Tuesday, December 28, 2010
First for some personal blogging history. Up until four years ago, I didn't even know what a blog was. Then I had to take some time off for knee surgery and was out of the pharmacy for three months. My physician did not allow me to drive my vehicle for the first 2-1/2 months, so I spent a lot of time, I mean a lot of time in my house playing on the computer.
One day I was searching for something and I stumbled upon a blog written by a nurse in Pennsylvania. It was written very well and gave some insights into her profession. I followed some of the links on her page and read other nurse and physician blogs. Eventually I found a couple pharmacy blogs that I liked and began to read them. Once I returned to work, it didn't take me long to start my own blog.
With my first blog, I remained anonymous. Just like all of the other blog authors. I used the blogging process to vent my frustrations with my job. Bad experience with a patient... I'd change details but still vent about it. Insurer screwing the pharmacy over... blog post. All of the little things that got under my skin were fair game. Some days I would post minutes after an incident happened in the pharmacy.
Then I had an article that I submitted to Drug Topics get published. The email response to my article was amazing. That article was the first time that I had my own thoughts attributed to my own name. I liked the idea that people would know who was behind the thoughts. It didn't take long for me to stop writing that blog, remove most of the posts, and no longer identify with that blog persona.
But enough of my history. Let's get back to the two articles.
Both articles mention the negativity of the content of the blogs. I totally understand where the blog authors are coming from. A lot of pharmacists feel like their comments are not taken seriously by upper levels of management. The blog posts are a means to share feelings and frustrations without revealing who you are. If you send an email in a corporate setting, your name is attached to your comments forever. The anonymity of blogging is a security blanket. The comments that follow a post let the author know that they are not alone in their thoughts.
In blog posts, pharmacists share their interactions with patients. Most of the time these posts may appear to paint the patient in a not-so-good manner. I hate to say it, but my experiences over the past 15+ years as a licensed pharmacist mimic those that are blogged. Patient health literacy is poor. People aren't concerned about their disease states, they just want a pill to fix their problems. People don't want to accept personal responsibility for their health conditions. And as long as the manufacturers are able to continue with their DTC advertising, why should people take the responsibility? These types of posts are simply a commentary on what our society has become.
The articles mention that the pharmacy blogs are an early warning system for what is happening in the profession of pharmacy. I totally agree. I honestly believe that the pharmacist bloggers can spread the word on workplace and professional issues much better than any organization. When a pharmacist blogs, there is no peer-review process that slows down the publication. If I have a thought to share, it's out there as fast as my fingers can fly over my keyboard. Journals and other publications take months to share information.
With the speed that the health-care system is changing, we can't sit back and wait for the national and state pharmacist organizations to evaluate, study, form an opinion on new legislation, then share it with the pharmacists. Pharmacists need a fluid environment to get thoughts out to be discussed. Blogs provide that.
As for professionalism within the blog posts. I can only speak for myself and say that I try to remain professional. I keep the language clean and try not be overly critical of patients. I'm putting my name to my writing and I am owning my words. When you identify who you are, you watch what you say. Some other bloggers use more colorful language in their posts. I don't pay much attention to the words as to the message that the author is trying to convey.
As I mentioned in my state of the profession series, local pharmacist organizations are practically non-existent these days. The chains have scheduled pharmacists to the point that we don't have time to meet after work to discuss issues that we face as a profession. Maybe that's the role that pharmacist blogs are playing in our digital world. The combination of different types of blogs is simply a reflection of the different personalities that would be at the meeting. Some people are story-tellers. Some people share currents trends in the workplace. Others just sit back and take it all in. By evaluating all of the commentary that is put out there, blog readers can get a pretty good idea of what is happening in the profession.
Saturday, December 25, 2010
Remember those who have fallen
And the families they leave behind
Friday, December 24, 2010
Wednesday, December 22, 2010
So in an effort to save all of us some headaches as this benefit year winds down and a new one gets ready to ramp up, I've decided to share a few tips for the pharmacy patients out there to make the year-to-year transition go a little bit easier.
If you a currently in the donut hole and have enough medication to carry you into the new year, please wait until the new year to get your refills. You will save yourself money. Any expenses in December do not count towards your deductible in January.
Every year it happens. Sometime between Christmas and New Year's Eve I have a patient call in for a refill on their Plavix. Of course it's written for a three month supply. The patient will pick-up the medication and pay the $400+ copay. Then on the first Sunday of the new year, their adult child will call in to complain that we charged their mother or father such a high copay, and that we should have known and just filled enough to cover them until their new coverage/benefit year goes into effect.
Ummm....no. You need to be responsible for yourself/your parent. It's not my job to watch out for that. Personally, I don't even look to see what the copays are when I'm checking the prescriptions. It's my job to make sure the right medication is going to the right person at an age-appropriate dose. It's my job to make sure that there are no drug interactions or contraindications for therapy on the prescriptions. It's my job to educate and inform the patient about their medication if they accept the offer of counseling. It's not my job to pay attention to your/your parent's finances. When the cashier tells you what the price is for your medications, that's when you should say something. Waiting for a week, then calling in to complain about the price isn't going to change anything.
This one goes hand-in-hand with the first one. If you call ahead for a refill and don't plan on picking it up until after the start of the new year, it's still going to be billed to the previous year's coverage. In pharmacy, we bill your insurance on the day that we fill the prescription. We don't wait until you come in to pick it up, then file a claim. Every year my pharmacy wastes hours and hours of labor unfilling prescriptions that were billed to the previous benefit year and refilling them under the current benefit year.
Don't come in to the pharmacy during the first week of the new year unless it is absolutely necessary.
I've been at this for a long time and there is one thing that you can bank on every single year. The insurance companies do not have all of the eligibility information loaded into their computers at the start of the year.
I agree with you, they should have the information updated.
But they don't.
It creates the proverbial clusterduck.
It's not the pharmacy staff's fault, so don't gripe at us about it. Call your insurer and make sure that your eligibility has been updated. Or stand there and stare at the pharmacy staff as we make the phone call that you could just as easily make. Just don't gripe while we are trying to help you and a dozen other people who have the same issue.
