Is a Pharmacy Student the Customer or the Product? PDF

American Journal of Pharmaceutical Education 2014; 78 (1) Article 3. STATEMENTS Is a Pharmacy Student the Customer or the Product? David A. Holdford, PhD School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia Submitted June 21, 2013; accepted August 4, 2013; pub...

American Journal of Pharmaceutical Education 2014; 78 (1) Article 3. STATEMENTS Is a Pharmacy Student the Customer or the Product? David A. Holdford, PhD School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia Submitted June 21, 2013; accepted August 4, 2013; published February 12, 2014. Academic entitlement and student consumerism have been described as a cause for unprofessional behavior in higher education. Colleges and schools of pharmacy may inadvertently encourage student consumerism and academic entitlement by misunderstanding who is the primary customer of pharmacy education. Pharmacy colleges and schools who view students as the primary customer can uninten- tionally pressure faculty members to relax expectations for professionalism and academic performance and thereby cause a general downward spiral in the quality of pharmacy graduates. In contrast, this paper argues that the primary customer of pharmacy education is the patient. Placing the patient at the center of the educational process is consistent with the concepts of pharmaceutical care, medication therapy management, the patient-centered home, and the oath of the pharmacist. Emphasizing the patient as the primary customer discourages academic entitlement and student consumerism and encourages an emphasis on learning how to serve the medication-related needs of the patient. Keywords: academic entitlement, pharmacy students, student consumerism, higher education, pharmacy INTRODUCTION (2) educators are responsible for student learning, not the Faculty members at colleges and schools of pharmacy student; (3) effort, not performance, should be rewarded often experience episodes of uncivil and unprofessional in grading; and (4) open or passive aggressive behavior behavior by the millennial generation in the classroom. toward faculty members is acceptable if student expec- Behaviors include surfing the Web, studying for other tations are not met.3 Academic entitlement likely occurs courses, texting, social media use, chronic absenteeism, in only a small proportion of students in institutions, but arriving late to class or leaving early, not completing pre- this vocal minority can sow discontent throughout the class assignments, and shirking responsibilities in team educational system. assignments. Most faculty members can recount anecdotes Academic entitlement can occur in any student. Even of unprofessional behavior in students. Academic entitle- the most accomplished students, those with stellar grades ment has been suggested as a significant contributing factor and positions as class leaders, can develop expectations to this behavior.1,2 that they deserve special treatment. In fact, they may even Academic entitlement is defined as the tendency of have earned it because of exceptional contributions to the students to expect academic success without taking per- school. The problem occurs when demands for special sonal responsibility for achieving that success. It has been treatment cross the line into unprofessional behavior to- associated with externalized responsibility for success ward others and disrespect for the educational process. (eg, “My professor did not give me what I needed to Moreover, the problem is compounded when students achieve an 'A' in this class.”) and entitled expectations and pharmacy educators disagree on specific behaviors (eg, “I cannot believe that my professor gave me a bad that are inappropriate. Compare student and faculty re- grade on the assignment. I deserve a better grade because sponses about the acceptability of skipping class to study I worked really hard on it!”).1 It has also been described for a test, surfing the Web during a presentation by a guest as revolving around several related student perceptions speaker, anonymously castigating a professor's perfor- including (1) knowledge is a right more than a privilege; mance on a course evaluation, or almost any other contro- versial behavior, and major disagreements will emerge. It Corresponding Author: David A. Holdford, PhD, Professor seems that educators and students are often working from of Pharmacotherapy and Outcomes Research, School of a different script about what it means to be a professional. Pharmacy, Virginia Commonwealth University, MCV Although it might be tempting to blame the millen- Campus, Box 980533, 410 North 12th Street, Richmond, nials, their parents, and society, academia should share VA 23298-0533. Tel: 804-828-6103. Fax: 804-828-8359. a portion of the blame. Entitlement is encouraged by fac- E-mail: [email protected] ulty members who give high grades for mediocre work, 1  American Journal of Pharmaceutical Education 2014; 78 (1) Article 3. thereby reinforcing students' inflated perceptions of their a good job, even if some of the graduates are unemploy- performance and expectations for high grades in the fu- able as pharmacists. ture.4 Grade inflation is further encouraged by school But where is the patient in this process? How does the administrators who emphasize student course evaluations patient fare in a system that places student satisfaction when assessing faculty performance, especially as students first? Will indulging students be in the best interests of are more likely to reward faculty members who are lenient the patients they are trained to serve? Are students really over ones who are rigorous.5 the primary customer of pharmacy education? Students may use academic entitlement as a mecha- nism for coping with the pressures and disappointments of THE STUDENT AS THE PRIMARY the educational process.6 In pharmacy education, many CUSTOMER conflicts between professors and students are seen over A reasonable argument can be made that professional grades. Conflicts can be aggravated by the dissonance education is a service; thus, service-marketing strategies students feel when