Short-Cycle Dispensing A Health Care Reform Mandate for Long-term Care

2CE hours/ Expires: February 28, 2014

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The medication dispensing process, or dispensing methodology, refers to both the day's supply and the packaging system used to deliver a medication to the end user.1 The traditional dispensing system for most retail prescriptions is a 30-day (or one-month) supply of medication packaged in a vial or bottle. A 30-day supply has also been the primary dispensing cycle used in long-term care settings, such as nursing facilities; although the packaging system is primarily punch cards (also referred to as blister cards or bingo cards) with unit-dose cassette-based systems, multidose/multimed pod or pouch systems also used in some facilities.2 Specialized packaging systems are used in long-term care to enhance medication administration and accountability. Although dispensing systems using 30-day supplies are common, the concept of short-cycle dispensing is neither new nor unusual. Many long-term care pharmacies utilize shorter dispensing cycles to better reflect the average residents length of stay and/or the acuity of the resident and the need for frequent medication changes during the course of his or her illness. This is particularly true when a resident is admitted for a short-term Medicare Part Acovered stay.2 Determining the type of packaging and the length of a dispensing cycle has typically been the responsibility of the long-term care facility, with input from various administrative and clinical staff, including pharmacy, nursing, and medical specialties.3 Now, for the first time, the federal government is mandating a set dispensing cycle for a particular health care setting. Commonly referred to as short-cycle dispensing, the federal government is requiring that brand name drugs be dispensed to Medicare beneficiaries who reside in a nursing facility in 14-day-or-less quantities starting January 1, 2013. On March 23, 2010 the Patient Protection and Affordable Care Act (ACA), also known as the Healthcare Reform Act, was signed into law.4 It is a sweeping piece of legislation that promises to make significant changes to U.S. health care, most of which involves improving access to care for the uninsured and closing the donut hole, or coverage gap, for Medicare beneficiaries. However, buried deep in the document is a surprising paragraph that affects only those Medicare Part D beneficiaries who reside in a long-term care facility, or more specifically, a nursing home. Section 3310 of the act addresses Reducing Wasteful Dispensing of Outpatient Prescription Drugs in Long-term Care Facilities and it specifically states the following: The Secretary [of the Department of Health and Human Services (HHS)] shall require [Medicare Prescription Drug Plan] PDP sponsors of prescription drug plans to utilize specific, uniform dispensing techniques, as determined by the Secretary, in consultation with relevant stakeholders (including representatives of nursing facilities, residents of nursing facilities, pharmacists, the pharmacy industry (including retail and long-term care pharmacy), prescription drug plans, MA-PD plans, and any other stakeholders the Secretary determines

