Over the past several months the Joint Oversight Task Force for Prescription Drug Monitoring has been working to develop and operationalize a Missouri state prescription drug monitoring program (PDMP). The Public Policy committee recently conducted a MSHP member survey to gather input and provide feedback directly to this task force.  The goal of the survey was to identify and communicate the priorities of MSHP members with regard to a MO state-wide PDMP. A majority of respondents (91%) agreed that the PDMP should have full integration within the electronic health record (EHR). The survey collected a list of the most common EHRs utilized by members for the taskforce, to aid them as they evaluate vendors for this capability. MHSP members also voiced that the PDMP should have interconnectivity between all 50 states. A PDMP with a high level of interconnectivity would be advantageous in a state like Missouri, which shares its border with eight different states.  The survey also identified some functionality of the current Saint Louis County PDMP that worked well that would ideally be carried forward in the MO state PDMP. The Public Policy Committee shared the comments and data collected in the survey directly with Joint Oversight Task Force for Prescription Drug Monitoring. Additional discussion on the PDMP and other exciting topics will continue in the monthly Public Policy Committee meetings.

Hundreds of community and health-system based pharmacists came together in Jefferson City. On April 6th, we flooded the capitol with white coats, talking to our legislators about a variety of issues that greatly impact the practice of pharmacy and the care which we can provide our patients. Here is where each of the pharmacy/healthcare related bills of MSHP, MHA and MPA’s ended up by the conclusion of the 2022 MO Legislative session on May 13, 2022:

HB 2305

Creates provisions relating to insurance coverage of pharmacy servicesSponsored by:

• Representative Dale Wright, represents portions of St. Francois, Ste. Genevieve, and Perry counties

Summary:

• Whitebagging - Requires coverage from insurance plans for certain services including pharmacist-administered services, and coverage for products even if not obtained from covered entity   
• 340B - Health carriers/PBMs may not discriminate against reimbursement of 340B drugs.
• Biosimilars - Requires coverage for biosimilars in which the reference product is covered.

Updated Status:

• Referred to the House’s Insurance Committee
• A public hearing was completed on 4/5/2022 in which MSHP and MPA members spoke in support of the bill
• The bill did not reach the floor for a vote prior to the close of session 

HB 1677 (SB 921)

Enacts provisions relating to payments for prescription drugs

Sponsored by:

• Senator Bill White, represents Jasper, Dade, and Newton counties
• Representative Dale Wright, represents portions of St. Francois, Ste. Genevieve, and Perry counties

Summary:

• Requires increased reporting from PBMs on rebates received from manufacturers and amount that was not passed on to Missouri Consolidated Health Care Plan
• PBMs cannot discriminate against 340B drug pricing, and must reimburse fairly
• Penalties can be imposed on a PBM for each violation

Updated Status:  

• Referred to the House’s Health and Mental Health Policy Committee
• Passed in the House and sent to the Senate on 3/28/2022
• Referred to Senate’s Insurance and Banking Committee on 3/31/2022
• Public Hearing was held on 4/12/2022
• The bill did not reach the Senate floor for a vote prior to the close of session 

HB 2452 (SB 1126)

Modifies provisions relating to the administration of medications by pharmacists

Sponsored by:

• Senator Holly Thompson Rehder, represents Bollinger, Cape Girardeau, Madison, Perry, Scott, and Wayne counties
• Representative Bennie Cook, represents Texas, Phelps, Pulaski, and Howell Counties.