And if you decided to wait until the last day of the Medicare Part D enrollment period (December 31) to sign up, don't expect your coverage to be updated at 10 AM on New Year's Day.
If you have your 30 day supply of Vicodin filled on December 20th and want us to refill it on January 3 using your new insurance, it's not going to happen. We're going to make you wait until the refill is due. Don't waste my time. I'm the Vicodin/Xanax/Tramadol/Percocet cop.
If you managed to stay out of the donut hole for the previous benefit year and have your prescriptions refilled in the middle of December, don't try to squeeze in one more refill before the end of the year, before your copays go up.
The insurance companies know that you will try this. They aren't going to pay for an early refill. Ever.
Hopefully these tips will help ease the transition into a new benefit year for you.
Saturday, December 18, 2010
I photocopied the prescription and placed it into a file. I might need to keep this for later, I thought.
Two weeks later I was reviewing the previous weekend's prescriptions (we were a slow pharmacy so we were able to do all of the QA stuff that corporate wanted). There was one of our refill authorization forms with an "OK x 1 by MD" written on the face of the form. I did a little checking. The prescription was processed at 2:15 on Saturday afternoon. So I called the doctor's office. They had released both my partner and her husband as patients over 12 months prior. I spoke directly with the physician and he stated that he did not authorize the medication over the weekend.
From there it took one phone call to the pharmacy board and 5 days later, my partner had her license suspended. The BoP had been investigating this pharmacist when she worked on the other side of the state, but she moved before they could make a case against her. Since our inspector's have such a gigantic caseload, her file did not get forwarded to our local BoP agent.
And my employer did not do a background check on this pharmacist. They hired her simply because she was breathing and had a license. I had known her back in college, but she fell behind after our first or second year so I lost track of her. Never would have suspected her of stealing medications or forging prescriptions.
She has since completed a rehab program and had her license reinstated.
The best part..... when the BoP agent came to the pharmacy to bust her, our DM was requested to be present. And he was hauling around one of the corporate VPs that day. She had to sit in the store's dingy office for two hours while the bust went down. HA!
Wednesday, December 15, 2010
But that only encompasses part of the professional aspects of our profession. Those are duties required to accurately process a prescription medication order. As pharmacists, we currently give away our professional knowledge without being compensated for it. I have a possible means by which we can be reimbursed for what we are currently giving away.
I'm talking about our OTC consults.
Think about a typical consult. We gather pertinent information about both the condition and the patient that we are being asked to help treat. Think of it as taking a history of the patient and condition. After gathering this information, we basically diagnose what we are being asked to treat. Most of the time we can select an OTC product, but other times we refer the patient (notice...patient, not customer) to be evaluated because the condition is more complex and beyond the scope of our practice.
And we do this for free.
If this patient went to the ER, urgent care, or their physician, the same triage process would be done. Most of it by a nurse. The prescriber would come in, take a look at the patient, make a diagnosis and move on. For this the physician would bill anywhere from $70 to $180, depending on the complexity of the visit. More if it was done in an ER.
Why can't we bill for our triage. Think of the hundreds and thousands of dollars we save the health care system every day by keeping people away from the ERs. We are individual health care providers, but we just haven't decided to bill for our services.
How these are going to work, I haven't a clue. But pharmacy/pharmacists have the opportunity to capitalize on this. This may seem a little bit Big Brotheresque, but it is what it is. If we are going to be required to maintain electronic health records, let's go all in with it.
I propose that all persons should have a card, similar to a credit card, that has their insurance information embedded on it. The information can only be modified by certain entities, such as insurance carriers and benefits administrators. If a person has coverage, it is recorded on the card. If coverage has been dropped, the administrator modifies the data. Get a new job, you take your card to your new benefits administrator to have the information added to your card.
The card is required for all transactions surrounding a person's health care. That way a person can't jump from provider to provider, using insurance at one place and claiming to be self-pay at another. The card would simply carry the patient's insurance information and record which providers they have seen. No medical information would be captured on the card. But in the event of an emergency, it would provide information about where the patient had been seen. Phone calls could then be made. No more calls to see if Mr Jones had his prescriptions filled at CVS, Walgreens, or Target. The ER would know simply by swiping the card.
Glad you asked. Whenever we provide any professional services for anything other than that which is mandated by OBRA, we must be presented with the card. No card = no service.
Basically we swipe the card on a PDA-type device to gather the patient's information. Conduct our OTC consult as normal, but at the end we record the details of our consultation. Depending on the length of time and complexity of the consult, we bill the insurance appropriately for our services. The details we provide determines the reimbursements that we receive. At the end of the day, we upload our interactions for the day and submit the claims. All claims are tied to our individual NPIs, so reimbursements are sent directly to individual pharmacists.
(For people without insurance, the data is still recorded for the sake of electronic health records. Rather than bill for the intervention, pharmacists receive a tax break as "charity care")
This post only addresses the community pharmacy aspect, but it can be easily adapted to clinical and consultant services.
Thursday, December 9, 2010
The effect of the $4 generic programs has reduced the profession to a product. People aren't valuing the professional expertise of the pharmacists, they are frequenting the pharmacies that sell the product cheaply. In my state, a regional chain has started offering $2 generic prescriptions. Couple that with the free diabetes medications at a certain Pittsburgh-based chain and free generic antibiotics offered by several pharmacies and I can see why the public doesn't value our services.
It's because we don't value our services.
I honestly don't see pharmacy rebounding to the point where a respectable dispensing fee will ever be offered to pharmacies. The chains and insurers have seen to it that we will accept horrible reimbursements, so why should we expect to ever see a decent dispensing fee again?
What I propose is to remove pharmacist services from the equation when it comes to setting reimbursements to the pharmacy for the product. CVS, Walgreens, Target, Walmart, whoever can accept whatever reimbursements they want for the product, because we (the pharmacists) would be getting reimbursed for the professional functions on each and every prescription.
