Examining the Value of Subsidies of Health Plans and Cost-Sharing for Prescription Drugs in the Health Insurance Marketplace.

BACKGROUND: The Affordable Care Act (ACA) initiated federally and state-run health insurance exchanges, or marketplaces, with health plans offering subsidies for plan members as well as coverage for essential health benefits, to help individuals, families, and small businesses find health plans that fit their specific needs. A recent study found that the value of these healthcare subsidies varied with the number of health plans in the different geographic rating areas, but that study only examined the premiums and the deductibles of those health plans. OBJECTIVES: To examine the value of subsidies of health plans, including cost-sharing for prescription drugs in the health insurance marketplace. METHODS: We have used publicly available health plan data from HealthCare.gov and from county population data obtained from the US Census Bureau in June 2015. The average-weighted premium; medical deductible; medical maximum out-of-pocket spending; and cost-sharing for generic drugs, preferred and nonpreferred brand-name drugs, and specialty drugs were calculated for the second lowest-cost silver plan in each geographic rating area. These were then compared across geographic areas with different numbers of plans to determine the value of the subsidies. We also compared the difference between the cost of the average silver plan and the second lowest-cost silver plan for each area to determine the cost to enrollees if they selected the average silver plan. RESULTS: The monetary value of the subsidies provided by health plans was lower in areas with a larger number of plans, because the second lowest-cost silver plans in these areas tended to have lower premiums and higher deductibles. For the most common type of cost-sharing for generic and for preferred brand-name drugs, plan enrollees would likely have a lower or similar copayment if they selected the average-cost silver plan instead of the second lowest-cost silver plan. However, they may end up paying approximately $8 less in copayment for nonpreferred branded drugs and approximately 4% less for coinsurance after a deductible for specialty drugs if they resided in a geographic area with fewer than 11 plans. CONCLUSION: The value of subsidies provided by the ACA-initiated health plans in the healthcare marketplace, including cost-sharing for prescription drugs, varies across geographic areas with different numbers of health plans. This suggests that potential enrollees should consider cost-sharing for prescription drugs in addition to health plans' premiums and deductibles when choosing their health plan.

Antipsychotic Medication Use in Nursing Homes: Approaches to Reduce Use and National Trends.

Consensus exists regarding the need to reduce antipsychotic medication use in nursing homes, multiple initiatives have been implemented with the intent to achieve this goal, and progress is being made. While limited high quality research is available documenting the impact of various approaches, resource tool kits and best practice descriptions can help guide efforts.

Patients' perceived value of pharmacy quality measures: a mixed-methods study.

OBJECTIVE: To describe patients' perceived value and use of quality measures in evaluating and choosing community pharmacies. DESIGN: Focus group methodology was combined with a survey tool. During the focus groups, participants assessed the value of the Pharmacy Quality Alliance's quality measures in evaluating and choosing a pharmacy. Also, participants completed questionnaires rating their perceived value of quality measures in evaluating a pharmacy (1 being low value and 5 being high) or choosing a pharmacy (yes/no). Thematic analysis and descriptive statistics were used to analyse the focus groups and surveys, respectively. SETTING: Semistructured focus groups were conducted in a private meeting space of an urban and a rural area of a Mid-western State in the USA. PARTICIPANTS: Thirty-four adults who filled prescription medications in community pharmacies for a chronic illness were recruited in community pharmacies, senior centres and public libraries. RESULTS: While comments indicated that all measures were important, medication safety measures (eg, drug-drug interactions) were valued more highly than others. Rating of quality measure utility in evaluating a pharmacy ranged from a mean of 4.88 ('drug-drug interactions') to a mean of 4.0 ('absence of controller therapy for patients with asthma'). Patients were hesitant to use quality information in choosing a pharmacy (depending on the participant's location) but might consider if moving to a new area or having had a negative pharmacy experience. Use of select quality measures to choose a pharmacy ranged from 97.1% of participants using 'drug-drug interactions' (medication safety measure) to 55.9% using 'absence of controller therapy for patients with asthma'. CONCLUSIONS: The study participants valued quality measures in evaluating and selecting a community pharmacy, with medication safety measures valued highest. The participants reported that the quality measures would not typically cause a switch in pharmacy but might influence their selection in certain situations.

