On February 7, 2012, representatives of the pharmacy industry met in San Diego, CA to discuss NCPDP Standards in Pharmacy Rules and Regulations: From Inception to Implementation - Navigating the Changes and Mitigating the Potential Risks. Michele Davidson, manager, pharmacy technical standards, development and policy, Walgreen Co and co-vice chair of NCPDP’s Educational Programs Committee opened the program and welcomed attendees. Scott Robertson, Pharm.D. , principal technology consultant in health IT strategy & policy, Kaiser Permanente and co-vice chair of NCPDP’s Educational Programs Committee moderated the program.

The 2012 Educational Summit opened with Harry L. Reynolds, Jr., director of health industry transformation for IBM Global Healthcare and Life Sciences Industry. His session, “NCPDP’S Impact on Pharmacy Rule Making” challenged attendees to embrace and drive industry changes and underscored the need to play in all areas of healthcare. Moving forward, the industry will not operate in silos of providers, pharmacies and payers. Being part of one sector of healthcare will not be enough; NCPDP must reach beyond pharmacy. Reynolds discussed trends, reactions, and assumptions and noted the amazing changes in the industry (health neighborhoods, medical homes, quality and outcomes will be marketed) and new leaders that are emerging to impact the industry. He also discussed changing the destinations of care with home care, residential care and acute care and challenged the industry to continue working together with involvement of diverse stakeholders to drive sustainable change.

In the session “Are You Always Submitting Compliant HIPAA Transactions and What May Happen If You Don’t?” , Denise Buenning, MsM, director of the administrative simplification group, CMS Office of E-Health Standards and Solutions provided a general overview of existing HIPAA transaction and code set enforcement. She touched on filing a complaint on the Administrative Simplification Enforcement Tool (ASET), the enforcement process, and new penalties for noncompliance, as well as changes to enforcement that will come out of the Affordable Care Act’s Section 1104. By December 2013 (and again in 2015), health plans must certify that they are compliant with all HIPAA transactions, code sets, identifiers and operating rules in effect at that time. Buenning reminded the audience that failure to certify has significant monetary penalties.

In “Workers’ Compensation: What a Difference NCPDP Makes” , Jim Andrews, R.Ph., senior vice president of pharmacy services, Cypress Care, noted that historically an injured worker brought a prescription to the pharmacy, paid cash and submitted the receipt for reimbursement to his or her employer. There were no monitoring vehicles to ensure quality of care, prevent drug interactions, control costs or manage the overall care of the injured worker. Pharmacies and billers had a significant percentage of these claims rejected for payment by carriers; it was not uncommon to have a 180-day+ outstanding accounts receivable. Andrews noted that working in tandem with the pharmacy community, NCPDP developed standards for the processing of on-line and off-line (paper bill) workers’ compensation claims. NCPDP provides instructional guidelines and operational standards for on-line processing of all types of prescription services. Providers of on-line or point of service pharmacy services are aided by the use of industry standard ID cards that identify all pertinent information required to adjudicate a claim in real-time. To assist providers of prescription services and third-party billers with the processing of paper bills, the pharmacy community, working through NCPDP, developed and adopted processing requirements applicable to a standardized claim form resulting in the publishing of the Workers’ Compensation/Property and Causality Universal Claim Form (WC/PC UCF). The pharmacy industry as well as numerous governmental entities have adopted and require compliance with NCPDP Telecommunication Standard and several states are recommending the use of the WC/PC UCF. Andrews reminded the crowd that current and emerging NCPDP standards are facilitating automated solutions that result in cost containment and improved billing.

NCPDP standards and X12’s technical reports are mandated by HIPAA’s Transaction and Code Sets Final Rule. In the session “Standards in Regulation is Like Making Sausage” , Lynne Gilbertson, vice president, standards development, NCPDP, attempted to demystify the proposed rule making process, debunk HIPAA myths, and demonstrate how we leverage lessons learned since 1996 to improve the standards development and federal adoption process.

