Signing Out From Boston!

Hello friends!! The summer is winding down and this is the last post you are going to see from me here. Fear not- if you miss me you can head on over to the P4 rotation blog to catch up on all of my latest adventures! I cannot believe how quickly this summer went- three months just isn’t enough (sorry to all the rest of the classes who won’t even have that!)


This summer I have been working to develop a couple of quality improvement projects. The first one focused on stroke prevention in atrial fibrillation. Basically, the guidelines say that if a patient with atrial fibrillation is at risk for stroke they should receive oral anticoagulation (traditionally with warfarin). This becomes quite difficult in our members, however, as they are all elderly and many are disabled. They have difficulty complying with the monitoring requirements of warfarin, are often treated with interacting medications and are also at a high risk for falls and subsequent bleeds. With the approval of the new direct thrombin inhibitor, dabigatran (Pradaxa) in October, our clinicians now have another option for anticoagulation in this population. We identified members who had a diagnosis code for atrial fibrillation and determined their stroke risk through the use of a CHADS score (this looks at whether a patient has congestive heart failure, hypertension, is over age 75, has diabetes or has had a previous stroke). We were able to use pharmacy data in order to determine whether they were receiving warfarin, dabigatran or aspirin and from this, we developed our best guess of which patients could benefit from therapy with dabigatran. I worked to create educational material for our clinicians and to draft communications to be sent out to each of the identified patients’ primary care physician. Next year they will pull this data again and see whether a higher percentage of patients are now being appropriately anticoagulated. I wish I were staying longer so that I could be involved in the education efforts and to see the effect that all of these efforts have on patient care!

I’ve also been working on some smaller projects. I have created reports to send out to all of the different sites regarding patient adherence and cost effective prescribing. I drafted letters to be sent out to our members (after CMS/MassHealth approval of course!) regarding MTM services and regarding changes in coverage. I also drafted communications to our clinicians regarding the new simvastatin dosing guidelines.


My final project has been attempting to develop a polypharmacy quality improvement project. So far, I have done a literature review of all the different tools that exist to assess polypharmacy (this turned out to be a huge amount of information!) Tomorrow I’ll be meeting with our pharmacy director and the medical affairs department so that we can develop criteria for the identification of members to target and what intervention we can use. We will also need to identify indicators so that we can assess the progress of the project after implementation. I will definitely not be around when this project is rolled out but I have still learned so much from working on it!


I have enjoyed my summer at CCA immensely! I love thinking about the unique pharmacy issues that the elderly population faces and am definitely thinking about steering my career in that direction. I can’t wait for my rotations coming up this year where I can start to delve into this interest- see me jumping for joy?!

“Insurance = Evil”? Think Again.

Hi all! My name is Tony Lin and I will be a P3 in September. I apologize for those that have been dying to hear how “brain-washed” I am with my Managed Care (aka insurance company) internship…it’s better being late than never!

This summer I will be interning at Blue Cross Blue Shield of Michigan (BCBSM) Department of Pharmacy Services.

Perhaps for those that have worked in community pharmacy (or from your own personal experience), many people often view the insurance companies as these evil groups that never seem to pay for any drugs for the patients. To tell you that any “Prior Authorization” or “Rejection” messages are being displayed on your pharmacy computer screen only after complex logical calculations might be hard for you to believe. Well, the analogy I would use here is that many people think all pharmacists ever do is count pills—try again…it IS more complicated than just that!

In a nutshell, an insurance company (aka a Health Plan) pools financial resources together from clients (such as your parents’ employers) and use them effectively in paying for the claims (prescription drugs in our case) filed by beneficiaries. With limited resources, strategies must be implemented to be cost-effective.

While most of the public think that drugs are like cars—the newer the better, us pharmacists know better and realize that it is not always the case. Many drugs can easily cost hundreds or thousands of dollars per prescription or per unit. This is why insurance companies set Prior Authorization in place, ensuring generic drugs (which work just as well as brand names) or other more inexpensive alternatives have been tried first.

My specific duties this summer are to be with the Pharmacy Network team. The team prepares, reviews and manages all contracts from pharmacies in the state of Michigan. No—Blue Cross isn’t the DEFULT insurance for anyone. And yes—each individual pharmacy (chain or independent) must set up specific contract with BCBSM in order to serve patients with Blue Cross plans. More on this will come as the summer goes on.

I’m going to leave you all with few “Blue” Fast Facts:

** Total Employees: 7000 (3000 employees just moved their offices to downtown Detroit from Southfield to join the existing 3000 employees that were already in the city)

** Members: 4.3 million

** Claims paid in 2009: $19.8 billion ($5 billion paid in pharmacy claims)

** 50 million pharmacy claims annually

Did you know?