The NPI number of the pharmacist is included on every claim that is submitted to the insurer. This is in addition to the pharmacy's NPI that is submitted for product reimbursement. Prior to submitting a claim, all of the pharmacist's professional functions are summarized and coded to be submitted with the claim (software determines the coding). Based on the level of pharmacist intervention, the pharmacist will be reimbursed personally for his/her intervention.
If the pharmacist doesn't want to be reimbursed for their professional services, they can opt to submit the facility's NPI instead of their own. But once pharmacists see other pharmacists raking in the money from their interventions, all pharmacists would be submitting their own NPIs on the claims.
For example, a mother drops off a prescription for cefdinir 250mg/5ml 2.6 ml qd x 10 days. The prescription is entered for a quantity of 60 ml (the smallest package available) for the 10 day supply.
The pharmacy dispensing system flags the order as being an overdose for the patient age. Pharmacist reviews the dose and documents that the dose is appropriate for the patient's age and weight and that the days supply is 10 days due to both the prescription order and the expiration dating of the reconstituted product.
When the claim is submitted, the pharmacy is reimbursed to the product at the contract price. The pharmacist receives payment for verifying the dose and day supply. There would have to be a means to edit the intervention info based on the OBRA-mandated counseling session (maybe professional service claims get submitted every Saturday night), but I think you get the drift of where I would like to see this going.
Anybody know if an idea like this has ever been explored?
Friday, December 3, 2010
Now is one of those times.
I have ideas for pharmacist billing of services sketched out on a legal pad, but translating it into a post isn't happening right now.
So today I'm going to share a comic that used to be taped on the wall, next to my desk back when I was a student at Ohio Northern University. Hopefully you will like it.
Tuesday, November 30, 2010
Pharmacists across the United States want to bill for services that they are providing to patients. One of the largest areas of billable services is medication therapy management services. But there's one big problem.
Insurers aren't paying for them.
I mean, some of the Medicare Part D prescription drug programs are reimbursing pharmacists for comprehensive medication reviews (CMRs) and a few other services. But the medical insurers aren't paying.
In my state, I have yet to find an insurer who even gives pharmacists the ability to enroll as an individual medical provider. When I think about this, I see this as a failure of the organizations that represent pharmacists.
For years we have heard from the organizations about how pharmacists can improve patient’s quality of life thru pharmaceutical care, medication therapy management, whatever you want to call it. But we need to be recognized as providers in order to be able to bill for our services and show the results of our services.
Prescription drug plans aren’t going to reimburse us for these services because they aren’t the ones paying the medical bills for the patients. If Caremark had to pay for Mr. Smith’s ER visit from a preventable medication event, they might pony up some money for pharmacist services.
But the PBMs don’t have any skin in that game, so they could care less if Mr. Smith gets hospitalized.
Pharmacist services need to be sold to the medical insurers. And that’s the responsibility of the national organizations. The American Pharmacist Association should be leading the way on this.
When I think about the American Medical Association, I picture an organization that is looking out for the survival of their profession. One of the key components is getting appropriate reimbursement for services rendered. Heck, today on Twitter I found a link where the AMA was successful in having the cuts in reimbursement rates delayed. You know as well as I that the AMA will be successful in keeping their reimbursements. The physicians will stop being providers if the rates get cut.
I don’t know if I can say the same about the APhA. From what I see, the APhA would rather sit back and take a wait-and-see approach when it comes to issues like this. We don’t want to assert ourselves and piss off the physicians.
This has led us to the point where we are not recognized as medical professionals. We can’t enroll as individual health care providers. For 20 plus years of talk about pharmaceutical care and medication therapy management, we have exactly three CPT billing codes that we can use. The American Medical Association (the people who determine which CPT codes are to be used) has all the power when it comes to determining which services are going to be covered.
I would love to see the APhA step up and design a series of CPS codes (Current Pharmacist Service codes) that we can use to bill insurers. And then get the insurers to recognize us as individual providers.
Who says that pharmacists need to be at the mercy of physicians when it comes to billing for our professional services?
Tuesday, November 23, 2010
Sometimes I feel that I am alone in my thinking about what the future of pharmacy holds. Having been a pharmacy manager at each of the companies that I have worked for, I have had access to the financial reports. Over the years, I have seen a steady decline in the gross profits on each prescription.
And when I speak of gross profits, I’m not talking in terms of a percentage. I’m talking about actual dollars.
At my current pharmacy, about sixty percent of our prescriptions have a total pharmacy reimbursement of under ten dollars. Due to the effects of $4 generic pricing and how insurers adjust their MACs, WACs, and GEAPs based on the usual and customary prices that are submitted to them, a good portion of the prescriptions bring in less than five dollars.
When we look at the percentages, the pharmacy is making a profit of 30, 40, or even 80 percent. But an eighty percent profit on a four-dollar prescription is $3.20.
How long can you stay in business filling scripts for a $3.20 profit? Not too long unless you are cranking out 30 scripts per hour, per pharmacist. And that’s just to break even.
What is the profession going to do in order to continue to generate a revenue stream?
Medication therapy management is one possible avenue. But why would somebody want to pay for a service when there a pharmacists and pharmacies that are giving the service away?
Right there is the major problem to pharmacists getting reimbursed for their services.
Too many pharmacists and pharmacies are giving away the one product that we have that is all our own….information about medications.
Over the years, pharmacists have embraced the idea of being the most trusted profession. Over the last few years some other professions have taken over the top spot, but pharmacists still rate pretty high. I don’t know if holding the top spot messed up our brains, but for whatever reason it has become taboo for a pharmacist to think about (gasp) charging patients for the information that we possess.
We are the only “professional” profession that doesn’t charge for our specific knowledge. Granted, we are required by law to provide certain information when we are counseling a patient on their prescription. But where in the law does it state that we can’t charge for information that doesn’t directly relate to a prescription that we are dispensing?
If I have a question about a contract that I am about to sign and run it by my attorney, I can expect a bill in about a week for his time. If I send an email to an accountant with a question about the tax consequences of a financial decision, I can expect a bill. Heck, if I ask an interior decorator their opinion on what color would look good in my foyer, I would expect to receive a bill.
