 1873 1951 2173 2413 2694 2862 3081 3309 282 3484 256 1343 1487 1651 1801 2027 2268 2495 2640 2811 3041 269 3235 235 1000 2000 3000 4000 5000 6000 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Phase I 2016 Phase II 2017 Phase I 2017 Phase II

ASHP Resident Matching Program 2007-2017 PGY1

# applicants # positions # matched Phase I: 93% Fill Rate Phase II: 92% Fill Rate Combined Fill Rate: 99.2% 239 330 384 483 541 677 777 917 1002 1148 140 1208 138 286 334 380 439 514 585 692 792 906 1000 88 1108 130 195 267 297 369 438 505 601 706 794 899 64 965 69 41 81 88 114 144 179 230 260 297 319 369 200 400 600 800 1000 1200 1400 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Phase I 2016 Phase II 2017 Phase I 2017 Phase II

ASHP Resident Matching Program 2007-2017 PGY2

# applicants (includes early commits) # positions (includes early commits) # total match (early commit+match) # early commit Phase I: 87% Fill Rate Phase II: 53% Fill Rate Combined Fill Rate: 89.4% 1203 1356 1900 2092 2508 2915 3277 3706 3933 4142 4358 4864 5160 1091 1222 1612 1769 1873 1951 2173 2413 2694 2862 3081 3323 3491 1000 2000 3000 4000 5000 6000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Applicants vs Positions PGY1

# applicants # positions

Since 2010: Applicants up 77% Positions up 79%

1,669

1/11/2018 9

ASHP Certification Resources

• Review and recertification resources
• BPS-approved provider – oncology,

pediatrics, pharmacotherapy, critical care, geriatrics, ambulatory care

• Developing review materials for two new

specialties – cardiology and infectious diseases

Product Line Offerings

• Review course – BPS exam preparation
• Recertification offerings

– Review course – live and on-line – Literature studies – 2 offerings/year – Intensive studies – at Midyear and on-line

• Core Therapeutic Modules – on-line only

Professional Certificates

• A certificate is NOT certification
• High quality, practical continuing education
• Certificate = demonstration of competence

ASHP Certificates

• Teaching Certificate for Pharmacists
• Pharmacy Informatics Certificate
• Sterile Product Preparation Training & Certificate Program
• Advanced Sterile Product Preparation Training &

Certificate Program

• ASHP / ISMP Medication Safety Certificate Program
• Coming soon…….

– Pain Management – Pharmacogenomics

Coming Soon………. Pain Management Pharmacogenomics

Pharmacy Technicians

• There is growing complexity in medication use and

a continued focus on medication safety and quality

• There is a need today for well-qualified, competent

pharmacy technicians for the safe provision of medications in all settings

• The existence of competent pharmacy technicians

will be fundamental to advancing the patient care role of pharmacists in the future

1/11/2018 10

Emerging Pharmacy Technician Roles and Responsibilities

• Prescription clarification
• Quality assurance and quality

improvement initiatives

• ACA Marketplace Certified

Application Counselors

• CMS-CMMI Grant Projects

(Innovations Center)

• Community outreach programs
• DUE/ADR monitoring
• Informatics
• Medication safety initiatives
• Telepharmacy
• Medication reconciliation
• Medication therapy management
• Immunization
• Indigent care prescription

programs

• Sterile & non-sterile compounding
• Clinical technicians (e.g., chronic

care, appt. scheduling, medication adherence, smoking cessation, vital signs measurements, data management, etc.)

• Tech-check-tech

Activities of Pharmacy Technicians

2% 5% 9% 9% 10% 15% 18% 30% 35% 41% 61% 74% 79% 88% 96% 96% 100% 0% 20% 40% 60% 80% 100%

Dispensing with remote video supervision Preparation of clinical monitoring information Screening of medical records for MRPs Medication assistance program mgmt Facilitating Transitions of Care Order entry (for pharmacist verification) Tech-check-tech Medication reconciliation (obtaining list) Technician supervising other technicians IT system management Controlled substance system mgmt Billing Quality Assurance act/unit inspections Compounding sterile preps Packaging activities Purchasing Restocking floor stock and/or ADCs