appropriate), such as weekly, daily, or automated dose dispensing, when dispensing covered part D drugs to enrollees who reside in a long-term care facility in order to reduce waste associated with 30-day fills.4 The provision in Section 3310 was given an effective date starting on or after January 1, 2012 and is now set to be effective on January 1, 2013.1,4 The rationale behind the Section 3310 mandate is that shorter dispensing cycles are expected to result in fewer unconsumed medication units (waste), which would result in a Medicare prescription drug cost savings.5 Centers for Medicare & Medicaid Services (CMS) defines waste as the previously dispensed medications (i.e., the Part D-covered drug dispensed to a Part D enrollee residing in a long-term care facility and billed to a Part D plan) that are ultimately not consumed by the Part D enrollee. CMS provided the following examples of actions that may result in unused dispensed drugs, or waste, including drug discontinuation, enrollee discharge to the community, enrollee hospitalization, or enrollee death.1 However, several commenters were concerned that the term waste may not be consistent with other agencies definitions and, as a result, in its final regulation CMS decided to use the term unused drugs instead of waste.1 There are also advantages for short-cycle dispensing beyond reducing financial waste. CMS notes that the Environmental Protection Agency (EPA) recommends that long-term care facilities reduce the amount of pharmaceutical waste generated by limiting the amount of pharmaceuticals dispensed at one time.6 Therefore, short-cycle dispensing provides both economic and environmental benefits. The Congressional Budget Office (CBO) scored savings from mandating a short-cycle nursing home medication dispensing methodology at $5.7 billion during the 8-year period from 2012 to 2019.7 CMS reported on savings estimates ranging from a low of approximately 3% to as high as 17% for 7-day supplies and as high as 20% to 25% for automated dose dispensing.1 However, neither the CBO nor CMS has provided supporting documentation as to how it arrived at its estimated savings. A recent published survey of 8 long-term care pharmacies servicing 33,700 residents in 425 nursing facilities disputes the CBOs estimate and reports that the cost savings resulting from short-cycle dispensing is expected to be $125 million annually, which is significantly less than the CBO estimate.5 CMS recognizes that there is an obvious divergence in estimates and a degree of uncertainty in the rate of conversion to more efficient dispensing methodologies.1 Despite these uncertainties, the initiative is on schedule to be implemented on January 1, 2013. The ACA designated the Secretary of HHS to implement the provisions of Section 3310; however, the Secretary quickly delegated this responsibility to the CMS, which began the process of adding a new regulation at 423.154 to the Medicare Modernization Act (MMA) to govern how Part D sponsors direct network pharmacy dispensing of covered Part D drugs in long-term care facilities. A timeline of activity regarding Section 3310 can be found in [Table 1]. Table 1. Timeline of Activity Impacting Short-Cycle Dispensing Activity Date

Patient Protection and Affordable Care Act (ACA) signed March 23, 2010

CMS proposed rule on Section 3310 of the ACA released November 22, 2010 Public comment period for proposed rule CMS final rule on Section 3310 of the ADA released Implementation date for short-cycle dispensing January 21, 2011 April 15, 2011 January 1, 2013

During the rule making process, CMS reviewed comments from a number of individuals, industry groups, and professional organizations representing long-term care providers throughout 2010. Additionally, CMS participated in the Short Cycle Dispensing Focus Group for Long-term Care, hosted by the National Council for Prescription Drug Programs (NCPDP) in March of 2010, which brought together long-term care facilities, the pharmacies servicing long-term care facilities, vendors, Part D prescription drug plans, and pharmacy benefit managers (PBM). At that meeting, a representative from CMS made the following 3 very key points: 1) medication waste in long-term care facilities has been a concern of the CMS even prior to the release of the ACA; 2) long-term care pharmacies that reduce waste should be paid higher dispensing fees; and 3) all methods that do more to reduce or eliminate waste should be paid higher dispensing fees.8 Panelists at the conference discussed a number of issues involved with moving to an industrywide short-cycle dispensing increment, including drivers for adoption, waste reduction, dispensing costs, billing and adjudication issues, and the impact on quality of care. The general discussion reviewed the following 3 main dispensing and distribution models: 7-day manual dispensing (punch cards), automated dispensing at the pharmacy (multi-dose strip packaging), and remote dispensing (on-site, on-demand packaging).8 Most panelists agreed that a 7-day or less dispensing cycle results in less unused medications. However a 7-day or less dispensing cycle using traditional methods (such as punch cards) requires significantly more labor and is more error prone that other systems; but this may be necessary for long-term care pharmacies that cannot afford a rapid investment in new technologies.8 An additional meeting was held in June of 2010 to discuss waste from the long-term care facilities and the implementation of Section 3310. As a result of the input from these meetings, CMS determined that 75% to 80% of the cost from drug wastage arises from only 20% of the drugs: that 20% is made up exclusively of brand name drugs.6 In an effort to target the drugs that result in the most financial waste and to lessen the burden on the long-term care facilities transitioning from a 30-day supply cycle, CMS has chosen to limit the short-cycle mandate to regulate brand name drugs only.1 Who Must Comply The ACA short-cycle mandate applies to covered Part D drugs dispensed to Medicare beneficiaries residing in long-term care facilities. Medications dispensed to non-Medicare beneficiaries or to residents covered under a Medicare Part A stay are not affected by the mandate. However, for the sake of consistency, it is anticipated that the dispensing methodology chosen by a long-term care facility will be uniform for all residents regardless of their payer type. By definition, a long-term care facility includes a skilled nursing facility (SNF) or a

