I knew this rotation was going to be challenging…

amanda-brenneke-photo“Mama always said life was like a box of chocolates. You never know what you’re gonna get.” I’m sure most of you know and recognize this famous quote from the film Forrest Gump. What I didn’t know about this quote is how it would exemplify my June advanced pharmacy practice rotation experience in Jefferson City. When choosing this site for one of my nine rotations, I thought this might be a chance to learn about association work, policy, and non-traditional pharmacy career paths. Little did I know that I would learn so much more in my short one-month experience, than I could have imagined. I value my time spent at this rotation because I do not think that I could have learned the majority of what I did here at any of my other scheduled sites or most of the other offered rotations.

My primary location for June was at G.L.O. and Associates, a pharmacy consulting business that works closely with the Missouri Pharmacy Association as well as Missouri Medicaid (MO Healthnet). I knew this rotation was going to be challenging and full of information when I was handed a three page document of mostly unfamiliar acronyms on the very first day. From there I was oriented to the tremendous load of projects that were underway, learning that juggling isn’t just for circus acts. As the days passed, I found myself immersed in various projects across the spectrum from reading legislature to helping implement new state wide projects. Through various conference calls and meetings I started to pick up the lingo (after asking the meaning of additional acronyms used of course) and began feeling more comfortable in this very foreign to me, government based world.

I was fortunate enough to be able to attend a couple of really insightful meetings including the Drug Prior Authorization Committee Meeting, Community Health Center Pharmacy Integration Meeting, and the Chronic Pain Management Show-Me Echo sessions. While at the Drug Prior Authorization Committee Meeting for Missouri Medicaid, I sat with the voting members of the committee and was able to observe first-hand how preferred drugs and drug edits are changed and adapted into policy. This meeting really showed me all of the thought and time put into those rejections that I am so use to getting at my retail pharmacy job and made me think about the big picture on a state level. The Community Health Center Pharmacy Integration Meeting was even more eye opening for me. Dr. Steven Chen a faculty pharmacist from the University of Southern California spoke about the ways he has been able to integrate pharmacy into health centers using a large grant. I also heard from Missouri health care providers about all of the ways they are currently utilizing pharmacists in their clinics. Finally, observing the Chronic Pain Management Echo was like watching a futuristic collaboration, except that it is happening right now! The Echo program uses telehealth technology so that participants can video chat in real time with one another. Providers from rural areas are able to participate using any electronic device (computer, tablet, cell phone) and collaborate with others as well as an expert panel associated with the University of Missouri.

Perhaps my favorite project to watch grow and assist with has been the Polypharmacy Risk Reduction Program, fondly referred to as PPRR. This program utilizes a group of dedicated Missouri pharmacists to review current Medicaid patients’ medications. Here’s how it works: high risk patients will be identified and assigned to participating pharmacists across the state; those pharmacists review claims data to access therapy and provide recommendations to the patient’s provider. Theoretically, this program will hopefully produce better out-comes for MO Healthnet patients as well as save tax payer money.

This rotation has been so rewarding for me and I plan to recommend it to younger students when I get back to Kansas City. I have gained a very valuable understanding of so many different aspects of pharmacy and many things that cannot be taught in school which I believe will be very important to understand in my pharmacy career. It has been a truly great month in Jefferson City and I am grateful to have spent a month with G.L.O. and Associates and the Missouri Pharmacy Association.

Amanda Brenneke
University of Missouri-Kansas City
2017 Pharm.D Candidate

Myth busters: Provider Status Legislation

Mario-CoronadoBy Mario Coronado, STLCOP Pharm.D. Candidate 2016

While this is not strictly a Missouri issue, I wanted to take some time with this blog to cover a few points on the current provider status legislation, HR 592 and S 314. This is the preeminent issue impacting pharmacists and pharmacy services today, and it is important that everyone understands the scope of what the bill is proposing.   Here are some common myths that I have been hearing:

  1. Provider status will only impact pharmacists in rural communities: This is my least favorite myth because it implies either that some pharmacists think it’s not worth the effort or that pharmacists in cities have different goals than pharmacists in rural communities. Most importantly, all pharmacists must have the same goal of providing patients with the best care possible, partly through expanded services; this legislation will allow financial support for those services through Medicare Part B reimbursement. Second, it’s just wrong. This bill allows Medicaid Part B reimbursement to pharmacists serving patients in any Medically Underserved Area (MUA) or Health Professional Shortage Area (HPSA). You can check your designation with this link, but to offer an example, my neighborhood in South St. Louis City is an HPSA1.
  2. Physicians are against pharmacists expanded services: Admittedly, this one is going to vary physician to physician, and I haven’t spoken with all of them, but my impression so far is that physicians appreciate pharmacists’ involvement. Notably, the American Medical Association does not oppose this legislation. And why would they? There is a known shortage of primary care physicians, and if a pharmacist is available to perform “services medically necessary to treat a condition or disease,”2 physicians will be able to see more patients. The health-care team is evolving rapidly to care for our expanding patient population. Our role in that team must evolve as well.
  3. Pharmacists are already performing these services OR Pharmacists won’t be performing these services anyway: These myths are two sides of the same coin, as HR 592/S314 does not expand the scope of services a pharmacist can provide. This comes down to the state level, which is an area for potential advocacy moving forward. We are lucky to live in Missouri which is expanding pharmacy services throughout MO HealthNet. MPA has worked extensively with the Pharmacist Service Expansion Project to give community pharmacies an avenue for reimbursement for the expanded services a pharmacist performs. The Diabetes Accreditation Standards-Practical Applications (DASPA) certification is just one example to ensure community pharmacists can receive the reimbursement they deserve for providing patient care beyond the traditional role of a pharmacist. The provider status bill would open up Medicare Part B reimbursement for pharmacists’ services. It will impact what clinical services we perform, rather, it will incentivize increased clinical services through reimbursement with federal dollars.
  4. Pharmacists provide different services than physicians or nurses, why should they be classified the same: Yes, doctors and nurses are providers under the Social Security Act that covers Medicaid Part B, but so are midwives, dieticians, social workers, and clergy. Clergy are considered healthcare providers and pharmacists are not. I’m not diminishing the importance of clergy, I’m just astounded that pharmacists are still not considered providers eligible for Part B reimbursement. HR 592/S 314 will finally place pharmacists among the list of providers like we belong. Again, the bill does not impact the scope of pharmacy practice, it just provides reimbursement for the services we perform.
  5. This will just increase the cost of healthcare: Technically, the jury is still out on this argument. The Congressional Budget Office “scores” every bill, meaning they estimate the potential cost it will have on the federal government. The Pharmacy and Medically Underserved Areas Enhancement Act has been submitted for a score, and this is currently pending. Rest assured though that expanded pharmacy services have been shown to decrease the overall cost of healthcare while improving quality. There are many legislators who have, appropriately, held off on co-sponsoring this legislation until a score has been posted. Hopefully a low score will bring a host of new co-sponsors that will help move this legislation forward through congress.
  6. My support won’t make a difference: This past October, the American Pharmacists Association with Pharmacists Provide Care led an advocacy effort to recruit more co-sponsors for this legislation, particularly within the House of Representatives. This important indicator of support jumped from 219 to 266 representatives promoting patient access to pharmacists’ services3. The bottom line is that everyone’s support adds up to make a great difference. Even without advocating to your legislators, ensuring that your community understands what services a pharmacist can provide is an important step towards ensuring that all patients have access to quality healthcare.

All pharmacists stand to benefit from this legislation, and it is important that we all understand the impact this will have on our profession. I urge everyone to voice their support for this bill and any initiatives that come up at the state and federal level that expand patient access to valuable pharmacy services.



  1. Find Shortage Area by Address. Health Resources and Services Administration Data Warehouse. Updated May 29, 2015. Accessed February 29 at http://datawarehouse.hrsa.gov/GeoAdvisor/ShortageDesignationAdvisor.aspx.
  2. What Part B Covers. Medicare.Gov. The Official U.S. Site for Medicare. The Centers for Medicare and Medicaid Services. Accessed February 29 at https://www.medicare.gov/what-medicare-covers/part-b/what-medicare-part-b-covers.html.
  3. Pharmacists Provide Care. American Pharmacists Association. Accessed February 29 at http://www.pharmacistsprovidecare.com/.

From MPA to the Capitol

How does one even express the importance of an organization in their lives when it’s changed their path in such a significant way? It’s incredibly hard. But, in a few words, I’d like to highlight how the Missouri Pharmacy Association has been such a huge catalyst for my success professionally, personally, and spiritually. I want to thank so many of you as you’ve participated and invested in the process so generously. t-headshot

In 2006, I was offered an opportunity to work for pharmacists in the state of Missouri as a staff member of the MPA. I came here to work on issues ranging from pharmacy practice act legislation, to association administration, to marketing the value of the MPA to pharmacies and pharmacists, to create content and build a social media presence, among so many other things. When I moved to Missouri, thanks to a job opportunity with the MPA, I met my wife, we were married and began to build a family (two beautiful little girls), and we began getting involved in our community.

