All right, and I am pleased to introduce our next speaker, Barry Goodell. Good afternoon. That's not a good sign when the whole crowd gets up and leaves when you're up there. That's always bad feedback all the time. So my name is Barry Goodell. I'm at University of Wisconsin-Madison. My clinical practice is at the William S. Middleton VA in Madison, or the Madison VA is what I'll refer to it. So I'm going to approach my presentation talking about the role of a pharmacist a little bit differently from my other colleagues here, because it's a little bit different. Because when you talk about it, I'm very interested in listening to you about the reimbursement and the revenue generation. I think as many of you know, pharmacy historically has been revenue generation has been tied to a product, or a capitation of some products, holding down expenditures, which I'm sure everybody knows when they've been told, no, you can't have something. I'm going to talk to you a little bit different. You can see from the title of my presentation, it's really focusing on access to care. And that's a little bit different. My objective for this program is to really try to introduce you a little bit to maybe what I would call non-traditional roles for pharmacists, and maybe what you're used to either in the hospital setting, the organized health care system that you're working with, or in a community pharmacy. So here are my disclosures. Now I'm going to talk to you about what I know best. I'm going to show you a couple different models here. As I mentioned, my clinical practice is at the Madison VA. We are part of the VA Epilepsy Centers of Excellence, which as you can see, is a, is there a laser pointer? Yeah. Hopefully I won't make this go bad. Okay. That is a national network of comprehensive epilepsy programs. Plus, I do have to put a pitch in here. I think the Madison VA, we were the very first epilepsy center in the VA system in the United States. But as you can see, we have a national presence. Now why is this important? Because as we've heard from other, my colleagues here, and this is true, every state is a little bit different. And pharmacy practice acts, and the ability to bill for services or provider status that I'll talk to about at the very end, yes, in fact, that can vary. But the, one of the models, the reason I want to introduce you for those who aren't familiar with the VA setting is because we are a national organization. So if you are licensed to practice in one state in the United States, you can practice in all of them. And we're under then federal laws, which supersede the state pharmacy practice act. So why is that important to us? Well, it's because as pharmacists, and this is not a new thing, this has been, oh, really around for as long as I've been in practice, which is a little over 30 years now. Pharmacists can be credentialed as advanced practice providers. And we originally changed from clinical pharmacist to clinical pharmacy practitioner to really reflect what we really are doing. And what is the unique thing about that credentialed pharmacist? Now what do I mean? First of all, let me define what is a credentialed pharmacist. Typically, as I think probably most people in this room know, that the entry level degree for pharmacy is a PharmD, a doctor of pharmacy. This is typically a seven to eight year degree. But to be credentialed is one thing, to be licensed, to be credentialed and to gain a scope of practice in the VA system, which allows you to have prescriptive authority and to work fairly autonomously within a practice model, typically requires a minimum of one, if not two years of residency, postgraduate residency training. So what are really some of the differences here? What are kind of the differences in vision or abilities? Well, again, probably the thing I want you to walk away from is there is now an established model of having pharmacists as prescribers and being able to fairly independently manage a lot of different medical conditions. And I'll go into a little bit more detail of what that means for neurology. So where pharmacists really first started getting involved in sort of this scope of practice clinical care was in primary care, again, because of our training across a wide variety of diseases and classes of medications and the pharmacokinetics, different drug interactions. We've talked a little bit about those, which I did not know about ketosis. Thank you for telling me that. Some of these different interactions, again, being able to manage complex multi-drug regimens. Now what is the difference? I think a lot of folks here are probably used to in their institutions of working with clinical pharmacists. Things that don't require advanced degree or credentialing is some of the typical therapeutic drug level monitoring, making recommendations about doses, antimicrobial stewardship, all those kind of things. That is actually a very different function. Those individuals, they do serve an incredibly valuable role within the institutional setting, but they are not considered advanced practice providers. All right, so let me talk then a little bit, how many people are we talking about? Is this widespread? You know, there are a lot of pharmacists. Well, this is data from a couple years back now, the most recent VA data that's been published. But we're really