they realize the strategies that once can improve the quality of educational programs.8-10 The made them successful in undergraduate settings no longer problem with academic entitlement and student consum- translate to success in pharmacy school. Faced with a erism is not the use of marketing strategies in education. pharmacy school classroom of high achievers, students Rather, it is that colleges and schools misidentify their frequently find that efforts that once resulted in A grades primary customers and the products they offer. In market- in prepharmacy curricula now yield B’s and C’s. When ing, a customer is an individual or group whose needs and disappointed, academically entitled students are more wants are served by the product, and a product is something likely to blame external causes (eg, their professor) rather of value which is designed to meet the needs and wants of than accept personal responsibility6 and, consequently, customers.11 How educators define their product and their act out their frustration with unprofessional and uncivil customers determines their approach to education. behavior.2 This paper argues that the idea of student consumer- Student consumerism has been associated with ac- ism is based upon a fundamental misunderstanding of the ademic entitlement.2 Student consumerism is defined primary customer of pharmacy education. Pharmacy col- as the perception by students that because they pay for leges and schools serve multiple customers – students, their education, they deserve to be treated as customers.7 alumni, funding agencies, college or university adminis- This means that educators are there to serve and satisfy tration, employees and faculty members, employers of them. In pharmacy education, some educators may con- graduates, the community, and patients. These customer tribute to the “student as customer” perspective out of groups often have competing demands and priorities which pressure to attract and retain academically competitive require prioritization by educators. The primary customer students. should take precedence over all other customers. However, indulging student consumerism and feel- When colleges and schools deem students as the pri- ings of academic entitlement can damage the educational mary customer, student desires become the driving force process. It may hurt the education of good students by behind the educational process and its outcomes. Al- causing schools to lower academic expectations, thereby though they might demand a high-quality education, making the students less prepared and competitive for their demands are shaped by a limited understanding postgraduate experiences like residencies and fellow- of what it takes to be a professional in a dynamic health ships. For students who struggle, however, it might tempt care environment. Like consumers in any service setting, colleges and schools to keep them in order to meet ACPE they will focus on the process of education (eg, was it de- benchmarks for student progression through the program livered in a convenient, friendly manner) because of their and to achieve enrollment targets established by univer- inability to assess the educational outcome (eg, profes- sity or college administration. Thus, marginal students are sional competence).12 allowed to progress through the program, barely passing With the student as the primary customer, the ap- courses. To ensure that these marginal students can pass proach to pharmacy education might be captured in the the North American Pharmacist Licensure Examination customer service promise shown in Table 1. Although (NAPLEX) and receive a license, colleges and schools laughable, most educators will see some element of their may offer board preparation classes or other remediation policies and practices in this customer service promise. measures. Then, when their graduates receive a license, Indeed, when applied in moderation, accommodating stu- these schools congratulate themselves on the success of dents' lives and learning preferences is a good educational their students, highlight their board-passing rates in pro- strategy that will increase student engagement and learn- motional materials, and tell themselves that they are doing ing. When taken to the extreme, however, it can pressure 2  American Journal of Pharmaceutical Education 2014; 78 (1) Article 3. Table 1. Service Promise for a Pharmacy School That Sees the Student as the Primary Customer 8-Step Customer Service Promise We are committed to you, the student, at ACME School of Pharmacy. Your patronage is important to us and our commitment is backed up by our 8-step customer service promise: (1) Class Schedules: Our classes are designed to fit your personal schedule. If we offer our classes at inconvenient times, let us know so we can accommodate you. (2) Entertaining: We believe that learning should be fun and easy. We promise to be so entertaining that your learning will be effortless. (3) Course Content: We tailor our classes to your personal interests. If you do not like what is being taught, let us know and we will change it. (4) Comfort: We care about your personal comfort. If you dislike responding to difficult questions from faculty members, working with team members who are not your friends, dealing with the sick or elderly, or doing any educational activities that might cause you stress or embarrassment, let us know and we will remedy your distress. (5) Satisfaction: Student satisfaction is job one. Be sure to tell us how we are doing, so we can serve you better. (6) Grading: If you are unhappy with your grades, talk to your professor. He or she will work with you to achieve the grades you want. (7) Customer Centered: You, the customer are always right. Should we ever forget this, please remind us. (8) Guarantee: We promise that you will get a degree, as long as you continue to pay your tuition. faculty members to relax expectations for professional- to serve patients and other professionals who serve pa- ism and academic performance and result in a general tients. After graduation, these students will be more highly downward spiral in the quality of pharmacists graduating