Missouri Pharmacist Q3 2016

Oct. | Dec. 2016 Volume 90, Issue IV

MEET THE

2016 MPA

Award Winners pa ge 9

young

LEADERS

Are You One ? pa ge 16

GET THE FACTS ON

ACETAMINOPHEN

5 Safety Tips for Patients pa ge 32

MEET THIS YEAR'S

PRESIDENT

What's On The Agenda? pa ge 34

Making the right choices through diabetes patient education.

M

ACT NOW, SCHOLARSHIP GRANT MONEY IS AVAILABLE FOR A LIMITED TIME. Living with diabetes is never easy, but knowing how to manage this disease can make a big difference.

YOU HAVE THE POWER TO EDUCATE AND CHANGE THE LIVES OF PEOPLE WITH DIABETES. Diabetes Self-Management Education (DSME) site accreditation grant money is available.

Be the first to apply.

Scholarship grants are available July 2016 – June 2017 with a limited quantity of grants available.

All Diabetes Accreditation Standards-Practical Applications (DASPA) trained Missouri pharmacists are encouraged to apply for the PSE DSME scholarship grant. DASPA training, along with site accreditation, allows you to bill Medicare Part B and potentially other commercial payers and Missouri Medicaid for diabetes patient education.

Visit MoRX.com/pse now to learn

more and to submit a DSME scholarship grant application.

This grant opportunity is in partnership with the Missouri Department of Health and Senior Services and MPA. Living with diabetes is never easy, but quality education from a local Missouri pharmacist can make a big difference in someone’s life.

Pharmacist Service Expansion Project

Missouri Pharmacist Magazine, Volume 90, Issue IV

THE TABLE OF

Departments

CONTENTS

From the President pg 2 CEO Update pg 3 Tech Corner pg 6

Board of Directors

Member News pg 9 Expert Insight pg 18 Rich History, Bright Future pg 20 Law & Finance pg 28 Education News pg 30 Need To Know pg 32 Technology Tune-Up pg 36 Now & Then pg 40

MPA Staff

RON FITZWATER, MBA, CAE, Chief Executive Officer ROBYN SILVEY, CMP, Chief Operating Officer CHERYL HOFFER, Vice President Pharmacist Program Initiatives TRAVIS FITZWATER, Director of Strategic Initiatives DREW OESTREICH, Pharmacy Provider Relations ERICA GILLILAN, Administrative and Meetings Coordinator SARA WALSH, Member Services Coordinator LAUREN BROWN, Membership Coordinator

President – MARTY MICHEL, RPh, MBA, CDE Key Drugs, Poplar Bluff President Elect – MELODY SAVLEY, RPh ALPS Pharmacy, Springfield Treasurer – CHRIS GERONSIN, RPh Beverly Hills Pharmacy, St. Louis Secretary – LISA UMFLEET, RPh, CDE, CGP Parkland Health Pharmacy, Desloge Immediate Past President – JUSTIN MAY, PharmD Red Cross Pharmacy, Sedalia

Members At Large

JERRY CALLAHAN, RPh Elsberry Pharmacy, Elsberry JONI FORBUS, PharmD The Medicine Shoppe, Joplin DANIEL GOOD, MS, RPh, FASHP Mercy Health, Springfield CURT WOOD, RPh, CGP, FASCP Elder Care Pharmacy Consultants, LLC, New London

Ex-Officio Members

RUSSELL MELCHERT, PhD, RPh UMKC School of Pharmacy, Kansas City JOHN PIEPER, PharmD, FCCP St. Louis College of Pharmacy, St. Louis

MISSOURI PHARMACY ASSOCIATION | 211 EAST CAPITOL AVENUE | JEFFERSON CITY, MO 65101 PH: (573) 636-7522 FAX: (573) 636-7485 MoRx.COM MISSOURI PHARMACY ASSOCIATION MISSION: The Missouri Pharmacy Association promotes and protects the role of pharmacists as the medication expert in patient care relationships, and as an integral part of the health care team. Missouri Pharmacist is mailed to MPA members, non-member pharmacists, pharmacy educators, pharmacy technicians and pharmacy students in the state of Missouri. All views and opinions expressed in articles are those of the writer and are not necessarily the official position of the Missouri Pharmacy Association.

To advertise or for advertising rates email advertising@MoRx.com or call (573) 644-2258.

For editorial inquiries, contact Robyn Silvey at Robyn@MoRx.com or call (573) 636-7522.

Missouri Pharmacist, Vol 90, Issue IV, Fall 2016 is owned and published quarterly by the Missouri Pharmacy Association, 211 East Capitol Avenue, Jefferson City, MO 65101. Postage paid at Fulton, MO and additional mailing offices.

Postmaster: send address changes to Missouri Pharmacist, 211 E. Capitol Avenue, Jefferson City, MO 65101-3001

FROM THE PRESIDENT

A Year of Pharmacist Opportunity

by MARTY MICHEL, RPh, MBA, CDE

TO ACCESS MO-PCN CONTRACTING DOCUMENTS, VISIT MO-PCN.COM

A

s I start my year as your MPA President, there is much to reflect upon and there are goals to achieve for our profession. I have been practicing pharmacy for 33 years. Over the course of those years, we have spoken often about the pharmacist’s valuable role in impacting health care outcomes and sustainable payment required for pharmacist-delivered services.

that are clinically appropriate and fiscally responsible healthcare provided to Missouri’s most vulnerable segment of population.

Pharmacists bill for services by submitting a HCFA 1500 form to MO-PCN. Reimbursement is based on time spent for billable items including change in medication due to efficacy, cost or dose; suggesting a lab or discontinuation of a medication; identifying non-adherence; a

"PPRR is a tremendous opportunity to demonstrate our ability to positively impact patient outcomes and lower costs for the state."

Marty Michel, RPh, MBA, CDE, Key Drugs, Popular Bluff, Mo. is President of Missouri Pharmacy Association.

I am pleased to highlight a new MO HealthNet (Missouri Medicaid) program that recognizes and values the pharmacist role: Polypharmacy Risk Reduction Program (PPRR). Program participation is available to you through the Missouri Pharmacist Care Network (MO-PCN), an LLC operating under MPA. PPRR is a tremendous opportunity to demonstrate our ability to positively impact patient outcomes and lower costs for the state.

In the initial analysis of MO HealthNet patients, approximately 12,000 patients incurred 40 percent of the total Medicaid spend. PPRR identifies a subset of approximately half of those patients who meet the criteria of taking 12 or more chronic medications and being at risk for complications. We need your program commitment and participation, delivering pharmacist services associated with the potential 6,000 patients.

Many patients who are chronically ill may end up on multiple medications from multiple physicians. These medications can be duplicative or inconsistent with best practice guidelines. Utilizing paid claims data, MO HealthNet and its partners will identify targeted patients.

As pharmacists, we will review clinical information and then work with patients’ primary prescribers and implement the PPRR process, discussing findings and potential solutions. The PPRR goal is to review and submit suggestions

2 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

significant drug to drug interaction; an adverse drug event; or drug-disease interaction.

This is a great program to get involved with, especially if you are a part-time pharmacist or retired. It allows you to work at your own pace in the comfort of your own home.

I look forward to partnering with you on the PPRR opportunity, as well as accomplishing other MPA objectives throughout the next year.

Next Steps?

• Visit www.mo-pcn.com to access MO-PCN contracting documents and join today, if you are not already a MO-PCN contracted pharmacist.

• Pursue Medication Therapy Services (MTS) designation on your Missouri Board of Pharmacy license. Go to the Missouri Board of Pharmacy website under applications and forms.

• Contact the Xerox Help Desk at 888-581-9797 to become a MO HealthNet pharmacist provider. *See the "MO-PCN Gains Momentum" article on page 38 for complete PPRR details.

CEO UPDATE

A Cup of Coffee with Friends

by RON FITZWATER, CAE, MBA

T

he smell of freshly brewed coffee was a welcome aroma as the sound of laughter rang through the small meeting room. Around the table, four longtime friends discussed pharmacy issues. Not the fun issues, but the tough issues that are impacting community pharmacists all over Missouri, as well as the rest of the country.

But as serious as the issues are—and they are critical to the future of pharmacy—the conversation was shared among colleagues that have sat around similar tables at past meetings for a number of years.

nomic pressures are growing too. I have sat in hundreds of meetings over the years where the bottom line question is—how do we expand the services needed by patients that pharmacists can provide in a healthcare economic landscape that is rapidly changing? There we sat, exploring the options and trying to design workable solutions to these critical problems. One lacking ingredient in the discussions that was also addressed was the under-representation of the next generation of pharmacists. It is their future that is being discussed, but they are not dominant participants in the discussions.

"The prevalent question was, how could they as leaders in the profession respond to these issues and continue the growth and outreach of the pharmacy profession?"

As they shared their stories you could see the passion in their eyes and hear in their voices the love they have for their patients. The longtime patient who had been coerced by her insurance company to change to mail-order.

The devastating effect that DIR fees are having on community pharmacists and their ability to continue to provide services to their patients.

The threats from managed care companies who somehow convince insurance companies and other third-party payers that they can provide better care for patients from a corporate office somewhere rather than a face-to-face encounter with a patient by a trained pharmacist.

While the breakfast plates were being cleared by the hotel staff, the discussions continued. The prevalent question was, how could they as leaders in the profession respond to these issues and continue the growth and outreach of the pharmacy profession? There is no disputing the fact that the role pharmacists play in the new developing healthcare system is continuing to grow and expand. But the eco-

The meeting where this exchange of ideas occurred was the MPA Annual Convention, billed as a strong educational forum held in a relaxing resort setting at the Lake of the Ozarks But around our breakfast table that morning these four colleagues knew that the Annual Convention is more than about the continuing education programs that are provided. It is equally about the relationships and friendships that are built and the opportunity to sit around as we did that morning and discuss tough ideas and potential solutions in a relaxed atmosphere.

It is much like the first major league baseball game that I took three of my grandchildren to this spring. Today, they wouldn't be able to tell me the score of the game if I asked them. To them it wasn’t about the “business side” of the game. It was about the experience—the sights and sounds of the game. The baseball that was tossed to them by a player, their first stadium hot dog, the ice cream, the National Anthem ringing throughout the park as the game began.

Ron Fitzwater, MBA, CAE, is the CEO of Missouri Pharmacy Association.

The meetings that MPA hosts and sponsors are much the same. Obviously, the CE credits are important. But an equally important aspect is the friendships and relationships that are built. It is sitting around a table with a cup of coffee with a group of past presidents and picking their brains for ideas. It is interacting with the vendors who are there. It is meeting that next generation of pharmacists.

