Helping Pharmacists to Help their Patients: The Opioid Epidemic

The news headlines tell it all: the incomprehensible deaths of healthy individuals in their 20s – sadly, no longer such unusual occurrences. Babies born to opioid-addicted mothers, whisked into the NICU for days of harrowing withdrawal. And the shocking news story recently published in the New York Times, describing impoverished, recovering drug addicts who often deliberately relapse and begin new drug treatment programs – just to keep a roof over their heads by allowing their unscrupulous landlords to pocket the Medicaid kickbacks from their revived substance abuse treatment.

All of the above scenarios illustrate that the opioid epidemic, which had in the past been seemingly contained to the periphery of society, has now become everyone’s problem. According to a report cited by Mass.gov, nearly 4 in 10 residents of Massachusetts know someone who has misused prescription drugs within the past five years.  There are 17 branches of the state-wide, peer-led support group Learn to Cope – and each one holds weekly meetings. More than 6500 residents of Massachusetts have died from opioid overdoses in the past 11 years.

Given the scope of the crisis, the Massachusetts Pharmacists Association applauds Governor Charlie Baker for convening a working group focused on the epidemic. The Baker work group recommendations follow on the heels of several measures adopted by the state’s legislature and Patrick administration in the past few years, including the passage of Chapter 258 of the Acts of 2014, which established the Opioid Drug Formulary Commission and requires a pharmacist  to dispense: “an interchangeable abuse deterrent product if one exists; or, if none exists, a less expensive, reasonably available, interchangeable drug product as allowed by the most current formulary or supplement thereof.”  

Baker’s working group released its new recommendations in late June.  MPhA supports the recommendations; here are just a few we think are great:

Provide state funding for evidence-based opioid prevention programs in school. Although “Just Say No,” First Lady Nancy Reagan’s anti-drug campaign from the 80s, now seems almost wildly simplistic, it made an impact in educating young people about the dangers of drugs.  Recreational drug abuse declined during the Reagan administration. (Benze, James G., 2005). Hopefully, if a child learns about the dangers of opioids from an early age, he or she will be less likely to start using and get hooked.

Improve affordability of Naloxone through bulk purchasing. Since Naloxone sprung into widespread use in Massachusetts starting early last year, it has reversed hundreds of potentially fatal opioid overdoses. (It is, after all, known as the “rescue drug.”) It is crucial to keep Naloxone as affordable as possible.

Certify and register alcohol and drug-free housing to increase accountability and credibility. In order to maintain sobriety, addicts need to live in a safe place. If they return to their previous living situation, they often use again. The creation of more specialized housing for addicts will be an important step in their recovery.

Encourage the American College of Graduate Medical Education to adopt requirements for pain management and substance use disorder education. A recent survey by the Johns Hopkins School of Public Health revealed that physicians are surprisingly uninformed about opiate abuse, and many are unable to identify the most common manner in which opioids are abused (pharmacytimes.com). In addition, doctors from the VA Medical system violated the agency’s own rules when they prescribed opiates over too long a timeframe or in conjunction with benzodiazepines —  a mix that has proven fatal in far too many cases.

While this education requirement would require legislation from the state, it could be well worth the effort. As the prescribers, doctors need to be informed of the dangers of opiates, as well as the benefits.

As Massachusetts starts to implement these and other recommendations, MPhA wants to ensure that pharmacists join the medical community on the “front lines” of the war against opioid addiction – and that they are armed with the tools they need. Pharmacists, who assume such responsibility when dispensing opiates, must be supported.

Here are a few ideas to help make this happen:

Gov. Baker’s working group recommended that the Prescription Monitoring Program be improved to ensure data compatibility with other states.  MPhA endorses this. “It is important that Massachusetts join the 29 other states that are actively sharing PMP data,” says Karen Ryle, RPh, MS and member of MPhA, “This is particularly important for pharmacies bordering another states, where ‘doctor shopping’ may occur.”

In addition, the working group proposed that legislation be filed to require pharmacists to submit data to the state’s Prescription Monitoring Program (PMP) within 24 hours of receipt. In theory, this sounds great. Yet, as we know, not all pharmacies are created equal – or at least, not equal in terms of resources and manpower. It will be more difficult for smaller independents than large chain pharmacies to keep on top of the additional workload, for example. Perhaps this new requirement could be rolled in gradually, until all employees are trained.