valued by employers and more competitive for jobs. from schools. How educational processes differ when defining the primary customer of pharmacy education is illustrated in THE PATIENT AS THE PRIMARY Table 2. When the student is the customer, educational CUSTOMER institutions assume a transactional approach that parallels A stronger argument can be made that the patient is many of the major complaints lodged against higher ed- the primary customer of pharmacy education because with- ucation.2,15,16 In a transactional approach, students tend out the patient, there is no reason for the profession or for to see every interaction with the school as a commercial pharmacy education. The patient is at the center of the exchange in which they say, “If I do 'x', I expect to get 'y' in definition of pharmaceutical care (“the responsible provi- return.” With this approach, students who pay tuition ex- sion of drug therapy for the purpose of achieving definite pect schools to serve them in return. If they complete an outcomes that improve the patient's quality of life,”13) and assignment, they expect an acceptable grade as compen- medication therapy management (“a distinct service or sation. However, when the patient is the primary cus- group of services that optimizes drug therapy with the in- tomer, a more sophisticated relationship and approach tent of improved therapeutic outcomes for individual pa- to education results. In this educational relationship, stu- tients”14). Patients are also central to the patient-centered dents and faculty members collaborate to develop pro- medical home concept. These guiding principles of phar- fessional competence in students. Education is neither macy practice and medicine place the patient at the center delivered to students, nor something to which students are of all things accomplished within the profession. Although entitled. Rather, value emerges by the student and school co- important, pharmacists and pharmacy students should al- creating the education process. Both students and educators ways take a backseat to the needs of the patient. are responsible for the process and outcome of education. It might be better to see the student as the product of Flexibility and educational choice can be encouraged as pharmaceutical education rather than the customer. Viewed long as they serve the ultimate goal of developing profes- this way, students are a means for pharmacy schools to serve sional competence. Attention can still focus on the learner their various stakeholders including patients, employers of as long as the learner and the educator agree that their graduates, the community, and funding agencies. With the ultimate goal is the service of patients. student as the product, colleges and schools compete by With the patient at the center of the educational pro- serving the stakeholders with graduates who are held ac- cess, colleges and schools only enroll students who they countable for the highest standards of professional and believe have the intelligence and enthusiasm to effectively ethical behavior. Students benefit, too, by being trained represent both the school and profession. The profession 3  American Journal of Pharmaceutical Education 2014; 78 (1) Article 3. Table 2. Contrasting How the Process of Education Changes Depending on Who Is the Primary Customer Process Student Is the Customer Patient Is the Customer Educational philosophy Pharmacy education is a right Pharmacy education is a privilege Goal of education Student satisfaction Professional competence Educational model Students are taught Education is a collaboration Who is responsible for a student's education? Faculty members Students and faculty together Role of grades Rewards for effort Feedback on effort and performance Relationship between faculty Faculty member serves Faculty members and students co-create members and students the student the educational experience Students are... Entitled Held accountable Educational outcome A degree Professional competence Ultimate goal for students A job A career where one can make a difference and academy should only support the accreditation of phar- d I will embrace and advocate changes that improve macy colleges and schools that hold students to the norms patient care. of the profession, which are generally summarized in the d I will utilize my knowledge, skills, experiences, oath of the pharmacist: and values to prepare the next generation of pharmacists. I take these vows voluntarily with the full realization of the I promise to devote myself to a lifetime of service to responsibility with which I am entrusted by the public. others through the profession of pharmacy. In fulfill- Reprinted with permission of the American Pharmacists Association.17 ing this vow: d I will consider the welfare of humanity and relief of The oath emphasizes service to the patient. Students suffering my primary concerns. who take this oath pledge to serve the needs of the patient d I will apply my knowledge, experience, and skills to and develop their ability to serve those needs. The oath the best of my ability to assure optimal outcomes for also insists on excellence and effort, meaning that phar- my patients. macy education demands a great deal of time and effort. d I will respect and protect all personal and health information entrusted to me. Students who are not capable or willing to do what is d I will accept the lifelong obligation to improve my asked of them should seek another profession. professional knowledge and competence. With the patient as the primary customer, a different d I will hold myself and my colleagues to the highest 8-step customer service promise emerges (Table 3). In principles of our profession’s moral, ethical and this promise to students, pharmacy colleges and schools legal conduct. discourage entitlement but do so in a positive, supportive Table 3. Service Promise for a Pharmacy School that Sees the Patient as the Primary Customer 8-Step Customer Service Promise We are committed to preparing you to serve the pharmaceutical and health needs of your patients. Our commitment is backed up by our 8-step customer service promise: (1) Challenge: Our classes are designed to prepare you for the complex health care system of the future. We will challenge you to exceed your expectations. (2) Respect: Pharmacists are one of the most trusted professionals. You will be treated as a respected member of the profession as long as you uphold its standards and your oath as a pharmacist. (3) Participation: Learning is not a spectator sport. Your participation in the educational process is valued and expected. (4) Confidence: You will develop the confidence needed to step outside of your comfort level. Every day, your confidence to serve patients will grow. (5) Integrity: We expect high levels of integrity in the actions of all individuals at our institution whether they are students, faculty, staff, or administration. (6) Accountability: All students will be held accountable for demonstrating the behavioral and learning outcomes expected by the school and profession. (7) Patient-Centered: Your primary duty as a professional is to patients you will serve. All elements of the educational process are focused on that goal. (8) Success: Your success is our success. We pledge to do everything we can to help you succeed. The rest is up to you. 4  American Journal of Pharmaceutical Education 2014; 78 (1) Article 3. manner. Although the promise emphasizes effort and chal- REFERENCES lenge, it also promises personal development and the pos- 1. Chowning K, Campbel NJ. Development and validation of sibility to make a difference. In addition, the message to a measure of academic entitlement: individual differences in students' externalized responsibility and entitled expectations. J Educ Psychol. faculty members is positive and uplifting. It encourages 2009;101(4):982-997. rigorous expectations of professionalism and academic 2. Cain J, Romanelli F, Smith KM. Academic entitlement in performance and a clear guide to educational priorities. pharmacy education. Am J Pharm Educ. 2012;76(10):Article 189. The message is that granting a degree will only happen 3. Dubovsky SL. Coping with entitlement in medical education. after achieving rigorous educational outcomes established N Engl J Med. 1986;315(26):1672-1674. to serve the needs of patients. Doing anything less would be 4. Lippman S, Bulanda R, Wagennar TC. Student entitlement issues and strategies for confronting entitlement in the classroom and a disservice to the students, alumni, employers, profession, beyond. Coll Teach. 2009;57(4):197-204. public, and most of all, the patient. 5. Clayson DE. Student evaluations of teaching: are they related to Much of the problem associated with student entitle- what students learn?: a meta-analysis and review of the literature. ment is one of communication. When communications J Mark Educ. 2013;31(1):16-30. are framed with the students at the center of pharmacy 6. Boswell SS. I deserve success: academic entitlement attitudes and their relationships with course self-efficacy, social networking, and education (eg, we are here to serve you), student entitle- demographic variables. Soc Psychol Educ. 2012;15(3):353-365. ment results. However, when framed with the patient at 7. Delucchi M, Korgen K. We're the customer-we pay the tuition: the center of pharmacy education (and backed up with student consumerism among undergraduate sociology majors. Teach actions by faculty members and administration), students Sociol. 2002;30(1):100-107. start to become professionals. Students and educators 8. Holdford DA, Reinders TP. Development of an instrument to need to agree that the primary purpose of pharmacy ed- assess student perceptions of the quality of pharmaceutical education. Am J Pharm Educ. 2001;65(2):125-131. ucation is to prepare students to serve patients, and the 9. Hughes K. Quality and marketing issues in nursing education. Br J privilege of pharmacy education comes with expecta- Nurs. 2000;9(12):763-768. tions delineated in professional documents like the Oath 10. David SP, Greer DS. Social marketing: application to medical of the Pharmacist. Conversations need to be ongoing education. Ann Intern Med. 2001;134(2):125-127. because student perceptions of entitlement and consum- 11. Holdford DA. Marketing for Pharmacists. 2nd ed. Washington, erism are not easily changed. Still, there is a lot of com- DC: American Pharmacists Association; 2007. 12. Holdford DA, Schulz R. Effect of technical and functional mon ground because both students and educators want quality on patient perceptions of pharmaceutical service quality. students to succeed. The key is to place service to the Pharm Res. 1999;16(9):1344-1351. patient as a primary element of student success within 13. Hepler CD, Strand LM. Opportunities and responsibilities in the profession. pharmaceutical care. Am J Hosp Pharm. 1990;47(3):533-543. Finally, a case may need to be made within educa- 14. American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in tional institutions themselves. Some educators and ad- pharmacy practice: core elements of an MTM service model ministrators may not understand that learner-centered (version 2.0). J Am Pharm Assoc (2003). 2008;48(3):341-353. and patient-centered education are compatible as long 15. Williams JJ. Deconstructing academe: the birth of critical as both emphasize developing student knowledge, com- university studies. The Chronicle of Higher Education. February 19, petency, and habits of professional behavior over pleasing 2012. http://chronicle.com/article/An-Emerging-Field-Deconstructs/ students. Although student satisfaction and learning are 130791/. Accessed June 19, 2013. 16. Christensen CM, Eyring HJ. The Innovative University: likely to be highly correlated in an engaging, supportive Changing the DNA of Higher Education from the Inside Out. 1st ed. environment, achieving student satisfaction must always Hoboken, NJ: Jossey-Bass; 2011. be secondary to preparing students to meet the medica- 17. American Pharmacists Association. Oath of a Pharmacist. 1994. tion-related needs of patients. http://www.pharmacist.com/oath-pharmacist Accessed January 30, 2014. 