If you joined us at Tan-Tar-A, thank you.

I hope that it was a tremendous experience. If you weren't able to be there, I hope you will join us for the 2017 IPhA & MPA Joint Annual Conference September 7th-10th in St. Louis.

We will buy you a cup of coffee as you begin your own networking discussions.

Thank you for your support.

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 3

RED LETTER DATES October American Pharmacists' Month

December 1

Legislative Bill Filing Opens Jefferson City, MO

December 8

MPA Board of Directors Meeting Jefferson City, MO

March 24-27, 2017

APhA Annual Convention

San Francisco, CA APhA2017, the well-respected national pharmacy meeting for pharmacy professionals, delivers nationally recognized experts that cover topics from leadership to patient safety to medication errors. aphameeting.org

March 28, 2017

MPA Board of Directors Meeting Jefferson City, MO

March 29, 2017

January 4, 2017

Legislative Day

Jefferson City, MO

May 12, 2017

Legislative Session Opens

Jefferson City, MO

February

Legislative Session Closes

MPA's regional meetings are held throughout Missouri to network, discuss upcoming legislation, and examine opportunities with MPA all while earning 1-2 hours of continuing education. Meet and greet begins at 6:30 p.m. followed by dinner & presentation at 7:00 p.m.

MoRx.com

May 2017

MPA Regional Meeting

February 2, 2017 | Kansas City, MO February 8, 2017 | Columbia, MO February 9, 2017 | St. Louis, MO February 15, 2017 | Branson, MO February 16, 2017 | Springfield, MO February 22, 2017 | Dexter, MO February 23, 2017 | Cape Girardeau, MO

Jefferson City, MO

NCPA Legislative Conference Washington, DC

July 7-9, 2017

MPA Young Leadership Retreat

Old Kinderhook Lodge | Camdenton, MO

July 9, 2017

MPA Golf Tournament Old Kinderhook | Camdenton, MO

August 3-5, 2017

March 20-24, 2017

MPA Board Retreat

Jefferson City, MO

September 7-10, 2017

Legislative Spring Break

Branson, MO

IPhA, MPA Joint Annual Conference & Trade Show St. Louis, MO

THE PLACE FOR PEOPLE

GOING PLACES For more than 125 years, the UMKC School of Pharmacy has trained some of Missouri’s best health-care professionals.

Our secret? Teamwork.

Fewer than 20 schools in the country have schools of medicine, dentistry, nursing and health studies. UMKC is one of them.

Our students work on one campus toward one goal — making sure Missouri gets the very best in health care.

Interprofessional education is just one of the great things about UMKC. Discover the rest at pharmacy.umkc.edu.

Daniel Snyder School of Pharmacy Class of 2017

TECH CORNER

THE GREAT

CLINICAL

by JANNA BROWN

PharmD Candidate UMKC School of Pharmacy 4th Year Student

EXPANSION How can technicians assist pharmacists within an expanding clinical practice profession?

D

o your pharmacists want to expand their clinical services to your patients by increasing the pharmacy MTM services or implementing other patient care services? Do they involve the entire pharmacy team to help them succeed in these efforts, or are they attempting to do it all on their own?

In 1996, the City of Asheville, North Carolina launched an unusual approach to expand the role of pharmacists in order to effectively manage their diabetic patient community. Implementing this pharmacist-managed patient care service significantly improved patient outcomes while decreasing the city’s healthcare costs.1 In the July/August issue of Missouri Pharmacist, Dr. Sandra Bollinger explained the concept of team-based care and how important it is to implement this idea in pharmacy practice to successfully improve patient outcomes.2 Let’s take a closer look at how technicians can help improve patient care in a community pharmacy with the team-based approach.

Patient care services can include MTM services, health and wellness screenings, smoking cessation programs and immunization programs.

These services rely heavily on a pharmacist’s specialized knowledge and direct pharmacist to patient interaction. Assistance from trained pharmacy technicians can help make certain the pharmacist is available to provide these services. Technicians can help by scheduling patient visits, contacting patients for follow-up or appointment reminders, documenting encounters, obtaining patient medical records, and billing for services.

Proper patient scheduling involves both patient and pharmacist availability. Technicians also need to ensure not only that the pharmacist is available, but that the pharmacist won’t be overextended during that time. Technicians can also help workflow by verifying that the patient’s medications have been filled and are ready to be picked up at the time of the visit.

6 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

Patients participating in these programs will also likely need to complete different types of paperwork, from health histories to HIPAA acknowledgments. The technician can determine which paperwork is necessary and ensure that it's completed before the pharmacist sits down with the patient. This could be done by scheduling time before the actual visit or by mailing the paperwork to the patient a week in advance.

Technicians can also make reminder phone calls one or two days before appointments not only to verify the appointment time, but to also make certain the patient brings in necessary items for the visit, such as medication bottles or blood glucose logs.

The record-keeping involved in providing patient care services can be overwhelming unless a team-based approach is used. Building, organizing and filing patient charts can easily be done by technicians, especially when the technician is involved in the initial patient contact.

While compiling patient charts, technicians

TECH CORNER can also send requests for patient records or lab results to the patient's physician or primary care provider, and notify them the patient will be participating in the service program. Completing these requests and organizing them well in advance of the patient visit can help make the task less daunting while ensuring a more valuable encounter for the patient.

assist pharmacists in this, too. Seasoned technicians often have greater expertise in the intricacies of third-party insurance billing than some pharmacists, and provide valuable input into successful reimbursement.

Completing this process at the end of the patient care service could also coincide with the technician offering to schedule the patient’s next visit.

Obtaining the patient’s complete medical record is vital to the success of a patient care service program. Technicians can help pharmacists by gathering medication histories from patients or other sources. That may seem a bit frightening due to the extensive medication regimens that some patients may have, but you can work closely with your pharmacist to learn the best practices. Your pharmacist can help you by explaining and reviewing all the information that would be important to obtain, such as specific dosage considerations needed or any over-the-counter medication usage. The pharmacist can also provide you with resources you can consult to help get information that may be missing due to the patient’s lack of knowledge regarding their medication regimen.

As the pharmacy profession embraces extensive patient counseling services, many roles of pharmacy practice need to evolve to ensure success.

These services can not only generate revenue for the pharmacy but can also significantly improve patient outcomes as proven by The Asheville Project results. The time in administrative tasks for these services can limit the ability of pharmacists to provide valuable patient encounters.

With proper training, and a team-based approach, technicians can help with tasks that do not require pharmacist professional judgment, freeing the pharmacist to focus on clinical activities and enabling successful patient care service programs.

Processing insurance claims and appropriately billing for prescriptions is a task pharmacy technicians complete daily. Most patient care services require specific billing, and pharmacy technicians could easily

1. Cranor, CW, Christensen, DB. The Asheville project: short-term outcomes of a community pharmacy diabetes care program. Journal of the American Pharmacists Association. November-December 2012; 52 (6): 848 - 850.

2. Bollinger S. Implementing team-based care into a pharmacy practice. Missouri Pharmacist. July-August 2016; 90 (3): 8-9.

3. Powers MF, Bright DR. Pharmacy technicians and medication therapy management. Journal of Pharmacy Technology. November-December 2008; 24 (6): 336-339.

Gabriel W. Hulsey, CLCS 573-298-6480 ghulsey@redwoodfg.com

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 7

THE PTCB

ADVANTAGE • Improved employment opportunities • Demonstrated value to the pharmacy team • Validated achievement • Future career growth options • Prestige among coworkers • Potential for higher salary

Certification by PTCB is the gold standard for pharmacy technicians. Many employers now require their employees to be PTCB-Certified Pharmacy Technicians (CPhTs).

PTCB has a new website, a streamlined application process, sponsorships, and free verifications. The Pharmacy Technician Certification Exam (PTCE) reflects current knowledge areas demanded across all practice settings. PTCB’s requirements to become a CPhT include a high school diploma and a passing score on the PTCE. Learn more and apply at www.ptcb.org.

Get the

PTCB ADVANTAGE Become a

PTCB CPhT TODAY

SETTING THE STANDARD www.ptcb.org 8 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

CONNECT ONLINE:

SPRING 2015 3

2016 MPA Awards

The Missouri Pharmacy Association recognized the outstanding efforts of state pharmacy leaders during its Annual Conference and Trade Show in September at Tan-Tar-A Resort in Osage Beach.

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 9

Incoming President Award McKesson Plaque & National Community Pharmacists Association’s Leadership Plaque

Honorary President

Presented to Marty Michel, RPh, MBA, CDE Key Drugs, Poplar Bluff, MO

Each year, the incoming MPA President selects an honorary president.

Dr. Michel, a retired pharmacist from Poplar Bluff and father of incoming president Marty Michel, was honored with the designation this year.

Michel was recognized and will serve as president of the MPA Board of Directors for 2016-2017. He also received the NCPA’s Leadership Plaque.

This award is presented to the incoming president to acknowledge the time, talent and commitment that is required to lead a state pharmacy association.

President’s Award Presented to Ron L. Fitzwater, CAE, MBA Missouri Pharmacy Association, Jefferson City, MO

Each year the MPA President may select an individual for the President’s Award who has shown devotion to the Association and who has helped the president accomplish goals. Fitzwater was recognized for his outstanding service and loyalty to the Missouri Pharmacy Association and drew a standing ovation. Fitzwater serves as CEO of MPA. 10 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

Presented to Ken Michel, PharmD., FASCP Poplar Bluff, MO

Past President’s Pin and Award Presented to Justin May, PharmD. Red Cross Pharmacy, Marshall, MO

Dr. May, outgoing president of the Missouri Pharmacy Association, received the Past President’s Pin and Award, in recognition of his dedication to the Missouri Pharmacy Association as 2015-2016 president.

Appreciation Award Presented to Melody Savley, RPh ALPS Pharmacy, Springfield, MO

The MPA President annually selects a fellow board member to receive the Appreciation Award. Savley was chosen for her hard work and dedication to the MPA Board of Directors.

“Bowl of Hygeia” Award Presented to David Eden, RPh Mount Vernon, MO

This prestigious award is given to a pharmacist for outstanding community service in the pharmacy profession. Eden has been actively involved in his community for years and is the current Mayor of Mount Vernon.

Eden, who owned a pharmacy for 18 years, still takes calls at all times of the day and night for emergencies or to simply answer questions. He is a member of the Mount Vernon Planning & Zoning Commission, the Missouri Veteran’s Home Assistance League, the Mount Vernon Area Economic Development Corporation and serves on the UMKC Pharmacy Foundation Board. Previously he served on the Mount Vernon Board of Aldermen, and was a member of the Mount Vernon Community Foundation Board.