In the panel “HIPAA Implementation: The Good, The Bad, The Ugly” , Amy Harvey, manager of third party payer compliance, Rite Aid Corp., Kathy Knapp, client service operations, Argus Health Systems, Inc., Rita Russell, senior director program management, pharmacy solutions, RelayHealth, and Tom Weiss, product manager - business capabilities architect, Omnicare-Rescot Systems Group examined the impact of the implementation of the NCPDP Telecommunication Standard version D.Ø in 2012. They discussed perspectives of the pharmacy, PBM, payer, processor, intermediary, and long term and post acute care environments. The group discussed specific issues encountered during testing on or near the compliance date and provided possible solutions for the different stakeholders. Panelists provided their perspectives on the improvements made in Version D.Ø compared to Version 5.1 and brought forward recommendations for future implementation of the next HIPAA standard. Although educational materials, webinars and white papers were made available, there still was confusion on implementation requirements, sharing of payer sheets, certification needs, and lack of time for transitions by some participants. The industry continues to work diligently on guidance and new code values, but some entities are not using the full functionality.

The panel “A Need for Prior Authorization Solution: A Frank Discussion, ” underscored the industry-wide need for electronic prior authorization (ePA) and described efforts underway to meet the challenge. Panelists included Victor Beraja, MD, co-founder and CEO, Ibeza, LLC, Ron Fine, vice president national health plan accounts, CoverMyMeds, LLC, Kim Nolen, Pharm.D., medical outcomes specialist, Pfizer, Inc., Steve Mullenix, R.Ph., senior vice president, communications & industry relations, NCPDP, and Bruce Wilkinson, MBA, clinical advisor, CVS Caremark. The prior authorization process continues to evolve to keep pace as prescribers’ transition towards electronic prescribing and electronic patient records to better manage their patients' pharmacy care. Steve Mullenix set the stage by defining prior authorization, the impact to the industry, and the role NCPDP has played. Bruce Wilkinson described the electronic prior authorization pilot CVS Caremark is involved in and the functions involved in the process, while Kim Nolen discussed prior authorization from the pharmaceutical manufacturer perspective, focusing on servicing the patient. This means having accurate formulary and benefit information available, known criteria, and information exchange as part of the clinical workflow so the prescriber and the patient can make a joint decision. Wilkinson then discussed prospective ePA and retrospective ePA and Ron Fine discussed the CoverMyMeds ePA processes integrating into the prescriber’s system for retrospective and prospective ePA. The panel concluded with Victor Beraja discussed the automation of the PA process that will read the medical chart and only requests missing information. He offered solutions that would use a glossary of medical terms organized according to CMS guidelines.

In the session “Short Cycle Dispensing – The Long and Short of It” Mara N. Mitchel, vice president, 3rd party operations, PharMerica and Gary J. Schoettmer, R.Ph., senior vice president of technology, Advanced Pharmacy explained that the intent of the "short cycle dispensing" provision of healthcare reform was to reduce unused medications in long term care (LTC) pharmacies by moving from traditional 30-day fills to biweekly, weekly or daily fills. The rationale behind this mandate was that shorter fills would result in fewer unconsumed medication units ("waste") that normally occur due to medication switching, discharges from the facility, death or other causes. In April 2011, CMS issued a Final Rule to dispense all solid oral brand name drugs to Part D enrollees in LTC facilities in 14-day-or-less increments starting January 2013. The rule also requires Part D plans to collect data on the dispensing methodology and amount of unused Part D drugs for each dispensing event. As such, LTC providers and payers will need to identify those prescriptions that meet the short cycle requirements and process them accordingly. Mitchel and Schoettmer provided stakeholders with a view of the key components of the rule, how to identify dispensing methodology, upcoming reporting requirements and how NCPDP’s standards play a critical role in this new regulation. Schoettmer discussed the efforts of Work Group 14 task groups to assist the industry in consistent implementation.

John Klimek, R.Ph., senior vice president, industry information technology, NCPDP presented “Meaningful Use – What is the Meaning and What is the Use?” Klimek discussed the CMS electronic health record (EHR), a Meaningful Use criteria summary, the stages of meaningful use, and Medicare vs. Medicaid requirements. He noted that the end of 2011 saw an uptick in participants and that the Office of the National Coordinator for Health Information Technology (ONC) is working on a privacy survey to consumers. Klimek also stated there is confusion in the industry on electronic prescribing incentives and which criteria a prescriber may fall under (MIPPA, PQRS, ARRA).