5  Oath of a Pharmacist I promise to devote myself to a lifetime of service to others through the profession of pharmacy. In fulfilling this vow: I will consider the welfare of humanity and relief of suffering my primary concerns. I will promote inclusion, embrace diversity, and advocate for justice to advance health equity. I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for all patients. I will respect and protect all personal and health information entrusted to me. I will accept the responsibility to improve my professional knowledge, expertise, and self-awareness. I will hold myself and my colleagues to the highest principles of our profession’s moral, ethical and legal conduct. I will embrace and advocate changes that improve patient care. I will utilize my knowledge, skills, experiences, and values to prepare the next generation of pharmacists. I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public. Pharmacists Help People Live Healthier, Better Lives.  Code of Ethics for Pharmacists PREAMBLE Pharmacists are health professionals who assist individuals in making the best use of medications. This Code, prepared and supported by pharmacists, is intended to state publicly the principles that form the fundamental basis of the roles and responsibilities of pharmacists. These principles, based on moral obligations and virtues, are established to guide pharmacists in relationships with patients, health professionals, and society. I. A pharmacist respects the covenantal relationship between the patient and pharmacist. Considering the patient-pharmacist relationship as a covenant means that a pharmacist has moral obligations in response to the gift of trust received from society. In return for this gift, a pharmacist promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust. II. A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner. A pharmacist places concern for the well-being of the patient at the center of professional practice. In doing so, a pharmacist considers needs stated by the patient as well as those defined by health science. A pharmacist is dedicated to protecting the dignity of the patient. With a caring attitude and a compassionate spirit, a pharmacist focuses on serving the patient in a private and confidential manner. III. A pharmacist respects the autonomy and dignity of each patient. A pharmacist promotes the right of self-determination and recognizes individual self- worth by encouraging patients to participate in decisions about their health. A pharmacist communicates with patients in terms that are understandable. In all cases, a pharmacist respects personal and cultural differences among patients. IV. A pharmacist acts with honesty and integrity in professional relationships. A pharmacist has a duty to tell the truth and to act with conviction of conscience. A pharmacist avoids discriminatory practices, behavior or work conditions that impair professional judgment, and actions that compromise dedication to the best interests of patients. V. A pharmacist maintains professional competence. A pharmacist has a duty to maintain knowledge and abilities as new medications, devices, and technologies become available and as health information advances. VI. A pharmacist respects the values and abilities of colleagues and other health professionals. When appropriate, a pharmacist asks for the consultation of colleagues or other health professionals or refers the patient. A pharmacist acknowledges that colleagues and other health professionals may differ in the beliefs and values they apply to the care of the patient. VII. A pharmacist serves individual, community, and societal needs. The primary obligation of a pharmacist is to individual patients. However, the obligations of a pharmacist may at times extend beyond the individual to the community and society. In these situations, the pharmacist recognizes the responsibilities that accompany these obligations and acts accordingly. VIII. A pharmacist seeks justice in the distribution of health resources. When health resources are allocated, a pharmacist is fair and equitable, balancing the needs of patients and society. * adopted by the membership of the American Pharmacists Association October 27, 1994. (pharmacist.com)  Center for the Advancement of Pharmacy American  Education (CAPE Outcomes) Association  www.aacp.org/resource/cape-educational- outcomes of Colleges  American Association of Colleges of Pharmacy (AACP) of Pharmacy  Results of the Doctor of Pharmacy Education (AACP)  Included in the syllabi of the LECOM School of Pharmacy  Accredits schools of pharmacy Accreditation Council for Requires reporting and Pharmacy on-site visits Education (ACPE) Monitors performance of graduates  Complete the Doctor of Pharmacy degree Transcripts BOP Forms for degree verification Eligibility Apply for licensure with a state board of pharmacy Pick a state for Research the requirements of that state/jurisdiction Licensure Apply to NABP for eligibility to take their exams https://nabp.pharmacy/programs/naplex/ Registration Bulletin New version each year All states require the NAPLEX MPJE is state-specific Process of Application 1. Apply for licensure with a state board of pharmacy 2. Apply to NABP for eligibility to take the exams 3. The state BOP will notify NAPB after they determine that you are eligible to take the exams 4. NABP will email when you are allowed to purchase your exams 5. Purchase your exam and then you will receive Authorization to Test (ATT) from Pearson VUE 6. Schedule your exam at a Pearson VUE Testing Center (locate testing centers online)   Find the website and the most current information  Find the application for new graduates  Read the application process State Board  What documents do you need to gather and of Pharmacy  submit? LECOM registrar processes paperwork for individual states  [email protected]  [email protected] Exam Administration   Pearson VUE  http://www.pearsonvue.com/nabp/  Testing software tutorial (Pearson VUE Demo)  Rules are specific to the NAPLEX and MPJE Test  Remember other people in the testing center are not under the same rules you are under administration  It is your responsibility to know your rules  Video of security procedures  https://home.pearsonvue.com/test- taker/security.aspx   