talking about people that have a scope of practice. We're talking, and now it's a little bit more of this, about over 5,000 or so clinical pharmacy practitioners across the VA setting, both whether it's in institutional setting or in the community-based outpatient clinics. So as again, there's a lot of folks here. So why did the VA do this? Okay, so we're not using it as a revenue generating mechanism. Why did the VA adopt this model a few decades back? And it's really the first box up there. It's again, access to care. So our metrics for success, besides obviously very good, high-level quality of care within the VA, which within the ECOE, I think we do very nicely, is being able to get veterans in, being able to get patients in. We don't, and I'll show you a little bit of that information, not all of it, but you know, we have the ability by leveraging, and it's not just pharmacists, but also other APPs, like within our epilepsy center, if a veteran say has, maybe it's a new seizure that somebody has on a Friday, our epilepsy clinic meets on Monday mornings. They have a new seizure. Their primary care doctor sees them on Friday. We will likely get them in Monday morning to be seen in the epilepsy center. And it's because, and I'll show you some of the data within our clinic, because we have clinical pharmacy practitioners that are able to manage the routine patients and allows our attending to see the new patients, our attending and our fellows to see new people. So that's really the approach I want to get here, is access to care. Now let me just tell you again, I told you about the number of pharmacists that are out there doing this stuff. And again, neurology is fairly new to the game here. You can see that these complex medical conditions, diabetes, and other things, and historically cardiovascular anticoagulation management. The other big area, and again, this is very important for us, obviously, as an epilepsy community, is mental health. Clinical pharmacy practitioners have been integral in managing and maintaining mental health services in a lot of different VA settings, particularly in the rural settings where may not be able to get access to a psychiatrist, and may not be able to bring a psychiatrist in. And to have pharmacists that have had postgraduate residency training in mental health has allowed, again, for the psychiatrists that we are lucky enough to have, for them to be able to see the new patients, or the more complex patients, and for my PharmD colleagues to be able to manage those other patients. So again, that's kind of the numbers. What about neurology? This is now from VA, the central of VA, it's realizing, again, let's leverage this beyond the primary care teams, let's leverage it beyond mental health services. And now, so it's epilepsy, I'm happy, as we've now been recognized as one of those areas, but clearly the high dollar ticket areas, multiple sclerosis being probably the biggest ticket area, where again, as you probably know, these are incredibly expensive therapies. And they're expensive therapies that if they're not managed correctly, and if the adverse effects are not monitored, managed, and adjusted for, a lot of money is being spent that, again, could be spent elsewhere on otherwise a therapeutic failure. And so the big push has been to have clinical pharmacist practitioners nationally be in the ambulatory setting, but also there is a role, I'm gonna touch on a little bit from my colleagues at the Greater Los Angeles VA of inpatient EMU role as well. All right, so let me go through this really quickly. Again, I talked about ambulatory care, primary care, and sort of the growing role, the number of encounters. This is nationally the impact of clinical pharmacy practitioners and neurology visits across the VA. And if anything, the more recent data with COVID, these numbers actually grew because of, again, the VA has been early adopters, I think, in telehealth and being able to extend that beyond simply mental health or some other disorders. All right, so let me give you some now concrete examples. That's background. I'll talk about, let me talk about our setting first at the Madison VA. I think I put this in bold here simply to point out the demographic. We are, Wisconsin is largely a rural state. In our capture area for the Madison VA, it's about 50% rural. So in rural, as we know, rural healthcare is an incredibly important component. And there are some differences in how we can reach out to patients and how we can manage things. We actually, my colleague, Marlena Tobey, we actually published this in Federal Practitioner last year of actually, we decided after about three decades, I guess I was behind, that we should probably actually look at some numbers. What is our impact on access? And really what it comes down to, and I'll summarize these numbers. We have a very multidisciplinary clinic. We are very fortunate to have nurse practitioners, occasionally a psychiatrist. And between that, between myself as a clinical pharmacy practitioner, as well as my resident, we always have a resident that do the math here. We see about 40% of the patients, really. We do not see new patients, but they're return-to-clinic patients. They're the ones that we're really doing, once the diagnosis has been made, we're really doing medication management. And