The workgroup also recommended that addiction specialists be installed to the state medical boards of medicine, nursing, physician assistants, and dentistry. But what about the Board of Pharmacy? The Board regularly takes up such issues as controlled substance security and diversion. An addiction specialist could add a valuable perspective to the Board. Pharmacists need to learn all they can about the patterns of addicts if they are to combat diversion and other crimes that occur in pharmacies.

Finally, in the call for regulation over opioid prescribing, MPhA encourages a balanced approach. With the increased awareness of the dangers of addiction, legitimate prescriptions can be harder for patients to fill. Recently, a patient contacted MPhA because he had difficulty securing his prescription from the pharmacy, and felt like he was treated “like a criminal” by the pharmacist. While checks and balances on opioid prescriptions are undoubtedly necessary, a little sensitivity by prescribers and dispensers can go a long way for patients.

MPhA supports Gov. Baker’s working group and applauds its recommendations. We know the opioid epidemic has hurt too many families and ravaged too many lives. As medical professionals, pharmacists want to do their part — and we stand ready.

Making Patient Adherence Easy: the Value of MedSynch

If you are a patient with multiple chronic illnesses like diabetes and high blood pressure, you could be on four, six, or ten medications. That’s a lot of prescriptions to track, manage, and pick up at the drugstore. A complex regimen of medications could be a major stumbling block toward your medication adherence.

In recent years, medication synchronization or MedSynch, also called the “Appointment-based model” (ABM) has emerged as a tool to combat patient non-adherence and misinformation. This program can benefit anyone taking prescription medication, but is especially helpful for those patients who suffer from chronic diseases, like diabetes, high blood pressure, or heart conditions, with those ages 65+ the target market.

How does the MedSynch model work? What are the pros, the downsides? And, most importantly, is this model beneficial for both patients and pharmacists?

A patient taking part in the MedSynch program has a scheduled day each month to pick up all of his/her medications, typically receiving a reminder call from the pharmacist a few days ahead of time.  On the scheduled day, the pharmacist can review the medication list and discuss drug interactions or compliance issues with the patient. According to the APhA Foundation, this program changes the process from “passively filling prescription orders” to initiating an appointment and interaction with the patient (Pharmacy’s Appointment-Based Model: A prescription synchronization program that improves adherence, APhA Foundation).

The retail chains are getting on the MedSynch bandwagon. CVS markets a medication synchronization program on their website, and Rite Aid advertises the program in its stores.

The leading pharmacist associations are also catching on to MedSynch. The APhA Foundation has urged patients to tell pharmacists to “Align my Refills” (APhA Foundation.org).

In 2011, the National Community Pharmacists Association (NCPA) developed a program entitled Simplify my Meds to aid pharmacists in implementing a medication synchronization program, and MedSynch continues to make inroads among community pharmacies. A 2014 NCPA Digest survey found that 67% of independent community pharmacies offered some kind of medication adherence program. (ncpa.org). In Massachusetts, there are 23 independent pharmacies that have implemented the appointment-based model or MedSynch.

Among these pharmacies is Sullivan’s Pharmacy in Roslindale. Delilah Barnes, a pharmacist and department manager of assisted living facilities in Sullivan’s Long-Term Care Division, focuses on specialty medicine packaging to elderly who are in assisted living or homebound. Barnes synchronizes and organizes the multiple medications in “pop-out” compartments (for morning and night), pill boxes and baggies.

For the past five years, pharmacists in Sullivan’s retail division have executed MedSynch by analyzing the patient’s medication profile and issuing partial refills if necessary, so that all medicines are ready on the same day, Barnes explained. The pharmacists then counsel the patient about any medication interactions and adherence. By reviewing the patients’ profile, the patients’ pharmacists get a sense of the full picture. “You need to look at the patient as a whole...not at an individual prescription,” explained Barnes. “MedSynch is made to see the patient as a whole.”

Similarly, Brian Ambrefe, a pharmacist and owner at Village Pharmacy in Lynnfield, has performed medication synchronization for the past eight years.  Ambrefe says patients who take four or more medications or who meet Medicare guidelines for Medication Therapy Management (MTM) comprise the majority of MedSynch patients, though Village Pharmacy offers this option to anyone who could benefit from it. To sync, Ambrefe starts with the most expensive drug (known as the “anchor drug”) as the basis for the refill schedule, then works the other refills around this one, resulting in partial refills until the “synch” is complete.

