Texas Pharmacy Today 4-11-14 - Texas Pharmacy Association

McInnis Closes Out Symposium with a Challenge
Terry McInnis, MD MPH, President- Blue Thorn, Inc. began her Breaking the Mold- Creating the Future presentation at TPA’s Leadership Symposium (April 5) with a

simple statement: "I’m going to challenge you.”

And working through her session, she repeatedly called to pharmacists to push for provider status and focus on patient care.

McInnis pointed out that (nationally) from 2008 to 2014, the number of clinicians in patient care medical homes (PCMH) has grown from 214 to 34,492.

There has also been growth in accountable care organizations (ACO’s). McInnis defined ACO as "A group of healthcare providers who agree to take on a shared responsibility for the care of a defined population of patients while assuring active management of both the quality and cost of that care.”

McInnis stated that there are three critical elements that pertain to pharmacists’ relationship with ACO’s:

The implication is that the growth of ACO’s represents a positive outlook for both the public (in terms of savings) and pharmacists, as they can be incorporated into their clinical care teams.

Moving on to talk about medications and chronic disease, McInnis said that, "Medications should be evaluated not just on their cost, but on their impact in terms of hospitalization, value, and effectiveness in a population."

"One of our biggest opportunities in healthcare involves getting our medications right. You as pharmacists have the expertise to contribute and to help do that.”

McInnis suggested that "better medication management might be achieved through programs offered by ACOs, medical homes, and other team-based delivery models.” She emphasized that in terms of financial considerations "volume is out-value is in,” stating that:

McInnis wrapped up her session, saying that, "You should have provider status—as part of a collaborative team. You must look at medications in terms of patients and their needs. The current model of dispensing is not your future. Students must be trained to deliver a higher level of care, because that’s where your future is. Now is your time to break the mold.”

Advocacy

House Public Health Addresses Interim Charges
On Monday, April 7, the Texas House Public Health Committee held its first meeting to address the interim charges issued by Speaker Joe Straus (R-San Antonio). The hearing lasted more than eight hours and addressed two of the four key issues impacting pharmaceuticals, pharmacies and pharmacists. In addition to this week’s meeting, more hearings will be held on Monday, April 14 and 23.

Charge #1
Assess the prevalence of nonmedical prescription drug use in the state (including opioids analgesics, stimulants, tranquilizers, and sedatives). Identify adverse health impacts. Recommend strategies to curb emerging substance abuse trends among children, pregnant women, and adults, as well as to reduce health care costs and mortality.

Charge #5
Monitor transition of the state's immunization registry to a new system. Determine whether the registry can be better utilized to prevent and/ or respond to communicable disease outbreaks, including pertussis. Identify potential factors contributing to the rise in the number of pertussis cases and strategies to prevent future outbreaks.

Three invited panels participated in discussions for Charge #1 regarding opioids. The first panel consisted of Dr. Jane Maxwell, Senior Research Scientist at University of Texas at Austin; Mike Maples, Acting Commissioner Mental Health and Substance Abuse; and Ron Bordelon, Commissioner of Worker's Compensation.

Maxwell outlined the history of issues with opioids in the State of Texas, including the addictive principles, the patterns of abuse and the rise of certain opioids use. She also spoke to the death rates from the different opioids that are abused as well as methadone which is used for opioids addiction treatment. Dr. Maxwell pointed out the dramatic increase in heroin use in Texas in recent years and that in Texas, vicodin and hydrocodone are more frequently abused than oxycodone.

Maxwell then spoke to the drug therapies for opioids addiction and the accessibility of drug therapies for opioids addiction, as well as the growing concerns of the use of opioids by pregnant women. She pointed out that at times un-prescribed opioids or other drugs are identified in tests of those prescribed an opioids cocktail. She noted that more training is needed for all doctors writing these types of prescriptions.

Mr. Maples addressed the initiatives that are being implemented to address the increase in prescription drug abuse. He stated that the current focus is on pregnant women with opioids in their system during pregnancy. He highlighted the rate increase in neonatal absence syndrome (NAS), i.e., infants born in detox. There has been a 200% increase in those using opioids during the past years. He also outlined the importance of early identification to the success of treatment.

In his testimony, Mr. Bordelon spoke about the applicability of workers compensation regarding the issue of opioids. He presented data covering the cost, demographics and formulary used by his agency in treating prescription drug abuse

The second panel consisted of Steve McCraw, Director Texas Dept. of Public Safety; Gay Dodson, Executive Director Texas State Board of Pharmacy; and Mary Robinson, Executive Director of Texas Medical Board.