medical institution or nursing facility for which payment is received from Medicaid or Medicare.6,9 Therefore, the mandate does not apply to settings such as group homes or assisted living facilities. Additionally, CMS has waived the requirement for short-cycle dispensing to Part D enrollees residing in intermediate care facilities for the mentally retarded (ICFMR) and institutes for mental disease (IMD).1 The ACA short-cycle mandate is not limited to pharmacies dedicated to dispensing medications to residents of nursing homes. Rather, CMS requires all pharmacies that service long-term care facilities, including not only closed-door exclusively long-term care pharmacies, but also retail pharmacies and mail order pharmacies that dispense to long-term care facilities, to comply with the provisions of the short-cycle mandate.1,6 However, in recognition of the unique circumstances encountered by pharmacies in the Indian Health Service/Tribal/Urban system who service long-term care facilities, such pharmacies are waived from the requirement to comply with the new short-cycle regulation.1 Dispensing Cycle While Section 3310 of the ACA provides some examples of dispensing time frames, such as weekly, daily, or automated dispensing systems, the directive in Section 3310 does not define a specific time frame for the dispensing cycle and simply requires that uniform technologies be utilized to reduce waste associated with 30-day fills. This language allows for flexibility in determining the dispensing increments and methodology. Although CMS originally proposed a 7-day or less dispensing increment, in the final rule CMS determined that a 14-day or less dispensing requirement would place less of a burden on pharmacies and long-term care facilities, while allowing CMS the opportunity to collect data to determine the impact of a 14-day or less dispensing methodology on unused drugs. While CMS believes that a 7-day or less dispensing cycle is more effective for minimizing the volume of unused drugs and the resulting financial waste paid under the Part D program, the final rule mandates a 14-day or less dispensing cycle.1,6 Despite the 14-day or less dispensing mandate, pharmacies and facilities can elect to use shorter dispensing increments, such as the dispensing of a drug once a week (7-day dispensing); is it also possible to dispense a drug for 3 or 4 days (3day/4-day dispensing). In addition, the dispensing of a drug for 2 days, followed by the dispensing of a drug for another 2 days, followed by the dispensing of a drug for 3 days (2day/2-day/3-day dispensing) or daily dispensing (24 hour), as well as automated shift or dose dispensing are all viable options.1,6 The long-term care facility, in collaboration with their contracted pharmacy, is responsible for choosing the dispensing increment. However, there is an incentive for long-term care pharmacies to dispense in increments of 7-days or less with solid oral doses of both brand name and generic medications because they will be exempt from reporting unused drugs.1 Medication Packaging Section 3310 of the ACA requires that uniform dispensing techniques be utilized. CMS interprets uniform to mean that the dispensing methodologies will be uniform with respect to the type of packaging used to dispense Part D drugs within a long-term care facility, but may vary by the