Cardinal Health Generation Rx Award of Excellence Presented to Richard Logan, PharmD. L&S Pharmacy, Charleston, MO

This award recognizes a pharmacist who is committed to substance abuse education in his/her community. The recipient must have raised awareness of the dangers of prescription drug abuse among the general public and among the pharmacy community. Dr. Logan owns community-based L&S Pharmacy in Charleston, with additional locations in Sikeston and New Madrid. Dr. Logan has also served as a police officer for the last 20 years. He's currently an active member of the Scott-Mississippi County Prescription Drug Task Force, which focuses on over prescribing, doctor shopping, and fraudulent prescription practices.

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 11

Distinguished Young Pharmacist Award Presented to Misty Collier Farr, PharmD. Walmart, Florissant, MO

This award is presented to a licensed member of the MPA who received his or her entry degree in pharmacy no more than nine years ago; is actively practicing in retail, hospital or consulting pharmacy; and participates in pharmacy associations, professional programs and/or community service. Dr. Farr is Pharmacy Manager at Walmart in Florissant and serves on the MPA's Professional Affairs committee. She is also a member of the Minority Women Pharmacist Association, serves on the St. Louis College of Pharmacy Strategic Planning Committee, is active in her community, and volunteers at various community health fairs. She is the 2016 recipient of the St. Louis College of Pharmacy Black Heritage Distinguished Alumnus Award and the 2016 St. Louis American Foundation’s Excellence in Health Care Award.

12 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

Excellence in Innovation Award Presented to Alicia B. Forinash, PharmD., FCCP, BCPS, BCACP Kirkwood, MO

This award recognizes a pharmacist who has demonstrated a rare, unique, or innovative style of pharmacy practice that results in improved patient care. Dr. Forinash is a Professor of Pharmacy Practice at St. Louis College of Pharmacy. Her practice site is at St. Mary's Health Center in the Maternal-Fetal Care Center. She is a nationally recognized expert in medication use in pregnancy lactation and other women’s health issues and has developed an innovative role as a pharmacist specialist within an OB/GYN specialty practice. Dr. Forinash has published several articles on women's health and is a co-author for the 11th edition of Brigg's Drug Use in Pregnancy and Lactation. She serves on the editorial board for the Annals of Pharmacotherapy for women's health and is a member of ACCP, ASHP and Organization of Teratology Information Specialists.

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 13

Traveler Of The Year Award

Technician of the Year Award

Presented to Kathy Davis Merck, Springfield, MO

Presented to Doyle D. Daniel, CPhT Greenfield Pharmacy, Greenfield, MO

This award recognizes a sales representative who calls on Missouri pharmacies, has shown a willingness and initiative to help pharmacists better serve their patients and the community, and has shown support and interest in the Missouri Pharmacy Association through support of programs, exhibits and/or attendance at district and/or state meetings. Davis has been in the vaccine division of Merck for the past 10 years, and has more than 25 years of experience with Merck. She has represented Merck at annual conferences, and has educated pharmacy owners on vaccines. Davis is a Court Appointed Special Advocate (CASA) volunteer and follows children in the foster program until they are adopted or return to their biological families.

14 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

This award recognizes a pharmacy technician who has demonstrated outstanding skills that help the pharmacist and pharmacy provide better pharmacy care and more efficient service to the patient/customer, and who shows an interest in and concern for the community. Daniel is a Certified Pharmacy Technician at Greenfield Pharmacy. Daniel’s nominator remarked that he is a “conscientious employee” who “manages inventory like every dollar was coming out of his own personal pocket.”

Active in his community, Daniel is a member of the Pennsboro Christian Church, served two terms on the Greenfield R-IV School Board, coached a summer Coach Pitch baseball team and was treasurer of a local saddle club.

Pharmacist Making a Difference Award Presented to Jay Bryant-Wimp, RPh Accurate Rx Specialty Pharmacy, Columbia, MO

This award recognizes a pharmacist who has gone above and beyond the call of duty to provide quality pharmacy care and to make a difference in the quality of life of patients. Bryant-Wimp is president and CEO of Accurate Rx Specialty Pharmacy in Columbia, a business he and his wife Stacy co-own and founded in 2009. Accurate Rx serves patients with chronic disease in their Ambulatory Infusion Clinic, Home Care and Specialty Pharmacy settings. Bryant-Wimp has built a successful pharmacy on a sound strategy, strong employee leadership, extra-mile customer service and clinical excellence. In addition, he developed and implemented a hospital-based Ambulatory Infusion Center in Bremerton, Washington, a national hemophilia and Centers of Excellence program in place at one of the largest pharmacies in America; and implemented a Specialty Pharmacy Cost Savings Program at Missouri Medicaid. He also helped with passage and language of the hemophilia standards of care law that was implemented in Missouri.

STLCOP Faculty Member of the Year Award Presented to Jamie M. Pitlick, PharmD., BCPS St. Louis College of Pharmacy, St. Louis, MO

This award is presented annually to one faculty member at the St. Louis College of Pharmacy campus for their contributions to the practice of pharmacy. Dr. Pitlick is an Associate Professor of Pharmacy Practice at STLCOP, and is also a Clinical Specialist in Ambulatory Care at the Mercy Hospital JFK Clinic. At the clinic she works in the pharmacy-managed diabetes clinic, weight loss clinic, and completes transitions of care phone calls post-hospital discharge.

UMKC Faculty Member of the Year Presented to Eric Wombwell, PharmD., BCPS UMKC School of Pharmacy, Kansas City, MO

This award is presented annually to one faculty member at the University of Missouri – Kansas City, School of Pharmacy campus for contributions to the practice of pharmacy. Dr. Wombwell is a Board Certified Pharmacotherapy Specialist (BCPS) and Clinical Associate Professor for the Department of Pharmacy Practice and Administration.

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 15

CALL TO ACTION, CALL TO ACTION

Young Leadership Retreat

by ERICA MAHN, PharmD

P

harmacy school does a great job of preparing you to become a pharmacist.

General medication information and patient counseling tips are presented and practiced through years of curriculum and rotations.

However, upon graduation, many pharmacists are placed in leadership roles they may have never had before. There is no longer a professor to email or a preceptor to model – technicians and patients looking for the pharmacist; the person that leads the pharmacy’s actions and protects each patient’s well-being.

Leadership is now a part of a pharmacist’s everyday responsibilities, whether they have years or days of experience. The Missouri Pharmacy Association’s first annual Young Leadership Retreat provided an opportunity for Missouri pharmacists to develop and discuss leadership skills within their pharmacies and communities. By the end of the weekend those who attended learned how to take their leadership roles even further by answering the question, “What makes a good leader?”

This question has come up many times for me over the years when making decisions both large and small. I have been a pharmacist for four years in a thriving, independent pharmacy in Springfield, Missouri. In my daily activities at the pharmacy, I help manage and train pharmacists, interns, technicians, delivery drivers, and auxiliary staff.

In pharmacy school, I learned to take care of patients and their medicines. There aren’t courses about managing staff or solving complications in work flow. During our time at the Young Leadership Retreat, we learned to start with the basics and hone the leadership skills we already possess to become better leaders.

Our journey started by learning who we are as leaders. Through the Myers-Briggs Type Indicator (MBTI) we learned how our personal quirks could be put to use within our leadership style. We also learned how people with other leadership types may play a role in our lives, whether professionally or personally, and how to work best together.

After receiving the results of the MBTI, we were divided into groups based on our results.

By working together, and getting to know each through the activities during the retreat, this information provided insights into who we were as leaders on a team. Each description for the leadership styles began to explain personality traits and habits: introvert versus extrovert, specific details versus big ideas, thinking versus feeling, deadlines versus flexibility – each combination showing the different things that are valued by people. The group had a broad mix of leadership styles and we were able to talk about what being a leader meant to each of us individually.

We also completed “unconscious bias” training to better prepare us for interactions

16 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

with both staff and patients. Everyone holds unconscious beliefs about the identities of groups of people around them. Through the activities provided, attendees quickly realized that each of us drew conclusions just from looking at a picture of a person or only hearing part of a conversation. In our daily lives we can tend to categorize groups of people and their needs without fully taking the time to evaluate the situation. This discussion afortified our learning and leadership goals by showing how being a leader in difficult situations will be the most defining moments in our leadership skills.

On Sunday before leaving, we were able to learn about opportunities in Missouri to be leaders in pharmacy. The saying, “Get into politics or get out of pharmacy,” was well portrayed when discussing the current issues in the state and how decisions could affect our current practices.

Overall, the Young Leadership Retreat was a great opportunity for attendees to learn about a different side of pharmacy. Pharmacy courses and continuing education hours teach you how to be a pharmacist; to understand medications, counsel patients, and make interventions. This retreat helped to show how pharmacists can be better leaders in their pharmacies. Through my experience at the Young Leadership Retreat, I feel I am better prepared for my future in pharmacy and I'm motivated to play a role in the future of pharmacy in Missouri.

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 17

EXPERT INSIGHT

Biosimilars, Biologics, Bioeqivalents: Do You Know the Difference?

by SANDRA BOLLINGER

PharmD, FASCP, CGP, CDE, CPT, CFts, MCMP-II Health Priorities, Inc., Cape Girardeau, MO

T

Bioequivalent Products

he landscape of medicine is expanding from conventional bioequivalent drugs into one where biological and biosimilar medications are more readily becoming drug therapy options.

The Merriam-Webster dictionary defines bioequivalence as:

“the property wherein two drugs with identical active ingredients (as a brand-name drug and its generic equivalent) or two different dosage forms (as tablet and oral suspension) of the same drug possess similar bioavailability and produce the same effect at the site of physiological activity”.

Bioequivalents are small molecule formulations of pure chemical substances with identifiable structures. A generic drug is considered to be “bioequivalent” to a brand-name drug whenever the active ingredient, dosage form, safety, strength, route of administration, quality, performance characteristics and intended use are the same as the brand-name.