A new topic to the regulatory environment is operating rules. In “Operating Rules Made Easy” Dale Chamberlain, president, Gateway Pharmacy Consulting, LLC, Gwen Lohse, deputy director of Council for Affordable Quality Healthcare (CAQH) and the managing director of the CAQH Committee on Operating Rules for Information Exchange (CORE), and Margaret Weiker, director of the HP business exchange services and healthcare payer administrative services, Hewlett-Packard, discussed the new regulations for operating rules. Weiker provided background on what an operating rule is as defined by the regulation. Chamberlain discussed the collaboration between NCPDP and CORE on the development of connectivity rules for medical and pharmacy. Lohse noted that uniform procedures for performing HIPAA’s eligibility and claims status transactions were named in regulation by the U.S. Department of Health and Human Services (HHS) in July 2011 and health plans and other covered entities must comply with these rules by January 1, 2013. Recently HHS proposed regulations for EFT/ERA standards, with an operating rule regulation expected. Lohse discussed NCPDP’s work with CORE on the development of ERA/EFT rules and the impact of those rules on pharmacy. Weiker concluded by providing a definition of acknowledgements, described the ASC X12 acknowledgement standards and explained when to use them in a batch and real-time transactions.

The 2012 NCPDP Educational Summit concluded with “Pharmacy Issues Do Not Discriminate: States’ Perspective.” Rebecca Snead, executive vice president, National Alliance of State Pharmacy Associations (NASPA) provided an understanding of day-to-day operational challenges and opportunities experienced in a pharmacy. Snead discussed the impact of NCPDP Telecommunication Version D.Ø implementation, operational questions or better use of the standards guidance for coordination of benefits (COB) processing, e-prescribing, prior authorization, prescriber identification, compounding and synchronization of chronic medications. Snead also identified state-specific issues and trends that affect dispensing, processing claims and improving patient outcomes. She noted that the exploration of these issues experienced at the point of care by pharmacists are opportunities for the pharmacy industry working together to identify solutions that will ultimately enhance patient care.

NCPDP wishes to thank all the presenters of the 2012 Educational Summit, as well as a special thanks to our sponsors: Express Scripts, Inc. for their continued support of the educational programs, and educational grant sponsors FDX and HCC Pharmacy Solutions. If you would like to be part of the team creating educational opportunities by joining the Educational Advisory Committee, please contact David Goodspeed at dgoodspeed@ncpdp.org.

On February 8, 2011 in Las Vegas, NV, NCPDP held an educational summit “Leveraging New Technologies: Impact on the Patient and Healthcare Industry ". The program focused on the pharmacy of the future and discussed the impact of emerging technologies on healthcare, pharmacy and patient care. What transformational technologies are available today? What is on the horizon? How do these technologies support improved patient care and outcomes? What are the benefits and impacts on the patient, pharmacy, payer and vendor? What will be the role of the pharmacist and technician in the future?

Michele Davidson, R.Ph., Manager, Pharmacy Technical Standards, Development and Policy, Walgreens, Chair of Educational Programs Committee opened the program. Paul Hooper, Vice President of Pharmacy Network Services at Emdeon, served as moderator. He set the stage for discussion of drivers in our industry, including patient-centric healthcare, regulations and acts, and information technology initiatives.

Paul J. Oesterman, Pharm.D., Southern Nevada College of Pharmacy, spoke on “The Evolution of Pharmacy Through the 7 P's”. He examined how technology has impacted all phases of healthcare focusing on pharmacy and how technology allows for more informed patients. Prescriptions evolved from “hand-scribbled” notes to e-prescribed documents. The design of pharmacies changed from simple and traditional to deliberate layouts focusing on merchandising, adjacencies or specialty pharmacies. The pharmacist is no longer merely a dispenser of product but is recognized as a valued member of the healthcare team. The products dispensed reflect ongoing technological advances. The payers for pharmacy service are taking a more significant role in healthcare. Together these contribute to the new model of pharmaceutical care. He discussed the internet influencing patient healthcare decisions, and the changes in the relationships and interactions between patient, provider, and pharmacy.

Rick Sage, Vice President of Clinical Services, Emdeon, presented “The Magic in the Middle - Technology Infrastructure” where he explored the factors from the industry that is placing more demands and opportunities for pharmacists such as physician shortage, technology, services (MTM, REMS, lab result reviews) and all the exchanges of clinical information (CHINs, RHIOs, HIEs, ecosystems of exchanges, etc). Sage discussed the need for the expected convergence of all healthcare information (administrative and financial, and clinical). There are many opportunities for connecting healthcare entities and moving information between them. Discussion needs to break down barriers so information can be exchanged with privacy and security needs met. ROI may not work the first time; but the next evolution, with technology improvements on the receiver side, the ROI models then change. Technology moves at different speeds, but it continues to move. Adoption is key.

