Thursday, July 29, 2010

Drug Topics wouldn't touch this idea

The following is the article I submitted to Drug Topics. I asked them to give me a response to see if they would consider using it and they haven't responded yet. Rather than sit and wait for weeks or months for a reply, I'm publishing it here. They can put it in Drug Topics as well, but I feel that this article may help pharmacists to view themselves as individual health care providers instead of as employees of some corporation.

So here, enjoy the post that Drug Topics might be afraid to publish.

Recently I had to take my daughter to the local emergency department for a nasty cough. It was on the weekend and in the middle of the night, so her pediatrician was not available and the urgent care centers were closed.

It’s been a few weeks and the insurance EOBs are starting to arrive in the mail. While reviewing these I had what may be an epiphany.

For our hour or so in the ED, we will be receiving bills from the emergency department, the ED physician, the radiology department, and the radiologist. Two bills from the facility and two bills from the health care professionals.

That got me thinking. On-line and in the pharmacy publications I see pharmacists wanting to be reimbursed for their professional services. Some pharmacists are able to generate an income stream through Coumadin clinics and medication therapy management services, but for a lot of community pharmacists the populations we serve can barely afford their medications, let alone these additional services.

Then it hit me. Why aren’t pharmacists billing the insurance companies for our professional services each and every time we fill a prescription?

We’ve allowed the reimbursements for pharmacy services to be lumped into the reimbursement formulas for the drug product. Guess what people? Those contracts are with the pharmaCIES to provide the product. PharmaCIES are businesses or departments where medications are stored and sold. (A July 12 article by David Witmer on the ASHP blog echoes this thought)

PharmaCISTS are medical professionals who review medication orders for accuracy, perform drug utilization reviews on each and every prescription, and educate patients on the proper use of their medications. The pharmaCY can’t do this, only the pharmaCIST. But only the pharmaCY has a contract with the insurer.

I believe that if we, as pharmaCISTS, want to show our value to the health care system, we need to actually try to get reimbursed for each time that we perform a professional function. Physicians do it every time they take a blood pressure; it increases the complexity of the visit. Why not us? Why aren’t we billing for our services each and every time.

We’ve allowed our professional services to be lumped in with the dispensing fee that is tacked on to the MAC or AWP-minus formula that the insurers set. I don’t know about you, but I feel that my professional expertise is worth more than $2.25 per prescription (0.00 on three month Medicare D orders). Well actually less than $2.25 when you factor in costs of vials, labels, technicians, utilities, etc…

As pharmaCISTS, we need to find a way to bill for our professional services each and every time we fill a prescription. The insurers need to contract with the pharmaCISTS, as well as the pharmaCIES, to provide the entire prescription product (medication, consultation, education). They do it for both the hospital and the physician. Why not pharmaCY and pharmaCIST?

I suggest that software be designed to send the NPI of the dispensing pharmacist to the insurers and that the insurers send reimbursement for professional services directly to the pharmacist of record. If we, as pharmaCISTS, truly want to be reimbursed for our professional services, we need to get serious about it and approach it on a wide-scale.

I don't know if this idea has been proposed before. I don't care if it has been or not. It needs to be discussed now. Right now we, as pharmaCISTS, need to get our act together before it's too late. Don't count on the corporations to look out for the well-being of the pharmaCISTS. They are doing everything they can to get tech-check-tech and other legislation passed so they can decrease pharmacist payroll, if not the pharmacist position completely. Don't count on the pharmacist organizations to do anything for you.

It's up to you.....the PHARMACIST.

Wednesday, July 28, 2010

I need some duct tape (a small rant)

I just read the APhA statement to the FDA about REMS in reference to extended-release opioids.

In a statement to the narcotics advisory board at the FDA, the APhA continues "to advocate for a standardized system-based approach that is feasible and scalable to accommodate the growing number of REMS programs".

I'm underwhelmed. Way to step out there and lead pharmacy by advocating. And for a standardized approach.


Then the APhA statement has to mention that pharmacists give flu shots.


My head is going to explode.

I'm sorry, but WTH?

I'm beyond words. I'm speechless. All I can think is "?????????"