quantity of medication (a days supply) dispensed at a time.6 To enforce this uniformity of dispensing techniques, CMS requires that Part D sponsors ensure that their contracted pharmacies dispense Part D drugs using a consistent dispensing packaging throughout a single facility. A variety of dispensing methodologies are used by long-term care facilities. Currently, the most common dispensing methodology for oral solid medications is the 30-day punch card, also referred to as a blister card or bingo card.2 This system allows for 30, 60, or 90 doses (depending on tablet or capsule size) to be placed individually in blisters on a cardboard frame. Typically one card contains a 30-day supply of medication unless the tablet or capsule is large, in which case multiple cards may be required. The card allows for accountability and efficiency in the medication administration process because the nurse can quickly view the medication dose, easily punch the medication into the medication cup without touching the medication, and compare all remaining doses to both the start date of the card and the medication administration record to verify that the appropriate amount of medication has been administered. Most 30-day punch cards are a common size, which are designed to fit securely in a variety of the locked medication carts available at long-term care facilities. In preparing to move to a 14-day or less dispensing system, the pharmacy will have the option of either making changes to the number of doses packed in the standard 30-day card or moving to a different card stock for a 14-day or 7day system. However, consistency with card size should allow for continued use of the medication carts currently available at the facility. Moving to another type of dispensing system, such as unit-dose cassette-based systems or multi-med or pouch systems, may require changes in the medication storage systems at the facility, necessitating greater conversion expense and preparation time. A recent membership survey conducted by the American Society for Consultant Pharmacists concluded that the use of a remote automation dispensing technology is uncommon among longterm care pharmacies.2 However, CMS has endorsed using an automation dispensing technology located at the facility for on-demand medication dispensing as the most efficient dispensing methodology and the most effective at reducing waste.6 Still, CMS recognizes that there are substantial limitations to the rapid adoption of automation dose dispensing technology, including capital acquisition costs, state pharmacy board restrictions, the lack of final automated medical records and interface standards, as well as the physical plant size and the electronic and computer networking capability at the long-term care facility and/or pharmacy.6 Therefore, CMS empowers the long-term care facility, in collaboration with its contracted pharmacy, to choose the type of dispensing methodology or methodologies to be used in that facility.1 CMS is very clear in stating that the choice of dispensing methodology belongs to the facility and not the Part D sponsor: they enforce that Part D sponsors may not require the use of a different packaging system or technology than that selected by the long-term care facility.1 Brand Name Drugs A brand name drug is one for which an application is approved under section 505(c) or 505(b)[2] of the Federal Food, Drug, and Cosmetic Act, which specifically refers to a drug approved under a New Drug Application (NDA).1 CMS originally proposed to exclude certain brand name drugs from short-cycle dispensing, specifically noting that drugs dispensed for an acute illness and drugs that are difficult to dispense in small quantities could be exempted. CMS further outlined specific types of medications that would be exempt from short-cycle dispensing, such as eye

drops, ear drops, inhalers and inhalation drugs, nasal sprays, reconstituted antibiotics, drugs with a parenteral route of administration, topical medication, and drugs that must remain in their original container.6 While many types of drugs were considered inappropriate for short-cycle dispensing, CMS originally proposed that liquid medications would be required to be dispensed in smaller quantities to meet the short-cycle mandate, stating that this could be accomplished by the use of smaller bottles or oral syringes.6 The proposed rule resulted in numerous comments regarding drugs that should be excluded from short-cycle dispensing. After reflecting on these comments and with recognition of the potential difficulty in interpreting and operationalizing the drugs difficult to dispense language, CMS eliminated the reference to acute illness and drugs difficult to dispense. The final rule requires a 14-day or less dispensing cycle for solid, oral doses of brand name drugs, including controlled substances.1 Antibiotics and drugs that must be dispensed in their original container, or are customarily dispensed in the original container to enhance patient compliance, such as oral contraceptives, are excluded from the 14day or less dispensing requirement.1 Return and Reuse In its originally proposed rule, CMS considered return for credit and reuse of drugs as an additional option for reducing pharmaceutical waste in long-term care facilities.6 Under this scenario, Part D sponsors would have policies in place, consistent with state law, to require unused Part D drugs to be returned to the pharmacy for credit to the Part D program and then reused to fill another Part D patients prescription. However, during its review, CMS recognized limitations to this option, including the fact that return and reuse is not permitted in all states and is frequently limited to only expensive brand name drugs or that it may exclude generic drugs and may be limited to only certain types of packaging systems. Additionally, the Drug Enforcement Agency (DEA) limits the return and reuse of controlled substances. A number of industry representatives shared concerns about the safety and quality control of drug storage in the long-term care facility, the chain of custody of the drugs to be returned, and issues regarding drug diversion during the return process. Upon consideration of these facts, CMS determined that return for credit and reuse would not be the optimal solution to address drug waste generated by long-term care facilities under Part D.6 In its final rule, CMS affirms that the prevention of the accumulation of unused drugs, rather than the handling of unused drugs after they have accumulated in long-term care facilities, will more effectively reduce financial waste.1 While return and reuse of drugs is not an alternative to short-cycle dispensing, CMS recognizes that it may be a supplement to reduce the minimal pharmaceutical waste associated with shortcycle dispensing and can be effective in certain situations, such as when there is an on-site pharmacy at the long-term care facility.1 CMS explicitly allows the return for credit and reuse of medications in long-term care pharmacies where this practice is permitted by state law and allowed under the contract between the Part D sponsor and the pharmacy. In such instances, CMS notes that dispensing fees paid to pharmacies may take into account restocking fees.1 Data Collection & Reporting The effects of unused drugs on long-term care facilities has not been fully quantified. In an effort to determine the full effects of unused drugs and the potential cost savings as a result of the ACA