McCraw outlined several key points relating to the abuse of prescription drugs and its contribution to criminal activities in Texas. He briefed the Committee on tools that DPS has developed to help get information to pharmacists faster to help with prevention. He was asked why physicians are not mandated to participate in the state’s Prescription Management Program (PMP) and how that effects DPS's efforts at prevention. In his response, McCraw shared that 16 states do mandate physician reporting and that not requiring participation create problems for law enforcement. Prevention is by far the most effective and preferred method of addressing this problem. He believes it would be valuable to law enforcement to require doctors to use the PMP. He explained the capability of the software and what else could be added.

Ms. Robinson explained that a law was passed last session expanding the group of individuals who can access the PMP and shared the process law enforcement must follow to use the PMP in enforcement as well as the process of getting a formal order to get results from the program as then supplied by DPS. The law requires a legal basis for requesting the information. A discussion of the obstacle and safeguards in place to prevent abuse as well as the scenarios where requests are made followed

Robinson continued her testimony by pointing out that drug mortality has doubled in recent years. She shared images from a "Pill Mill" which included guns, bullet proof glass and cash counting machines. She outlined the difference between legitimate pain treatment and pill milling. There is a special registration for pain management clinics - if 50% of patients are treated only for pain it must be registered.

Mrs. Dodson testified about the role of the Board and pharmacists in preventing prescription drug abuse. She pointed out that hydrocodone is the #1 prescribed drug in the US. Most of the illegal use are cash transactions. However, they still are required to be placed in the PMP. Dodson shared what can be indications of wrong doing and that these are difficult cases for local authorities to prosecute.

The third invited panel included Cathy DeWitt, Texas Assoc. of Business; Dr. Graves Owen, Texas Medical Association and President of Texas Pain Society; and John Ulczycki, National Safety Council.

Mrs. DeWitt began her testimony by sharing her organization’s concern with the impact of inappropriate or illegal drug use has on business and the economy. She stated that the U.S. consumes 90% of the world’s hydrocodone supply and highlighted the need for education regarding pain management in the US relative to our use of pain medication. DeWitt noted the importance of modernizing the Prescription Monitoring Program and asked for better communication between physicians, pharmacies and the DPS. Physicians should be mandated to report to the PMP. Without a mandate in place, compliance by physicians compliance is only 20%. She also stated that family practitioners are the highest prescribers.

23% of adults use drugs for non-medical reasons and 26% get their drugs from friends and family members. DeWitt spoke to a myriad of strategies that have been used across the country to address prescription medication abuse and noted the Good Samaritan law among the recommendations. Seventeen states have the law in place to prevent those turning in abuse from facing criminal penalties.

Dr. Owen testified in favor of establishing a multi-tiered solution because it is a multi-tiered problem. He laid out the suggestions for improvement and that use of the PMP is and should be part of the standard of care. He concurred that the abuse of prescriptions fall on primary care physicians, ER physicians and dentists.

Mr. Ulczycki testified regarding the rise in deaths from prescription drug abuse and stressed that this problem crosses all boundaries, racial, economic, geographic, etc. Drug overdose is the highest mortality rate for the 45 to 60 age group. He also shared the importance of an effective and continuous drug disposal program.

Ulczycki spoke to the effectiveness of Naloxone when used by first responders. He testified about the challenges presented by the need for prescriptions of the medication and that there also is a need for a national advertising campaign.

Other testimony included Sharon Brigner, Deputy Vice President Pharmaceutical Research and Manufacturers of America; Carley McConnell, Texans Standing Tall; Lisa Poynor, Substance Abuse of Texas; and Shannon Edmonds, Texas District and County Attorney's Association.

Only one invited panels participated in discussions for Charge #5 regarding the statewide immunization registry. Participants included Janna Zumbrun, Assistant Commissioner for Disease Control and Prevention Services Department of State Health; Dr. Donald Murphy, Texas Academy of Pediatrics; and Dr. Stanley Spinner, Texas Children's Hospital

Mrs. Zumbrun spoke about the current and the new MTRACK registry, its use, the operation of her department in addressing vaccinations. She shared that currently state funding appear to meet the needs but that might change with population increases and aging. The children’s program is 100% federally funded. A discussion of the state vs. federal funding mechanisms followed.