Biological Products (Biologics)

IN CONTRAST TO A BIOEQUIVALENT PRODUCT, A BIOLOGIC

is a large molecule that is oftentimes 200 - 1,000 times the size of a small molecule (chemical) drug. Biologics are proteins that are made within living cells via recombinant DNA technology. The protein is formed by adding a piece of DNA within a living cell whereby the cell will either copy or translate the DNA piece into a protein. It’s the protein that then becomes the biological medicine. Biological medicines include: • vaccines • blood and blood products for transfusion and/or manufacturing into other products • allergenic extracts, which are used for both diagnosis and treatment (for example, allergy shots) • human cells and tissues used for transplantation (for example, tendons, ligaments and bone) • gene therapies • cellular therapies • tests to screen potential blood donors for infectious agents such as HIV1

18 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

Biologics are difficult to produce on a large scale because of their extreme sensitivity to temperature and pH. Even the slightest alteration in the production process could lead to changes in characteristics such as how a cell behaves, its structure or stability. Any change in the cell could potentially affect the product’s safety, efficacy or shelf life, and ultimately increase the risk of an unwanted immune response.2 Most biologics are difficult to identify because of their complex makeup.

Biosimilars

BIOLOGICAL PRODUCTS ARE DIVIDED INTO TWO TYPES: 1)

biosimilar and 2) interchangeable products. A biosimilar product is very “similar” to the reference product, (an already FDA-approved biological product), but is not identical to it. Some differences exist because biologics are made from living organisms. However, no clinically meaningful differences are found in regards to safety, purity or potency when compared to the reference product. In order for a biosimilar product to receive FDA approval, the biosimilar product has to have the same mechanism of action, route of administration, dosage form, and strength as the reference product. In addition, the FDA will only approve the indications and conditions of use for a biosimilar that have been previously approved for its reference product.

An interchangeable biologic is different from a biosimilar in that an interchangeable biologic is expected to produce the same clinical result as the reference product in any given patient.3 Biosimilars are not the same as generics and the terms should not be interchanged.4 Differences exist in the complexity of their makeup, in the manufacturing processes and also in the data that is required to demonstrate similarity for approval:5 PROPERTIES

GENERICS (Bioequivalents)

BIOSIMILARS

SIZE

Small

Large

MOLECULAR WEIGHT

<500-900 Daltons

4000 to >140,000 Daltons

STRUCTURE

Simple and well-defined

Complex with potential structural variations

MANUFACTURING

Predictable chemical pro- Specialized biological process to make identical copy cess to make similar copy

COMPLEXITY

Easy to fully characterize

Difficult to characterize due to heterogeneity

STABILITY

Relatively stable

Sensitive to storage and handling conditions

ADVERSE IMMUNE REACTION

Lower potential

Higher potential

MANUFACTURING QUALITY TESTS

≤ 50

≥ 250

APPROVAL REQUIREMENTS

Small clinical trials in healthy volunteers

Large clinical trials in patients

EXPERT INSIGHT Keeping It All Straight

Summary

THE “PURPLE BOOK” IS A REFERENCE BOOK THAT CONTAINS

BIOSIMILARS OFFER PATIENTS A WIDE RANGE OF THERAPEU-

valuable information about biological products. In it you can find:

tic options. While some companies are developing biosimilars on their own, many are starting to partner up to share costs. As more biological products are marketed it will become increasingly important to be able to differentiate between those that are biosimilar and those that are interchangeable in order to keep the safety of patients at the forefront.

1. The biosimilar and interchangeable biological products that have been licensed by the FDA under the Public Health Service Act (the PHS Act).

2. The date a biological product was licensed under 351(a) of the PHS Act

1 http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/Appr ovalApplications/TherapeuticBiologicApplications/ Biosimilars/ucm241719.htm accessed 8//8/2016

3. Whether the FDA evaluated the biological product for reference product exclusivity under section 351(k) (7) of the PHS Act.

2 http://www.amgenbiosimilars.com/the-basics/the-power-of-biologics/ accessed 8/18/2016

4. Whether the FDA determined the biologic to be biosimilar to or interchangeable with a reference biological product. The Biosimilar and interchangeable biological products licensed under section 351(k) of the PHS Act will be listed under the reference product to which biosimilarity or interchangeability was demonstrated.

3 http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/TherapeuticBiologicApplications/Biosimilars/ucm241718.htm accessed 8/18/2016 4 Biosimilar drugs: concerns and opportunities. BioDrugs. 2007; 21(6):351-6.

PMID: 18020619 5 http://www.amgenbiosimilars.com/the-basics/biosimilars-versus-generics/#bs927639EFC1294437B7A8774FB74CC426 accessed 8/18/2016

The Affordable Care Act amended the PHS Act to create an abbreviated licensure pathway for biological products that have been demonstrated to be “biosimilar” to or “interchangeable” with an FDA-licensed biological product. This pathway is provided in the part of the Affordable Care Act known as the Biologics Price Competition and Innovation Act of 2009 (BPCI Act).

Prescribing and Filling Prescriptions

KEEPING IN MIND THAT BIOSIMILARS ARE SIMILAR TO, BUT

not identical to, the reference product, regulatory guidelines require demonstration of the interchangeability between two different biological medicines. Clinical data that proves that multiple switches between a biosimilar and/or reference product pose no additional risk to patients is required. Healthcare providers can prescribe biosimilar and interchangeable biological products just as they would prescribe other medications.

The BPCI Act describes an interchangeable biological product as a product that may be substituted for the reference product without the intervention of the healthcare provider who prescribed the reference product. This is same process that is currently followed in regard to bioequivalents when substituting a generic product for a brand-name product.

In contrast, a biosimilar product is not recognized as interchangeable by the FDA and therefore will be specifically prescribed by the healthcare provider and cannot be substituted for a reference product at the pharmacy level.6 Separate lists for those biological products regulated by the Center for Drug Evaluation and Research (CDER) and the Center for Biologics Evaluation and Research (CBER) will be updated periodically.

6 http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/TherapeuticBiologicApplications/Biosimilars/ucm411418.htm accessed 8/18/2016

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THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 19

Rich History, Bright Future LAUGHTER'S THE BEST MEDICINE

How St. Louis College of Pharmacy is transforming to supp

20 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

port student pharmacist growth and learning.

RICH HISTORY, BRIGHT FUTURE

For 152 years, St. Louis College of Pharmacy has educated outstanding pharmacists who serve their patients and the profession with care and distinction.

From its founding in 1864 in the midst of the Civil War, the College has grown into one of the largest Doctor of Pharmacy programs in America and the fourth ranked private college of pharmacy in the U.S. The College is currently embarking on a transformational journey with the most ambitious campus expansion in its history. The $110 million project involves the construction of two new seven-story buildings on the College’s nine-acre campus adjacent to the Washington University Medical Center, one of the nation’s leading biomedical complexes.

“It’s an exciting time at St. Louis College of Pharmacy, full of energy, promise and innovation,” said President John A. Pieper, PharmD., FCCP. “We are undergoing significant growth, and our entire campus community is making a meaningful difference in the St. Louis region, the nation and across world.”

Academic and Research Building

I

In just the second year of classes and activities inside the award-winning Academic and Research Building (ARB), the resources are already having an impact on pharmacy education.

The 213,00 square-foot facility includes a 33,000-square foot library, large auditorium, large and small classrooms, numerous laboratories and study areas. The ARB is home to two innovative centers, the Center for Clinical Pharmacology (CCP) and the Center for Interprofessional Practice and Education at Washington University Medical Center (CIPE).

22 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

DEPARTMENT TAG

A

‟We are undergoing significant growth, and our entire campus community is making a meaningful difference in the St. Louis region, the nation and across world.”

– President

John A. Pieper

ACADEMIC AND RESEARCH BUILDING (ARB)

St. Louis College of Pharmacy draws from their pioneering spirit to transform to cutting edge in teaching, research and facilities.

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 23

RICH HISTORY, BRIGHT FUTURE

LEADING THE WAY

Dr. Jeremia Ory, phD, works with STLCOP students Jocelyn Teagarden and Tanner Bross within the newly constructed labs at St. Louis College of Pharmacy.

“Our location, and the construction of the ARB, have facilitated the creation of forward-thinking partnerships and collaborative research centers that offer educational, research and pharmacy practice opportunities,” Pieper added. “It’s a setting few colleges of pharmacy in the world can rival.”

The CCP is a joint effort with Washington University School of Medicine in St. Louis. It was formed to address the rational use of existing and new medicines and accelerate the translation of basic research to clinical treatment for improving patient care.

“The Center is a coalescence of several unmet needs, desires and aspirations,” explained Evan D. Kharasch, M.D., PhD., director of the CCP. “We’re building upon

the existing strengths of both institutions to create a new research focus, new opportunities for researchers and students, and a new paradigm of collaboration with an inherent opportunity for synergy, growth and expansion over time.”

The CCP’s initial focus will be on optimizing the use of pain medication. The CCP fills half the ARB’s 30,000 square feet of research space. The other portion of space is devoted to STLCOP faculty research.

For example, Martha Bhattacharya, PhD., assistant professor of biology, is currently researching the degeneration of neurons exposed to chemotherapy medications like taxol and vincristine.

24 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

In the lab, Bhattacharya observes how the nervous system in fruit flies is affected by taxol exposure. She hypothesizes it will lead to the identification of a biological target that could be used in patients to block nerve degeneration.

“If we know what those molecules are, we may be able to stop them from being activated, or hold them in an inactive state while someone is taking a chemotherapy medication,” Bhattacharya said. Her research began at Washington University, where her collaborators still maintain labs.

Just a few floors away in the ARB is the main office of the CIPE. It is a collaborative effort between the College, Goldfarb School of Nursing at Barnes-Jewish College and

Join the force. Impact your profession.

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STRENGTHEN THE VOICE OF PHARMACISTS Join MPA today, here is how:

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pricing on insurance products, quality

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industry, Medicare & Medicaid and national organizations.

We are your voice.

RICH HISTORY, BRIGHT FUTURE

‟St. Louis College of Pharmacy was born with a pioneering spirit of innovation that lives on today ...”

DESIGN WITH A PURPOSE

Input from the STLCOP community assisted in the design of the growing campus. Top: Academic and Research Building Auditorium. Opposite Page from top to bottom: Recreation and Student Center external rending; Recreation and Student Center gym rendering; Overlay of the RAS building within the STLCOP landscape.

Washington University School of Medicine.

The CIPE was founded to further the goal of improving patient safety and quality in health care.

“Patients receive better care when health care professionals work as a team,” said Heather Hageman, inaugural director of the CIPE, which brings together students in medicine, pharmacy, nursing, physical therapy, occupational therapy, and audiology and deaf education. “Health care workers make fewer errors when they collaborate and feel respected by one another.”

In addition to the expanded research and interprofessional work, the ARB is quickly becoming a favorite place to learn and study. The new sterile compounding lab

contains the latest laminar flow hoods that record students’ work in real time so faculty can provide direct feedback to improve their intravenous (IV) medications preparation skills. Students are developing critical pharmacy practice skills in the community pharmacy and hospital skills labs. The space also includes a state-of-the-art standardized patient facility for students to improve their patient care skills.