So why do we, as pharmacists, answer the questions from lawyers, accountants, interior designers, or anybody else without charging for the information? I think that my time has value. Why shouldn’t I charge for my time when I am using it to answer a question that can only be answered by somebody who has a pharmacist license?
It is my opinion that we, as a profession, need to wake up and realize that we have valuable information. We need to stop giving it away to every Tom, Dick, and Harry that walks into the pharmacy. If we want to be valued as the medication experts, we need to assign a value to what we provide. The only way to do so is by charging for our specific, professional knowledge.
Pharmacists need to step back and take a good hard look at where the profession currently stands. We also need to visualize where we want it to go. If you are satisfied making two or three bucks per prescription, don’t do a thing.
But if you want to see the profession grow into something more than pill-slinging, we need to look at ways to advance the non-dispensing aspects of the profession. It’s going to require thinking outside of the box. I have some ideas that I will be sharing in the future. I urge you to share your ideas as well.
Thursday, November 18, 2010
It’s 5 o’clock on a Tuesday morning. Who’s calling.
Oh crap, I better get that before it wakes everybody up.
I stumble into the kitchen to answer the phone.
Voice: Hey Eric, it’s your sister. You need to get here now.
Eric: What happened?
Sister: It’s Dad. He’s taken a turn for the worse.
That was not the call that I wanted to receive. Two and a half years earlier my father had been diagnosed with lung cancer…. Stage III-B. Within six weeks of diagnosis he had his left lung removed and had started both radiation and chemotherapy.
I returned to the bedroom to wake-up my wife and tell her what was going on. Within a half-hour we had our son in the car and started driving to my parents’ home, a little over an hour away.
We had been over to visit on Saturday to celebrate his birthday. His actual birthday was the previous Saturday, but we spent that day in the emergency room at the university that was treating his cancer. He had just been released after spending another week there.
Dad was acting like his usual self, only now he had to have oxygen. He could get around without it, but would tire easily so he decided to keep it on. He played on the floor with my two year-old son, just like every other visit. When we left it was the same as always… Dad always bounced back after his visits to the hospital.
Sunday night I had called to check on Dad. Mom said that he wasn’t bouncing back like normal. I talked with Dad. His voice wasn’t as strong as it was the day before. I had trouble during that conversation. Several times I had to stop because I was crying. For the first time in my life, I told my dad that I loved him as I hung up the phone.
We arrived at my parent’s house and went inside. Dad was sitting in his recliner, with a wheelchair nearby. On Sunday he had used a walker to get around the house, now he needed the chair to keep from getting winded.
We had previously discussed the idea of hospice and called them to discuss what options we had. We sat down and discussed several options that were available to us. They left in the late afternoon. All we had decided to do was to allow them to monitor and manage Dad’s pain. They were going to bring some morphine down in the morning. Since he could still get around in the wheelchair, we felt pretty good about our decision.
Then Tuesday night happened.
It was a rough night. Dad was gasping for breath throughout the night. My brother and I had to go in several times during the night to move Dad, adjust his oxygen, things like that. We didn’t get a lot of sleep.
Wednesday morning we lifted Dad into the wheelchair and took him out to his recliner. Over the past twelve hours my father went from being able to wheel himself around the house to being unable to get himself out of bed. We made the call to hospice for the additional help.
The hospice nurse arrived a little after eight. She gave my dad a dose of morphine and his breathing settled. He was able to talk with us, albeit in hushed tones. The nurse called to have a hospital bed delivered so we wouldn’t have to mess around trying to get Dad in and out of the bed in his bedroom.
The morphine was keeping Dad’s airway open and pain controlled, but he was getting a little agitated just laying in his recliner. The nurse thought that it might be a good idea to get a little Ativan on board to take the edge off. So we decided to go that route.
But there was nobody to deliver the medication. All of the hospice workers were out taking care of patients. The driver who was delivering the hospital bed was coming from a different part of the county so he couldn’t pick up the Ativan.
Since everything appeared to be under control, I took off to pick up the medication at the pharmacy 15 miles away. My wife left to go back to our house to get fresh clothes for us, along with our toiletries.
My trip took longer than it should have. The order for the Ativan was late getting to the pharmacy. I had worked at that pharmacy as an extern, so they took care of me as quick as they could. While there, a phone call came to the pharmacy… I had to run to the hospice office to pick up some other stuff for my dad. Of course that didn’t go as planned. I spent an extra half-hour waiting for this, that, and the other.
When I finally was able to return to my parent’s house, Dad was still agitated. The nurse showed us how to administer the Ativan Intensol and Dad calmed down instantly. She felt that we had the situation under control, so she left to check on another local patient.
Things went fine over the next couple of hours. Dad wasn’t able to talk to us, but we were still able to communicate. I don’t know if that makes a lot of sense but that’s how it was.
My wife returned from her trip and brought me some new clothes. I explained to her what was going on and then decided to escape upstairs to take a bath. Dad was resting peacefully and everything appeared to be under control.
My parents house was over a hundred years old. It would take a little while for the water upstairs to get warm. I checked out my facial hair in the mirror and decided that I would attack it with an electric razor after I had cleaned up.
There was about two inches of water in the bottom of the bathtub when I stepped in. Just having the water touch my feet and remove the grime felt good. As I was lowering the rest of my body into the water I heard a voice call up the stairs.
It was my brother.
Dad's breathing had changed. In the ten minutes since I had left his side, my father had taken a turn for the worse.
I hurried and put on my clothes to return to my father's side.
When I entered the family room, my mom was sitting at my dad's right shoulder, caressing his head. My brother was at the same position on his left shoulder.
My sister was at my dad's right hip, with her husband sitting next to her. My wife was at dad's left hip.
I sat down next to my brother and put my arm on his shoulder. He and my dad shared a birthday and the past two weeks had been especially hard on him. My brother had just turned twenty.
Over the next 90 minutes, our family sat by my father wondering if each breath would be his last. The gaps between breaths grew.
Finally, my dad drew his last breath.