Relationship of Prepharmacy Repeat Course History to Students' Early Academic Difficulty in a Pharmacy Curriculum.

OBJECTIVE: To examine the relationship between students' prepharmacy repeat course history and their academic difficulties early in a professional pharmacy program in conjunction with other prerequisite success variables known to predict academic difficulty. METHODS: For students admitted to a pharmacy program in 2010 and 2011 (n=160), admission variables [eg, prepharmacy coursework, grade point average (GPA)] and pharmacy program academic difficulty data (ie, academic difficulty defined as a pharmacy GPA in the bottom quartile of the class after 3 semesters of pharmacy course work) were extracted. Regression analysis was employed to examine the relationship between admission variables and academic difficulty. RESULTS: Twenty-six percent of the students (n=42) repeated a course, and 50% of these students (n=21) repeated more than one course. All of the admissions variables studied were found to individually increase the odds of a student having academic difficulty early in the pharmacy program. Specifically, repeat of a prepharmacy course increased the odds of academic difficulty threefold. CONCLUSION: Repeating prepharmacy coursework appears to be a strong indicator of future academic difficulties early in a professional pharmacy program.

Exploring consumer understanding and preferences for pharmacy quality information / Explorando comprensión y preferencias sobre la calidad de la información en farmacia

Objective: To describe consumer understanding of pharmacy quality measures and consumer preferences for pharmacy quality information. Methods: Semi-structured focus group design was combined with survey methods. Adults who filled prescription medications for self-reported chronic illnesses at community pharmacies discussed their understanding of Pharmacy Quality Alliance approved quality measures. Questions examined preference of pharmacy quality information rating systems (e.g. stars versus percentages) and desired data display/formats. During the focus group, participants completed a survey examining their understanding of each pharmacy quality measure. All focus group discussions were transcribed verbatim. Data were analyzed using thematic analysis and descriptive statistics. Results: Thirty-four individuals participated (mean age= 62.85; SD=16.05). Participants were unfamiliar with quality measures information and their level of understanding differed for each quality measure. Surveys indicated 94.1% understood "Drug-Drug Interactions" and "Helping Patients Get Needed Medications" better than other measures (e.g., 76.5% understood "Suboptimal Treatment of Hypertension in Patients with Diabetes"). Qualitative analysis indicated participants preferred an overall pharmacy rating for quick access and use. However, participants also wanted quality measures information displayed by health conditions. Participants favored comparison of their pharmacy to city data instead of state data. Most participants liked star ratings better than percentages, letter grades, or numerical ratings. Conclusions: Individuals who have a chronic illness and regularly use community pharmacies are interested in pharmacy quality measures. However, specific quality measures were not understood by some participants. Participants had specific preferences for the display of pharmacy quality information which will be helpful in the design of appropriate quality report systems (AU)