“We were very thoughtful and purposeful on the design of all educational spaces,” Pieper said. “The design process incorporated the valuable input of students, faculty, staff and alumni as well as what we identified as best practices from newer buildings at the nation’s top health care education institutions.”

26 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

When studying or relaxing between classes, students say how much they like the natural light streaming through the windows. They also appreciate having strategically-placed outlets to charge their electronic devices as well as the availability of white boards. State-of-the-art features also include monitors in study rooms, which have become an integrated part of group learning sessions.

“Students here have the complete college experience,” Pieper explained. “In addition to learning with the aid of the latest technology, the ARB auditorium is regularly used for enriching and horizon expanding appearances by noted authors and performers, including members of the St. Louis Symphony.”

RICH HISTORY, BRIGHT FUTURE Recreation and Student Center

F

From the windows on the ARB’s north side, you can see the next phase of the College’s master plan quickly taking shape. Construction on a second building nearly identical in size is nearing an end. The 193,000-square-foot Recreation and Student Center (RAS) is scheduled for completion in February of 2017.

Amy Luchun, project architect at St. Louis-based Forum Studio, was tasked with fitting four very different, significant needs into the building: two gymnasium/ recreation centers; a student center; a 232-bed residence hall; and a dining facility. The building’s entire square footage is nearly 40 percent larger than the field the Cardinals play on at Busch Stadium, yet there is little wasted space with so many features in the building.

“The biggest challenge was bringing all four functions together and how they could relate to each other and share amenities,” Luchun said.

Counseling, student development, tutoring and the Student Success Center connected to the Office of Culture and Campus Life will be greatly expanded in the RAS. A multicultural student center and quiet serenity room will be available to all students, faculty and staff. The top three floors of the RAS will be a second residence hall. With the glass-lined walls and sharp angles, the building’s design is meant to complement the ARB, as well as stand out among the many new buildings on the medical center campus.

When the RAS is complete, the College will have added more than 400,000 square feet of space for living and learning.

The College has come a long way since its founding in a rented classroom in a downtown St. Louis medical building. Alumni currently practice in 48 states and 14 different countries. In the St. Louis region, more than 70 percent of practicing pharmacists are graduates of the College.

“As the first college of pharmacy west of the Mississippi River, St. Louis College of Pharmacy was born with a pioneering spirit of innovation that lives on today, inspiring future pharmacists to make the world a better place by providing the finest patient-centered care,” Pieper said.

“These new buildings will help attract and retain the best and brightest students, faculty and staff, and expand teaching and research opportunities for faculty and create a welcoming environment for everyone living and working on or visiting campus for many years to come.”

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 27

LAW & FINANCE

by

DON. R. MCGUIRE JR., R.Ph., J.D.

T

And The Law – Advocacy

o paraphrase John Godfrey Saxe; laws are like sausages, it’s better not to see them being made. I am not an expert on sausages, but I would disagree with this comment with regards to laws. Even if we don’t get involved in the making of laws, we will be subject to them nonetheless. Pharmacists can ill afford to be impacted by laws drafted by those who know nothing about pharmacy.

Unfortunately for many of us, lobbying is a word with very negative connotations. It projects images of under the table dealings and improper exchanges of cash. So how do we inform lawmakers of the impact of proposed laws on the practice of pharmacy? Through advocacy.

Advocacy is simply the act of supporting a cause, an idea, or a proposed policy. Many state and national associations organize advocacy meetings for their members. While we can all do this individually, a group of concerned citizens visiting the lawmaker’s office together can certainly make a larger impact. The purpose of these visits is to educate the lawmaker and their staff on proposed laws that impact our profession.

We might be in favor of a proposal, opposed to it or want to amend the language as presented.

Lawmakers are serving because they want to make a positive difference in our society.

However, they are not experts in every field.

There is only one pharmacist, Buddy Carter of Georgia, in the 114th Congress. The other

Senators and Representatives need pharmacists’ help to understand how proposals will affect pharmacy practice.

I have participated in advocacy meetings on both the state and national level. In my experience, the lawmakers and staffers are eager to hear how proposals will affect constituents in their districts. The meetings usually consist of an introduction, explanation of why you are there, what the real impact in their district will be, and what action you want them to take. For pharmacists, the potential impact is not always direct. The impact may be on our patients; denying access, increasing costs, or creating hurdles to care. Of course, these indirect impacts will have impact on your pharmacy practice. Many times the true impact on patients is not readily apparent. Pharmacists can explain how a particular policy will make it more difficult for patients to get their medications. Don’t expect immediate action. It is always a pleasant surprise to get a commitment, but many times the materials that you provide are circulated in the office before decisions are made.

Not all advocacy has to take place in Washington, D.C. or your state capital. Invite your lawmaker to visit your pharmacy while they are home in the district. Then they will get to see first-hand what you are doing for your patients, their constituents. You can also advise them about how proposed laws will impact your ability to provide these services. First-hand knowledge

28 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

and stories of real impacts (not just theoretical ones) will have the most influence on the process.

If pharmacists don’t educate lawmakers about the effects of the changes on their practices and their patients, who will? Don’t think of it as lobbying. We are really educating our lawmakers. Joining and participating in professional organizations is a good way to get started. In the end, the profession will benefit and ultimately, our patients will too.

© Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, Risk Management & Compliance at Pharmacists Mutual Insurance Company.

This article discusses general principles of law and risk management. It is not intended as legal advice.

Pharmacists should consult their own attorneys and insurance companies for specific advice.

Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.

FINANCE & LAW

Volatility Is Not Risk

W

provided by

The two should not be confused.

KEVIN CALLAWAY & CHARLIE FRANK

What is risk?

To the conservative investor, risk is a negative. To the opportunistic investor, risk is a factor to tolerate and accept.

Whatever the perception of risk, it should not be confused with volatility. That confusion occurs much too frequently.

Volatility can be considered a measurement of risk, but it is not risk itself.

Many investors and academics measure investment risk in terms of beta; that is, in terms of an investment’s ups and downs in relation to a market sector or the entirety of the market.

If you want to measure volatility from a very wide angle, you can examine standard deviation for the S&P 500. The total return of this broad benchmark averaged 10.1 percent during 1926-2015, and there was a standard deviation of 20.1 from that average total return during those 90 market years.1 What does that mean? It means that if you add or subtract 20.1 from 10.1, you get the range of total return that could be expected from the S&P two-thirds of the time during the period from 1926-2015. That is quite a variance, indicating that investors should be ready for anything when investing in equities. During 19262015, there was a 67 percent chance that the S&P could return anywhere from a 30.2 percent yearly gain to a 10.1 percent yearly loss. (Again, this is total return with dividends included.)1 Just recently, there were years in which the S&P’s total return fell outside of that wide range.

In 2013, the index’s total return was +32.39 percent. In 2008, its total return was -37.00 percent.2

1 fc.standardandpoors.com/sites/client/generic/axa/ axa4/Article.vm?topic=5991&siteContent=8088 [3/31/16] 2 ycharts.com/indicators/sandp_500_total_return_ annual [3/31/16]

When statisticians measure the volatility of major indices like the S&P 500, Nasdaq Composite, or Dow Jones Industrial Average, they are measuring market risk. Trying to measure investment risk is another matter.

You can argue that investment risk is not measurable.

How can investors measure the probability of a loss when they invest? Even after they sell an investment, can they go back and calculate what their risk was at the time they bought it?

They only know if they made money or not.

Profit or loss says nothing about risk exposure.

Most experienced investors do not fear volatility.

Instead, they fear loss. They think of “risk” as their potential for unrecoverable loss.

In reality, most apparent “losses” may be recoverable given enough time. True unrecoverable losses occur in one of two ways. One, an investor sells the investment for less than what he or she paid for it. Two, some kind of irrevocable change happens, either to the investment itself or to the sector to which the investment belongs. For example, a company goes totally out of business and leaves investors with worthless securities. Or, an innovation transforms an industry so profoundly that it renders what was once a leading-edge company an afterthought.

Accepting risk means accepting the possibilities of equity investing.

The range of possibilities for investment performance and market performance is vast.

Financial advisors (L to R) Charlie Frank and Kevin Callaway discuss the state of the market at the 2016 MPA Annual Conference & Expo.

History has shown that to be true, history being all we have to look at. It fails to tell us anything about the negative (or positive) disruptions that could come out of nowhere to upend our assumptions. A “black swan” (terrorism, a virus, an environmental crisis, a quick evaporation of investor confidence) is always a possibility. Next year, the performance of this or that sector or the small caps or blue chips could be spectacular. It could also be dismal. It could certainly fall in between those extremes. There is no way to calculate it or estimate it in advance. For the equities investor, the future is always a flashing question mark, regardless of what history tells or pundits predict.

Diversification helps investors cope with volatility & risk.

Spreading assets across various investment classes may reduce a portfolio’s concentration in a hot sector, but it also lessens the possibility of a portfolio being overweighted in a cold one.

Volatility is a statistical expression of market risk, constantly measured. Volatility, however, should not be confused with risk itself.

Kevin Callaway may be reached at (573) 634-1371 or kcallaway@centralinvestment.net.

Charlie Frank may be reached at (573) 634-1157 or cfrank@centralinvestment.net.

This material was prepared by MarketingPro, Inc., and does not necessarily represent the views of the presenting party, nor their affiliates. This information has been derived from sources believed to be accurate. Please note - investing involves risk, and past performance is no guarantee of future results. The publisher is not engaged in rendering legal, accounting or other professional services. If assistance is needed, the reader is advised to engage the services of a competent professional. This information should not be construed as investment, tax or legal advice and may not be relied on for the purpose of avoiding any Federal tax penalty. This is neither a solicitation nor recommendation to purchase or sell any investment or insurance product or service, and should not be relied upon as such. All indices are unmanaged and are not illustrative of any particular investment.

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 29

EDUCATION NEWS

UMKC SCHOOL OF PHARMACY UPDATE The number one goal of the UMKC School of Pharmacy is to place student success at the center of all we do. We could not accomplish this goal without an outstanding faculty and staff and we have great news to share about faculty recruitment and promotions.

Since the last update for the Missouri Pharmacist, we have hired three new outstanding faculty members. Dr. Sarah Cox joins the faculty at our Columbia location on the Mizzou campus and will set up her practice at the University of Missouri Hospital. Dr. Cox is a graduate of the UMKC School of Pharmacy (MU location) and most recently completed two years of residency at Houston Methodist Hospital in Texas.