The last twelve years have passed quickly, yet it seems like an eternity since my father died.
I can't put into words the impact my father had on my life. He taught me to be the man that I am today, and for that I am truly grateful.
I only had my father on this earth for 26 years. My dad was a Christian, so I know that I'll see him again on the other side of eternity. It hurts to not have him around to see my kids grow up, but I am comforted in knowing that he is eternally pain-free.
Twelve years ago today, my father died.
I miss you, Mike.
And I love you.
Monday, November 15, 2010
That list was handy. When I was working at a busier pharmacy, my wife wasn't always able to contact me to check on the safety of a medication. She would look at the list and know if the medication was safe or not.
Let's fast forward to today. A few weeks ago, I had a young mom-to-be stop by the pharmacy because she was not able to locate a particular over-the-counter medication. She had a sheet of paper that had a list of acceptable products.
The list was almost identical to the list my wife had fifteen years ago.
And even better, the list wasn't printed from a Microsoft Word document. It was a photocopy of a typewritten list that was probably made in the early 90s.
Maybe it's just me, but I would hope that an obstetrician would update the handouts that they provide to expectant mothers. Seems like good patient care.
Several items on the list were brand name products. Of items that have been either discontinued or reformulated over the years. So it falls on me, the pharmacist, to determine what is safe for the patient. Which is part of the job, and is fine with me. But have you ever paid attention to the looks that you get when you say that the doctor is providing the patient with outdated information?
A lot of it is based on brand recognition. The manufacturers have sold the physicians and public on the idea that ABC Sinus tablets are far superior to the store brand. But this presents a problem when ABC manufacturer changes the formula of the medication. What used to be safe for use in pregnancy may now have a couple pregnancy category C ingredients, but it's still on the OB/GYN's list.
As pharmacists, we need to educate the public about the active ingredients that are in a product. General terms on a brand-name product label like congestion, sinus, and allergy mean different things to different people. I can't tell you how many people buy the store-brand syrup for cough and congestion when they really need something for cough and sinus congestion.
Personally, I would rather take several single ingredient medications than a three-in-one product. I want to treat the specific symptoms that I have. No need to try to kill a fly with a sledgehammer and suffer unnecessary side effects from unneeded medications.
In my cabinet at home, you will find the following OTC medications:
- diphenhydramine solution and capsules
- chlorpheniramine tablets
- ibuprofen tablets and suspension
- acetaminophen tablets and suspension
- pseudoephedrine tablets
- cetirizine tablets and syrup
But back to the OB/GYN list. Just give the women a list of active ingredients that are safe for use in pregnancy. Tell the women that if the product they are selecting has anything other than what is specifically mentioned on the list, it is not safe. Stop with the brand-name references.
Wednesday, November 10, 2010
I'd like to hear what policies and procedures really burn your butt. This is a chance to vent on things that make life in the pharmacy a little bit less pleasant. This is class-participation time.
If you desire, go ahead and name the company.
To protect your employment, comment anonymously.
Still hesitant, email it to me and I'll post it.
Please try to keep the language in check. If you use the really bad words, I won't allow your comments.
Tuesday, November 9, 2010
Personally, I'm getting a little tired (already) of people asking me questions about which plan to enroll in. I have my canned response to the question. Visit www.medicare.gov or call 1-800-MEDICARE for help in determining which plan works best for you.
I don't know why people think that a pharmacist wants to help them determine which plan to select.
Actually, I do.
They are too lazy to do the work themselves. They would rather pawn the responsibility off on to somebody else so they can complain about it later if things start to cost too much.
Isn't that the American way?
Wednesday, November 3, 2010
C'mon, it was just Halloween a few days ago. Have a sense of humor.
Monday, November 1, 2010
She almost had it right. Units, not cc's. Units.
If you've been in pharmacy for more than fifteen minutes, you know that this patient/customer isn't diabetic. She's injecting illicit drugs.
One of my technicians knew of her. Said she was busted for crack several years ago. From her looks and actions tonight, I'd say that she was messing with heroin now.
This is a situation that pharmacists face day-in, day-out. Do we or do we not sell syringes to injection drug users? My employer does not have a clear policy on the matter, so it falls on the individual pharmacist to make the call.
A few weeks ago I was reading the September/October issue of the Journal of the American Pharmacists Association. There was a case study on a female prostitute who developed a case of MRSA after reusing syringes because the pharmacy where she usually bought her individual packs of syringes changed their policy to sell only full boxes. No more packs to sell to the drug users. The prostitute's MRSA hospitalized her for six or seven weeks. And we can assume that the hospital or the taxpayers of the state ended up footing the bill.
There were two other articles in that issue that discussed syringe sales and syringe access programs. That got me thinking....
One of the arguments in favor of supplying clean syringes to injection drug users is that it decreases the transmission risk of certain diseases (hepatitis, HIV). By ensuring that injection drug users have clean needles, we are protecting public health.
Sounds like a good role for pharmacists... preventing disease transmission.
But I'm a pharmacist. It's my job to monitor the use of controlled substances and try to keep people from abusing them. Last time I looked, heroin was a Schedule I controlled substance. The worst of the worst.
If I sell syringes to this junkie, I'm enabling the abuse of this controlled substance. In my state, I have to report the sales of all C-IIs thru C-Vs to my state's prescription drug monitoring program. We try to control the abuse of narcotics by monitoring their sales. As a responsible pharmacist, I can't enable the abuse of C-Is when I must report the sales of other controlled substances.
If I sell the syringes and the drug user ODs, am I liable for supplying the syringes to them?
If I don't sell the syringes and the person contracts a blood-borne disease because they reused dirty syringes, have I protected the public health?
By selling syringes to injection drug users, will I attract more users to my pharmacy? Do I put my staff at risk by having more drug abusers come to my pharmacy to get their needles?
These are questions that pharmacists have every day when the question of selling syringes to injection drug users is posed.
I don't have an answer for this question. The arguments for both sides of the issue make perfect sense to me. Down in my gut, I don't want to sell the syringes. I can't justify the enabling of the abuser's addiction. But then I think, what if somebody I know gets HIV because this person used a dirty needle? I could have prevented that.