Summary:

• Repeals former legislation that limited pharmacists to administering only certain vaccines
• Allows pharmacists with Medication Therapy Services (MTS) certificate to administer ANY vaccine approved by the FDA to persons 7 years and older using statewide collaborative practice agreement

Updated Status:

• Referred to the House’s Emerging Issues Committee
• Perfected with Amendments HA 1, HA 2 as amended, HA 3 adopted on 4/14/2022
• Placed on the informal third reading calendar on 4/25/2022
• Dropped from Calendar, pursuant to House rules on 5/10/2022

Legislative advocacy can be an intimidating endeavor. It requires that you know what bills have been introduced to the legislature and if they are important for your profession. Then, it is important to know what those pieces of legislation say and what this means for your profession. The bills up for discussion during the 2022 Missouri Legislative Session affect all of us. They affect our profession as pharmacists and the level of care that can be provided to our patients. The following are the pharmacy/healthcare related bills of MSHP, MHA and MPA’s advocacy focus for this 2022 Legislative session:

HB 2305

Creates provisions relating to insurance coverage of pharmacy services

Sponsored by: Representative Dale Wright, represents portions of St. Francois, Ste. Genevieve, and Perry counties

• Amends chapter 376 by adding three sections pertaining to insurance coverage of pharmacy services
• Summary: A health carrier, PBM or any of their agents or affiliates shall not impose any penalty on participating providers, covered persons, or any pharmacy, including hospital pharmacies, for dispensing medically necessary clinician-administered drugs regardless of if the participating provider obtains the drugs from a source that is in network
• What this means: Previously patients had 2 options when it came to medications administered by their provider in an office or clinic if they wanted it to be covered by insurance.
  • Patients would have to work with their provider to ensure that the medication was obtained through one of the entity’s covered by their insuranc
  • The patient would have to go pick up a medication from a covered entity and take it to the providers’ office for the provider to then administer it.

This bill would eliminate that barrier, ensuring that a health carrier, PBM or one of their agents cannot penalize or provide less reimbursement to a provider, patient or pharmacy based on whether the clinician-administered medication came from one of the carrier’s covered entities

See the bill in its entirety here.

SB 921 and HB 1677

Enacts provisions relating to payments for prescription drugsSponsored by: Senator Bill White, represents Jasper, Dade and Newton counties and Representative Dale Wright, represents portions of St. Francois, Ste. Genevieve, and Perry counties

• Repeals sections 338.015, 376.387, and 376.388, and to enact in their place five new sections relating to payments for prescription drugs
• Summary:
  • Pharmacy benefits managers (PBM) utilized by the Missouri consolidated health care plan shall file reports with the plan for the immediately preceding year contain information regarding:
    • The aggregate dollar amount of all rebates the PBM collected from pharmaceutical manufacturers that manufactured outpatient prescription drugs
    • The aggregate dollar amount of all rebates, excluding any portion of the rebates received by the plan, concerning drug formularies that the PBM collected from pharmaceutical manufacturers that manufactured outpatient prescription drugs.
    • That were covered by the plan during that calendar year and were attributed to the utilization of such drugs during said calendar year.
  • The plan shall establish a form for the PBM to report the information required under the above-mentioned section
  • No documents, materials or other information submitted to the plan under the aforementioned section shall be subject to disclosure under chapter 610, except ones that are required under subsection 4 of this section.
  • Starting July 1, 2024, and annually thereafter, the plan shall submit a report to the standing committees of the general assembly having jurisdiction of health insurance matters containing the information stated above in section 1, subsection a from the preceding year. In addition, the plan shall prepare a report for the same time period, describing rebate practices of the plan and its PBM.
  • The plan may impose a penalty of no more than $7,500 on its PBM for each violation of the sections to follow.
• What this means: PBMs will be required to provide information regarding their MAC prices for medications, rebates obtained from manufacturers and business practices in relation to individual pharmacies. A PBM cannot pay a pharmacy less than the cost to purchase a drug or reimburse less for pharmacist services than they would for a PBM affiliate providing the same service. If violations of this bill are found then the PBMs will be held responsible by paying a violation fee.
• See the bills in their entirety here: https://www.senate.mo.gov/22info/pdf-bill/intro/SB921.pdf and https://house.mo.gov/billtracking/bills221/hlrbillspdf/4311H.02C.pdf

SB 1126 and HB2452

Modifies provisions relating to the administration of medications by pharmacists

Sponsored by: Senator Holly Thompson Rehder, represents Bollinger, Cape Girardeau, Madison, Perry, Scott, and Wayne counties and Representative Bennie Cook, represents Texas, Phelps, Pulaski and Howell Counties.