Objetivo: Describir la comprensión sobre las medidas de calidad de la farmacia y las preferencias del consumidos por la información sobre calidad de la farmacia. Métodos: Se combinó un método de grupo focal semiestructurado con una entrevista. Los adultos que presentaban una receta de medicación para una enfermedad crónica auto-reportada en farmacias comunitarias discutieron su comprensión de las medidas de calidad aprobadas por la Pharmacy Quality Alliance. Las preguntas examinaban las preferencias sobre los sistemas de información de clasificación de la calidad de farmacia (p.e. estrellas contra porcentajes) y los formatos/presentaciones de datos deseados. Durante la participación en los grupos focales, los participantes cumplimentaron un cuestionario que examinaba su comprensión de cada medida de calidad de farmacia. Todas las discusiones de los grupos focales fueron transcritas literalmente. Se analizaron los datos usando un análisis temático y estadística descriptiva. Resultados: Participaron 34 individuos (edad media=62,85; DE=16,05). Los participantes no estaban familiarizados con las medidas de calidad de la farmacia y su nivel de comprensión variaba entre las diferentes medidas. Las encuestas indicaron que el 94,1% entendía "Interacciones medicamento-medicamento" y "Ayudar al paciente a que obtenga las medicinas que necesita" mejor que otras medidas (p.e. 76,5% entendía "Tratamiento sub-optimo de la hipertensión en pacientes con diabetes"). El análisis cualitativo indicó que los participantes preferían las calificaciones generales de la farmacia para un acceso y uso rápido. Sin embargo, los participantes también querían información de las medidas de calidad expuestas por problemas de salud. Los participantes estaban a favor de su farmacia con los datos de la ciudad, en lugar de con los datos del estado. A la mayoría de los participantes les gustaban las calificaciones de estrellas más que los porcentajes, calificaciones por letras o calificaciones numéricas. Conclusiones: Los individuos que tienen una enfermedad crónica y usan regularmente una farmacia comunitaria están interesados en medidas de calidad de la farmacia. Sin embargo, algunos participantes no entendían las medidas de calidad de la farmacia. Los participantes tenían preferencias específicas para la exposición de la información de la calidad de la farmacia que serían útiles para ayudar en el diseño de sistemas idóneos de información de calidad (AU)

Partnership to decrease antipsychotic medication use in nursing homes: impact at the state level.

In 2012, the Centers for Medicare & Medicaid Services (CMS) established a partnership among stakeholders to decrease the percentage of residents in nursing homes receiving an antipsychotic agent by 15 percent. This goal emanated from concerns including the large percentage of residents taking antipsychotic agents, the questionable use of antipsychotics (e.g., off-label use), the high cost of inappropriate antipsychotic use, and toxicity in patients with dementia (e.g., black box warning regarding mortality). The successful achievement of this goal is evaluated via quality measures, which are greatly influenced by changes in exclusion of residents from the population examined. The partnership is focused on optimizing use of antipsychotic agents by training clinicians on nonpharmacologic approaches, educating on the dangers of antipsychotic medication use and sharing data on antipsychotic medications. In South Dakota, these efforts have yielded a 12 percent relative reduction (21.3 percent to 18.7 percent) in the percent of residents prescribed antipsychotic agents from the second quarter of 2012 to the second quarter of 2013. Future efforts in South Dakota include a Nursing Home Quality Care Collaborative that involves the majority of facilities across the state learning from peers and national experts. The South Dakota Dementia Coalition includes 17 stakeholders who guide education activities and communicate these opportunities to their constituents.

Exploring consumer understanding and preferences for pharmacy quality information.

OBJECTIVE: To describe consumer understanding of pharmacy quality measures and consumer preferences for pharmacy quality information. METHODS: Semi-structured focus group design was combined with survey methods. Adults who filled prescription medications for self-reported chronic illnesses at community pharmacies discussed their understanding of Pharmacy Quality Alliance approved quality measures. Questions examined preference of pharmacy quality information rating systems (e.g. stars versus percentages) and desired data display/formats. During the focus group, participants completed a survey examining their understanding of each pharmacy quality measure. All focus group discussions were transcribed verbatim. Data were analyzed using thematic analysis and descriptive statistics. RESULTS: Thirty-four individuals participated (mean age= 62.85; SD=16.05). Participants were unfamiliar with quality measures information and their level of understanding differed for each quality measure. Surveys indicated 94.1% understood "Drug-Drug Interactions" and "Helping Patients Get Needed Medications" better than other measures (e.g., 76.5% understood "Suboptimal Treatment of Hypertension in Patients with Diabetes"). Qualitative analysis indicated participants preferred an overall pharmacy rating for quick access and use. However, participants also wanted quality measures information displayed by health conditions. Participants favored comparison of their pharmacy to city data instead of state data. Most participants liked star ratings better than percentages, letter grades, or numerical ratings. CONCLUSIONS: Individuals who have a chronic illness and regularly use community pharmacies are interested in pharmacy quality measures. However, specific quality measures were not understood by some participants. Participants had specific preferences for the display of pharmacy quality information which will be helpful in the design of appropriate quality report systems.