Like I said, I don't have an answer for this dilemma. But why does it have to be a dilemma? Why is this something that falls into the hands of the pharmacist to decide?
From the articles I've read, the consensus seems to be in favor of syringe exchange programs. I'm cool with that. But let's not put the pharmacists in the middle of this public health issue. We always hear about expanding access to care. This is one area where I wouldn't mind seeing the access to care expanded to include the local Circle-K or any other retailer.
Tuesday, October 26, 2010
But if we just look at where we are now, we are missing one of the key points I wanted to address with this series.
It doesn't matter where we are or how we got here. We can't change the past. All that matters is where are we going from here. So today I'm going to throw out some of the topics that seem to dominate the headlines when it comes to the practice of pharmacy and share my thoughts on them.
A few years ago, several pharmacy outfits decided that it would be a good idea to offer generic medications at rock bottom prices. Four bucks for a month's supply of pills.
One of the consequences of these programs is a decreased profit margin on prescriptions. In order to maintain a profitable department, pharmacists have been forced to fill an increased volume of prescriptions in order to cover the costs of operating the prescription departments.
When you look at a pharmacy's P & L statements, the largest expense (after medication costs) is the pharmacist salary. You can hire four to six technicians for the price of one pharmacist. Don't you think that the non-pharmacist members of management are looking for ways to decrease or eliminate the need to pharmacists?
I'm not saying that we need to worry about this over the next year or so, but if you are not prepared for this we may see ourselves phased out of our own profession. Pharmacists need to start speaking up to our legislators and boards of pharmacy in order to make sure that the corporations don't phase us out. I hope I'm wrong on this issue.
In 1996 the APhA House of Delegates decided to push for pharmacist immunizations. After 14 years, pharmacists are able to give vaccinations in all 50 states.
So flippin' what?
How has this advanced the profession?
Pharmacists are now able to provide the same service that physicians and nurses have been doing forever. Doesn't really differentiate us, does it?
In fact, the beauty of pharmacist immunizations is that we can't bill for the act of giving the shot. When a physician gives a shot, they bill the insurance for an administration fee. Do pharmacists?
For the increased liability exposure, pharmacists receive absolutely nothing.
Medication Therapy Management
This is my pet project. I see this as the future of pharmacy.
MTM actually utilizes our unique skills as medication experts. But how do we market this? How can we get patients to want to pay us for these services.
Our profession has been tied to a product for so long that people are almost shocked when we say that we want to bill for the information that we possess. They think that the cost of the medication entitles them to all of the information that we can provide. Maybe if we actually made a decent profit on the product. But $1.85 profit on a script is going to get you $1.85 of info from this pharmacist.
We need to promote the informational side of what we do, but not give it away. OBRA 90 requires us to provide specific information during a counseling session. Anything above and beyond that should be compensated by either the patient or their insurer.
So far, I have not seen a successful model to follow in developing MTM services. I hope to be able to report back in five years and say "this is how I built my successful MTM business". We need to share our successes so that all of us may benefit.
Corporate ownership of pharmacies
North Dakota has it right. Pharmacists should be in control of the profession, not companies.
Makes total sense to me. I mean, we are the medication experts. Heck, freaking nurse practitioners and physician assistants have prescriptive authority. And we don't? Hell, insurance companies have more prescriptive authority (via formularies) than pharmacists do.
APhA and other pharmacy organizations, this is a huge issue where we would like to see measurable progress that is reported back to us.
Pharmacists need to have a voice as our profession moves forward. Unfortunately, too many of us have settled for the nice lifestyle that our salaries allow us to have and are afraid to speak up on matters that affect the profession. We live in fear of losing that paycheck if we say something that our boss doesn't like.
It's easy to sit back and complain to our techs and fellow pharmacists about issues surrounding the profession of pharmacy, and then do nothing about it. It takes some gumption to actually speak out and make your opinion known about the direction of the profession.
It's us, the pharmacists, who will determine the future of our profession. There's one catch. You have to find your voice, then use it to be heard.
Thursday, October 21, 2010
Tuesday, October 19, 2010
Is it something like this from the people over at Walmart:
Or maybe this offering from CVS:
Perhaps you think of a local, independent pharmacy's ad:
Maybe something like this from the Super Bowl?
Or this, presented by the ASHP:
Maybe your perception of pharmacy marketing is connected to the gimmicks that we've seen all too much of over the past 15 years.
- $25 gift cards for new/transferred prescriptions
- Fuel perks/ discounted gasoline
- $4 (or less) generic medications
- free antibiotics (and now, diabetes medications)
Whatever your perception of pharmacy marketing is, I think that we can all agree that it pretty much is centered around the product that we dispense. The large corporations try to get people into their pharmacies based on a few things:
- how convenient it is to get the product
- how cheap the product is
- what bonuses we'll give you for getting the product at our place
The corporations are going to continue to push the product. That's what they care about...sales.
But we, the pharmacists, need to promote the professional services that we provide. From the videos above, I like the message that the ASHP was trying to convey. They are attempting to show the other aspects of pharmacy. Just that, in the hospital setting, they can't bill for their services individually. Pharmacy is lumped into the rest of the hospital bill. If pharmacists billed for their services individually, the message of the ad would be great.
I'll be truthful here. I think that pharmacy needs to evolve into something different from what it is today if it is going to survive. I see outpatient medication therapy management and ambulatory care pharmacy as the future of the profession. If we think that counting pills will continue to be the bread and butter of pharmacy practice, we are set to be rudely awakened.
So how do we move from the product-determined method of payment to the service-based method of payment?
In a nutshell, I don't have a clue. But I do know that we need to start by billing for the services that we do provide. And when we do, we need to submit a dollar figure that shows how much we are saving the insurer. When we tell Mr Johnson to try XYZ cough syrup and keep him from running to the ER on Saturday night, we just saved the health care insurer at least $400. So we need to bill with that in mind. Maybe they'll pay us $15 when we save them $400. (I have an idea on how to pull this off. Details in a future post)
But back to the marketing of the professional services. I can see a series of videos that are basically testimonials where people share their story and explain how their partnership with their pharmacist improved their health. The commercial would include a link to a web-site that lists individual pharmacists who provide professional pharmacy services. We want to keep the focus on the pharmacists, not the building that they happen to work in.