• Repeals sections 338.010 and 338.165, and enacts in lieu thereof three new sections relating to the administration of medications by pharmacists
• Summary:
  • This bill repeals language defining the practice of pharmacy as including the administration of specific vaccines for specific patients by written physician protocol and adds language defining the practice of pharmacy as including the ordering and administering of US FDA-approved or authorized vaccines to persons at least 7 years of age or the CDC-approved age, whichever is older.
  • This act permits a pharmacist with a certificate of medication therapeutic plan authority to provider medication therapy services pursuant to a statewide order issued by the Department of Health and Senior Services. Medication therapy services may be provided by a pharmacist for patients of a hospital pursuant to a statewide standing order issued by the Department or pursuant to a physician protocol.
• What this means: Pharmacists authority to order and administer vaccinations will not be limited to certain kinds of vaccines and will be pursuant to rules promulgated by the Board of Pharmacy and Board of Registration for the Healing Arts or rules promulgated under a state of emergency instead of requiring a written physician protocol for specific vaccinations.
• See the bills in their entirety here: https://www.senate.mo.gov/22info/pdf-bill/intro/SB1126.pdf and https://house.mo.gov/billtracking/bills221/hlrbillspdf/5157H.02C.pdf

By: Annie (Stella) Kliewer

In September 2022 ASHP had their legislative day in Washington D.C. Soon after ASHP asked all of their affiliate associations to reach out to their U.S. Congress members in support of each of the following bills:

H.R. 7213 - Equitable Community Access to Pharmacist Services Act

• Would allow Medicare patients access to various treatment and testing services that pharmacists are licensed to provide and allow pharmacists to respond to ongoing and future public health threats

H.R. 4390 - Protect 340B Act

• Bipartisan legislation prohibiting discriminatory policies against 340B providers by a PBM, group health plan or other entities

H.R. 1384/S.445 - Mainstreaming Addiction Treatment Act included in Restoring Hope for Mental Health and Well-being Act of 2022.

• This bill would eliminate the need for an X-waiver, increasing access to medications for opioid use disorder for patients who struggle with addiction

Protect Funding for Pharmacy Residency Programs

• CMS has been clawing back funding from many health-system affiliated residency programs.
• CMS is alleging that standard hospital business and training practices violate its requirements for residency programs but lack guidance on this issue thus many programs do not know how to proceed in order to retain funding
• Ask: Request that your congressional offices ask CMS to suspend cost disallowances until the agency provides guidance answering questions surrounding residency compliance.

MSHP would greatly appreciate you reaching out to your U.S. Congress member regarding the above issues. You can find who your legislator is here. At the link to find your legislator, it will also have a contact button listed. Please reach out to your legislators using that link!

The MSHP Public Policy Committee did not create a form letter as often legislators will toss form letters in the trash because it isn't a personal message from a constituent. A message to your legislator doesn't have to be long but it being personally written by you will go a long way! Here you will find the leave-behinds that ASHP provided to members at ASHP Legislative Day so feel free to send that with your email or use it to draft your email to them. The more of us from the state of Missouri reaching out the better chance of our voices being heard!

Many multidose medications are disposed of upon patient discharge. This provides no continued help to the patient and increases hospital cost for proper waste management of these medications. But what if we could provide transitional care for the patient and reduce hospital waste management costs at the same time? The key is ensuring proper labeling and instructions for use to the patient upon discharge that does not cause an unreasonable increase in workload for staff.

               The Children’s Hospital and Clinics of Minnesota devised a system that utilizes the initial labeling when sent from the pharmacy as well as a generic supplemental label placed close to discharge. The supplemental label includes the hospital name and address as well as generic directions to “use as directed” with the prescriber’s name inserted and manufacturer of the product. The patient is then instructed to use the medication as directed on their discharge paperwork.