Robert E. Franz, R.Ph., Director of Clinical Studies, Medco, discussed “Leveraging Automation and its Impact on Dispensing”. He discussed the characteristics of a “system” and interactive planning of “where we want to be” versus “where we are”. Franz presented integrating the delivery of high-quality pharmaceutical care through state of the art delivery service pharmacies, state of the art cognitive pharmacies, and network partnership with retail/community pharmacies. One of the most advanced pharmacies in the world is the new next-generation automated 318,000-square-foot pharmacy, which opened in 2009, which utilizes automation and the skills of pharmacists, pharmacy technicians, engineering technology, and pharmacy support to dispense more than one million prescriptions a week at peak operation. Using the most advanced technologies, the pharmacy delivers among the highest level of prescription drug dispensing accuracy in our industry. A highly automated prescription dispensing system achieved dispensing accuracy rates 23 times better than those reported in a benchmark study of accepted pharmacy practices - resulting in a dramatic reduction in potentially serious drug-selection errors.

“Mobile, Money, and Medications” was the topic led by Robert S. Oscar, R.Ph., Founder, RxEOB, Today 40% of Americans own a “Smartphone,” and 20% access the Internet from a mobile device on a regular basis. Already 9% of cell phone users have downloaded a health “app.” Getting personalized pharmacy guidance to a consumer’s mobile device improves medication safety, promotes long-term compliance, fosters evidence-based care, lessens pharmacists’ administrative burdens, and reduces excessive drug costs. Specifically, mobile gets consumers information where it is most useful -- the exam room, the pharmacy counter, and the bathroom’s medicine cabinet. Capturing this value requires a properly executed program that combines clinical pharmacy expertise, data analytics, and deep understanding of user demand. He discussed attacking three problems together – improve care quality, reduce care costs, engage consumers directly. Oscar also provided a mobile Rx “design checklist”.

Scott M. Robertson, Pharm.D., Principal Technology Consultant in Health IT Strategy & Policy, Kaiser Permanente presented “The Consumer’s Health-Tech Market Place”. Consumers have access to a wide variety of technologies to help manage or improve their healthcare. Robertson presented a survey of market place consumer-centric health technology. Some products have been around for a while, while others are new and novel applications of technology. He explored products for Adherence, Monitoring, Drug Delivery, Safety, and Therapeutics; spanning from physical devices to applications and social media. Of particular interest is how healthcare, particularly pharmacy, can participate and leverage these technologies to aid the consumer. He also tackled health concerns that come along with some technology, as well as privacy, security and regulatory issues.

Wayne E. Armstrong, Senior Vice President, Argus Health Systems, Inc. posed the question “Does the Healthcare System REALLY Need to be Automated?” He presented a different view of the existing healthcare delivery system and the role of technology. He discussed the premise that in many instances the wrong constituents are driving the evolution of systems and the delivery of care. Armstrong discussed the various roles necessary to implement an effective strategic direction for delivering quality care with efficient administrative processes. What will drive the direction of healthcare in the future and its potential impact? He suggested thought-provoking changes in information exchanges and strategic missions of health plans that do not always require technology. He proposed that true analytics and forecasting should be integral to healthcare businesses. The consumer is coming and the industry needs to be ready to deliver information.

Thank you to all the presenters of the Educational Summit. Thank you to the sponsors Express Scripts, Inc. and Otsuka America Pharmaceuticals for their continued support of the educational programs. If you would like to be part of the team creating educational opportunities by joining the Educational Committee, please contact David Goodspeed dgoodspeed@ncpdp.org.

On November 2, 2010 in Portland, Oregon, in the NCPDP educational program “The New Economy and its Impact on Healthcare, Pharmacy, and the Patient" attendees explored the reality of the new economy and healthcare. Michele Davidson, R.Ph., Walgreens, Chair of Educational Programs Committee opened the program.

George VanAntwerp, General Manager, Pharmacy Solutions Group, Silverlink Communications, served as moderator.

Dilip Sedani, R.Ph., CFO of Pharmacy, Kaiser Permanente, led the program with "Defining the New Economy". How did we get here? What is the effect on the global economy and the responses to the financial crisis? Because of the recession and problems in the healthcare system, care is being put off due to income impact. Healthcare premiums have more than doubled in the last ten years. Sedani discussed the impact of healthcare reform. Futures include preventative care, Medication Therapy Management (MTM), comparative analysis, and virtual technology in medicine.

Gerald Cohen, JD, MBA, Oregon State Director, AARP, discussed "Impacts of the New Economy from a Patient’s Perspective". He provided insight via personal experience in his family. Cohen discussed partnerships with patients and caregivers. He highlighted the experiences in the AARP Oregon prescription lessons. The healthcare reform act affects long term care and impacts to the aging and includes social and medical home support. There is a need for more pilots and demonstrations.