In a few short years, we had made an impression on our community and I was asked to run for State Representative in Callaway and Cole counties. My wife and I accepted the opportunity and in November of 2014, I was elected to my first term as a State Representative. The opportunity to work for the MPA and move to Missouri was the catalyst along with providential calling. Not only has the MPA provided an opportunity to grow in a professional understanding of business, hard work, ethics, integrity, etc, but it’s also opened the door for me to have an impact on my community. For that, I’m eternally grateful to all of you who have invested in this adventure as contributors to our election efforts, and as those who found a need for a young man to take a role within your association in 2006.

So, now, I serve in Missouri’s Legislature. I walk the halls of Missouri’s Capitol in awe of the honor it is to serve there where few have had the opportunity. We took the Grand March in Missouri’s Capitol Rotunda on January 7th, 2015, during the Legislative Inaugural Ball with friends, family, and a few pharmacists there to celebrate with us. I was sworn in earlier that day in our historic House Chamber in Jefferson City. And, with a couple weeks of Legislative experience under my belt, I still can’t help but think about how much the MPA and pharmacists around the state have had an impact on making so much of this happen.

There will be more updates in the very near future about the goings on in Missouri’s Capitol, but I thought it important to write to all of you to thank you for helping set the course for myself, my family, and my career. It has been, is, and always will be an honor to serve pharmacists in the state of Missouri.

Missouri Board of Pharmacy Meeting: My Experience

I had the opportunity to attend a Missouri Board of Pharmacy meeting last week and I had no clue what to expect. It was eye-opening on how many people are involved in the well-being of pharmacy. Various topics were discussed at the meeting and for more information you can visit the Board’s website to see the complete agenda.1 The most interesting part of the meeting to me was when the board discussed the strategic planning for 2014. During this time period the public was able to voice their opinions and concerns.

MPA's July rotation student, Ashely Buehler, UMKC School of Pharmacy, Columbia campus.

MPA’s July rotation student, Ashely Buehler, UMKC School of Pharmacy, Columbia campus.

There were 10 things on the agenda for strategic planning and I will go into more detail about some of them below.1

1.)   Hospital Working Group:

The Board presented with this question “Does the Board want to continue active meetings of the Hospital Working Group?”1

2.)   Automatic Refills:

The Board presented with this question “Should the Board require additional safeguards prior to shipping automatic refills (i.e. – patient consent, patient notification)?”1 This topic was brought up due to the concern of sending refills to patients when the medication is unwanted or has been discontinued.1 Typically, automatic refills are used and implemented to help with adherence for patients.1 Centers for Medicare & Medicaid Services (CMS) wants beneficiaries to give consent for each new and refill prescription as they have been receiving more complaints about beneficiaries receiving medications they did not want.1 Overall, this topic brought about two sides different sides to argue. First, it was mentioned at the meeting the concern of decreasing adherence if automatic refills have more safeguards. Then, the second concern is voiced by CMS that patients are taking medications that have been discontinued or unwanted, which can increase health care costs.1 There was also issues expressed during the meeting about dangerous outcomes from patients taking medications that were discontinued.

3.)   Compounding for Office Use:

The Board requested that a discussion be held.1

4.)   Prescription Labeling:

The Board presented with this question “Should the Board amend Missouri law to clarify which pharmacy should be designated on the prescription label?”1 This is a concern when a prescription is filled in a different location than where the prescription is being picked up, for example a central fill pharmacy. The current statute about labeling (338.059) is phrased “the name and address of the pharmacy,” which does not specify which pharmacy.1 The Board discussed which pharmacy they believe should be liable and responsible, which would then be the pharmacy that should be on the label. A professional present in the meeting stated that Ohio had good phrasing on which pharmacy should be on the label if there was a central fill pharmacy used. The Ohio administrative code is 4729-5-16 that discusses the prescription label state rules.2

5.)   Charitable Services:

The Board presented with this question “Should the Board amend Missouri law to allow pharmacists to dispense prescriptions on the premises of a public health office or other charitable organization?”1

6.)   Automated Prescription Self-Service Devices:

The Board presented with this question “Would the Board like [to] address automated prescription self-service devices?”1 Since technology is advancing quickly today there have been discussions about having automated devices that receive prescriptions. Currently, the statute 338.095 is phrased as “it shall be an unauthorized practice of pharmacy and hence unlawful for any person other than the patient or the patient’s authorized representative to accept a prescription presented to be dispensed unless that person is located on a premises licensed by the board as a pharmacy.”1 Many ideas were discussed on how to move forward with this technology. California has implemented these automated prescription self-service devices with specific requirements for each device.3 Some of these requirements include, it can only be used for refill prescriptions, the device can identify the patient and only release the prescription to that specific patient, and has a telephone to talk with a pharmacy if necessary.3

7.)   Patient Safety Working Group:

The Board wanted to review the patient safety working group recommendations.1 “In 2013, the Missouri Board of Pharmacy initiated a statewide patient safety campaign entitled ‘MoSafeRx.’”1 In order to make this program work the Board created the patient safety working group and they defined what patient safety actually meant.1 Patient safety is defined as “the prevention and reduction of unnecessary harm caused by or associated with healthcare/pharmaceutical care.”1 The recommendation topics the working group determined were enhancing communication among healthcare professionals, enhancing communication among regulatory agencies, pharmacy technician training, quality assurance, scope of practice, and education and outreach.1

8.)   Revenue Sharing Agreements:

The Board presented with this question “Should the Board amend Missouri law to address prescription revenue sharing agreements between pharmacists and prescribers?”1

9.)   Drug Quality and Security Act:

The Board is concerned with implementation and has multiple questions to go along with this topic.1 These questions included 1

  • “How does the Board want to license outsourcers?”
  • “How does the Board want to license 3PLs?”
  • “Should we establish different inspection standards for outsourcers?”
  • “Can an outsourcer/pharmacy share the same space?”
  • “Discipline for compliance with federal requirements?”

10.) Sharing Pharmacy Space:

The Board presented with this question “Should the Board address sharing of pharmacy space with other healthcare providers [and] can a pharmacy store drugs for other healthcare providers?”1 This topic was brought up with the main concern of healthcare professionals storing medications in a pharmacy. An example mentioned at the meeting is when nurses store vaccines in a refrigerator in the pharmacy. The concern is should this be allowed and who accepts the responsibility of those particular drugs. The Board plans to look further into how to handle these situations.

Overall, I am glad I got the chance to attend a Missouri Board of Pharmacy meeting. It was a great experience and I was able to better understand the process of how rules and regulations get decided. I suggest that if you have the chance to attend a meeting to give it a whirl. The next Missouri Board of Pharmacy meeting will be held on October 16, 2014.4

Ashley Buehler
UMKC School of Pharmacy at MU
PharmD Candidate 2015
MPA Rotation Student, July 2014


1Revised meeting notice Missouri board of pharmacy. (2014, July 14). Retrieved from http://pr.mo.gov/boards/pharmacy/meetings/2014-07-15.pdf

24729-5-16 Labeling of drugs dispensed on prescription. (n.d.). Retrieved from http://codes.ohio.gov/oac/4729-5-16

3Board of pharmacy initial statement of reasons. (n.d.). Retrieved from http://www.pharmacy.ca.gov/laws_regs/1713_reasons.pdf

4Meeting information. (n.d.). Retrieved from http://pr.mo.gov/pharmacists-meetings.asp

NASPA Event Highlights Challenges, Opportunities

All the issues and trends impacting retail pharmacy professionals and the industry they serve filter through the 50 state pharmacy associations like currents that feed a larger stream. So the summer meeting of the National Alliance of State Pharmacy Associations served up a laundry list of the most nagging challenges and most promising opportunities facing pharmacy leaders in the coming years, as they confront new reimbursement paradigms, current regulatory hurdles, dramatically new health delivery models and the growing demand for a more patient-centered and more engaged form of pharmacy practice.

Over an uninterrupted, four-and-a-half-hour dialogue Saturday afternoon, dozens of state pharmacy association executives and industry leaders grappled with a wide range of topics that define the challenges and potential facing pharmacy, including:

  • Emerging models of healthcare delivery spurred by health reform and the new evidence-based reimbursement paradigm;
  • Medication adherence and the role that medication synchronization could play;
  • Federal supply chain legislation to establish a nationwide track-and-trace system; and
  • New efforts to establish and document the value of pharmacist interventions and new collaborative-practice models.

The meeting marked a new chapter in the relationship between NASPA and the National Association of Chain Drug Stores, NASPA president Ron Fitzwater indicated. “This is the first time we’ve done this, and we’re looking forward to continuing the relationship in the future. It’s a great opportunity to get state pharmacy associations more formally involved with some very important partners,” Fitzwater said, who is also CEO of the Missouri Pharmacy Association.

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