Managing Pharmacy Expenses in PACE: A Case Based Discussion. Valencia P. Covington, MD, MPH Jennifer Keller, PharmD, BCPS, CGP June 5, 2016

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1 Managing Pharmacy Expenses in PACE: A Case Based Discussion Valencia P. Covington, MD, MPH Jennifer Keller, PharmD, BCPS, CGP June 5, 2016

2 Disclosure: Valencia Covington I have no relationships, financial or nonfinancial to disclose in conjunction with the material covered in today s presentation.

3 Disclosure: Jennifer Keller I have no relationships, financial or nonfinancial to disclose in conjunction with the material covered in today s presentation.

4 Objectives Describe the benefits of a team-based medication review in terms of quality and cost. Summarize the process of a team-based medication review. Evaluate a participant case to distinguish opportunities for improved quality of care and reduced medication cost.

5 Find Broad Cost-Saving Interventions Reconsider formulary interchanges routinely Example: The inhaler initiative at PACE-SP resulted in a savings of $489/month and simplified regimens and puffs per day for many participants Example: Namenda XR to memantine BID transition resulted in a savings of $3640 per month

6 Find Broad Cost-Saving Interventions Minimize use of specialty medications Eliminate unnecessary OTC medications Dispensing fees add up Reconsider use of scheduled versus PRN medications to avoid stockpiling Keep communication lines with participants open for early warning of problems Christmas bag lesson

7 Benefits of Team Based Medication Review Reduced expenses per participant Improved pharmacotherapeutic plan for each participant Improved team awareness of participantspecific factors Example: Can t swallow pills, refuses most medications, high anxiety about changes, etc

8 Team-Based Medication Review Process - Overview STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 FL2 Exam Physician conducts FL2 exam and reviews medical history Set Expectations During FL2 exam, MD sets expectations for medications with participant and family Information Sharing Physician shares FL2 exam and pertinent history with team, including PharmD Pharmacist Review Clinical pharmacy review using physician supplied information Consult and Decision- Making Physician makes changes to medication therapy

9 Team-Based Medication Review Process - Overview STEP 6 STEP 7 STEP 8 STEP 9 STEP 10 All Meds to PACE Day 1 Medication Reconciliation Discrepancy Resolution Review of Changes Monitoring & Follow-up Participant brings all medications to PACE on first day of attendance PharmD reconciles medications brought in with FL2 and MD changes Physician reviews and makes final decisions Therapeutic changes reviewed with participant, caregivers and team Monitor, paying particular attention to areas impacted by changes

10 Participant Case Mrs. AM Mrs. AM 90 year old WF Lives with daughter. Recent ED visits x 3 for dizziness, SOB/COPD exacerbations CT, PFTs, and echo all unrevealing Pulmonologist consult (60 days prior to PACE) indicates patient negative for COPD

11 Participant Case Mrs. AM Dx from medical history: HTN, Pulmonary HTN, COPD, TIA, hyperlipidemia, GERD, anxiety, depression, allergic rhinitis, dependent edema, urinary incontinence, hearing loss, gait disturbance, hx of falls Physician impression: A&O x 3, very anxious, semi-ambulatory with walker

12 Participant Case Mrs. AM Participant medications: ASA 81mg daily MVI daily atorvastatin 10mg daily Pulmicort 2 puffs bid clorazepate 7.5mg q HS prn Duoneb qid prn montelukast 10mg daily ranitidine 150mg bid Spiriva 1 puff daily triamterene/hctz 37.5mg-25mg daily calcium + D 600mg-400mg daily fish oil 1000mg po daily paroxetine 20mg 1 & ½ tablet daily clonazepam 0.5mg po hs prn sleep paroxetine 40mg daily

13 Participant Case Mrs. AM During medication reconciliation process, it is found that Mrs. AM still has #24 clorazepate on hand. Physician chooses to allow her to finish her existing supply of tablets with anticipated date of completion noted. Will reassess at that time.

14 Participant Case Mrs. AM Before team review and changes: 3 ED visits within previous 1 yr related to SOB, high levels of anxiety 13 medications Monthly cost $770 After team review and changes: 1 ED visit due to fall in previous 1 yr 10 medications Monthly cost $140

15 Participant Case Mrs. AT Mrs. AT, 89 year old AAF Lives alone with some assistance provided by daughters, recent fall, moderate dementia but still driving and using stove, resistant to care Allergies to: PCN, ASA

16 Participant Case Mrs. AT Dx from medical history: dementia, HTN, diabetes mellitus type 2, glaucoma, urticaria, gait disturbance, wandering behaviors Physician impression: gait unsteady, should not be driving

17 Participant Case Mrs. AT Participant medications: valsartan/hct 80/12.5mg daily amlodipine 5mg daily memantine 10mg bid donepezil 5mg daily Tradjenta 5mg daily glimipiride 4mg daily MVI daily latanoprost 0.005% 1 gtt OU qhs valsartan/hct 160/12.5mg daily metformin/glyburide 500/5mg bid donepezil 10mg daily

18 Participant Case Mrs. AT Before team review and changes: Clunky medication regimen 8 medications Monthly cost $461 After team review and changes: Regimen dose optimized and simplified 6 medications Monthly cost $133

19 Take Home Points Periodically review expenditures for formulary interchanges Thorough information for each participant allows team to make solid recommendations and decisions when starting the program Be bold!...and then be sure you monitor results Consider an in house prior authorization for any medication costing over x amount.