Advancing the use of community pharmacy quality measures: a qualitative study.

OBJECTIVES: To describe consumers' ability to interpret pharmacy quality measures data presented in a report card, to examine the tools that consumers require to interpret the information available in a pharmacy quality report card, and to determine whether pharmacy quality measures influence consumers' choice of a pharmacy. DESIGN: Qualitative study. SETTING: Three semistructured focus groups conducted in a private meeting space at a public library in Sioux Falls, SD, from April 2011 to May 2011. PARTICIPANTS: 29 laypeople. INTERVENTION: Participants' skills interpreting and using pharmacy quality information were examined based on mock report cards containing the Pharmacy Quality Alliance (PQA) quality measures. MAIN OUTCOME MEASURES: Consumer perceptions of pharmacy quality data. RESULTS: Participants reported difficulty understanding quality measures because of knowledge deficits. They wanted supportive resources on drug class of their medications to help them understand the measures. Participants had different opinions on whether their pharmacies should be compared with other pharmacies based on specific quality measures. For example, they favored the use of drug-drug interactions as a quality measure for comparing pharmacies, while medication adherence was deemed of limited use for comparison. Participants stated that pharmacy report cards would be useful information but would not prompt a change in pharmacy. However, participants perceived that this information would be useful in selecting a new pharmacy. CONCLUSION: The results suggest that consumers require simplification of PQA quality measures and supportive resources to interpret the measures. Consumers may favor certain quality measures based on their perception of the role of the pharmacist. Education is required before full use of this quality-of-care information can be realized.

Managing depression for residents in nursing facilities.

OBJECTIVE: Review the current Centers for Medicare & Medicaid Services' (CMS) Interpretive Guidelines from the State Operations Manual (SOM) in light of evidence for management of depression found in the literature. DATA SOURCES: Articles indexed in PubMed for the last 20 years, American Psychiatric Association Guidelines, CMS Interpretive Guidelines from the SOM, and The American Medical Directors Association (AMDA) Guidelines. STUDY SELECTION AND DATA EXTRACTION: Forty published papers were reviewed, and criteria supporting the primary objective were used to identify useful resources. DATA SYNTHESIS: The literature included guidelines regarding the management of late-life depression (e.g., dosage and duration of therapy). This literature was examined in relation to the current CMS Interpretive Guidelines, which are provided to state surveyors to help them evaluate whether a nursing facility is in compliance with federal regulations. These guidelines provide explanation and clarification of the actual regulations and so are used during evaluation of the facility. CONCLUSION: Current recommendations indicate that a first episode of depression should be treated for 12 months beyond full remission, according to AMDA guidelines. Longer treatment durations (maintenance phase) are needed depending on the resident's situation (e.g., severity or number of episodes). In addition, evidence suggests that antidepressants should remain at the same dose through the maintenance phase of treatment. The Interpretive Guidelines require a dosage reduction to the lowest effective dose by decreasing the dose two times in the first year unless "clinically contraindicated to discontinuation" is documented. This correlates to a dosage reduction within the first nine months of antidepressant treatment. This necessitates that in the majority of depressive episodes, clinicians document their rationale for continuing treatment. Clinicians must commit to this process, and surveyors must acknowledge this appropriate approach to depression management.

Opioid-paracetamol prescription patterns and liver dysfunction: a retrospective cohort study in a population served by a US health benefits organization.