We have studies coming out all the time that show the benefit of pharmacist involvement in the health care of our patients. We just need to be bold about it and put it out there for the public to see.
Tuesday, October 12, 2010
But they do engage in some practices that, even though the practices are not part of the practice of pharmacy, end up shaping the opinion people have about pharmacists. We've all been put in the situation where we have to basically explain to the patient why their copay for a particular angiotensin receptor blocker is 85 bucks this month when it was only 15 dollars last month.
Patients don't want to hear that their insurance company has shifted the cost to them. Their perception is that the pharmacist is trying to price gouge them. Never mind that the actual reimbursement to the pharmacy is $2.40 over our actual acquisition price.
Then we have the nice little practice where the PBM requires that the patient utilize the mail-order service (or a particular retail chain) for their maintenance medications. This forces the patient to choose between staying with their preferred pharmacist (and paying a substantial penalty) or utilizing the PBMs choice of pharmacy (and realizing the full benefits of the insurance). Given the economic situation that most of our patients are in, they choose to use the PBMs preferred pharmacy.
Combine these little tricks with all of the hoops that insurers require us to go through just to get Mr. Jones a two-week supply of his carvedilol until his mail-order arrives and it's pretty easy to see why pharmacists don't really like PBMs. What should be a partnership to keep our mutual patients healthy has turned into an adversarial situation on each claim that we submit.
In my opinion, pharmacy benefits managers have too much say in the practice of medicine/pharmacy today. Rather than letting the health care practitioners select the best medication to treat a condition, a group of accountants are making the decisions.
Part of this is due to the manner in which pharmacy benefits managers are set up. PBMs exist solely to adjudicate claims. That's it. They have no vested interest in the overall health-care outcomes of the patients that they cover.
In order to truly treat the patient and not the corporate P & L, PBMs should be required to be part of a larger health care insurer. It has been my experience that insurers who manage both medical claims and prescription claims tend to manage the patient better than insurers who handle just the drug portion of the insurance. Insurers who handle both medical and prescription claims know that sometimes the more expensive medication is what actually is best for the patient and will help decrease health care expenses over the long haul.
If insurers had to cover both medical and prescription claims, we might be able to really advance the concept of medication therapy management. But as it stands now, only pharmacies can contract with the PBMs (with a few exceptions) and pharmacists are blocked from being providers for major medical plans.
If pharmacy benefits managers were truly interested in the benefits that pharmacy can provide, we would see them reach out to us in an attempt to help them control their costs by utilizing the specific skill sets that pharmacists possess. As it stands now, the only benefits the PBMs are interested in are their bonuses at the end of each fiscal year.
Thursday, October 7, 2010
Some of the people are hooked on substances that are illegal, but even more are addicted to substances that are legal. What once was a means of treating an organic illness or injury has transformed itself into an addiction.
It's easy to look down our noses at these people. We may think that they lack self-control and have allowed themselves to become addicts. For others, they may not be addicted. They just like the buzz they catch from abusing the medications.
Whatever the reason, the sad truth is that there are many people trying to escape issues in their lives and do so through the use of drugs.
There's a billboard along the interstate near the town that I live in. I've seen it hundreds of times and pretty much ignored it. Then one day after driving home, I pulled up the website that was on the bottom of the billboard.
I read the story. It's about a kid that was one of my patients right after I became a pharmacist. I know the family. Grandma, grandpa, and mom all came to my pharmacy. They are good people. Unfortunately, Zach is just another young life lost due to the misuse of drugs.
Tuesday, October 5, 2010
At that time, it was explained to us that all billing for medical services were switching to the NPI as the only recognized identifier. NCPDP numbers would no longer be used in pharmacy transmissions. Physicians would not be identified by their UPIN or DEA, but by their NPI.
So it makes no sense to this pharmacist that individual pharmacists are not able to contract with insurers because, get this, they only issue contracts to providers who have NCPDP numbers.
And what is even better is that the NCPDP will not issue numbers to non-dispensing locations or individual pharmacists. In simpler terms, the NCPDP will enter into a contract with a building (the pharmaCY) but not the health care providers inside the building (the pharmaCISTS).
If pharmacists want to get reimbursed by insurers for other-than-dispensing services, we need our organizations to get us recognized as providers based on our NPIs (the supposed standard for medical billing).
I would love to be able to bill for these interventions. Then the patients would be able to see how much our professional services are worth. The insurers could see how many visits to the ER were avoided due to pharmacist intervention. We will see some reimbursements for our services.
If we can show our value in this scenario, maybe it will open the doors to being able to bill for MTM services. If insurers see how much money we can save them in acute situations, they may be more open to our services for patients with chronic conditions.
There are a couple issues that could complicate this, which I may discuss if I do a post in the future on insurers. But for now we need to open our minds to the thought that we should be billing for and getting reimbursed for every consult we provide. All we would need to do is make a copy of the medical insurance card, fill out a short SOAP note on the encounter, and bill.
Pharmacy organizations, consider this to be your assignment for the next three months and show us some progress.
Thursday, September 23, 2010
Tuesday, September 21, 2010
Today I want to discuss reimbursement for the professional services that are provided by pharmacists. As the system exists now, pharmacists are not even recognized as providers by health insurers. I checked the websites of several insurers in my state (Ohio) and did not see a single instance of a pharmacist being recognized as a health care provider.
This is where the organizations that represent pharmacy need to get on the ball. For years we've been hearing about how pharmacists are able to decrease expenses and improve patient outcomes.
Well good for us. But that's not good enough. We need recognition as individual health care providers so that we can bill for the interventions and services that we provide. The organizations that I mentioned in my last post need to forget about showing the value of pharmacist services and get us recognized as providers. If pharmacists are able to bill insurers directly for services, you'll see a lot more pharmacists get on board. Money is a motivator.