She outlined the enhanced functionality of the MTRACK registry and shared that the CDC is funding the MTRACK upgrade program. When asked which immunizations are in the MTRACK system, Zumbrun said that it is only those consented to by adults and/or parents and guardians. In response to a question about advertising the availability of free shots, she explained that no federal money is received - only the vaccine. Her department partners with providers with immunization services and using state-provided vaccines. These providers handle the promotion of their services.

Zumbrun spoke to the successes that have been seen with vaccines over the years. Regarding the resurgence of pertussis, she shared that it could be related to the new vaccine but that the new vaccine has significant benefits and less side-effects. Adult manifestations are not as easily identified as it is in children.

Spinner shared that some vaccines are given the day of birth. Pertussis vaccine is delayed because it is not effective before two months after birth. Such parameters are established by medical practice. He also pointed out that instances of pertussis have increased in areas of non- vaccination. Physicians’ only goal is to make sure that those who need the vaccination are getting it when they should and a robust registry is crucial to that goal.

Dr. Murphy testified regarding the Wisconsin system and its advantages. He also embraced the optout option instead of the current opt inoption and explained how this process would make immunizations easier for practitioners. A discussion of infection rates followed and Dr. Murphy pointed out that at no point has pertussis truly been eradicated, only pushed to almost imperceptible levels.

Several members of the Committee expressed concern of registry data being exposed. Dr. Spinner shared that the damage caused by that damage being released does not compare to the damage presented by children not being immunized.

Other testimony included Rodney Throckmorton testified for himself regarding his personal challenges with pertussis and experience with his daughter dying from pertussis. Anna Dragsbeck, Immunity Partnership, testified about her group’s recommendations for eliminating pertussis and stressed the importance of immunization for pregnant women and boosters for adults.

Next Public Health Committee Meeting Set for April 14
The Committee will meet regarding at 10:00a.m., Monday, April 14, 2014, in the Capitol extension, room E2.012 to address charges associated with compounding pharmacies and biosimilar pharmaceuticals

Charge #2
Study and make recommendations for improvements to the licensing, regulation, and monitoring of compounding pharmacies, including a review of the joint cooperative efforts between the Texas State Board of Pharmacy, Department of State Health Services, and U.S. Food and Drug Administration. Consider the impact of the passage of SB 1100 (83R), additional appropriations made by the 83rd Legislature to strengthen inspections, and any relevant federal legislation.

Charge #4
Examine the current practice for dispensation of biologic and follow-on biologic (biosimilar) pharmaceutical products in our state. Review any practices for interchangeability of drugs that might pertain to these particular medicines. Review and make recommendations regarding the substitution of biosimilar and biologic medicines.

TPA will be in attendance and will be submitting our position statement regarding biosimilar pharmaceuticals. Look for next week’s Texas Pharmacy Today for a similar update.

Around Texas

Diabetes Care Training Program Offered in Dallas (May 15th)
The Pharmacist and Patient-Centered Diabetes Care Certificate Training Program is a newly revised, practice-based activity designed to equip pharmacists with the knowledge, skills, and confidence needed to provide effective, evidence-based diabetes care. Five self-study modules provide comprehensive instruction in current diabetes concepts and standards of care. The live seminar incorporates case studies and hands-on skills training focused on the situations most likely to be encountered—as well as the services most needed—in community and ambulatory care practice settings. Participants will gain experience evaluating and adjusting drug therapy regimens for patients with type 1 and type 2 diabetes, counseling patients about lifestyle interventions, analyzing and interpreting self-monitoring of blood glucose results, and assessing the overall health status of patients to identify needed monitoring and interventions. For more information click here.

Health Mart Healthy Living Tour to Make 15 Stops in April at Community Pharmacies in Texas

The Health Mart Healthy Living Tour is on the road to celebrate and recognize community pharmacists for the important role they play as trusted healthcare providers in their communities—helping to educate and counsel on a variety of conditions that can be better managed with the help of a pharmacist. Aboard the Health Mart Healthy Living Tour’s 40-foot health screening unit, tour staff will provide complimentary health screenings for risks associated with high blood pressure, diabetes, cholesterol and obesity.

Now in its fifth year of operation, the Health Mart Healthy Living Tour is aiming to raise awareness of the important role community pharmacists play in the healthcare system, providing broader access to clinical services and medication counseling, which helps improve the quality of care while lowering healthcare costs. The Health Mart Healthy Living Tour will encourage consumers to initiate healthcare conversations with Health Mart pharmacists who can partner with them for better health.