BACKGROUND: Paracetamol (acetaminophen) is the most common cause of acute liver failure (ALF). ALF attributed to paracetamol is most often associated with the following features: an unintentional overdose, a single product, an opioid-paracetamol combination, duration of <7 days, and a median dose of 7.5 g/day. Currently, the recommended maximum daily dose of paracetamol is 4 g. OBJECTIVES: The aims of the study were to determine opioid-paracetamol prescription patterns, including prescriptions exceeding the recommended dose of paracetamol (4 g/day) [prescriptions and beneficiaries]; examine factors associated with receiving opioid-paracetamol prescriptions in excess of paracetamol 4 g/day; and evaluate opioid-paracetamol prescription patterns for beneficiaries with liver dysfunction. METHODS: A retrospective cohort study examining prescription data of 4.8 million beneficiaries from a US health benefits organization from 1 January 2009 through 31 December 2009. The main outcomes examined were daily paracetamol dose and liver dysfunction. RESULTS: A large proportion (8.1%) of the 5.3 million prescriptions for opioid-paracetamol exceeded the recommended maximum daily dose of paracetamol (4 g/day), putting over one-quarter of a million (255 123 [18.9%]) of the 1.35 million beneficiaries receiving an opioid-paracetamol prescription at risk of toxicity. The most frequently prescribed products that exceeded paracetamol dose guidelines contained dextropropoxyphene and hydrocodone. Multiple factors, including type of product (i.e. dextropropoxyphene or oxycodone-containing), geographical location (Midwest), strength of the paracetamol in the opioid-paracetamol product (>325 mg) and prescriber specialty (dentist, physician assistant), were associated with high-dose paracetamol prescriptions. Liver dysfunction was diagnosed in 3818 cases, and 23.4% of these beneficiaries received an opioid-paracetamol prescription in the 90 days prior to the liver dysfunction diagnosis. CONCLUSIONS: Although most opioid-paracetamol prescriptions are written and dispensed for <4 g/day of paracetamol, a significant portion of beneficiaries are being prescribed and dispensed excessive doses of paracetamol. Efforts to curtail this practice may involve provision of prescriber and pharmacist education, utilization of benefit manager systems to flag excessive dosing or that require confirmation of dosing, and implementation of US FDA recommendations supported by these data.

Implementing standards 2007 to improve students' preparation for advanced pharmacy practice experiences.

OBJECTIVE: To examine the impact of implementation of the Accreditation Council for Pharmacy Education's (ACPE's) Standards 2007 on pharmacy students' preparation for their first advanced pharmacy practice experience (APPE). DESIGN: The doctor of pharmacy (PharmD) curriculum was altered to include introductory pharmacy practice experiences (IPPE), second-year therapeutics, classroom integration of practice experiences, more biomedical sciences, an electronic portfolio system, life-long learning exercises, and additional content based on Appendix B of Standards 2007. Curricular outcomes and the assessment plan also were revised based on Standards 2007. ASSESSMENT: To evaluate the impact of these changes to the curriculum, faculty members rated 9 behaviors of students observed during the third week of their first APPE and compared their scores with those of students who were evaluated in 2004 before the curriculum had been revised. Students completing the revised curriculum performed all 9 behaviors more often and had a better average score than students evaluated in 2004. CONCLUSION: Curricular revisions implemented to address ACPE Standards 2007 were associated with positive clinical behaviors in students beginning their experiential education.

First-year pharmacy students' self-assessment of communication skills and the impact of video review.

OBJECTIVES: To determine the ability of first-year students to self-assess communication skills and measure the impact of video review on students' self-assessment. DESIGN: Students participated in a digital video-recorded, counseling-simulation exercise and completed self-assessment before and after viewing their video. A faculty member evaluated the students using the same counseling assessment tool. ASSESSMENT: Correlation between the students' self-assessment scores and the faculty member's scores were poor (pre-video: r = 0.38, post-video: r = 0.46). The largest portion of the students overestimated their skills in comparison to the faculty member's evaluations (47.1% pre-video and 67.9% post-video). Those in the lowest quartile overestimated their skills, while those in the upper quartile underestimated their skills (pre-video). Video review brought about an increase in the self-assessment scores for nearly two-thirds (62.1%) of the students. CONCLUSION: First-year pharmacy students had difficulty self-assessing, and video review increased their perception of skill achievement. A curriculum should include opportunities for students to develop self-assessment skills early in the program, and this should be reinforced throughout the curriculum.