Let's follow this statement with the APhA recommendations to the FDA:
  1. Outreach and educational materials for pharmacists about REMS. The only outreach I need is my hand reaching out to attempt to slap some sense into the APhA headquarters. You send a letter to the FDA that basically says "more MedGuides, please".
  2. Recognize the role that pharmacists play as the medication experts.... The same crap that goes on every APhA statement.


Apparently the APhA isn't doing a very good job in getting pharmacists the recognition for the role that we play as medication experts.

I will give the APhA a little credit. They do challenge FDA and sponsors to continue to evaluate the potential impact, need for, and ability to compensate for patient care services at the point of dispensing as part of a REMS program.

Did you see the key word in there?

Compensate. Well evaluate the ability to compensate for patient care services.

I can see the results of the evaluation. Nope. Can't compensate pharmacists. Why don't you go run off now and give a flu shot or two.

I may need two rolls. Better make it Gorilla tape.

Monday, July 26, 2010

Why PBMs suck

And believe it or not, this post has nothing to do with our friends over at CVS/Caremark.

Quick question- how many of you pharmacists out there are aware of the terms of your contract with the PBMs?

I already know the answer... not many. And that makes perfect sense given that a majority of pharmacists are not owners, but mearly employees of a pharmacy. Only the owners know the terms are. Well, as long as the owner is reviewing the contracts and not leaving it to a third-party service.

I'm going to share a story from my recent past to illustrate exactly how pharmacy benefits managers screw over pharmacies on reimbursements and how pharmacies go along for the ride.

At my previous job, working for a regional grocery chain as pharmacy manager, I was brought in for a little discussion with both my store manager and the director of pharmacy operations for the chain. The subject... declining pharmacy margins. I'm not talking a percent or two. I'm talking big time declines, the kind that make your P&L statement dip into the red.

Let's take a step back, to let you know the climate that I was working in. I was working for a high end grocery chain. Exceptional customer service was the minimum acceptable level of performance. A majority of our pharmacy patients had insurance thru a local insurance company (XYZ Insurance). XYZ Insurance only operates in about five counties, and they are the major insurance carrier for all of the counties. At my pharmacy, the accounted for 35 percent of our business. Our business lived and died on XYZ's reimbursements.

Our original contract with XYZ had your typical reimbursement structure:
  • Brand: AWP - 15% + 2.25 dispensing fee
  • Generics: MAC + 2.25 (MAC being the HCFA MAC*, or the GEAP MAC* if there was no HCFA MAC)
  • or AWP - 30% + 2.25 if the medication was on neither the HCFA nor GEAP MAC lists

Pretty standard reimbursements. We made a nice little profit from them. Then XYZ Insurance stuck the screws to every pharmacy it was contracted with.

Quick history lesson, who can name what blockbuster products have gone generic over the last four years? If you answered every one of them, you are right.

Well right before all of these products went generic, XYZ changed the reimbursement structure ever so slightly. The people signing our contract with them didn't pick up on it, not until I asked for a copy of the contract and saw the change XYZ had made.

The contract language now stipulated that MAC means Maximum Allowable Cost as determined by the lessor of the Federal Upper Limit (FUL)... or the XYZ Insurance MAC. Then it had the same language about GEAP and AWP - 30.

That's where they screwed us. They could put any freakin' drug on their MAC list and we agreed to take it. You know how the acquisition price for the first generic manufacturer is usually about 15 percent less than the brand name price? During this period they were XYZ MACing us. Nothing like losing 15 bucks on each and every prescription. The best part...they wouldn't release a list of the XYZ MAC drugs. Proprietary information.

That's what happens when you don't read the contracts and just accept whatever the insurance company throws out at you. When you figure that you can't reject the terms because you can't afford to lose the customers/ script count, that's when they nail you.

How long until XYZ decides to MAC brand name medications? Wait, I better not say that. It might give them an idea.

*if you don't know what HCFA MAC s, GEAP MACs , or FULs are, you shouldn't be signing any contracts

MTM Website

I decided to finally get serious serious about this medication therapy management consulting business. Heading into the weekend I set up a website to direct potential clients to my consulting business. Next step is to have one of my buddies who is a web-designer go in and tweak the site before rolling it out.

I am also picking up some new patients thru My area has virtually no pharmacists providing MTM services to Medicare D patients. I had previously been doing TIPS for GetOutcomes.