mandate, CMS originally proposed that Part D sponsors include terms in their pharmacy contracts to require that all unused drugs, originally dispensed to the Part D sponsors enrollees, be returned to the pharmacy and reported to the sponsor, although the returned drugs were not necessarily required to be credited.6 The proposed regulation also required the contract to address disposal of the returned drugs in accordance with Federal and state regulations.6 However, the final regulation eliminated the requirement for unused drugs to be returned to the pharmacy and requires only that Part D sponsors must collect and report to CMS the dispensing methodology used for each prescription dispensing event of solid oral dosage forms of brand name covered Part D drugs and the nature and quantity of unused brand name and generic drugs dispensed to enrollees in a long-term care facility.1 CMS will use this information to determine the extent to which the new 14-day or less dispensing requirement reduces the amount of unused drugs and also to determine the potential cost-effectiveness of expanding the requirement to generic drugs in the future. In order to obtain this information, CMS plans to add 2 new fields to the prescription drug event transaction to allow for the reporting of place of service coding and to identify the long-term care dispensing methodology used. CMS has designated the following 2 types of order entry methods: cycle (chronic) order entry for maintenance medications that are refilled on a regular basis and direct (acute) order entry for short-term medications.10 Regardless of the order entry method used, CMS believes that when a medication is no longer being administered to the long-term care resident, the pharmacy receives information that causes the pharmacist to discontinue the medication. This information may be in the form of census data that indicate the resident has died or been discharged, a discontinuation order, or a medication change order that would make it apparent that the previous medication was no longer being used, such as a new dose for the same medication or a therapeutic alternative drug. Using this information, the pharmacy can compute the amount of medication prescribed for the days prior to a likely discontinuation and subtract this amount from the quantity dispensed to determine the amount of unused medication. CMS recognizes that this calculation may not precisely correlate with the amount of medication administered, but believe the result will be a close approximation of the unused amount. CMS has created some examples of how this process might work. Table 2. Examples of How to Calculate Unused Drugs10 Situation Pharmacy receives a D/C order. Assume Assume all medications were administered on the date of the D/C order. Use the date of death or discharge as the D/C date and assume all medications were administered on that date. Count as Unused The unused amount will be the days supply remaining following the date of the D/C order. The unused amount will be the days supply remaining following the date of death or discharge. There will be no unused

Pharmacy does not receive a D/C order, but receives notice of resident death or discharge.

Pharmacy does not receive a Assume the dispensed

D/C order, but within 1 - 2 days of the end of the current order, receives a new medication order for either the same drug (but different dose) or a therapeutic alternative drug.

amount was used before the amount, unless a refill was new medication was processed and delivered. started, unless a refill has been processed and delivered. If a refill was delivered, count the entire refill If a refill was delivered, amount dispensed as assume the refill amount is unused. unused. Assume new medications were begun on the first medication pass of the day following the delivery of the medication to the facility. Any amount remaining when the new medication is started will be considered unused. The unused amount will be considered the days supply remaining at the end of the day of the delivery of the new medication to the facility.

Pharmacy does not receive a D/C order, but more than 2 days prior to the end of the current order receives a new medication order for either the same drug (but different dose) or a therapeutic alternative drug.

