Best Practices of a 340B Peer-to-Peer Leading Practice Site

HRSA Office of Pharmacy Affairs Update

November 2014

HRSA has provided information to stakeholders on many aspects of 340B Program integrity efforts. This month, we’d like to highlight the 340B Peer-to-Peer Program.  

The Peer-to-Peer Program was created in 2011 by the HRSA Office of Pharmacy Affairs (OPA) and the American Pharmacists Association (APhA) to spotlight high performing 340B entities and recognize them as Leading Practice Sites. 

Recognized sites provide practical examples of excellence in 340B integrity and quality and serve as a resource for other 340B entities. 

One current Peer, DuBois Regional Medical Center (DRMC), is a disproportionate share hospital located in DuBois, Pennsylvania with 52 registered child sites and 24 contract pharmacy arrangements.

Below, DRMC reviews eight of their best practices in 340B compliance.

1Form a 340B Team.
340B program compliance is a group effort. DRMC advises to start out with a team of employees from their entity to get involved and to understand the Program from the start.  In addition to members of the pharmacy department, they suggest including compliance and accounting departments at minimum.  They always have at least five staff dedicated to ensuring their 340B program operates correctly.  

2 Self-Audit.
DRMC employs extensive self-auditing practices. By conducting monthly audits, DRMC has the opportunity to detect and correct any problems, institute corrective actions as necessary, and continually improve their processes. 

3Update the OPA Database.
Another important aspect of maintaining a compliant 340B program is making sure that your entity’s information is up-to-date on the OPA database. DRMC has more than 90 child sites, but only 52 are currently 340B-eligible.  
One strategy that DRMC employs is having a member of its 340B team meet with its practice management group monthly. During these meetings, it is communicated if an existing site is closing or a new 340B eligible site is being opened. The 340B team then ensures that the OPA database is updated to reflect any changes.  
They also work in conjunction with their compliance department to ensure the accuracy of the Medicaid billing numbers on the Medicaid Exclusion file. Integrity and consistency of data is one reason why their 340B accountant is also the person who does the Medicare Cost Report.

4Educate your staff.
Education is also very important to DRMC’s 340B program success. They took it upon themselves to go out and get educated on 340B from the start. They sought out HRSA-endorsed education in the 340B marketplace, including technical assistance from OPA and the 340B Prime Vendor Program (Apexus). 
Compliance happens when you understand how the 340B program functions within your particular facility. Making the effort to continually learn and stay abreast of developments in the Program, DRMC takes a conservative approach to 340B compliance.  

5Take ownership of your Contract Pharmacy arrangements.
DRMC’s minute attention to detail when it comes to 340B compliance continues over to their contract pharmacy oversight. They utilize a third party vendor but correctly understand that oversight is ultimately their responsibility. They are in constant communication with their contract pharmacies, and conduct internal contract pharmacy audits. DRMC’s 340B compliance officer has access to reports that detail all of the contract pharmacy transactions.

6Manually review non-exclusive providers at contract pharmacies.
Although DRMC employs 170 prescribers, only 40% of them are considered “exclusive.” If the provider practices at any other facility, DRMC does not include them on the 340B panel. Instead, DRMC conducts a manual review process to determine 340B eligibility. 
The prescription has to be based on documented care that originated from registered facilities by physicians employed or under contractual or other arrangements with DRMC. DRMC reviews whether the provider “owns” the patient’s medical record for that prescription.

7Hold referral prescriptions to the highest standard.
For referral prescription, DRMC not only determines if there is a referral in place, but if there was follow-up care for that prescription to close the “referral loop.”  As an indication of the accuracy of DRMC’s process, a recent external auditor while acknowledging that their process was time intensive, stated he had never found another system that was 100% compliant and could not find any gaps in their contract pharmacy arrangements.

8Apply 340B savings to expand the type and volume of care you provide to patients.
When DRMC describes the value of their 340B program, “it is not for dollars and cents; it is for the care of our patients.” The 340B program has allowed DRMC to continue and expand programs for its patients, including patient assistance programs and a free clinic. 
The 340B Program also has allowed DRMC to stay flexible to meet their patients’ evolving needs. For example, diabetes is one of the leading causes for readmissions at DRMC. The hospital discovered that patients were not actively monitoring their condition because test strips and other testing supplies were not covered by insurance, and the patients could not afford them. DRMC used 340B to supply their patients with diabetic testing supplies, as well as additional education, counseling, and routine visits to the clinic. Through the 340B Program, DRMC not only improved their patients’ health literacy but increased medication adherence.

Date Last Reviewed:  April 2017