The number of items on the exam is 225  200 count toward the score  25 are pre-test questions (not scored)  It is impossible to know which count NAPLEX  The time to take the exam is 6 hours with two Format 10-minute breaks that are scheduled and optional  The examination is not modified based on your choices   “Majority” of questions are asked in scenario- based format  Patient profile NAPLEX  Medical record Require scrolling, clicking tabs Format  Continued  Scoring uses difficulty weighting  All questions must be answered in order, cannot skip NAPLEX  Pass or Fail  If you fail, you will receive a Scoring report of your relative performance on the 6 major competency areas NAPLEX Blueprint  Area 3 – 35%  Clinical determination of medication without an indication, untreated conditions, duplication of therapy  Contraindications, precautions, adverse effects, drug interactions  Application of clinical guidelines  Area 4 – 14%, Calculate:  Patient factors such as BSA, CrCl, ANC  Quantities of drugs to dispense and use for compounding  Nutrition, rates of administration, dose conversions, drug concentrations  Biostatistics and pharmacokinetics NAPLEX Blueprint  Area 5 – 11%  Sterile and non-sterile compounding including hazardous  Drug product properties for stability, compatibility, pharmacokinetics  Storage, packaging, disposal  Area 6 – 7%  Medication safety with the medication-use system  Prevention, screening, vaccination, antimicrobial stewardship MPJE Content  Laws and regulations that must be followed in pharmacy practice  Federal  State  Questions ask what pharmacists need to do in order to act in compliance with all the laws or regulations that relate to the action described  Board of Pharmacy members in each state write questions  Study resources from NABP https://nabp.pharmacy/resources/publications/  Pre-MPJE is available for $65  Students are responsible to apply Licensure   Must apply for licensure with at least Process one state  Register with NABP to take the exams  Schedule exams at Pearson VUE testing center  State-specific variations in the process and the requirements  MPJE is state-specific   Required to renew the pharmacist license  States set requirements through legislation  Pharmacy Practice Act Continuing  States clarify requirements through rules  Boards of Pharmacy Education  Number of hours are specifically defined  Certain subjects may be required  Manner of learning may be specific, such as requiring some hours received in live sessions What is a pharmacy residency?  It is a post-graduate training program for pharmacists that lasts 1 year  Involves developing clinical skills in:  Direct patient care  Practice management  Pharmacy residency is optional but is highly encouraged for those interested in further refining their clinical skills after graduation Residency Research  In both a PGY-1 and PGY-2 residency, pharmacists will be required to conduct a 1-year long research project  These projects primarily focus on improving patient care, increasing opportunities for pharmacists, or implementing new services  After completing a research project, residents may be required to present posters or presentations at conferences  Some may require research to be published in a journal Academia/Teaching  Some residencies may offer opportunities for residents to teach at a college of pharmacy  Residencies may also offer a teaching certificate which increases chance of acquiring a faculty position at a college of pharmacy  Completion of a teaching certificate may be optional or required depending on the residency Other Components of a Residency  Residencies can also include:  Resident to present a continuing education presentation  A medication-use evaluation  Precepting advanced pharmacy practice experiential (APPE) students  Additional opportunities to attend conferences Accreditation of Residencies  American Society of Health System Pharmacy (ASHP) is the organization that oversees and accredits most pharmacy residencies  Some organizations, such as Indian Health Services, provides their own residencies separate from ASHP  ASHP also hosts their national conference “Mid- Year” for pharmacy students to scope out potential residency programs ASHP Midyear Conference  National conference for residency programs to meet and scope out new candidates  Conference occurs each year in December  Opportunity to network and become involved! https://www.qleanair.com/qa/resources/15/1512463300878/ASHP%20QA2_f48b.jpg What is a fellowship?  A pharmacy fellowship is a postgraduate program that prepares a pharmacist to become an independent researcher  Focuses to develop competency in scientific research process  Most fellowships focus on training individuals to prepare for drug development & design Types of Fellowship  Traditional Fellowships:  Academic fellowship that focus on research (up to 80% of time) and clinical experience (20% of time)  Industry Fellowships:  Fellows work in a pharmaceutical industry to gain experience in different departments of a company  May include drug information, health economics, and pharmacovigilance Residencies vs. Fellowships Residencies Fellowships  Always 1 year  May be >1 year  Always requires licensure  May or may not require licensure  Typical settings are hospital,  Typical settings are pharmacy outpatient, or community school or industry  Accreditation is through ASHP  No formal accreditation process  A lot of patient interaction  May not include patient interaction Both are very competitive What is board certification?  