** Nearly 92 cents from every dollar BCBSM collects in premiums goes to pay for health care services.

** Of the nearly 30,000 doctors in Michigan, more than 99 percent participate with the Michigan Blues.

** Nearly 2,400 pharmacies in Michigan participate with Blues plan prescription drug coverage programs.

** There are 159 hospitals in Michigan. They all participate with the Michigan Blues and accept the Blues member ID card for health care coverage.

The ABC's of Managed Care - D, E, and F

Hello again everyone! Now that monsoon season is almost over in Ann Arbor, I'm ready to take off my poncho (just kidding, I don't actually wear a poncho) and start writing again. Last time we kicked it old school with A, B, and C of our tour through managed care. Bet you can guess what's coming next..

D: Dynamic - Managed care is a dynamic environment. Why you ask? Let's just take a quick look at a couple of snippets from the FDA's Press Announcements just this month:

• May 23, 2011 - FDA approves Incivek for hepatitis C
• May 20, 2011 - FDA approves Sutent for rare type of pancreatic cancer
• May 20, 2011 - FDA approves new HIV treatment
• May 13, 2011 - FDA approves Victrelis for Hepatitis C
• May 06, 2011 - FDA approves new treatment for rare type of pancreatic cancer (This is not the same drug as on May 20th!)
• May 02, 2011 - FDA approves new treatment for Type 2 diabetes

This doesn't even take into consideration the surprising number of new drug formulations that are constantly being approved. Each of these newly approved drugs and formulations has to be reviewed carefully and decisions must be made as to their place in therapy. Clearly, managed care organizations like Blue Care Network (BCN) have their hands full adapting to the ever-changing world of pharmacy.

E: Evidence-based medicine - One of the exciting things about managed care is that you are making decisions not just for one individual patient, but for an entire population of patients. This is where evidence-based medicine (EBM) comes into play. With so much on the line, clinical pharmacists at BCN have to delve deep into the literature to find the best evidence to support their clinical decisions. Some of the questions the clinical pharmacists have charged me with investigating have been pretty tough so far:

• What is the correct dose and interval for IVIG in the treatment of relapsing-remitting multiple sclerosis (RRMS) exacerbations?
• Should alemtuzumab (Campath) be used in MS? Or should the patient try fingolimod (Gilenya) first? Or natalizumab (Tysabri)?
• What evidence is there for IVIG in urticarial vasculitis? (We could only find less than 10 case studies in the literature of this!)

I never thought I would say this, but that EBM class we all dreaded P1 year is truly paying off. Thank you Dean Welage; we will miss you greatly!

F: Fun - You can't have a career in pharmacy without a little phun! I can honestly say that I've had a fantastic time so far at my internship at BCN. The atmosphere there is truly unique. The dress is casual. The coffee is flowing. And each computer is equipped with an instant messenging feature to allow quick, fun communication between co-workers. It's a pretty tight-knit group at BCN, and the fun atmosphere seems to cultivate a culture of hard-work, efficiency, and teamwork. In the words of arguably the most entertaining boss in the world, Michael Scott: "What is the single most important thing for a company? Is it the building? Is it the stock? Is it the turnover? It's the people. The people." Well said, Mr. Scott. It is the people at BCN who make it such a great place to work.

Well, that's it for this week's adventures in managed care.

Your homework for next week: be dynamic, have fun, and uh... don't forget your EBM.

Commonwealth Care Alliance: A Comprehensive Prepaid Accountable Care Organization for Medicaid and Dual Beneficiaries with Complex Care Needs

... Phew! Say that 10 times fast!!

Hello! My name is Anna Polk, and I am a soon-to-be P4! I am spending my summer in Boston (please see photo of how stunningly beautiful Boston is in the spring) working at the Commonwealth Care Alliance, henceforth referred to as CCA. This is a small (around 3200 members) not-for-profit managed care organization that mainly covers dually eligible (Medicare/Medicaid) seniors throughout Massachusetts. I started earlier this month and have been working on several projects since arriving. More on those later, but first I want to tell you all about CCA and the work that they do. Before arriving I was excited to learn more about the world of managed care and was happy to be doing so in a not-for-profit so I would have a leg to stand on when people with managed-care-misconceptions accused me of being one of the bad guys! Once I arrived, however, and began learning more about the organization, I have become incredibly proud to be associated with such an innovative team. I really hadn’t begun to grasp the scope of the care they provide until I attended orientation this past Tuesday. Our CEO, Bob Master started off the day talking about the mission and the culture of the organization.