               Patient Safety & Quality Healthcare (PSQH) published an article in 2009 in which Spectrum Health in Grand Rapids, Michigan, laid out the criteria for an implementation process for sending patients home with the multi-dose products they used while inpatient. If the agreed upon criteria were met, the patient would be provided with the multi-dose medication (inhaler, ophthalmic product, topical preparation or insulin product) upon discharge.  The product had to be labeled according to federal labeling requirements. Hospital information would be printed on the label prior to dispensing for inpatient use, followed by a second label that would be applied to the clear bag containing the inhaler. Finally, the patient was offered counseling if they desired for the particular discharge medication.

The Big Picture

We want to provide the best care for our patients while also supporting our own health-systems. This initiative, while seemingly simple, can balance the labeling and counseling services that are required by reducing hospital waste. At the end of the day, a send-home program will improve the care of Missouri patients. There is no better reward than that. Do you provide this service at your hospital? If so, share your ideas with us at mshp@qabs.com!

We are in the People Business.
Every day, we go to work to take care of people. Pharmacists are in the business of protecting, educating, persuading, and serving people. It’s what we do, as we interact with patients, nurses, doctors, and other health care professionals. Today I’d like to ask for your help in educating, persuading, and serving a different group of people: Lawmakers!

Politicians Are People Too
As I have written in other articles, pharmacists, technicians and interns have to play according to the rules, and those rules have their foundation in the laws that are passed in Jefferson City. Part of MSHP’s 2021 strategic plan is to increase the amount of education and guidance we provide to the lawmakers who are working hard to create good laws that keep the Missouri public safe. That takes time, and it takes focus, and it takes effort. We can’t do it by ourselves. Will you help?

Three Ways to Help
We have a Public Policy committee that meets monthly to provide updates and discuss our options for getting engaged. We are also forming work groups to focus on provider status, reimbursement for cognitive services, and MSHP advocacy and education on legislative topics. If you would like to add your listening ear and your voice, please email me so that you can join our committee.

We are getting ready for the annual Legislative Day, which will be 3/30. This is a time for Jefferson City to focus on pharmacy, and it provides an opportunity for the Missouri Pharmacy Association and Missouri Society of Health System Pharmacists to come together with one voice to remind our lawmakers of the important role we play in caring for patients. It is a Tuesday, and usually there are events scattered throughout the day, so you will need to make a plan in order to be able to participate. Of course the event will look different this year, so stay tuned. We are not ready for signups, but if you are interested in receiving updates, please email me and I will keep you informed.

If you are not available on 3/30, that is no problem at all! There are 51 other weeks this year where you can reach out to your senator or representative and begin the process of building relationships with them and educating them on pharmacy-related topics. With the COVID vaccine in the news, all eyes are on pharmacy right now. This is a great time to begin the process of meeting the person who represents you so that you can provide them with important information when they need it. Don’t know who your lawmakers are? You can find them here in less than a minute. Send them an email to get on their email list. Don’t feel equipped to speak on behalf of Missouri Pharmacy? Email me and I will provide you with some talking points and agenda items to discuss.

Caring For Lawmakers
Remember, we are in the people business, and our lawmakers are people who need our expertise and care. Let’s make 2021 the year when we start making a difference in our patients by caring for our lawmakers!

Do you know how to contact both of your US Senators and your US Representative in one click?  If you invest 5 minutes with ASHP you will be able to do just that.  The ASHP Action Center is a website where you register to receive updates about pressing legislative issues, making it very simple to send expertly-written form emails at the times when they will have the greatest impact.  Click here today - it only takes a few minutes to register yourself and enter your information.  Only your email and zip code will be required for future logins.  

The Impact of Social Justice 

Social Justice is an issue that is so deep and broad that it can feel overwhelming.  But for me, the starting point is pretty simple - caring for people.  Each of us work for organizations that have 'caring' as part of our core mission.  Ours is "Above all else, we are committed to the care and improvement of human life."  Each of us work for organizations that have respect as part of our core values.  If we each model caring and respectful thoughts, words, and actions, that is a good place to start.   