Dr. Kathryn Holt is part of the faculty in Kansas City and is setting up her clinical practice at North Kansas City Hospital. Dr. Holt is a graduate of the South Carolina College of Pharmacy and joined us from South Carolina where she completed two years of residency at the Medical University of South Carolina.

Dr. April Risner is a member of the faculty at our Springfield location. Dr. Risner is a graduate of the UMKC School of Pharmacy (Kansas City location) and completed one year of residence at the Kansas City VA Medical Center and the second year at CoxHealth in Springfield. Dr. Risnerâ&#x20AC;&#x2122;s practice will be at the new Missouri State University Care Clinic in Springfield, Missouri.

We are also happy to announce several faculty promotions. In our basic science faculty, Dr. Hari Bhat was promoted to Professor of Pharmacology and Toxicology. Dr. Bill Gutheil was promoted to Professor of Pharmaceutical Sciences. In the clinical division, Drs. Kelly Cochran, Jeremy Hampton, and Erica Ottis were promoted to Clinical Associate Professor.

Congratulations to all of these faculty members on their recent success. We are fortunate to have them on our faculty and educating our student pharmacists.

UMKC SCHOOL OF PHARMACYâ&#x20AC;&#x2122;S BUSINESS PLAN TEAM

From left to right are UMKC team members Zach Reasoner, Doug Melton, Andrew Miller, Jessie Greer, Robert Hopkins, Levi Hare, and Marian Lyford.

NCPA ANNOUNCES FINALISTS FOR 2016 GOOD NEIGHBOR PHARMACY NCPA PRUITT-SCHUTTE STUDENT BUSINESS PLAN COMPETITION The National Community Pharmacists Association (NCPA) announced that three teams of pharmacy students have been named finalists in the 2016 Good Neighbor Pharmacy NCPA Pruitt-Schutte Student Business Plan Competition. Teams of pharmacy students from University of Maryland School of Pharmacy, University of North Carolina Eshelman School of Pharmacy, and University of Texas at Austin College of Pharmacy will present their business plans in a live competition Oct. 15, 2016 at NCPA's Annual Convention in New

30 MissouriPHARMACIST July | Sept. 2016 Volume 90, Issue III

Orleans. This year's competition drew submissions from 46 schools and colleges of pharmacy, and over 200 student and advisor participants.

The remaining finalists in the top 10 are Drake University College of Pharmacy & Health Sciences; University of Arkansas for Medical Sciences College of Pharmacy; University of Missouri Kansas City School of Pharmacy; University of Minnesota College of Pharmacy; University of the Pacific Thomas J. Long School of Pharmacy and Health Sciences; University of Washington School of Pharmacy; and Washington State University College of Pharmacy. The submissions were judged by a panel of 55 NCPA members, Good Neighbor Pharmacy Business Coaching consultants, and business team leaders from the Professional Compounding Centers of America (PCCA).

All participating schools receive a plaque commemorating their participation in the competition. Each year, competing schools receive an engraved plate to add to their plaque, and teams placing in the top 10 receive a special plate acknowledging this distinction.

ST. LOUIS COLLEGE OF PHARMACY PRESIDENT ELECTED TO INTERNATIONAL PHARMACY LEADERSHIP POSITION St. Louis College of Pharmacy President John A. Pieper, PharmD., FCCP, FAPhA, has been selected as president-elect of the Academic Pharmacy Section of the International Pharmaceutical Federation (FIP). As president-elect, Dr. Pieper will advance the section’s goals including promoting pharmacy education worldwide and contributing to development of teaching methodologies, student and faculty exchange programs, strategic planning and policy development.

Founded in 1912, the FIP is the global body representing pharmacy and pharmaceutical sciences. Through 139 national organizations, academic institutional members and individual members, FIP represents over three million pharmacists and pharmaceutical scientists around the world.

“The profession of pharmacy is growing and changing. In addition to being leaders in the community, pharmacists are taking on greater duties as part of the patient-centered, interprofessional health care team,” Dr. Pieper said. “We have an opportunity to prepare pharmacists to positively impact patients in an increasingly interconnected global society.”

Dr. Pieper became the fourth president of St. Louis College of Pharmacy on Aug. 1, 2010. Prior to his appointment at the College, Dr. Pieper served as professor and dean of the College of Pharmacy at the University of New Mexico (UNM), with concurrent appointments as vice president for research and deputy executive vice president at the University of New Mexico Health Sciences Center in Albuquerque. Dr. Pieper was also a senior fellow at the Robert Wood Johnson Center for Health Policy at UNM and was adjunct professor, Facultad de Farmacia, at the Universidad Autónoma del Estado de Morelos in Cuernavaca, Mexico.

Before his appointment at UNM in November 2002, Dr. Pieper served as professor

and chairman of the Division of Pharmacotherapy, School of Pharmacy at the University of North Carolina at Chapel Hill and as associate dean for clinical programs and founding chair of the Department of Pharmacy Practice at the School of Pharmacy, University of Colorado. He has also held faculty positions in the colleges of pharmacy at the University of Tennessee and the University of Florida. Dr. Pieper received a B.A. in molecular biology from the University of Colorado, a B.S. in pharmacy from the University of Wyoming and a PharmD. and post-doctoral fellowship training at the School of Pharmacy, State University of New York at Buffalo.

Dr. Pieper is the immediate past chair of the Board of Pharmacy Specialties (BPS) and is a non-specialist pharmacist member of the BPS Board of Directors. He is currently serving as vice president of the Independent Colleges and Universities (ICUM). He is also a past president of the American College of Clinical Pharmacy, past speaker of the house of delegates of the American Association of Colleges of Pharmacy and was recognized by the American Pharmacists Association as the Outstanding Pharmacy Dean in the United States in 2006. Dr. Pieper is a fellow of the American College of Clinical Pharmacy and the American Pharmacists Association.

STLCOP PARTNERS WITH NELSON MANDELA METROPOLITAN UNIVERSITY IN SOUTH AFRICA

St. Louis College of Pharmacy and Nelson Mandela Metropolitan University in South Africa partner to carve a new path for pharmacy technicians across Southern Africa. Together, the institutions have just published “The Southern African Pharmacy Technician Training Manual.” It is the first manual designed specifically for English-speaking pharmacy technicians in the region.

“Previously, we had to use textbooks from Europe or North America that were not specific to the African context,” said Shirley-Anne

EDUCATION NEWS Boschmans, PhD., co-author and head of the Department of Pharmacy at NMMU. “This manual focuses on technicians’ basic job responsibilities and is designed to be flexible.”

Faculty and students from the College have traveled to NMMU and Southern Africa numerous times during their three-year partnership. Faculty from NMMU have visited St. Louis as well. That face-to-face interaction with educators and patients is invaluable according to Ken Schafermeyer, PhD., professor of pharmacy administration and director of international programs at the College.

“Pharmacy technicians are an excellent resource in public-sector hospitals and primary care clinics, where they might be the only pharmacy personnel to manage medication distribution,” Schafermeyer said.

The manual features intensive instruction on medications to help patients with HIV/ AIDS and tuberculosis. Other topics include pharmacy calculations, basic pharmacology, compounding and patient communication.

The manual is accompanied by an instructor’s guide, co-authored by Stephanie Lukas, PharmD., M.P.H., assistant director of international programs at the College, that provides suggested exercises, assignments and discussion questions.

“This book can be used as a learning tool for pharmacy technicians as part of a university-level course or as part of an on-the-job training program,” said Teri-Lynne Fogarty, M. Pharm., co-author, lecturer and coordinator of the Pharmacy Technician program at NMMU. Estimates vary widely, but many believe there are more than 17 million patients living with HIV or AIDS in Eastern and Southern Africa. It’s the highest concentration of patients in the world. As a result, there is a dire need for pharmacy personnel to provide basic services like medication distribution.

The partnership with NMMU was funded through a grant from the American International Health Alliance.

As a community service, the manual is available to students, educators and organizations at cost.

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 31

NEED TO KNOW

I

n a recent patient encounter, a have side effects and monitoring woman came to the pharmacy parameters, but here are some tips inquiring about sinus medicaon how to keep your patients safe tion. She showed me a small while taking acetaminophen. packet which said “Advanced Sinus 1. Make sure they understand Relief” on the front and told me she what they are taking. Many paneeded more sinus medicine. After tients get confused when it comes to

by Amanda Brenneke, PharmD Candidate 2017 further questioning I learned that the generic names of pain relievers.

University of Missouri–Kansas City her employer provides these packets Stressing that patients know and recto the staff and she takes them freognize acetaminophen as Tylenol can help them decipher what is in their quently. She stated that the medicine medications. usually helps her sinus congestion, but always In 2011 the Food and Drug Administrahas to take both pills in the packet. A quick look tion asked all makers/manufacturers of pre2. Tell patients to use caution when at the active ingredients listed on the packet scription products that contain acetaminophen taking cold, cough, and flu medrevealed that each tablet of the sinus medication to limit the amount of the drug to 325 mg per ications. Once patients can recognize contained 5 mg of phenylephrine and 500 mg tablet or capsule. They also required a Boxed acetaminophen as Tylenol, they can begin checking what products they are using to of acetaminophen with directions to take 1-2 Warning on all prescription acetaminophen make sure they aren’t doubling up on doses. tablets every 4-6 hours. That means this paproducts that highlights the potential risk for tient was ingesting 1,000 mg of acetaminophen, severe liver injury. Boxed Warnings are FDA's 3. Explain that dosages add up. Teach without an indication for it, every time she had strongest warnings for prescription drug prodpatients the maximum dosage they can head congestion at work. She stated that she ucts, used for calling attention to serious or take in 24 hours and explain that every would take multiple packets a day when her life-threatening risks.3 The agency was hoping medicine containing acetaminophen adds sinuses were the worst. When asked if she knew to reduce the risk of severe liver injury associinto that total. what medications were in the tablets, the patient ated with acetaminophen by requiring these 4. Teach the patient why limiting alsaid that she read the ingredients and saw it said new procedures. Last year, in November of cohol is important with this mednasal decongestant and pain reliever. She said 2015, the FDA released final guidance to overication. If they do not know the reason she thought that was a pretty good combination the-counter acetaminophen manufacturers behind the recommendation, there is a for her symptoms and did not think anything on labeling verbiage. The new language can good chance they won’t follow it. Men of it. After hearing this I inquired about any be used as an alternative to the previous reshould be limited to two drinks a day while women can only have one while pain she was experiencing and she said she quirement of stating how many tablets/capsules taking acetaminophen. didn’t have any. When I told the patient that not to exceed in 24 hours. The new warning there was 1,000 mg of Tylenol in each packreads “Liver warning: This product contains 5. Stress to them the need to follow the et and that the daily limit was 4,000 mg, she acetaminophen. Severe liver damage may occur dosing instructions. It is important seemed uneasy and confused. The packaging if you take • more than 4,000 mg of acetaminothat they do not exceed the number of pills made no mention of the medication being for phen in 24 hours • with other drugs containing that is recommended on the label, even if pain, headaches, or fever in the advertising acetaminophen • 3 or more alcoholic drinks it is tempting to go one or two tablets over. on the front. This patient was unknowingly every day while using this product.” The FDA It can be easy to forget dosing regimens ingesting large amounts of Tylenol every time implemented this language because the previwhen you are in pain or have a pounding headher sinuses flared up. She easily could have also ous rule was thought to be confusing and imply ache. Some patients throw away labels or keep been taking additional combination products that severe liver damage could occur from less medications so long that the labels fade and which also contained acetaminophen. Withthan 4,000 mg.4 become unreadable. After reminding them of out knowing that these sinus tablets contained As medication experts, pharmacists have the importance for expiration dates, you can large amounts of acetaminophen, the risk of a duty to educate the public as well as our lopoint them to Tylenol’s website where they can exceeding the appropriate limits was highly cal patients on the harm of acetaminophen. find helpful patient friendly dosing charts like increased. That patient encounter showed me With more understanding of over-the-counter table 1. This chart is even helpful for those who how easy it was for patients to get confused or products and how they should be used, patients use pill boxes, because it shows what the pills to not understand what they are taking or why can better assess the risks and benefits to what look like. they are taking it. medications they are taking. All medications