The medication ordered was Assume the pharmacy is held by the physician or unaware of the hold order refused by the resident. or resident refusal and follow the prior assumptions that would otherwise apply.

Medications ordered to be held by the physician or refused will not be counted as waste.

The medication was ordered Exclude medications under Medications under PRN to be administered on a PRN PRN orders from the report. orders will not be counted (as needed) basis and the as waste. pharmacy has no knowledge concerning actual use. The medication was dispensed in greater than a 14-day increment because the census data initially showed a non-Medicare payer, but the data were retrospectively changed to a Medicare Part D plan. Follow all applicable prior assumptions. Count the amount of any unused medications based on the amount actually dispensed.

Waivers will be granted to long-term care pharmacies that utilize a 7-day or less dispensing methodology for all solid oral doses of both brand name and generic drugs and they will not be required to report unused drugs.10 Dispensing Fees and Copayments

In its final rule, CMS modified the definition of dispensing fees by adding that dispensing fees should take into consideration the number of prescription dispensing events in a billing cycle, the incremental costs associated with the type of dispensing methodology, the techniques to minimize the dispensing of drugs that go unused, and restocking fees associated with return for credit and reuse, when that activity is permitted.1 CMS stated that it was not their intent to include all activities in the definition of dispensing fees; however, the statutory requirements regarding dispensing to Part D enrollees in long-term care facilities support the need to address the potential pharmacy costs associated with attempts to reduce the volume of unused Part D drugs and increase dispensing efficiency. In particular, CMS recommends that dispensing fees negotiated between Part D sponsors and pharmacies that dispense to Part D enrollees in longterm care facilities should vary with the dispensing methodology and should incentivize the use of more efficient and cost-effective systems. CMS estimates the current aggregate level of dispensing fees will likely double with the implementation of the 14-day or less dispensing increment.1 Copayments will likely change from the current per-dispensing method to better reflect the different billing and dispensing methodologies used by various long-term care facilities. Varying copayments within a plan will be acceptable as long as it is consistent for beneficiaries who receive their Part D medications using the same dispensing methodology. Copayments may be collected at the first dispensing event in the month, the last dispensing event in the month, or prorated based on the number of days a Part D drug was dispensed in a month. Copayments for low-income subsidy (LIS) beneficiaries should be billed with the first or last dispensing event of the month.6 Ideas for Implementing Short-Cycle Dispensing There are a number of issues to be considered when deciding how best to implement the shortcycle dispensing mandate. Long-term care pharmacies must solicit input from their clients as a means to help determine the type of dispensing methodology preferred. In its final rule, CMS places the responsibility for selecting the medication dispensing methodology squarely on the shoulders of the long-term care facility. However, CMS nursing facility regulations identify the consultant pharmacist at the facility, in collaboration with the facility staff and medical director, as being responsible for recommending the dispensing methodology most likely to minimize errors.3 Finally, the long-term care pharmacy personnel should be equally involved in the decision-making process because they will be responsible for incorporating the desired dispensing methodology into the prescription-filling process. When preparing for short-cycle dispensing, the pharmacy must decide which dispensing system and dispensing increment will work best given the preferences established by its contracted facilities, the capabilities of the pharmacy plant, the availability of investment capital, and the cost of labor to convert and operate the new dispensing methodology. If automation technology is chosen, sufficient leadtime must be allowed for ordering, receipt, installation, and testing of the new systems. Both pharmacy staff and facility staff will have to be trained on the new dispensing methodology and/or automation technology and new policies and procedures will have to be developed. Planning the conversion to the new dispensing methodology will have to begin during the last few months of 2012 to ensure that all long-term care facilities are utilizing 14-day or less dispensing methodologies for their Part D residents following January 1, 2013.