Moving to a MedSynch or appointment-based model offers several advantages for the patient, the pharmacy, and the healthcare system. Patients enrolled in the ABM were “three to six times more likely to adhere to their medication regimes than consumers who were not enrolled,” at least in part because they felt a greater connection with the pharmacy, according a study from Thrifty White Pharmacy referenced by the APhA Foundation. Patients were also more likely to be content with the care they received from their particular pharmacy, with fewer trips to the pharmacy being one reason for their satisfaction.

Similarly, MedSynch provides benefits to the pharmacies that implement it. Ambrefe says MedSynch makes operational planning easier; he can make fewer deliveries to assisted living facility customers, and can arrange staffing levels more accurately. MedSynch also allows for inventory management. Ambrefe can order medications from wholesalers very shortly before his patients are due to pick them up, so expensive drugs never remain on the shelf for very long.

From a more global perspective, patient non-adherence is one of the largest drivers of healthcare costs, so a program like MedSynch that positively impacts adherence has the potential to bring healthcare costs down, as well as impact specific improvement metrics. “The measures of improvement will be useful to align the impact of pharmacists utilizing the ABM with the quality measures (e.g. CMS Five Star Quality Ratings) and cost savings many doctors, hospitals, and payers are striving to achieve.” (APhA Foundation). The CMS Five Star Quality ratings evaluate a drug plan according to member satisfaction, patient safety, and more.

Though the benefits of MedSynch are plentiful, there are still downsides.  Most of these center around cost, both to the patient and the pharmacist.  It may be a financial hardship for patients to pick up and pay for all of their monthly medications at one time, especially if their insurance will not cover the partial refills.

Slowly, this may be changing. While insurance coverage of partial refills varies from plan to plan, insurers have been covering these refills more frequently in recent months. Medicare Part D drug coverage of partial refills has changed. “As of January 1, 2014, changes under Medicare Part D required plan sponsors to offer prorated copayments, accomplished through new submission clarification codes, to Medicare beneficiaries for medication synchronization” (pharmacist.com). Brian Ambrefe has noticed just this year that insurance plans have gotten better at covering the prorated refills.

For plans that initially don’t cover partial refills, a pharmacist’s persistence can go a long way, says Barnes. She often will contact the insurance company to get these refills approved and the patient synched.

Pharmacists also experience a disadvantage because insurance does not cover the work involved in MedSynch, including organizing refills and patient counseling. While pharmacists can get paid for some Medication Therapy Management (MTM) encounters, these patients often get “cherry picked” by the Pharmacy Benefit Managers (PBMs), according to Ambrefe.

Synching prescriptions may also result in an overabundance of medication for the patient. Sometimes, a doctor will tell a patient to stop taking a certain medication, but no one communicates this to the pharmacist. With MedSynch, the particular prescription keeps getting filled. Similarly, if a patient picks up their prescriptions, then becomes injured and goes to a rehabilitation facility, he or she won’t need their medicine at home, and it piles up, says Barnes.

In addition, a pharmacist needs to be aware of certain situations that may arise with the ABM. When meeting with the patient, pharmacists should be on the lookout for potential patient misuse of controlled substances, says Barnes.

With pharmacists on the cusp of potentially earning provider status, they will have an opportunity to influence patient adherence more than ever before. MedSynch can be a valuable tool in their kit. Like any tool, though, it has its limits. While MedSynch improves adherence significantly, it is not a magic bullet. “Adherence is better, not absolute,” states Ambrefe.

Putting the Patient First: Let Deserving Community Pharmacists into Preferred Pharmacy Networks

Imagine as a patient, you have been frequenting one particular pharmacy for many years. As a senior citizen whose memory isn’t what it once was, you appreciate the way the pharmacy packages your many prescriptions, even designating the time of day you should take the medicine. Perhaps you’re an immigrant and don’t speak English well, so the routine of going to this particular pharmacy is familiar, comforting. Then one day, you receive a letter stating that this pharmacy’s services will no longer be covered under your Medicare Part D plan.