Many of us are in roles where we can also hold others accountable for their words and actions, and we create a culture by what we call people into and what we tolerate.  Even if you are not a formal manager, you still can make an impact on your work environment.   

I think the next thing we can do is purposefully think how we can serve and build into anyone who is a step or 2 behind us on life's journey.  That may be to mentor a student, or to provide a professional development series for technicians and arrange the schedule so that they can attend.  It may be to invest in that younger leader who has potential.  Or to meet routinely with a technician or intern and provide the type of career guidance that you have received from family, friends, and mentors in your life.  It may be to go to bat for your technicians to get them a raise that pays them for the value they provide.  In this way we are spreading justice and mercy and care and respect to everyone, and you will certainly help the ones who have been dealt a less favorable hand by life.  And it is always helpful to remember the words, "Be kind - everyone you meet is facing a hard battle."   

If you are interested in ASHP’s work on this topic, stay tuned to the ASHP Task Force on Racial Diversity, Equity, and Inclusion and reach out to me to get involved with the Public Policy committee. 

You Can’t Do Everything, but…

Right now we are all busy with everything that is going on.  Focus on these 2 practical ways to make an impact on our world.

Subscribe to newsletters, such as the Board of Pharmacy, MSHP, and ASHP. For example, our Missouri Board of Pharmacy has been very active as they have provided flexibility to Missouri pharmacies to deal with the pandemic response, and all of the information you need to know has been posted on the website and sent out via newsletters. You can subscribe to the ASHP Daily Briefing as well as Advocacy Updates and other options through your account NewsLink settings. You can also participate in the conversation on ASHP Connect. This MSHP newsletter is always informative, and MSHP is expanding our use of social media platforms to share information. Joint Commission, NABP, and USP also provide useful information. Read through the Pharmacy Practice Guide and the Department of Health hospital pharmacy rules. Schedule time on your work calendar or your personal calendar to catch up on current events in pharmacy and actually read those articles that are sitting in the “Read Me” folder. A small investment of time, consistently applied over weeks and months, will compound into a solid foundation of understanding.

Get Involved

Participate at your workplace as they work out the best plan for providing excellent pharmaceutical care in the ever-changing COVID landscape. Provide your input and your questions to the discussions about how to ensure that care, respect and opportunity is experienced by all patients and teammates, regardless of race. Join a committee or attend a live or virtual event to get involved with MSHP, with your regional chapter of MSHP, or with ASHP. Find out who your legislators are (link), and contact them. Let them know that pharmacists play an important role for our patients, and if we are given provider status we could do even more. It is an election year, so get educated and vote.

Uncertain times call for participation at all levels. As pharmacists, we have a responsibility to stay knowledgeable and get involved to ensure that our patients get the care that they need.

The Missouri legislative session wrapped up, after being significantly disrupted by COVID. Many of the legislative priorities were put on the backburner (think 2021), and a statewide Prescription Drug Monitoring Program was again voted down. However, a helpful proposal was passed that will make it safer for our patients to receive specialized compounded medications. When it has been signed by the governor MSHP will provide more information about how to implement this change. This is a patient safety improvement, and it was a wonderful example of MSHP working together with the Missouri Pharmacy Association and the Missouri Hospital Association to make a positive impact. We truly appreciate their leadership on this issue!

Regulatory: Government employees, inspectors, and boards

The Missouri Board of Pharmacy did an amazing job of responding to the public health emergency. They held multiple meetings and worked tirelessly over the past 3 months to ensure that they had done everything they could do to remove regulatory barriers that might get in the way of providing safe care to patients during the COVID emergency. Thankfully, many of the worst case scenarios did not materialize, but Missouri made a strong effort to be ready. The 2008 USP 797 standards will continue to be in effect, as the revisions go through the committee again. The FDA has finalized a document outlining clear regulatory cooperation with the state boards for interstate compounding. Each state board will review the document to determine if it meets the needs of their state.