A few years ago, the company I worked for wanted each pharmacist to get their own NPI. At the time I didn't think much of it. Now I can see the importance of your own NPI. If pharmacists are able to bill for the professional services that pharmacists provide, I want the reimbursement to come to the pharmacists, not the pharmacy. The pharmacy is just a building.
Right now pharmacists are able to bill for three CPT codes....three. All tied to medication therapy management services. The organizations that represent pharmacy need to get us more recognized services and codes so we can show all of the services that we provide.
The way the system works now, when I show a newly diagnosed asthmatic patient how to use their nebulizer, peak flow meter, inhalers, etc... I'm doing so basically out of the goodness of my heart. The $1.75 dispensing fee on the prescriptions doesn't cover the 15 minutes that I'm going to take to educate the patient. The same goes for diabetic patients and their glucose monitors and education on how to use their insulin delivery system. We need billable codes (that are unique to pharmacist services) so we can be reimbursed for the specific educational services that we provide.
And just like physicians are able to have patients come back in for follow-up visits to check BPs after starting a patient on a new medication, we should be able to bill for follow-up services to make sure that the patient is using their medical devices correctly. Or following our prescribed therapy. Or whatever service we have provided.
For the dispensing pharmacist, there should be reimbursement for the professional services provided on each and every prescription. We should be able to bill for all of the DURs we do. Of course we would need to document a little bit more, but it would reinforce the fact that we are providing a professional service on each and every prescription. The documentation process would use our individual NPIs to direct where the reimbursements would go.
The take home message today is this....pharmacy organizations, you need to stop worrying about showing the value of our services and get us recognized as individual health care providers. Pharmacists, you need to recognize that you provide unique professional services and should be compensated accordingly for these professional services.
More to come on reimbursements in my next post.
Thursday, September 16, 2010
When I look at the profession of pharmacy, I don't see a whole lot of organization among pharmacists. Sure, there are a lot of pharmacist organizations out there. Organizations like:
- American Pharmacists Association
- American Society of Consultant Pharmacists
- American Society of Health System Pharmacists
- Board of Pharmaceutical Specialties
- National Community Pharmacists Association
- American Association of Pharmaceutical Scientists
- The Pharmacy Alliance
- American College of Clinical Pharmacy
- Academy of Managed Care Pharmacy
- Christian Pharmacists Fellowship International
- National Association of Chain Drug Stores
- Society of Infectious Disease Pharmacists
- Hematology/Oncology Pharmacy Association
- College of Psychiatric and Neurologic Pharmacists
We've all heard the saying too many cooks spoil the broth. Well, too many organizations destroy the profession. One voice that is speaking gets heard, many voices speaking at once sounds like chatter and gets dismissed as background noise. I think that's where we are now. We have too many organizations trying to advance the profession and the messages are lost in all of the noise.
I look at the American Medical Association as the example of a strong voice for a profession. When the physicians group speaks, the legislators and media pay attention. We don't get multiple messages from the radiologists, pediatricians, internists, intensivists, pulmonologists, and oncologists. We get one statement from the AMA. That's where pharmacy needs to be.
Am I saying that the APhA should be the voice for all of pharmacy, since they have a name that is similar to the AMA? I don't know.
If they start to address issues that affect all pharmacists, then they could be the voice. I'll be honest with you, I'm an APhA member. I joined in August 2009 and just renewed my membership for another year. I hope to see progress from them. If not, I won't renew.
That being said about the national organizations, we need to look at the local levels of organization. Several months ago I put up a poll to see how many pharmacists were active in local pharmacist associations. I was not surprised when the results showed that a majority of respondents were not active.
How can we expect to have any organization and a voice if we are unwilling to meet as a group outside of work? I know that it's not convenient to meet and you just want to go home after work to relax. That's what is keeping us from having a voice in our profession. If we meet together, even if it's just once every other month, we are able to share our experiences and find out what is happening in other practice settings. Who knows, maybe the consultant pharmacist at the long-term care facility may be able to help solve an issue faced by a community pharmacist who is trying to start up a medication therapy management business practice.
We will never know if we don't get together to share our thoughts and ideas.
Once we have been able to discuss the issues that we face, we can forward them to the larger organizations and hopefully have an impact on the profession.
My concern is that if pharmacists don't get off of their butts to organize and advance the profession of pharmacy, there won't be a profession left in twenty years.
Tuesday, September 14, 2010
The medical fields are changing quickly. We, as pharmacists, need to know where we are and where we are going. If we don't adapt to the changes that are occurring, we may find ourselves to be extinct.
Over the next few weeks, leading up to American Pharmacists Month, I'm going to run a series of posts on issues that I perceive to be important as we move forward. Be forewarned, my experience has been in the retail environment for the past 15 years so my writing will be biased towards those who practice in the retail setting. I don't have the numbers, but I believe that most pharmacists work in a retail setting so I believe that we should address issues facing those in retail first.
That being said, the first topic in my state of the profession series is...
When you describe your occupation to somebody that you just met, what do you say you are?
- Retail pharmacist?
- Clinical pharmacist?
- Consultant pharmacist?
- Hospital pharmacist?
- Nuclear pharmacist?
All of these are valid answers to the question. But the answers are part of one of the problems we face as professionals.
We fragment ourselves.
By identifying with the particular practice setting we are involved with, we break ourselves down into, for lack or a better term, special interest groups. Me, I work in a community retail setting. If I view myself as a retail pharmacist only, I'm not going to concern myself with issues that affect other practice settings. By self-segregating ourselves into these groups, we lose the ability to speak as a whole profession.
I still have my dictionary from college. One of the definitions of unity in my dictionary is the quality or state of not being multiple : ONENESS.
Do you feel that the profession of pharmacy is unified? If not, what can you do to bring the profession into a state of unity?
I'm going to offer a simple solution that will hopefully start to bring unity to the profession. The solution lies in the answer to the question that I posed earlier.
When somebody asks you what your profession is, there is one and only one answer:
I am a Registered Pharmacist.