A panel discussed "Changes Ahead for the Pharmacy Industry: What Will the New Economy Bring?" The panel consisted of Fred Eckel, R.Ph., MS, Executive Director, North Carolina Center for Pharmaceutical Care, Carla McSpadden, R.Ph., Director of Professional Affairs, The American Society of Consultant Pharmacists, and John Lynch, III, Vice President of Operating Policy and Internal Controls, Eaton Apothecary. The current healthcare system is broken. Change is coming. Pharmacy believes it has an important role to play. Many forces within and outside pharmacy will influence those changes. They reviewed some of those forces and suggested their impact on pharmacy.

McSpadden discussed that everyone is impacted by the aging population. We are moving from institutional to home and community-based services. She also provided background and the status of the short cycle dispensing to reduce pharmaceutical waste and the impact to the industry. Impacts are expected to be to billing, audit, and dispensing options. On the topic of MTM she noted that grants, medical home, Independence at Home pilots, Accountable Care Organizations, and other opportunities are now available.

A 340B overview was given by Lynch. He discussed various impacts of health care reform to the 340B environment – what happens if all are insured? Do people care when they don’t really pay? He spoke of health care reform and the formation of “exchanges” and their operational impact based on experience in the Massachusetts program.

Eckel reviewed the vision of what pharmacists should be doing versus what is happening. Will the new economy change this? Does the current model facilitate the pharmacist accomplishing this? The current environment may not be as conducive to what we think the pharmacist should be doing. He posed the question “Do we need more pharmacists to act as “recovering dispensers”?” and the need to think differently and measure success. Another consideration is there are more pharmacists graduating, but what is the economic impact of patients not picking up their prescriptions?

Jean Paul Gagnon, Ph.D., Sanofi-Aventis US, presented "Comparative Clinical Effectiveness Research (CCER), Health Information Technology (HIT), and Health Coutcomes". The initial CER legislation was in 2003 with funding in future years. The second impact was the ARRA in 2009. Gagnon discussed the meaningful use requirements of 2009 and following and the creation of the Patient-Centered Outcomes Research non-government Institute (PCORI) – a non-profit corporation to assist in making informed health decisions. He posed the ability to create a “Consumer Reports” for clinical effectiveness.

"How Will the New Economy Impact Payers and Providers?" was presented by Sean Karbowicz, Pharm.D., Manager of Clinical Pharmacy Services, RegenceRx, Health plans are facing political, economic, and technological dynamics never seen before. The rapid development of sophisticated, high-cost medications, the recent economic downturn, and increased government intervention result in new requirements and opportunities for pharmacy benefit delivery and management. Innovative solutions are needed to ensure that health care resources and dollars are used most effectively and can meet governmental requirements. He discussed a heath-plan based pharmacy benefit service to learn about rigorous application of scientific evidence, integrated pharmacy and medical benefits, and unique utilization management programs to address these complex issues, engage members and deliver sustainable prescription drug benefits.

George VanAntwerp discussed "Business Approaches to Survive and Thrive in the New Economy". Pharmacy is evolving – consumers are overwhelmed, and consumer engagement is evolving. There are new technologies, delivery model pressures, and PBM differentiation. There are new tools for consumers. He asked how much do practitioners want to engage patients. “Location” and counseling are now virtual. Entities are engaging retired practitioners, PBMs are offering counseling. VanAntwerp suggested that commercial MTM, pharmacy in the medical home, communications through “apps”, and greater coordination between retail and PBM are changes coming.

A closing panel of Fred Eckel, John Lynch, III, Gerald Cohen, Sean Karbowicz, Jean Paul Gagnon, and George Van Antwerp discussed demonstrating value and promoting awareness of the pharmacist – using touch points for customer satisfaction, where experts could assist in pointing the consumer to tools. The panel discussed how the industry can embrace MTM to continue to increase adoption. The topic then switched to copayment subsidies (marketing coupons) and the various perspectives of the consumer, pharmacy, plan, and employer. The panelists then had the opportunity to react to other presenters.

Thank you to all the presenters of the Educational Summit. Thank you to the sponsors Express Scripts, Inc. and Otsuka America Pharmaceuticals for their continued support of the educational programs. If you would like to be part of the team creating educational opportunities by joining the Educational Committee, please contact David Goodspeed dgoodspeed@ncpdp.org.