again, because of prescriptive authority, pharmacists within the VA setting have the ability to either start new medicine, stop something, adjust doses, add things on, and do whatever. And our scopes of practice, if I need to order for my colleagues, I need to order an EEG or an MRI, I can do that as well. All right. So that's, again, my capture area is largely a rural capture area. What about more of an urban setting? And this is some information provided by Dr. Dergulas, Anita Dergulas, at the West Los Angeles VA, which is a fairly urban setting. And again, I'll summarize this slide fairly quickly. She's developed a refractory epilepsy-specific clinic. They've also developed an e-consult service. And they are able, again, to take a large number of these highly refractory patients with epilepsy. Again, the really complex medication management situations. And they're able to take over and manage those folks. They also have data, which I'm not going to show you, of looking at medication adherence over time and after the integration of this pharmacist, so being able to actually increase medication adherence. Also the role of the clinical pharmacist practitioner, again, my world is mainly ambulatory. And we also have pharmacists that are working in EMU settings. And within this, again, Dr. Dergulas, they presented some of this data. They actually have demonstrated cost savings in the EMU in decreased EMU stays. And the mechanism by which they've done that, when a patient is scheduled before they ever get to the EMU, a pharmacist works up that history, really delves into this and devises and works with the team to devise a medication tapering strategy of how to go about doing this. And how that work, that perhaps we have our neurology residents be doing on day of admission, is able to be done ahead of time. In some cases, taper schedules are started before the patient ever gets to the EMU. So again, able to save some time. And they've demonstrated good outcomes. And again, reduce some dollars. All right. So I have talked to you about the public sector, and again, access to care. So the logical question that I get asked is, OK, can this work in the private setting? I'm very fortunate to have colleagues, again, from the Cleveland Clinic that are here. And the answer is, yeah, it can work in the private setting as well. Dr. Nicole Babiak, who's in the audience today, developed a refractory epilepsy clinic program at the Cleveland Clinic, working with those patients. And again, has been able to develop a collaborative practice agreement. And again, I've talked about scopes of practice, and I work in a federal setting. So federal law lets me do a lot of different things. There are, for those who are not in the federal system, there are almost every state, as far as I understand, have within the legal structure and the Pharmacy Practice Acts, abilities for PharmDs to work with individual providers to develop these really scopes, in essence, the equivalent of a scope of practice. Being able to start, stop medicines, order laboratories, and so forth. And you can see that, again, in the private setting, in a very high-level center like Cleveland Clinic, this model works. And again, I can't get into, because I don't know, the reimbursement models, but again, it's access to care. It's allowing PharmDs, because we like working with these complex drugs, we really like drug interactions, to be able to do this, it allows for our attendings to be able to take on those new patients. All right, so I'm gonna finish off here. You know, again, the landscape is evolving. Every state, I actually, I think COVID maybe, perhaps, helped with this, where developing the scopes of practice and provider status. There are some models now where pharmacists can get reimbursed from CMS for certain things. I think it's about 90% of physician billing. State Medicaids is my state. Pharmacists can get reimbursed from Medicaid, but for a limited scope of activities. And then dealing with every single third-party payer is, you know, you've seen one third-party payer, you've seen one third-party payer, is dealing with the contracting, but again, there are state laws that need to be in place, and our state, Wisconsin, is actually moving in that direction. Again, for those colleagues who may be interested in developing these collaborative practices, and may not just, you know, besides access to care, but being able to actually bill for services to pay for a provider. So again, the impact on clinical care, I don't have that slide, but the impact of clinical care, I hope I briefly introduced you to. There are other models where pharmacists can fit into aid practice. Again, thinking of those complex medication profiles that take a lot of time, if you can have a provider, and besides just the anti-seizure medicine and anti-seizure medicines interactions, think of, you know, our patients that are on an average of seven to eight different other medications, be that, you know, cardiovascular medications, mental health, you know, you name it, diabetes medications, being able to manage these complex drug systems to really provide optimal outcome. I hope you see that perhaps there is a role for pharmacists.

non-traditional pharmacist roles

advanced practice providers

prescriptive authority

healthcare access

scope of practice agreements