Pharmaceutical Commerce - November/December 2016 - 15


Brand Communications
Targeting the gatekeepers in long term care
The 'age in place' trend creates challenges for market access to seniors
By Suzanne Shelley, Contributing Editor

As the graying of America continues
unabated, seniors now represent 14.5%
of the US population-one in seven
Americans. The oldest Baby Boomers
are turning 70 this year, and according
to US Census data, starting in 2011 and
continuing until 2030, roughly 10,000 Baby
Boomers celebrate their 65th birthday each
day. With advanced age comes increased
consumption of healthcare ser vices,
prescription medications and increased
reliance on long-term care (LTC) facilities,
including nursing homes, skilled nursing
facilities and rehabilitation centers.
The old are getting older, too: By 2050,
an estimated 27 million people will need
long-term care services and support, up
from 15 million in 2000, according to CDC
statistics.
These facts have been cited for many
years, but what is less noticed is how trends
in gerontology are changing the LTC
industry, and the pharmacy businesses
serving it. Speaking at an investor meeting
last spring, Gregory Weishar, CEO of
PharMerica, said this "sleepy little business"
is evolving as the concept of "age in place"
grows widespread: seniors are staying in
their own homes longer (increasing the
need for home health services), or moving
to assisted living facilities (a business
growing faster than nursing homes) and a
variety of senior communities that provide
a higher level of healthcare than in the past.
PharMerica, the No. 2 institutional
pharmacy company ser ving the LTC
industry, is addressing these trends by
expanding its home infusion service
business, and developing a sideline in
specialty pharmaceutical services, primarily
for oncology products. The No. 1 company
in LTC pharmacy, Omnicare, has undergone
its own dramatic change, being acquired by
CVS Health in 2015. A year later, that action
by CVS is already benefitting its bottom line
profitability.
Aside from these two market leaders,
there are approximately 1,200 independent
LTC pharmacies, which operate in much
the same relationship to the market leaders
as independent community pharmacies do
to the chain drugstores. In particular, the
bigger firms are consolidating the industry
by acquiring the independents; PharMerica
alone says it sets aside $100 million annually
for this purpose.
Evidence of how contested this arena is
becoming can be found in the formation,
in 2014, of the Senior Care Pharmacy
Coalition, a Washington, DC advocacy
group sponsored in part by the major
wholesalers who serve the independent LTC
pharmacies. It advocates for many of the
same issues as independent community
pharmacies, such as PBM reimbursements,
fe der a l r u l e s on com p o u n d i n g a n d
conflicting CMS guidances.

QuintilesIMS, in its annual Use of
Medicines report, pegs pharmaceutical
sales to LTC at $16.7 billion in 2015, up
only 3% from the year before and well off
the overall industry growth of 12.2% (the
figure does not include home health; it also
represents ex-manufacturer pricing and
not the discounting that occurs with most
pharmaceutical sales). A major factor in
revenue growth is the increasingly tighter
reimbursement policies of CMS; besides
Medicare itself (which pays for most elderly
pharmaceutical dispensing), the Medicare
Advantage plans that many insurers offer
contain the same formulary lists and
reimbursement tiers that put pressure on
pharmaceutical revenues for all types of
patients.
Per CMS data, there are more than
15,000 skilled nursing facilities (an SNF is
a nursing home certified to accept Medicare
payments); many are privately held (and
around 70% are for-profit), but many
are also run by charitable organizations
or community health services. And while
Argentum, a trade association of senior
living communities, counts 7,000 assistedliving, independent-living and memorycare facilities among its membership, there
are some 45,000 other senior living facilities
in the US.
A s en i o r, re s i d i n g p e r h a p s a t a n
independent living facility, is likely to go to
the local pharmacy or visit a local doctor,
just as in younger days. But for most
SNFs, some assisted-living facilities and
an undetermined number of other living

arrangements, the LTC pharmacies are the
main source of medications.
LTC pharmacies play a more central role,
generally speaking, than retail pharmacy
does for general-population healthcare.
Because many nursing home residents
have limited cognitive skills combined with
many comorbidities, there are extensive
federal regulations and professional best
practices on how their care is managed.
S o m e LTC p h a r m a c i e s p rov i d e t h e
consultant pharmacists that are required
to review a resident's medication regimen
monthly, which is designed to ensure
that medications are being prescribed for
medically valid reasons.
"Consultant pharmacists look at the
resident's overall medication profile to
ensure elements such as appropriate
indication for a medication, minimization
of drug interactions, appropriate medication
and lab monitoring, polypharmacy issues,
and proper medication administration,"
says Kimberly Binaso, PharmD, VP of
clinical services at Managed Health Care
Associates (MHA), a group purchasing
organization for post-acute care facilities.
"They also serve as an educator and advisor
to the facility, typically serving on various
committees and conducting quarterly
in-house services on a chosen disease state
or regulatory topic." As such, consultant
pharmacists have a key role to validate,
challenge and modify the initial drug
selections made by the attending physicians
and other health practitioners.
The American Society of Consultant

Pharmacists (ASCP; Alexandria, VA) counts
8,000 such pharmacists in its membership,
including students.
Besides these third-party consultant
pharmacists, there are others involved
in selecting medicines for LTC residents.
These include the prescribing physician or
nurse practitioner (who specify the initial
prescription), the nursing staff (who are in
a position to recognize symptoms that may
call for a given therapeutic treatment option
to be prescribed), the medical director of
the facility, and the pharmacy & therapeutic
(P&T) committee members who are
responsible for shaping the formularies that
will be used by an LTC facility.
Influencing the influencers
Generics occupy roughly the same
market share in LTC as in the general
p opulat ion-around 85%. But new
therapies are having a profound impact.
"In recent years, the range of medications
prescribed in nursing homes and other
LTC facilities has been greatly expanded,
to include more therapies that are used
for the long-term management of chronic
conditions such as cancer, HIV, endstage cardiomyopathy, multiple sclerosis,
inflammatory conditions, diabetes, hepatitis
C, autoimmune diseases and others, many
of which were unheard of in nursing
home settings only a few years ago," says
Dr. Richard Stefanacci, DO, chief medical
officer at The Access Group (Berkeley
Heights, NJ).
While this represents market

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