They don’t think of themselves as a managed care company, but rather a health-care delivery system. They employ their own group of primary care providers, nurse practitioners, registered nurses, social workers, physical therapists- the list goes on and on! They use a team based, multidisciplinary, coordinated approach to care, in an effort to keep patients functioning independently in their homes for as long as possible. Through this approach, they have been successful in reducing the hospitalization rate of their members nearly in half!

The field workers are granted the autonomy to make decisions for their patient’s care. For example: they don’t have to wait for a patient to develop bed sores before authorizing a specialized mattress for them- if their team feels it is in the best interest for the patient, then they can have it. If you are dying to know more, here is an article about CCA from WBUR (Boston’s NPR News Station.)

I took a few courses at the public health school in my first year of pharmacy school, and it has been so exciting seeing how the theories I learned about there are actually being put into action to improve care for this specialized group of patients. I am working on several projects here and can’t wait to tell you all about them.... stay tuned!

The ABC's of Managed Care

Hello everyone! My name is Bernie Marini, and I am an incoming P4 who will be doing an internship in managed care this summer at Blue Care Network (BCN). Yesterday was actually my first day, and it was definitely a change of pace from working retail. Managed care is a new world for me, and every day I am surprised by how attractive a career in Managed care might be. Since I (and you, maybe) are new to managed care, we'll start with the ABC's. Prepare to be Kindergartner-ized (I'm an author of a blog now, so I can make up words):

A: Acronyms - Managed care is FULL of acronyms. It's like learning a new language. At first, during meetings, I was pretty lost - terms like ERISA, ECRI, HEDIS, MAC, CFI, PREFALT, PCOT, AGL, FAIR, FACETS, and NCQA just flew over my head. It's made for a difficult start, but I'm starting to get the hang of it. I now know that PREFALT letters are those that are sent to providers when a PA is denied, letting them know what the preferred alternatives are. If I'm feeling ambitious, I might make a glossary for future interns by the end of the year.

B: Boring? Not so much. Every day is completely different. There are a lot of meetings in managed care, but they vary greatly from day to day. Today I attended my first webinar on a successful safety initiative in the Philadelphia area known as the Partnership for Patient Care. I had another meeting about compounding fraud, and another one discussing branching logic built for certain medication prior authorizations (more on this later...). I also am being assigned a different project just about every single day. I'm currently working on several short informational stories and brochures regarding COPD guidelines for both providers and patients, to improve compliance with NCQA guidelines. Next I'll be working on a presentation for the members of the Chrysler Automotive group on their medication use within the health plan compared to all other BCN members.

C: Clinical - One cool part about this internship is that I have my very own cubicle, and I get to work right next to the clinical pharmacists there....wait... whaaaat? Clinical Pharmacists? In managed care? That's right, BCN employs many clinical pharmacists, and much of the work done at BCN is very clinically based. The pharmacists have to create the branching logic for prior authorizations and other formulary rules regarding medication selection by members of the HMO. For example, let's take the hypothetical example where a doctor writes a prescription for tizanidine (Zanaflex), a muscle relaxant. Because of safety concerns with tizanidine, this would require a prior authorization, and the form that the doctors fill out asking questions such as "has the patient tried cyclobenzaprine (Flexeril)? (Y/N)..." is created by clinical pharmacists. The answers to these questions determine whether or not the prior authorization is approved. These safety and efficacy decisions concerning formulary rules and prior authorizations are one of the the many responsibilities of clinical pharmacists at BCN.

I think that's enough ABC's for today. Stay tuned for more adventures in managed care!

Next week: D, E, and F - get excited.

-Bernie

The value of MTM

Each one of us has had the experience of completing Med Histories on patients through P.Care Lab, P3 rotations and the OSCE assessment. Many of us complained about having to do this task: it took too long, we couldn’t do things “our way”, or the patients weren’t even real. I know I was among the complainers. I really disliked this “exercise” because either the patients were completely fake or my recommendations never made it back to the patient/physician (which was the case for P3 rotations). But here I am, doing Med Histories in my internship and it’s completely different from past experiences.

What is my role in MTM?

I call members to discuss their medications. I ask about allergies, immunizations, medications, OTCs, and herbals/supplements. I discuss with members any concerns they have regarding their drug therapy, and I question them on symptoms/side effects they’re experiencing from their medications. This MTM service is voluntary and only offered to members who meet the criteria: enrolled in Medicare Part D, at least 2 of 5 disease states (CHF, cholesterol, DM, HTN, COPD), have at least 8 prescriptions, and having the total cost of drugs at $3,000 or more.