% Hospitals with technicians performing activity

Increased by 7% since 2014 Increased by 12% since 2014

Traditional functions Non-traditional functions

Source: 2016 ASHP National Survey

Non-traditional Pharmacy Technician Activities

Hospitals with pharmacy technicians utilized in three or more non- traditional Staffed beds % <50 22.8 50-99 24.5 100-199 23.3 200-299 28.6 300-399 47.5 400-599 40.9 ≥600 57.6 All hospitals – 2016 27.7 All hospitals – 2014 18.3 All hospitals – 2013 19.8 All hospitals – 2012 20.6 All hospitals – 2011 22.2

Technician activities considered non-traditional:

• Order entry activities for

pharmacist verification

• Information technology

system management

• Supervising other technicians
• Initiation of medication

reconciliation (obtaining list)

• Tech-check-tech
• Criteria-based screening of

medical records for MRPs

• Preparation of clinical

monitoring information

• Dispensing medications with

remote video supervision

• Medication assistance

program management

Source: 2016 ASHP National Survey

Current and Future Time Allocation

ASHP national survey of pharmacy practice in hospital settings - 2015

Pharmacy Technicians Current Future Change Order processing / entry 3% 5% Traditional drug preparation and distribution 78% 65% Non-traditional activities 10% 20% Administrative 9% 9% Other <1% <1% Pharmacists Current Future Change Order review and verification 44% 34% Drug distribution 18% 14% Clinical 24% 36% Administrative management 9% 8% Training (residents, students) 6% 8% Other <1% <1%

State Regulations of Technicians Vary Widely

• 45 states and DC regulate pharmacy technicians
• 24 states include national certification in regulations
• 5 states accept only the Pharmacy Technician

Certification Board (PTCB) exam for national certification

• 19 states require a background check
• 22 states require CE
• 10 states have a pharmacy technician serving on the

state Board of Pharmacy

• Many states have pending legislation or regulations

PTCB

About PTCB Mission Statement

PTCB develops, maintains, promotes and administers a nationally accredited certification program for pharmacy technicians to enable the most effective support of pharmacists to advance patient safety.

1/11/2018 11

PTCB By the Numbers – 12/31/2016

• 618,408 pharmacy technician certifications since

1995

• 283,267 active certified pharmacy technicians
• 53,353 exams conducted in 2016

PTCB

Certification Program Changes

New PTCB requirements:

• 2015: PTCB only accepting technician-specific CE
• ON HOLD – the 2020 requirement that technicians must

complete an ASHP/ACPE-accredited education program prior to sitting for initial certification has been put on hold

Advanced Certification Programs in Development

• Task force met in May 2015 for sterile compounding

ASHP/ACPE-Accredited Pharmacy Technician Training Programs

• 50

50 100 150 200 250 300 281 Note: There are hundreds of estimated non-accredited programs in existence

Pharmacy Technician Credentials

PTCB Certification Completed a ASHP-ACPE Accredited Technician Training Program Staffed beds % % <50 76.8 14.9 50-99 75.1 18.0 100-199 81.5 17.2 200-299 71.9 21.0 300-399 76.8 9.4 400-599 72.5 11.8 600 90.5 6.7 All hospitals – 2017 77.8 13.8 All hospitals – 2016 77.7 17.9 All hospitals – 2015 77.5 17.5 All hospitals – 2014 71.2 14.9 All hospitals – 2013 70.9 14.2 All hospitals – 2012 67.5 13.6 All hospitals – 2011 65.8 11.1 Source: 2017 ASHP National Survey

Pharmacy Technician Stakeholder Consensus Conference

• Convened by ASHP, ACPE, and PTCB
• Held in February 2017
• Goal – gain consensus among the broader

pharmacy community for a national standard in technician education, training, certification, and regulation

• Agreement that a national standard should guide

technician education, that technician education programs should be accredited, and that national certification should be required prior to registration

• r licensure by Boards of Pharmacy

Assessment

Are the… Increasing? Decreasing? Staying the Same? Number of pharmacists practicing in hospitals… Number of pharmacists completing residencies… Number of pharmacists

• btaining board

certification… Number of technicians

• btaining PTCB

certification… Number of technicians completing an ASHP/ACPE accredited training program…

1/11/2018 12 QUESTIONS?