Table 3. Preparing to Convert to Short-Cycle Dispensing Issue Considerations Multiple systems may ensure that each contracted facility can choose a system more to their liking. But the investment in time, materials, and resources to run multiple dispensing technologies may be too burdensome. Offering one primary dispensing methodology can be more cost-efficient, but may limit facility choices and place the pharmacy at a competitive disadvantage if other long-term care pharmacies offer a more attractive dispensing methodology. Bingo Card Low entry cost High potential for labor costs and errors 14-day or 7-day dispensing increments can be accomplished utilizing existing 30-day card stock or using new card stock with complementary dimensions, allowing existing medication carts to be used at the facility. However, this system requires more touches, which increases labor costs and the risk for human error. Automated bingo-card filling systems may reduce costs and error potential. Unit dose strip-pack systems have been used for a variety of dispensing increments, from 30-day to daily. 14-day or 7-day increments can be accomplished by using existing stock (boxes) or equipment (cassettes). Using traditional manufacturers strip packaging requires more touches, increasing labor costs and risk for human error. In-pharmacy systems provide flexibility in dispensing increments with little additional labor costs, allowing for variations among facilities and/or payer types (Part D versus Part A). They also provide flexibility in dispensing methodology (from unit-dose strips to multidose compliance packaging) to fit the broad range of needs from

How Many Dispensing Systems

Bingo Card, Unit Dose, or Automation Technology

Unit Dose Low entry cost High potential for labor costs and errors

Automation Technology High entry cost Lower potential for labor costs and errors

different facility types. In-facility systems (also called remote dispensing) provide immediate access to medications, reduce delivery costs, reduce pharmacy labor, and provide flexibility in dispensing methodology (per shift, med-pass, unit dose, or compliance packaging). However, automation technologies require significant capital investment and physical plant resources, such as Internet connectivity, electrical support, ventilation, and sufficient space. A dispensing increment of 14-days will meet the short-cycle dispensing mandate and will reduce the number of touches on the prescription per month, compared with a 7-day or less increment. However, a dispensing increment of 7-days or less may exempt the pharmacy from having to report unused drugs which may be a significant time and labor savings.

Dispensing Increment

Brand name drugs are considered a contributor to the primary cost of unused drugs. Limiting short-cycle dispensing to only brand name drugs will significantly reduce the number of drugs that must utilize the shorter prescription mandate and reduce the number of touches required to fill prescriptions for the facility. Brand Name Only or However, incorporating the solid oral dosages of both brand name Brand Name and and generic medications into the system will provide better Generics consistency for the nurses who order, store, and administer medications at the long-term care facility. Additionally, dispensing brand name and generic medications in 7-day or less increments will exempt the pharmacy from having to report unused drugs. The ACA mandates short-cycle dispensing only for Part D enrollees residing in long-term care facilities. However, many long-term care pharmacies are already providing a less than 30day supply to Part A residents, as well. Keeping dispensing increments consistent across all payer types in a facility will facilitate the training of nursing staff on the dispensing methodology, the creation of policies and procedures, and the acquisition and utilization of medication storage equipment in the facility. However, if the pharmacy is currently providing 30-day supplies to all residents, moving to a short-cycle dispensing

Part D Only or All Residents

increment for all payer types will require more touches for all prescriptions per month. Pharmacy software vendors will need to update their systems to accommodate the new record keeping and billing needs that may be associated with the short-cycle mandate. The pharmacy must understand how the dispensing methodology will be reported to the Part D plan for each prescription dispensing event (how and when unused medications will be reported to the plan [and who in the pharmacy will drive that calculation], how copayments will be collected [first dispensing, last dispensing, or prorated]) and the system will interface with automation technology in the pharmacy or at the facility. Medication storage at the facility may change as a result of choosing a new dispensing methodology. If in-facility automation systems are selected, the pharmacy must determine if the facility has sufficient physical plant resources to host the system and if the facility is willing to share in the cost of the technology. New medication carts may be necessary to accommodate systems that are not based in the facility. New pharmacy services policies and procedures will need to be developed to reflect ordering, receipt, storage, administration, discontinuation and destruction of unused medication using a new dispensing methodology. Conversion to a new dispensing methodology will require education of facility staff and a planned implementation schedule so that all contracted facilities are on-board with their new dispensing methodology by January 1, 2013.

Pharmacy Software Needs

LTC Facility Needs