Any member who elects this service will be designated an appointment via telephone. Each phone conversation lasts on average 10 minutes and in that time I gain a wealth of knowledge on the member. After the phone call I evaluate my notes and make recommendations for the pharmacist to review before the final letter is mailed to the member. Finally! My work, my recommendations, are actually making it to the patient. Thus far, I have talked with over 30 members and there was only one where I didn’t have a recommendation. Since the criteria for this service is extensive, these members are in need of constant monitoring. I am able to apply the clinical knowledge I’ve learned in therapeutics to make extremely helpful recommendations.

The in-class setting of taking a Med History feels unrealistic and very awkward – the “patient” is a volunteer and trained on how to respond to each one of our questions. But I do have to say, that the skills I learned in class were extremely helpful. Before I started making MTM calls at work, the pharmacist in charge only asked one question, “You do med histories in school, right?” I responded with a yes, and with that he gave me the patient profiles and said “Have at it! Let me know if you have any questions” and walked away. I was just expected to know who to do this. The patient profile I was given only contained a list of medications that were processed at the pharmacy and billed to the insurance – I received no other information. I wasn’t even provided with a Med History form. And to my fellow classmates, does this sound familiar?...the OSCE! All the complaining we did, who would have thought, that the OSCE we took did actually simulate real practice settings.

My bottom line to you: Although the exercises we do in class with the volunteer patients may seem awkward and uncomfortable, it really does help prepare you for the real practice setting. It's very rewarding knowing I was able to help a patient whether it was lowering their medication costs to avoiding a drug interaction.

The Other End of the Stick

To anyone who has worked retail…..

With summer almost over, there’s a lot of catch up on! Here is goes:

This summer I have been interning at Blue Care Network in Southfield, MI. Prior to this I had worked retail and with five years of dealing with rude customers, no lunch breaks and forever long insurance calls - this is a nice break. I started this job knowing only that, calling the help desk at an insurance company resulted in an extremely long phone call that most likely ended with bad news for the patient (who was already mad and hating the pharmacy). But after working at BCN my attitude and frustration towards insurance companies has completely changed!

The first day I started I was given a crash course in Managed Care Pharmacy. I attended a meeting with Medco (they process pharmacy claims for BCN) and was quickly lost in conversation. The acronyms thrown about were insurmountable compared to starting pharmacy school – LOE, COB, DMR, GCN, etc. With managed care, it’s a whole new lingo. For example, patients are no longer “patients” but “members”. In order to keep things straight I carried a notebook with me everywhere to down things I didn’t know (which was basically everything).

Now, for those of you retail interns who are still frustrated with calling and dealing with insurance companies, there is a lot that goes on behind the scenes at an insurance company. Most of you are probably skeptical, as I was, but the goals of BCN are extremely patient focus. The roles of a pharmacist are very clinical in every aspect, trying to achieve the best treatment regimen for all disease states. Almost all of my projects deal directly with assessing clinical guidelines and reviewing literature in order to develop the best treatment algorithms for our members (I can’t remember who taught EBM, but as much as we hated that class, I can’t tell you how useful it really is. I use it every day!) Without-a-doubt there is a “most cost-effective” aspect to managing health insurance, but this is where pharmacists have their role of pushing the clinical aspects.

As an insurance company, managing the formulary is a main focus – things are constantly changing – new drugs are developed, brands change to generic, and clinical guidelines are being updated. One of my first projects was to write an article to physicians on the new criteria for topical NSAIDs. For my article, literature supported that topical NSAIDs should not be used first-line in managing osteoarthritis pain. Branching logic (the different medications that patients must try and fail before given approval to try the drug) was developed and I needed to inform the physicians.

Another project I was given was to research drugs such as Victoza and Provenge. Victoza is for the treatment of Type 2 Diabetes. But due to specific treatment regimen for this drug, BNC created QLs (quantity limits) to ensure it’s prescribed appropriately. These QLs, if exceeded, will stop the claims processing at the pharmacy. It was my job to determine from a therapeutic standpoint the correct QL for Victoza. Provenge, a treatment for metastatic castrate resistance prostate cancer, needed to be evaluated to determine whether or not it should be added to formulary. The cost of this drug is $93,000 per member and it is only 3 infusions. Based on extensive research, I did actually recommend Provenge be added to our formulary. As we speak, documents are now being created to present this drug at the next P&T committee.