ACETAMINOPHEN know the facts

32 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

NEED TO KNOW

An additional area of concern for our patients is child dosing of acetaminophen. It can be difficult for parents to understand the different units used in dosing as well as the importance of using a dosing cup or syringe. As pharmacists we can be there as a resource to educate and guide parents in the best and safest practices of medication use. There is a convenient dosing chart (Table 2) for parents on Tylenol’s website that can aid in the confusion of dosing for children.

pathways become saturated and a higher percentage of acetaminophen is metabolized to NAPQI. NAPQI is then converted by glutathione (GSH) to form an acetaminophen-GSH conjugate, a non-reactive molecule. However, excess NAPQI caused by the overdose, eventually depletes GSH stores and starts to form protein adducts through binding to cysteine groups on cellular proteins. Mitochondria are usually targeted leading to depletion in energy and hepatocyte death.2 Acetaminophen ranks as one of the most frequently used drugs in the United States.

With so many people using this medication, it is vital that the public be educated on the risks associated with its usage. Giving patients a better understanding of the potential side effects and harm that can come from overuse of acetaminophen can keep them safe and possibly prevent an overdose. As health care professionals, it is our job to provide knowledge and resources to our patients so that they don’t continue to take products inappropriately.

1. "Acetaminophen Safety: Be Cautious but Not Afraid - Harvard Health." Harvard Health. N.p., 2014.

Web. 30 June 2016.

2. Hinson, Jack A., Dean W. Roberts, and Laura P. James. “Mechanisms of Acetaminophen-Induced Liver Necrosis.” Handbook of experimental pharmacology 196 (2010): 369–405. PMC. Web. 30 June 2016.

3. "U.S. Food and Drug Administration." New Steps Aimed at Cutting Risks from Acetaminophen. N.p., 2009. Web. 30 June 2016.

4. "U.S. Food and Drug Administration." Notice to Industry: Final Guidance for Over-the-Counter Products That Contain Acetaminophen. U.S. Food and Drug Administration, Nov. 2015.

Web. 30 June 2016.

Warning patients of possible side effects from acetaminophen is crucial, but how does it actually cause liver damage? Let’s take a quick review. Over 90 percent of acetaminophen is metabolized by glucuronidation and sulfonation. Then about 5to 10 percent is metabolized by cytochrome P450 into N-acetyl-p-benzoquinone imine (NAPQI). NAPQI, a very reactive molecule, binds to protein and is considered toxic. In an overdose situation the glucuronidation and sulfonation

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 33

2016-2017 MISSOURI PHARMACY ASSOCIATION BOARD OF DIRECTORS PRESIDENT

Meet Marty

Marty Michel, RPh, MBA, CDE 2016-2017 Missouri Pharmacy Association Board of Directors President Owner of Key Drugs Pharmacies

About Marty Marty Michel, (Poplar Bluff) graduated with honors from the University of Mississippi with a B.S. in pharmacy in 1983. Michel continued his education by graduating from the Southeast Missouri Law Enforcement Academy in 1993 and received a Master’s degree in Business Administration in 2001 from William Woods University. He and his wife Julita currently own three pharmacies: Key Drugs (Main Location) in Poplar Bluff, Key Drugs at Northwest in Poplar Bluff, and Key Drugs at Dexter.

Statement The profession of pharmacy has come a long way in my 30 years of experience. I would like to see it take a step into the future. With my eight years of involvement with the Missouri State Board of Pharmacy, I know the battles we have to overcome, and I can help lead us into the future.

What is one long-term goal you want to see the Board of Directors make progress on during 2016-2017?

Increasing our membership of pharmacists and pharmacy students in the organization allowing us to have better interaction and relationships with everyone throughout the state.

Currently, what do you see as the most pressing issue in the pharmacy profession?

• DIR fees from Medicare Part D plans have drastically affected many pharmacies. This is a federal issue but we need to make sure we are heard in Washington DC. • Trying to stop mandated mail order plans by some PBMs. • Trying to pass a MAC pricing bill with teeth that pharmacies can use against PBMs for keeping their prices too low.

34 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

Professional Affiliations • Current President of Missouri Pharmacy Association • Current President of Three Rivers College Endowment Trust Board • Current Board Member of Compliant Pharmacy Alliance Buying Group • Adjunct Clinical Instructor in the division of Pharmacy Practice for University of Missouri Kansas City School of Pharmacy • St. Louis College of Pharmacy Adjunct Clinical Instructor in Pharmacy Practice • University of Mississippi Adjunct Clinical Instructor • Member of the Ozark Foothills Healthcare Consortium • Operation Red-Flag Drug Committee • Chairman of Poplar Bluff Drug Commission • Poplar Bluff Healthfest Committee • Secretary of SEMO Pharmaceutical Association • American Association of Diabetic Educators • 2001 committee member of NABP Task Force on Electronic Transmission of Prescriptions • 1999 committee member of NABP Manpower Shortage Task Force • 1998 committee member of NABP recycling of Rx vials and confidentiality issues Task Force • Member National Association of Board of Pharmacy • 1999, 2000, 2001, committee member of NCPA on Health Health Care Pharmacy Services • 1998 committee member of NCPA National Legislation & Government Affairs • National Community Pharmacist Association Member • President of Independent Pharmacist Association • Member or President of Missouri Board of Pharmacy 1998 to 2005

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THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 35

TECHNOLOGY TUNE-UP

An Apple a Day Keeps Your Store Up to Date

by REP. TRAVIS

FITZWATER

Your Mobile Device Can Make Your Life Easy Peasy, Benefiting Your Pharmacy.

I

f you’re an Apple fan boy like me, you know that they have just released their latest version of one of the most popular mobile devices in the world, the iPhone 7.

For some, all this updated technology is overwhelming, for others (like me) it’s thrilling.

Updates to the camera, speed of the device, additions to the software, increased battery life, expanded application offerings, and much more are just a part of the update. But, how you can functionally use the phone every day is changing in a big way as well. If you think through how to take advantage of these opportunities, that mobile device can and will make your life easier for you and your pharmacy.

So, what are a couple ways your mobile device makes your life easier?

1. If you are the owner of a small pharmacy in Missouri, you may not have the budget for a marketing professional and must rely on a technician or yourself to do all the marketing. Why not put your phone to work for you in this area? You can schedule posts on your social media ahead of

time, say at the beginning of the week, and know that your message will be going out at the exact times you’d like for it to. Your marketing will be working for you while you work for your pharmacy. And, most of these applications include statistics so you can review what’s working in your marketing and what’s not.

4. Mobile phones make it so much simpler to communicate with your employees.

Use the many different messaging apps to allow your employees to collaborate, give reviews on your store processes, or to connect your employees to each other for team building, among other ways to connect your employees.

2. Video and photos tell a story. In your pocket you have one of the best cameras money can buy (even Android devices have good cameras). Tell the story of your pharmacy and staff by taking pictures and video of your operation and sharing them broadly.

People love their local pharmacies. They will love them more if they know the stories behind the company, her employees, and her patients.

5. Use pharmacy applications on your mobile device that connect you to your most important software in your store. Some of the software that you utilize in your store will have a companion app that you can install on your phones to follow your critical processes in the pharmacy without having to log into a computer. Make sure you and your staff are trained on how to use these critical apps to make your life easier.

3. While you’re away from your store, you can watch what’s happening there without logging onto a computer. Most security companies now can install cameras that you can watch real time through their mobile device apps.

These are just some thoughts on how you can use your mobile device (hopefully the new iPhone 7!) in your pharmacy to make your life easier. Your phone can be great tool to your pharmacy procedures and your business. Take advantage of the incredible technology that you carry around with you every day!

36 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

SPRING 2015 13

FOR CONTRACTING DETAILS, VISIT MO-PCN.COM AND CLICK "JOIN MO-PCN"

T

MO-PCN Gains Momentum

he Missouri Pharmacist Care Network (MO-PCN) is an LLC operating under the umbrella of the Missouri Pharmacy Association (MPA).

It is a pharmacist network open to licensed pharmacists of all skill levels and practice settings. MO-PCN is designed to support and/or administer Missouri clinical pharmacist care services through contracts or partnerships with foundations, associations, health plans, employers, program administrators, government entities, manufacturers or others.

MO-PCN's objectives are to: • Create and manage a pharmacist-centric provider network to deliver patient care services.

• Facilitate pharmacist network development across all practice settings.

• Pursue commercial networks with payable opportunities.

• Create a value-based intervention program curricula, training and credentials.

• Evaluate and report on health management interventions and other pharmacist care programs.

• Pursue regional and national grant-funded opportunities.

If you contracted prior to Summer, 2016, re-contracting is required. If you are not yet a participating MO-PCN provider, please contact us to contract today!

Polypharmacy Risk Reduction Project (PPRR)

MO-PCN collaborations, partnerships, and projects continue to expand. MO-PCN is currently seeking Missouri pharmacists to participate in their newest funded opportunity, the Polypharmacy Risk Reduction (PPRR) program.