Through complimentary health screenings at these pharmacy events, tour staff will identify people at risk for various health conditions and encourage them to manage these conditions with help from Health Mart® pharmacists, who advise on ways to reduce medication spending and better understand drug regimens and complications. Attendees will also take home a sample bag. Health Mart® recognizes that community pharmacists are essential to the towns and cities where they live and work. Health screening open to all eligible individuals!
For locations and more, click here.

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Association News

Member Spotlight, featuring John R. Carson, Oakdell Pharmacy
You might say pharmacy runs in John Russell Carson’s family. Carson, who just got his 50th year certificate as a pharmacist, owns Oakdell Pharmacy in San

Antonio, and has been in business for 35 years.

"Overall, there’ve been nine pharmacists in our family,” says Carson. "I have four uncles on my father’s side who are all pharmacists. My son Jeff is a pharmacist—he’s chief of staff and part owner of one of our stores in San Antonio.”

Carson’s father was a rancher, and he still operates a family ranch which has been in the family for 135 years.

"I was raised on a ranch near Gonzalez, TX and went to school in Cuero,” says Carson. "My dad had four brothers—all pharmacists. One of them—Charles Carson—owned the original Eagle Pass Drug Store. I have a photo of him around the turn of the century.”

My uncles thought maybe I should pursue a career in medicine or dentistry, but they had all been successful, so I chose to follow.

Carson, who graduated from the University of Texas College of Pharmacy back in 1964, currently owns three retail stores, one long-term care and assisted living facility, and one home intensive care pharmacy- mainly offering sterile products (IV sterile solutions).

"We have the only accredited compounding labs in South Texas in our pharmacies,” says Carson.

Times Change
Things have changed incredibly since Carson studied to be a pharmacist.

"Pharmacy has changed dramatically since I entered the profession in 1964,” says Carson. "Medicare and Medicaid have been a big change over the years for pharmacy. And then of course the arrival on the scene of PBMs has caused drastic changes, not all for the better, I might add.”

"If you had told me in 1964 that I would fill prescriptions below my cost, I would say you were crazy,” he says. "PBMs, and maximum allowable cost (MAC) have put enormous pressure on pharmacies. It’s harder today to make a profit than 10 or 15 years ago. The big chains have the ability to buy drugs at higher volume and lower costs. For example, Walmart can leverage the fact that they own multiple stores and buy medications at a lower cost. Fortunately, independent pharmacies have gotten together in buying groups, and that has helped.

Over the years, Oakdell Pharmacy has grown astronomically. They handle a lot of medical supplies, and hold seminars to educate their customers.

"Oakdell still gives the same great service as always,” says Carson. "We want a doctors to see us like a "one-stop shop.”

Oakdell delivers, and offers personal charge accounts. Additionally, they provide night service.

"Our employees will deliver 24-hour emergency service,” says Carson. "I’ve gotten up at 2:00 in the morning to deliver medications to nursing homes, or call doctors to get prescriptions, fill them and deliver them.”

Looking Ahead
Looking to the future, Carson cites employee Chris Alvarado as a leader to watch. "He is an exceptional young man,” says Carson. "Chris worked 10 years for me as a tech, and then he decided to go to University of Incarnate Word to get his Pharm.D. degree. I take my hat off to anybody who goes back and get an advanced degree after 10 years. That’s remarkable. I know how difficult that is—you have so many obligations at that point. Chris is good with customers, facts, and management. He’s simply outstanding. And he’s involved politically. He’s an upcoming leader, for sure.”

Carson, who was TPA president (1983-1984), and president of National Community Pharmacy Association NCPA (2000-2001), knows that there are challenges that lie ahead.

"You have to be involved in politics whether you like it or not. If you want to survive, you’ve got to have representation. It’s our job to educate legislators so that they know what our position is,” says Carson. "TPA has a division that handles legislative affairs, but some of the buying groups have taken the lead in this area. They have taken over a large part of the responsibility for legislative affairs. So they have become competition for TPA. And it’s hard to get everyone to work together—not everyone cooperates with each other. Everyone wants to be the primary entity, so there’s been a lot of division in who represents pharmacy. Who’s speaking for pharmacy today? If everyone could get together and pull the same wagon in terms of legislative affairs, it would be the best thing for pharmacy today, and we’d have more clout!”

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