Associations: Groups of thought leaders, providing best practices and direction for the profession

The 2020 ASHP House of Delegates has approved a slate of professional policies (link). These are designed to clearly explain the wishes and priorities of the 55,000 ASHP members. They are developed and approved with input from elected members from each state, including member of MSHP. MSHP Board of Directors approved guidance for safe implementation of a technician product verification program within the hospital setting. This guidance document was put to the membership for a vote and was passed. Stay tuned for more information.

My first face-to-face encounter with professional advocacy occurred following my first year of pharmacy school at UMKC in July of 2018. That summer, I had the privilege of attending the APhA-ASP Summer Leadership Institute in Washington, DC. Part of this experience involved visiting Capitol Hill and advocating for pharmacy issues, specifically provider status and the opioid crisis. Despite spending significant time reviewing the talking points, I recall feeling incredibly nervous walking into Representative Sam Graves’ office and later into Senator Claire McCaskill’s office. Thankfully, I was able to attend these meetings with peers who were more experienced than me, and they coached me on how to be effective in these meetings. Upon sitting down with staffers for each of these legislators, the nerves subsided, and I realized that they were there to hear our perspectives on what could be done to improve patient care. Unfortunately, we are still fighting for change on these issues and others, but I believe that if pharmacists and student pharmacists take personal responsibility for advocating, then we will see the changes we wish to see and improve the care we can provide for patients.

Advocating for pharmacy is a team sport, much like football. Being from Kansas City, I am incredibly excited that the Chiefs won the Super Bowl. A big component of their success was that they pulled together as a team. They were unstoppable when the receivers ran the correct routes and the offensive line blocked their assignments, allowing Patrick Mahomes to complete pass after awe-inspiring pass and lead the team to victory. This is similar to pharmacy advocacy; if the many team members involved in pharmacy advocacy are going in different directions and not working together, then it will be more difficult for us to improve our profession. A simple unifying idea is that our pharmacy advocacy team should always begin with the best interests of patients in mind. A good team must have all of the players, including pharmacists, technicians, and student pharmacists. I am a student, and I have learned much about advocating for our patients and profession from experienced mentors who have a wealth of knowledge to share. By passing knowledge along to students and young pharmacists who are new to the profession, we will be able to build upon what is already being done instead of re-developing knowledge and tactics for advocacy that have already been formed.

I have been asked why I care about advocating for the profession and why student pharmacists should care about advocacy. For me, the answer is simple: I want to be able to provide the best care possible to patients, and I want to enhance the care I can provide throughout my career. Student pharmacists are preparing to embark on a career that will span decades. In order to optimize what we can accomplish over the course of that career, we must take personal responsibility for advocating for our patients and the future of the profession. This personal responsibility includes multiple forms of advocacy. As the medication experts, it is one of our responsibilities to advocate for our patients as a member of the healthcare team. It is also our responsibility to send letters to legislators and make phone calls to encourage legal changes that will help us better serve our patients. This includes actively seeking opportunities to advocate for issues on both the state and federal levels. Oftentimes, this can start with something as simple as attaching your name to a form letter and sending it to a legislator. It can also grow into attending Legislative Day, which was on April 1st this year, or setting up a personal meeting with a representative or staffer. As long as the members of our advocacy team do their part and continue fighting, we will see the changes we want to see and continue providing the best care possible for patients.

1. Jeff Little, Melissa Ortega, Michael Powell, Mark Hamm, ASHP Statement on Advocacy as a Professional Obligation, American Journal of Health-System Pharmacy, Volume 76, Issue 4, 15 February 2019, Pages 251–253, https://doi.org/10.1093/ajhp/zxy040
2. Scott Knoer, Erin R Fox, Advocacy as a professional obligation: Practical application, American Journal of Health-System Pharmacy, , zxz328, https://doi.org/10.1093/ajhp/zxz328
3. Kate Traynor, Pharmacists make advocacy happen on ASHP Legislative Day, American Journal of Health-System Pharmacy, Volume 77, Issue 2, 15 January 2020, Pages 69–70, https://doi.org/10.1093/ajhp/zxz296