Launched in June 2016, PPRR targets the high utilizers of medications in the MO HealthNet program, those who take 12 or more

medications. Patient cases are distributed to participating pharmacists to review the medications and report participant drug therapy related recommendations to the participant’s physician. A face-to-face encounter with the patient is not required for the program. Instead, emphasis is placed on building a relationship between the pharmacist and the participant’s physician to use a team-based approach to patient care, which should ultimately results in positive health outcomes for the participant and a reduction in healthcare expenditures in MO HealthNet’s pharmacy program. PPPR will measure outcomes of changes in the number of chronic medications being taken by the participant; changes in medication cost PM/PM; and changes in the number of hospitalizations, re-admissions and ER visits. The program's goals are to ensure that an indication for use exists for each medication; to improve medication adherence; and to design more balanced medication regimens based upon appropriateness, effectiveness and safety.

Funding for the first phase/launch of the PPRR program was appropriated by the Missouri Legislature through June 2016, and additional funding was appropriated to continue phase two of the program through the State's 2017 fiscal year. Positive patient and economic outcomes will provide the potential for continuation of the program beyond that.

Recruitment of Missouri licensed pharmacists for participation in the second phase of the program is underway. Requirements for pharmacist participation in the PPRR program include: 1. Being a MO-PCN member 2. Having the MTS designation on their Missouri Board of Pharmacy License 3. Being a MO HealthNet Provider with an active provider status 4. Completion of the PPRR program Orientation video

38 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

COPD Severity and Adherence to GOLD Guidelines in the Community Pharmacy Setting

St. Louis College of Pharmacy (STLCOP) was awarded a collaborative research project from GlaxoSmithKline (GSK) to study Missourians with COPD. The study evaluates the medication management of patients with COPD at the community pharmacy level by characterizing the severity of their disease and assessing the appropriateness of and adherence to their pharmacotherapy. Missouri has one of the highest rates of COPD in the country and thus provides a valuable study opportunity.

Project Overview

STLCOP contracted with MO-PCN to provide the network of pharmacist providers trained as Community Pharmacist Investigators (CPIs) with a total of 875 patients to be enrolled across 35 participating pharmacies over a six-month time period. Besides GSK and MO-PCN, other program partners include: MPA, National Community Pharmacists Association (NCPA), and the Missouri Health Connection (MHC) -the state-wide health information exchange.

The project process: • CPI recruits 25 patients in person or over the phone • CPI enrolls patients onsite and obtains signed informed consent • Each patient completes the study questionnaire and is offered a $10 incentive check for participation • CPI sends a PDF file of the data collection form/questionnaire and consent/authorization documents via MHC CareMail secure email to STLCOP investigators • CPI generates a report of prescription fill data for enrolled patients

MO-PCN GAINS MOMENTUM Training & Support

Participating pharmacists complete the CPI training, which includes CITI Institutional Review Board, GSK and STLCOP project training. The CPIs are supported by a STLCOP investigator team and full range of program resources and materials that includes a STLCOP hosted program website, recruitment phone script, participant study questionnaire, template reports and project check list.

Payment

Pharmacies receive a $200 payment for each CPI who completes the training. The participant study visit with the CPI is face-to-face at the community pharmacy. A $60 payment is made for each completed study participant questionnaire, estimated to take 30-minutes.

Community pharmacists are well positioned within the healthcare team to manage and educate patients with COPD as well as communicate with providers regarding drug-related problems. Community pharmacists have access to the patient’s medication fill history, which provides insight into patient's medication-taking behaviors.

American Health Care and NCPA Population Health Management Pilot

American Health Care (AHC) is a pharmacist-owned national population health management company. AHC, in partnership with MPA, MO-PCN and NCPA, is bringing population health management programs, proven and guaranteed to lower health care costs, to Missouri employers. The programs are based on the renowned Asheville Model. The AHC marketing and sales team pursue brokers and employer group leads and work directly with MO-PCN network pharmacists to support and follow-up on local lead generation.

Project Overview

The program’s specific process and methodology focuses on people with chronic conditions including diabetes, high blood pressure and high cholesterol. The pharmacists regularly

meet with the patients to discuss medication adherence, lifestyle goals (including diet and exercise) and collaborate with their physicians to make sure the patients are taking the most effective medications. Through this program, pharmacists are able to provide patients with that additional time and help to manage their condition and keep them on the treatment plan prescribed by their physician.

Program participation summary: • NCPA accepts applications from community pharmacists who want to provide patient care services to qualified patients.

• AHC contracts directly with pharmacists and pharmacies for participation.

• Participating pharmacists are care managers and meet every one to three months with patients.

• Documentation is completed on AHC’s web-based electronic health record, Digital Outcomes Communication System (DOCS tm).

Training & Support

Missouri pharmacists are trained on the DOCS platform, which provides medical, pharmacy, laboratory, and encounter data to support disease and wellness management services.

Payment

Payment for pharmacist-delivered patient care services is $63 for the initial care management visit and $52.50 for follow-up visits.

New MO-PCN Corporate Contracting Option

Historically, MO-PCN has offered an individual pharmacist contracting option.

There is now a Corporate Master Participation Agreement (with a corresponding individual Corporate Pharmacist Agreement) option that supports convenient pharmacy contracting.

Joining the MO-PCN network is a twostep process: 1. Complete the Pharmacist Enrollment Form, which contains specific requests for information regarding your qualifi-

cations and credentials. Upon receipt of your submitted enrollment, MO-PCN will conduct a verification process to ensure stated credentials are valid and current.

2. Execute a MO-PCN Master Participation Agreement. You have two options for Master Participation Agreement execution: contracting 1) as an individual pharmacist or 2) as a corporate pharmacy. a. Individual: MO-PCN Master Participation Agreement b. Corporate: MO-PCN Corporate Master Participation Agreement and individual Corporate Pharmacist Agreement.

A pharmacist becomes eligible to access MO-PCN programming opportunities once the two-step process has been completed. Each MO-PCN program has a separate associated Program Addendum that describes the details of that specific program, and it must also be executed by the pharmacist or corporate pharmacy in order to participate.

If you have additional questions regarding MO-PCN or its programs, please contact Vice President, Pharmacist Program Initiatives, Cheryl Hoffer at 314-249-2840 or cheryl@morx. com or Pharmacist Consultant, Sandra Bollinger, PharmD., FASCP, CGP, CDE, CPT, CFts, MCMP-II at 573-450-1263 or sandra@morx.com.

MO-PCN’s Close Academic Relationships

Academic involvement is integral to MOPCN’s success. St. Louis College of Pharmacy and the University of Missouri-Kansas City School of Pharmacy played a key role in the original concept development and network launch of MO-PCN. Both academic institutions continue to support and influence its continued growth and success.

Supporting the Growth and Strength of Missouri Pharmacists!

The larger and stronger MO-PCN becomes, the more successful we will be at delivering viable, profitable opportunities to you.

THE LEADING VOICE FOR THE MISSOURI PHARMACIST | MoRx.com 39

Now&Then

I

America’s Most Famous Businesswoman? BOB PRIDDY by

It is hard to think of any businesswoman in American history whose name has been attached to a product longer than.

Lydia Estes was born in 1819 to a Quaker family in Lynn, Massachusetts, and grew up to be a teacher, an abolitionist, and a supporter of women’s rights and temperance. She was also a housewife who used her basement to concoct a home-made herbal remedy that she shared with her neighbors. When the 1873 Depression plunged her family into serious financial trouble, one of her sons urged her to broaden distribution of her creation and sell it.

Lydia’s first bottle of vegetable compound was sold for a dollar in 1875 in Lynn. Her son persuaded her four years later to put her picture into newspaper ads that proclaimed her the “savior of her sex.” Author Justin Pollard in his 2010 book, Boffinology: The Real Story Behind our Greatest Scientific Discoveries, notes that by 1878, her ads were running in more newspapers and magazines than any other advertisements.

The compound claimed to prevent a prolapsed uterus as it could “dissolve and expel tumors from the uterus in their early stages;” and would also“remove faintness, flatulency” and “Bloating, Headaches, Nervous Prostration, General Debility, Sleeplessness, Depression, and Indigestion.”

By the time she died in 1883, her company was grossing about $300,000 a year.

But Lydia wasn’t really dead to her consumers. Those responding to ads encouraging women to write to her about their problems and sufferings got letters from her until the Ladies’ Home Journal published a picture of her tombstone in 1905.

The company said it was her daughter-in-law, Jennie, who was answering the letters—until Collier’s Weekly revealed that the company had a corps of typists who composed form letters that usually suggested more uses of the famous Vegetable Compound.

The Pure Food and Drug Act of 1906 forced the company to divulge the contents of the compound that began with pleurisy root, life root, fenugreek, unicorn root, and black cohosh. It was then that consumers learned the medicine compounded by this temperance advocate was 18% alcohol. The alcohol that was used only “as a solvent and preservative” left the vegetable compound about 40-proof. Even then, the medical profession never found Lydia’s medicines anywhere near as curative as the advertising testimonials claimed and bottle collector Doris B. Linden has noted on her webpage that a Boston newspaper in the 1920s continued to assert that the main ingredient was “Sweet Extract of Hokum.”

The company started making “pink pills for pale people” a few years later and promoted them as helping women through “the change.” Ferrous sulfate, licorice, Jamaica dogwood root, and the familiar pleurisy root were the ingredients. Later, it started marketing pills “to relieve constipation.”

The company stayed in the family until 1968 when Cooper Laboratories bought it. Lydia Pinkham medicines are now produced by at least two companies and are still found on many drug store shelves and marketed on the internet. Questions about their effectiveness are still being raised.

There was—and is—more to Lydia Pinkham’s company than its compound, though. She is remembered for her lasting advocacy for women’s health. The company’s Department of Advice emphasized the importance of good diet, good hygiene and exercise (along with taking the compound), and provided, at no cost in a time of widespread ignorance about such things, literature explaining the facts of life to women including the reproductive system and menopause.

Lydia’s home in Lynn, Massachusetts is on the National Register of Historic Places. A clinic in nearby Salem serves young mothers and their children and is run by one of Lydia’s descendants.

40 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV

Bob Priddy covered Missouri politics and government for forty years as the news director of the Missourinet statewide radio network. His most recent book is The Art of the Missouri Capitol, History in Canvas, Bronze, and Stone. He’s now working on his second book about the Capitol.

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42 MissouriPHARMACIST Oct. | Dec. 2016 Volume 90, Issue IV SPRING 2015 7