#module b

we are the hollow men/we are the stuffed men

deaths dream kingdom

between the (x)/and the (y)/ falls the shadow

Module B:

HEDIS is the Healthcare Effectiveness Data and Information Set and is a tool used by many insurance plans. The measures are created by NCQA (National Committee for Quality Assurance).

HEDIS measures address a broad range of important health issues. Some of these measures are.    

Asthma Medication Use

Persistence of Beta-Blocker Treatment after a Heart Attack

Controlling High Blood Pressure

Comprehensive Diabetes Care

Breast Cancer Screening / Prostate Cancer Screening 

Antidepressant Medication Management

Childhood and Adolescent Immunization Status

Childhood and Adult Weight/BMI Assessment

HEDIS measures tie into stars that Medicare assigns to health plans, so the company wants to make sure that members are getting all of the necessary screenings and appointments! This also greatly improves outcomes, so it is a priority for the plan.

I’ve gotten to meet with crucial employees to the company and learn what they do! I’ve met with company vice presidents, doctors, case managers, nurses, the physician engagement team and pharmacists. I’ve even had lunch with the CEO (twice)!! I have loved getting the opportunity to ask each person what their typical day is like and hearing their role at the company. 

My rotation site employs 15 pharmacists who each have very different jobs, and are all SO COOL!!!!!!!! There are so many opportunities here for pharmacists that I never knew about!!!

Here are a few of the positions 

Medicare Pharmacist

Oversees medicare formulary, manages medicare clinical programs

Medicaid Pharmacist

Oversees medicaid formulary, manages medicaid clinical programs

Manger of Formulary and Clinical Operations

Oversees commercial formularies, heads P+T committee, manages medication exception requests

Manged Care Pharmacists 

I can’t define this one, because they all do so much!! Some of the things they do is complete medical exception requests, help with appeals, talk to members, sit on various committees within the company and help manage the formularies 

Clinical Pharmacy Specialist 

Embedded in Enhanced Primary Care (EPC) practices, which are this company’s version of a Patient Centered Medical Home! Participate in MTM services and do training/information sessions for contracted MTM pharmacists. 

Medicare Stars Pharmacist

Evaluates HEDIS (Healthcare Effectiveness Data and Information Set) measures and creates programs/outreach to make sure patients are getting optimal care and that HEDIS measures are met

Director of Pharmaceutical Care Programs 

This is my preceptor and the best way I can summarize her job is... doing ABSOLUTELY EVERYTHING!!!!!!! She is everywhere and knows everything ever about every drug and condition! So maybe part of her job is being the most informed person on earth, I’m not sure :P She is so involved in every aspect of pharmacy here, and it is very cool to see what she does each day!!!!!!! She is so great at showing us strange cases, orphan drugs and training us to understand why the company does specific things!

Vice President, Clinical Integration/Chief Pharmacy Office

While I’ve been on rotation, some pretty huge (and VERY EXPENSIVE) drugs have been approved by the FDA!

Entresto (sacubitril/valsartan)

Entresto is for treatment of heart failure with reduced ejection fraction. It is indicated in patients NYHA class II-IV, and is used to reduce the risk of cardiovascular death and heart failure hospitalizations. Sacubitril has a novel mechanism of action and is a neprilysin inhibitor. Entresto will be administered in conjunction with other heart failure therapies, in place of an ACE or other ARB. It has been proven to significantly reduce risk of cardiovascular death when compared to enalapril alone.

Cost: $12.50 a day, or about $4,500 a year

 Praluent (alirocumab)

Praluent is the first of two PCSK9 inhibitors coming out this summer! It is a subcutaneous injection given every 2 weeks that has shown to reduce LDL 50 - 70%. Praluent is a monoclonal antibody that binds to PCSK9 (proprotein convertase subtilisin/kexin type 9). PCSK9 inhibitors decrease LDL receptors degradation by PCSK9, and thereby improve LDL-C clearance and lower plasma LDL-C. This medication has been approved for use in addition to diet and maximally tolerated statin therapy in adult patients with heterozygous familial hypercholesterolemia (HeFH) or patients with clinical atherosclerotic cardiovascular disease such as heart attacks or strokes, who require additional lowering of LDL cholesterol

Cost: $16,000 a year (to put this in perspective, with this insurance plan, you can get a year of typical ARBs for $40 - $100 a year)

 Orkambi (lumacaftor/ivacaftor)

Orkambi is the first of its kind to treat the cause of the disease in cystic fibrosis who have two copies of a specific mutation. The F508del mutation, which causes the production of an abnormal protein that disrupts how water and chloride are transported in the body. Having two copies of this mutation (one inherited from each parent) is the leading cause of CF. This drug may be a breakthrough therapy option for patients with CF and must be given for life