Because of the focus on the consulting over the last several days, I haven't put much thought into blog items. I have a piece that I submitted to Drug Topics. If I don't hear from them soon, I will post it here. It could be the article that is too controversial to be published (how's that for a teaser?).

Thursday, July 22, 2010

Born yesterday

She called me early this afternoon. It's been about two years since the last time that she called me. It's easy to remember her calls.


Because she uses the TTY relay. For those of you who are unaware of the TTY system, it allows deaf people to use the phone. They type what they want to say, an operator speaks it to you, you respond, and the operator types it back to the deaf person. This was texting before texting was texting.

Today she wanted me to order a case of Accu-chek Active test strips and Prestige test strips. She wanted me to charge her credit card and ship them to her on Monday.

What I don't understand, Mrs. Rev. Angel Umbato, is why do you want me to ship them? In your email from last month, you were going to be coming to the United States and sharing the sum 36 million US dollars with me. Remember?... I sent you all of my banking information and you were going to deposit the funds.

Somehow, Mrs. Rev. Angel Umbato, I feel that you aren't being entirely truthful with me.

Wednesday, July 21, 2010

Read the fine print

The lead physician at the local quick clinic/stat care/ whatever you want to call it just moved herself up on Eric's cool scale.

When patients are discharged from the clinic, the prescriptions are at the bottom of a full sheet of paper. When the patient drops off the script, we tear the prescription off at the perforations and hand the top part of the sheet back to the patient since it has the home-going instructions, etc.

Patient was a 24 year-old female who has seen a super-sized Big Mac meal or two in her lifetime. She didn't have the time to wait for us to hand back the top part of the paper. When this happens we usually enclose the instructions in the prescription bag when the patient returns to the pharmacy.

The orders are for this larger woman. Bactrim suspension and ibuprofen suspension.

For me, I don't think that there's anything that burns my butt more than people who say that they can't swallow pills. You are an adult. It's time to grow up and take your medicine like a big person. I know that this chick can take care of a Whopper in about three bites.

We go ahead and get the prescriptions ready and are putting the home-going instructions in the bag when we notice the physicians comments:
  • rest
  • fluids
  • practice swallowing cake sprinkles!

I love the comment. But doc, if you tell this chick to practice swallowing the cake sprinkles she's going to have them attached to a cake.

With ice cream.

And Hershey's syrup.

Wednesday, July 14, 2010

When I was an intern....

It was a balmy August afternoon. The temperature was hovering around 95. So was the humidity. The breeze, if you could call it that, was barely noticeable.

They lived near the top of the hill that overlooked town. Their house sat back a lane that was shared with the church that was at the top of the hill. The lawn was huge, but there was only one tree. It was at the northeast corner of the house.

From the outside, the house looked very small. It had an attached one-car garage, but it was almost as big as the rest of the house. It was one story tall and had what appeared to be a painted cinder block exterior. There was no front porch, just a couple wooden steps that led up to the screen door.

It was the summer before my last year of pharmacy school. I was working for an independent pharmacy about 25 miles from my hometown. Over the course of the summer I had made several trips to the local seniors to deliver their prescriptions. Most were to the apartments in the town's retirement complex. Occasionally I would deliver to an actual house. The pharmacy owner would usually have me stop by the local Tasty Freeze and bring back milkshakes for all of the employees.

Usually one of our front end clerks would deliver to this house, since it was on her way home. But Janet was on vacation this week. That meant it was me, the intern, who got to make this delivery.

Virginia had called at noon. She had run out of her insulin and needed it right away. James, the pharmacy manager, said that he would get it there right away along with all of her other medications that were waiting to be picked up. So at 12:30 I hopped in my truck and started on my way. Their house was only about 5 minutes away from the pharmacy, so I told James that I would be back soon. I asked if he wanted me to pick up anything at the Tasty Freeze. He just laughed and said to get going.

So I'm driving down the lane. There's an old beater of a car sitting in the driveway. An older Lincoln or Buick. A car that was fairly large. I parked my truck and hopped out, leaving the engine running. I walked up to the front door. It was dark inside.

I knocked and waited. A voice from the back of the house told me to come in. So I opened the door. That's when it hit me.

The stench.