Board certification is when a pharmacist becomes certified in a specialized area of practice  The Board of Pharmacy Specialties (BPS) is the organization that offers board certifications to pharmacists  Certification usually requires certain number of years of experience and passing a certification exam  BPS certification may help increase job opportunities and may even be a requirement for certain jobs Basic Insurance Principles MATT IE FOLLEN, PHARMD, MS  Important Key Words Beneficiary – the person eligible for benefits under the insurance policy Deductible – the amount the beneficiary/member owes for covered health care services before the health insurance or plan begins to pay Copayment – an amount the beneficiary pays as their share of the cost for a medical service or item (i.e., doctor’s visit) Coinsurance – the beneficiaries' share of the cost for a covered health care service ▪ Usually calculated as a percentage of the allowed amount for the service Premium – the amount the beneficiary pays for the health insurance or plan each month Network – the doctors, hospitals, and suppliers the health insurer has contracted with to deliver health care services to their members  What is insurance anyway? Insurance: contractual agreement in which one party (insurer) agrees to reimburse another party (insured) for losses that occur under the terms of the contract You (or someone on your behalf) pays a premium to the insurance company to transfer the “risk” from you to them Types of insurance ▪ Life ▪ Home ▪ Auto ▪ Disability ▪ HEALTH  Medicare THE U.S. GOVE RN ME NT FUNDE D HEALTH CARE MOD EL  Where did Medicare come from? Social Security Act of 1935 ▪ Passed as part of “New Deal” reforms under FDR ▪ Designed to provide some material needs of Americans, particularly the elderly – NOTE: NOT HEALTH INSURANCE 1950’s – Idea of universal health care is proposed, debated, and ultimately abandoned in congress  Where did Medicare come from? 1965 – Lyndon B. Johnson re-elected ▪ Congress brings together 3 separate pieces of legislation 1. Hospital care for elderly (Part A) 2. Optional physician services (Part B) 3. Need based health insurance for the poor – state & federal funds (Medicaid) 1990s-2000s – Expansion of Medicare parts C & D 2010 – Affordable Care Act  Department of Health & Human Services Responsible for 18% of overall federal spending (2018) ▪ $3.5 trillion dollars (more than any other country in the world) Notable agencies housed under HHS ▪ Centers for Medicare & Medicaid Services (CMS) – largest of all agencies housed under HHS ▪ Health Resources & Services Administration (HRSA) ▪ Indian Health Service (IHS) ▪ Food & Drug Administration (FDA) ▪ National Institutes of Health (NIH) ▪ Agency for Healthcare Research & Quality (AHRQ) ▪ Centers for Disease Control & Prevention (CDC)  Medicare Federal health insurance program for: ▪ People who are 65 years or older ▪ Certain younger people with severe disabilities ▪ People with end-stage renal disease (ESRD) Covers 62 million Americans In 2020, the Medicare program cost $776 billion – about 12% of total federal government spending  Part A and Part B Premiums Most people do not pay a monthly premium for Part A ▪ “Premium-free Part A” If beneficiaries do not qualify for premium-free Part A, they can buy Part A Everyone pays a monthly premium for Part B  How Does Medicare Work? Beneficiaries have options in how they get coverage with Medicare Once enrolled, they will need to decide how they will get Medicare coverage There are two main ways: ▪ Original Medicare ▪ Medicare Advantage How Does Medicare Work? Original Medicare ▪ Includes Part A (hospital insurance) and Part B (medical insurance) ▪ Beneficiaries pay a deductible at the start of each year and usually pay 20% of the cost of the service (coinsurance) ▪ Up to the maximum out-of-pocket cost ▪ Beneficiaries may choose to add a separate drug plan (Part D) ▪ Pays much, but not all, of the cost for covered health care services and supplies ▪ A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs How Does Medicare Work? Medicare Advantage (Part C) ▪ Includes services covered by Part A, Part B, and usually Part D ▪ “All in one” alternative to Original Medicare ▪ Most plans offer extra benefits that Original Medicare does not cover (vision, hearing, dental, etc.) ▪ Must follow Medicare’s coverage rules ▪ Each plan can charge different out-of-pocket costs and have different rules for how members get services  Medicare Prescription Drug Coverage (Part D) Helps pay for prescription drugs Members join a Medicare-approved plan that offers drug coverage ▪ Each plan can vary in cost and specific drugs covered ▪ Medicare drug coverage includes generic and brand-name drugs ▪ Plans can vary the list of prescription drugs they cover (formulary) and how they place drugs into different "tiers" on their formularies Plans have different monthly premiums Beneficiaries will also have other costs throughout the year in a Medicare drug plan ▪ How much they pay for each drug depends on which plan they choose  Medicare Part A Hospital insurance program Costs ▪ Free to anyone receiving social security ≥ 65 years of age ▪ Free to anyone who worked in a government job ▪ Free to those < 65 who: Collect social security disability benefits Has end stage renal disease requiring dialysis or transplant  Medicare Part A Covered services: ▪ Inpatient hospitalizations ▪ Skilled nursing facilities ▪ Home health care after a hospitalization ▪ Hospice care ▪ Emergency care outside U.S.  Medicare Part B Those eligible for Part A can enroll in Part B for about $104.90 per month Eligibility ▪ Anyone who is eligible for Part A can participate in Part B ▪ OPTIONAL coverage (~93% of patients enroll) ▪ Monthly cost deducted from social security check ▪ People that would have to pay for Part A can enroll in Part B without purchasing Part A  Medicare Part B Covered services: ▪ Outpatient medical care ▪ Physician and outpatient hospital services ▪ Home health care NOT covered by Part A ▪ Vision ▪ Physical therapy ▪ Mental health ▪ Laboratory ▪ Mammography and other cancer screenings  Medicare Part C Medicare Advantage “Medicare Advantage Plans” ▪ Combines services of Part A, Part B, and usually Part D into one insurance Supplemental premiums may be charged to offer additional services In 2021, more than 26 million people were enrolled in a Medicare Advantage plan, accounting for 42% of the total Medicare population Plans are administered by PRIVATE insurance providers ▪ Cost is determined by the private plan ▪ Must be “equivalent” to coverage provided by A & B NOT EXACTLY THE SAME!  