Medication use patterns in elderly South Dakota Medicare patients.

Optimizing medication use through the evaluation of Potentially Inappropriate Medications (PIMs) has been the focus of a great deal of research. The Centers for Medicare & Medicaid Services (CMS) has created its own definition of PIMs from a variety of existing criteria and has contracted with each state's Quality Improvement Organization (South Dakota Foundation for Medical Care in South Dakota) to work on reducing PIM rates. In South Dakota, 16.4 percent of Medicare beneficiaries who filled a prescription (April 1, 2008, through September 30, 2008) received a PIM. Of the patients receiving PIMs, 13.6 percent received PIMs from two or more categories, and 88.3 percent filled a prescription for at least one of the five most common PIM categories. These five PIM categories were propoxyphene, skeletal muscle relaxants (select agents), nitrofurantoin, oral estrogens and antihistamines (select agents). While there may be rare occasions when these agents are justified, safer or more effective alternatives exist.

Impact of an introductory pharmacy practice experience on students' performance in an advanced practice experience.

OBJECTIVE: To determine the impact of an introductory pharmacy practice experience (IPPE) on students' clinical skills during their initial advanced pharmacy practice experience (APPE). DESIGN: A 4-week First Steps course that focused on students developing pharmacy practice skills, clinical communications skills, and effective use of reference materials was introduced in 2006 at the end of the third-year curriculum, prior to students beginning their APPEs. ASSESSMENT: During the third week of the first APPE, faculty members rated students' demonstration of 9 clinical skills on a 5-point Likert scale (1 being always and 5 being never). The evaluation was performed in 2005 prior to implementation of the course (control group) and again in 2006 after implementation of the course. Students who completed the First Steps course scored better on all 9 skills and had a better average clinical skills value (2.3) compared to the control group (2.6, p < 0.01). CONCLUSION: Completion of an IPPE course that focused on critical pharmacy practice aspects, clinical communication skills, and use of reference materials resulted in increased frequency of desired clinical behaviors on a subsequent APPE.

Geriatric primer: implications and management of decline for the elderly patient.

Decline among older adults has the potential to produce dramatic changes in the elderly person's life, having an influence on the place of residence, self-sufficiency, and quality of life. Although the prevalence of decline among the elderly had decreased, the relevance of this topic will continue to grow with the expansion of the elderly population. It is important to understand the terminology used to describe decline, how it is measured, its ramifications, associated risk factors, and potential causes in order to participate in preventing and managing decline. Pharmacists should also be aware of the relationship of medications to decline including the management of causative conditions and medication-use patterns that are associated with decline. Finally, pharmacists must be prepared to help elderly patients who are having difficulties administering medications as a result of decline.

Propoxyphene and pain management in the elderly.

Pain is frequently reported and often undertreated in the elderly population. In light of these concerns, it is important to examine potentially ineffective or problematic pain medications. Propoxyphene is one such agent whose efficacy and safety have been questioned by researchers, clinicians and the U.S. Food and Drug Administration (FDA). Specifically, multiple studies have found propoxyphene to be no more effective than acetaminophen (APAP), yet propoxyphene causes opioid side effects and has been involved in many drug-related deaths. In addition, propoxyphene/APAP products are often prescribed at doses that exceed maximum values (49.2 percent of APAP/propoxyphene napsylate 100 prescriptions for South Dakota Medicaid patients exceeded the maximum daily dose). The relevance of propoxyphene use is seen by the 7.1 percent prevalence of propoxyphene prescriptions among the South Dakota Medicare beneficiaries, which is comparable to the 6.8 percent reported in the U.S. community-based Medicare population. Therefore, it is very important to consider alternatives to propoxyphene such as APAP, nonsteroidal anti-inflammatory drugs (rare use due to adverse effects) and other opioids, when managing elderly patients with pain.