Imagine as a community pharmacist, you spend time packaging the prescriptions for your patients to encourage adherence. You counsel patients thoroughly, even though your pharmacy fills hundreds of prescriptions per day. You perform full Medication Therapy Management services, despite the fact that the reimbursement rate for such services does not even cover your hourly rate. Even given your hard work, you will no longer be able to treat and fill prescriptions for patients like this senior citizen without Medicare reimbursement.

This scenario is becoming very real since the advent of the healthplan star ratings system. Created by the Centers for Medicare and Medicaid Services (CMS), this system rates the Medicare Part D plans by a metric of one to five stars.

CMS introduced the star ratings into an environment where patient medication non-adherence costs the healthcare industry approximately $300 billion per year. With the dawn of the Affordable Care Act, pay-for-performance became the new healthcare model. Medicare Part D plans can realize significant bonuses from CMS based on high star ratings. Plans with high star ratings also can pitch more powerful marketing messages, enjoy a longer enrollment period, and charge higher premiums.

The plans are rated according to four different criteria: drug plan customer service; member complaints, problems getting service, and choosing to leave the plan; member experience with the drug plan; and drug pricing and patient safety.

The Part D plans also contract with preferred pharmacy networks to which they direct their patients. When pharmacies enter into a PPN contract, they accept not only a lower reimbursement model, but also a lower co-payment for the patient and thus a hopefully greater volume of business. (www.ncpanet.org).

So, the Part D plans have a vested interest in choosing a network, and pharmacies, that help them to earn high star ratings. However, the data collection process that the plans and PBMs use is arduous and potentially prone to error.

As networks increasingly become the conduit to patients, participation in these institutions grows more crucial for pharmacies. Yet, not all high-performing pharmacies are part of a network, and it can be difficult and time-consuming to sort through the red tape to determine if they are.

Karen Horbowicz, Pharm.D, a Manager of Clinical Pharmacy at Inman Pharmacy in Cambridge, has experienced the network issue first-hand. She recently had three customers receive letters stating they would no longer get their prescriptions covered at Inman. One of these patients is enrolled in Inman’s medication packaging plan, where she gets her multiple medications prepackaged in dosage cards by the day and time they are to be taken. To do this, Horbowicz gets a detailed medication list and communicates directly with the patient’s physician. The process takes at least an hour.

Horbowicz fears that this patient will be reluctant to visit another pharmacy, and even if she does, a chain pharmacy may not be willing to go through the same process with her medication. Though the star ratings are designed to improve patient medication adherence, they will indirectly contribute to the opposite effect if this particular patient, and others like her, get lost in the shuffle.

Currently, there is a not a simple way for community pharmacies like Inman to learn of their performance according to the health plans’ star ratings. Inman’s would likely score highly on criteria such as customer service and member experience —due to the comprehensive Medication Therapy Management services the pharmacy offers with specialty packaging and patient follow-up.

Horbowicz has persistently contacted the health plan and pharmacy network, which has not led to a resolution. Given that the plan year is already underway, it does not appear that gaining admittance to this network is going to be possible. This is important since not belonging to a network will cost Inman patients, and its experience may is shared by many urban community pharmacies. A recent study issued by the Centers for Medicare and Medicaid Services (CMS) found that “fewer urban beneficiaries have convenient access to pharmacies offering preferred cost-sharing than beneficiaries in suburban and rural areas.”

The study went on to assign some accountability to the way the plans health plans contract with the preferred pharmacy networks, acknowledging the very problem Inman is encountering. “While we appreciate the importance of providing lower costs to beneficiaries, these findings reinforce CMS’ concern that plans are offering access to pharmacies with lower cost-sharing in a way that may be misleading to beneficiaries, in violation of CMS requirements. In addition to providing meaningful levels of access, plan sponsors must also provide a uniform set of benefits throughout the plan service area.”

Horbowicz’s manager pursued this issue and contacted CMS to issue a formal complaint, as did the National Community Pharmacists Association (NCPA). Following this, CMS created a “special enrollment period” for beneficiaries to choose a new Part D plan – specifically, a plan that would allow the patient to have drug coverage at his/her preferred pharmacy.

While helpful, this action still doesn’t impact the networks that exclude the deserving community pharmacies. For Inman, the very core of the business model of their community pharmacy, and many others like it, is at stake. “If we don’t get reimbursed {by Medicare}, we can’t do this anymore,” says Horbowicz.