Medicare Part D Benefits offered by private insurance providers Eligibility ▪ Anyone who has Part A or Part B can enroll in Part D ▪ Anyone with Part C probably already has prescription benefits in the plan and therefore does not have Part D  Medicare Part D – Costs ▪Cost of the plan and copay structure depend on plan particulars ▪ Monthly premium: ~$30 per month ▪ Deductible: ~$445 ▪Initial coverage period Coinsurance/copays vary by plan and by drug within plan In most plans, after spending about $4,130 in total drug costs, beneficiaries reach the coverage gap ▪Coverage gap (prior to 2020) During the coverage gap, beneficiaries pay 45 – 65% of the cost of their drugs In all plans, after spending $6,550 out of pocket, beneficiaries leave the coverage gap and reach catastrophic coverage ▪Catastrophic coverage During this period, beneficiaries pay 5% of the cost for each of their drugs, or $3.70 for generics and $9.20 for brand-name drugs (whichever is greater) Key Point: The dollars for various stages are based on the CASH PRICE for the drugs NOT COPAY AMOUNT Medicare Part D Closing the Coverage Gap ▪The donut hole is closing for all drugs (2020) ▪ When beneficiaries enter the coverage gap, they will be responsible for 25% of the cost of their drugs ▪ They were previously responsible for a higher percentage of the cost of their drugs (i.e., 45% for brand drugs and 65% for generic drugs) ▪Beneficiaries may still see a difference in cost between the initial coverage period and the donut hole ▪ If a drug’s total cost is $100 and they pay the plan’s $20 copay during the initial coverage period, they will be responsible for paying $25 (25% of $100) during the coverage gap  Medicare Part D Variations in standard plan ▪ Benefit and cost sharing structure can vary by plan ▪ Most used Managed Care philosophies to create: Tiered co-pays Systems of Prior Authorization and Formulary Restrictions ▪ Prices can be negotiated with manufacturers by individual plans but NOT Medicare itself Formulary requirements ▪ Every plan MUST have at least 1 medication in every class on formulary Medicare recipients enroll or make changes in Part D plans through the government Medicare member portal: ▪ Plan Finder webpage at www.medicare.gov  Medicare Prescription Drug, Improvement and Modernization Act of 2003 Created Medicare Part D ▪ Voluntary prescription drug benefit Administered by prescription drug plans (PDPs) ▪ Formularies ▪ Patient cost sharing ▪ At least 20 to choose from A total of 45 million people with Medicare are currently enrolled in plans that provide the Medicare Part D drug benefit, representing 70% of all Medicare beneficiaries Five dominant companies ▪ UnitedHealth, Humana, CVS Caremark, Coventry Health Care, Express Scripts  Medicare Prescription Drug, Improvement and Modernization Act of 2003 Medication Therapy Management ▪ “…program that may be furnished by a pharmacist that is designed to ensure that covered medications are used appropriately to optimize therapeutic outcomes through improved medication use, and to reduce the risk of adverse events, including adverse drug interactions.” ▪ Targeted beneficiaries Multiple chronic diseases (diabetes, asthma, hypertension, hyperlipidemia, congestive heart failure) Multiple covered drugs Drug costs above $4000/year ▪ Optimize therapeutic outcomes and reduce risk of adverse effects and drug interactions  Out-of-Pocket Costs Beneficiaries’ expenses for medical care that are not reimbursed by insurance ▪ Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that are not covered Medicare pays only about ½ of health expenditures ▪ Medicare households spend 14% of their budgets on health care (3 times more than non-Medicare families) ▪ Out-of-pocket average per year is $4734  Medigap Coverage Medicare Supplement insurance that helps fill “gaps” in original Medicare ▪ Sold by private companies Medicare does not cover everything! Medigap policy can help pay some of the remaining health care costs, including: ▪ Copayments ▪ Coinsurance ▪ Deductibles  Medigap Policies Things to Know ▪Beneficiaries must have Medicare Part A and Part B ▪ Only supplements Original Medicare benefits ▪Beneficiaries pay the private insurance company a monthly premium in addition to the monthly Part B premium that they pay to Medicare ▪Medigap policies only cover one person ▪Medigap policies are NOT allowed to include prescription drug coverage  Medigap Policies Things to Know Medigap policies do not cover everything Services typically not covered: ▪ Long-term care ▪ Vision or dental care ▪ Hearing aids ▪ Eyeglasses ▪ Private-duty nursing  Medicare Funding Overseen by the Department of the Treasury ▪Part A – Hospital Insurance (HI) Trust Fund ▪Part B – Supplemental Medical Insurance (SMI) Trust Fund ▪Part C – does not have a distinct funding source Draws from the HI and SMI funds ▪Part D – Prescription drug plans SMI funds pay for some Part D prescription drug coverage Medicaid STATE INSURAN CE  Remember your history… Part of the SSA amendments passed in 1965 ▪ “Grants to the States for Medical Assistance Programs Provide medical care (insurance) for low-income individuals & families  Medicaid State program to provide health care to low-income Americans No State is REQUIRED to have a Medicaid program, but all states have them During the 2020 policy year, over 75 million Americans enrolled in their states’ Medicaid and CHIP programs Total Medicaid spending (including the federal and state share) in 2020 was $359.6 billion  Medicaid Voluntary state participation (all have participated since 1982) Federal government pays at least ½ of expenses States administer the program under federal oversight State budget expenditures for Medicaid are only exceeded by their expenditures for education  Medicaid Eligibility Income based (varies between states) AND Categorically needy: ▪ Children ▪ Pregnant women ▪ Elderly ▪ Disabled ▪ Parents Medically needy are covered by many states ▪ Do not meet income requirements, but have high medical costs  Medicaid Coverage COMMONLY COVERED, BUT STATES MUST COVER: OPTIONAL: ▪ Inpatient and outpatient ▪Prescription drugs hospital services ▪Clinic services ▪ Physician, midwife, and NP services ▪Prosthetics ▪ Laboratory and X-ray ▪Hearing aids ▪ Nursing home and home health ▪ Screening, diagnosis, and ▪Dental care treatment for children