There are a number of reasons a prescription rejects at the pharmacy, whether it’s due to step therapy not being meet to exceeding quantity limitations, don’t hate the insurance companies. As you will seen (through me) BCN does a great deal of work in order to provide patient-centered care.

420/330

My summer has boiled down to two courses, 420 and 330. (Makes me wish I actually paid attention in those classes, j/k...) Working with Nathan is like a whirlwind of everything I learned in the last year condensed into 9-10 hours a day. My first major assignment combined all we learned in 420 and 330, John Clark would be so proud Dean Welage not so much.

Johns Hopkins owns their own Managed Care Organization. This hospital also services a disproportionate share of low-income and patients without insurance. Which means the Hopkins Medical Center is authorized to purchase drugs under the 340B pricing guidelines. The hospital is also involved with a high level of charity care in which the hospital takes on all costs of treating a patient without coverage or assists patients with their medical bills. This all seems simple but there is a lot more to it that I don't care to explain at the moment, by the end of my first day I think I had 340B somewhere in all of my sentences. Moving on, the managed care organization wanted to increase their charity work for the Fiscal Year 2011 (which for Hopkins begins in July 2010) and therefore needed to decrease their spending on drugs. Here is where I come in...

In order to save money on prescription drugs I was tasked with reviewing their drug formulary and looking for cost saving options. The only bit of advice I was given by Nathan was to review five classes of drugs: PPI, Statins, Diabetes, ARB's, and Pain Management. The first thing I do is identify each drug for each class, for each class there was at least 6 meds regularly used in their formulary. Next I had to find the price per pill for each drug under the 340B pricing. A side note, 340B pricing is a minimum of 49% discount some brand names were so cheap I couldn't believe it, $0.01 for a bottle of 100 Prevacid 30mg??? So now I have multiple drugs under each category of varying strengths and I have their price per pill under 340B purchasing. Here's where the 330 comes into play, now I need to research the comparative efficacy of each of the drugs in the class. This was a serious headache and I found myself channeling all of my EBM knowledge into this tasks, I had to not only research the task on sites like PubMed, Micromedex and UpToDate, but also appraise the articles for their validity.

Long story short for the five classes: PPI to Omeprazole, Statin's to Simvastatin/Lipitor 80mg, Diabetes to Actos, ARB's to Cozaar, and Pain Management was inconclusive. With the following changes I then had to apply my formulary adjustments to the total spend of the pharmacy for the first three quarters, then annualized for a full year of spending. With this I could show the managed care organization how much money they would have saved this year if they used my proposed formulary. The formulary adjustment equated an 6.5% savings per year which doesn't seem like much, but when compared to an annual spend of $200k in drugs, the costs savings add up.

I then prepared a presentation of my project to be presented today for the Johns Hopkins Charity Committee. The proposed formulary adjustment will be discussed and voted on and could see integration for the second quarter of the 2011 fiscal year. In the last three weeks I have accomplished something of significance that I could not have prior to my first year in pharmacy school. The funny thing is that this is one of 6 projects that I have taken on in the last 3 weeks with more to come. I plan to keep showing the other interns here why they call us the "Leaders and the Best"

Clinical: Not Always the Hospital Setting

So this is my first week at Prime Therapeutics in Bloomington, Minnesota. I am doing the AMCP/FMCP/Pfizer Managed Care Summer Internship and am already learning a wealth of information. Currently I am rotating through the Drug Formulary Development department, and seriously putting my evidence based medicine skills to use.

Updating/maintaining the drug formulary is a year long process. Each pharmacist is responsible for a few therapeutic topics, and have to make sure their respective chapters are complete and up to date. What does this involve? Looking at the literature, clinical guidelines, FDA reviews, etc. and applying their clinical knowledge to evaluate the value of a medication in therapy. The pharmacists also review new drug products as they are approved by the FDA and released. My preceptor asked if I knew Ampyra, and I quickly ran through my mind all the meds I learned in therapeutics. When I couldn't recall it, he said it was just released 2 months ago. I find it really cool that the pharmacists know about the drug products as they are released. They are on top of the information because they need to evaluate the safety, efficacy and uniqueness of new medications to see if such medications should be placed on formulary.

When talking to pharmacists within the department, they each emphasized to me how their job is very clinical. Before starting this internship, I did not realize that managed care is very clinical. When I hear the word "clinical" I used to think of the pharmacist working in the hospital setting, and I am sure many students think this as well. At Prime, the pharmacists definitely use their clinical skills in evaluating medical literature and making judgment to ensure that patients' drug therapy is safe, efficacious and cost efficient.