I had never smelled anything so putrid in my life. It literally took my breath away. I turned to the door to get a little fresh air, then headed to the lady sitting at the back of the room.

She was wearing what could best be described as a tent with a floral design. I would guess somewhere in the range of 450 to 500 pounds (based on how large the people are on those shows on the Discovery Health Network). Her dress was bunched up in her fat rolls. Sweat soaking the cloth. I walked over to hand her the prescription bag, thinking I would be leaving soon.

I was wrong.

Her 400 pound son had stepped into the room and taken position near the front door. Then it started.

The questions.

One after another.

You see, Charles (the pharmacy owner) had helped this woman and her son out in the past. Virginia and Steve had not talked to Charles in quite a while, so they were wanting to see how things were going for him. They were shut-ins for the most part. The only time they got out was to visit the doctor.

So for two hours I'm trapped in this sweltering house (no air conditioning or fans) with two very large, smelly people who only want some company. Finally James calls to see if I had left yet, he needed me back at the pharmacy. That's when I escaped.

To see that my gas tank was almost empty. When I left the pharmacy I had a half-tank. But it had been running for two hours.

I eased down the drive to the main road. From there I coasted downhill to the gas station at the bottom. I fill up the tank and head back to the pharmacy.

When I open the door to the store, all of the staff burst out laughing. I had been initiated into the store. James has a gigantic smile on his face. He knows what he had just put me through.


Too bad for him that the smell had leached in to my clothes, so James got to smell Virginia and Steve until we closed at 6:00. Serves him right.

Friday, July 9, 2010

Bored at work

So what does your pharmacy staff do when it gets a little slow?

One afternoon at Happy Drug World we were a little slow. It think we were getting hit with a major thunderstorm so people weren't out and about.

I had hooked my mp3 player up to the computer and was listening to some top-40 music thru the Media Player. Anything beats the crap that is broadcast on the store muzak.

Anyhow, the tech who was working with me couldn't stand the music, so she retreated to the other end of the pharmacy. (She's into the heavier, darker metal) So she grabs one of our staplers,

sticks her index finger in it, and squeezes.

Of course it hurt and she tried to pull her finger out, but it was stuck.

There wasn't enough room for her finger to be withdrawn since the staple was stuck halfway into her finger.

I was laughing, she was both laughing and crying.

So I took a look at her finger and sized up the situation. I grabbed on of the counting do-hickeys and jimmied the stapler open far enough for her to get her finger out. Then all we had to do was grab some tweezers to get the staple out of the finger.

Total time of the incident....about 90 seconds.

Laughter about the incident....tons.

and we didn't even send her to the ER (I'm sure all my nurse readers will be proud of me for that).

So what do you do when you're bored?

This is a repeat post from my old blog. I love telling the story and just thought that I would share it again.

Tuesday, July 6, 2010

Legislation that WILL change the profession of pharmacy... a call to action

Last week Kay Hagen (along with Al Franken) introduced a bill to the United States Senate that will change pharmacy as you and I know it. With the introduction of the "Medication Therapy Management Expanded Benefits Act of 2010" (S.3543), access to medication therapy management services may be expanded to more Medicare D beneficiaries.

This bill, by my read of it, is basically identical to the "Medication Therapy Management Benefits Act of 2009" (HR 3108) that was referred to the House Ways and Means and Energy and Commerce committees last summer. Right now the Senate version has been referred to the Senate Finance Committee.

The APhA is applauding the introduction of the bill to the Senate, just as they did when the House introduced their version. And they should...MTM has been their baby all along. But right now both bills are sitting in committee. Which means nothing will get acted on unless the Senators and Congressmen feel pressure to act on the bills.

When I look at both bills, one thing jumps out at me. Both bills have language that says "In order to assure that enrollees have the option of obtaining medication therapy management services under this paragraph, a PDP sponsor shall offer any willing pharmacy in its network and any other qualified health care provider the opportunity to provide such services" (Senate version)


"A PDP sponsor shall offer any willing pharmacy in its network the ability to provide medication therapy management services to assure that enrollees have the option of obtaining services under the medication therapy management program from community-based retail pharmacies" (House version).

Did you see what I see?

The bills only allow pharmaCIES to contract with the PDPs, not pharmaCISTS.

That's where we, the pharmaCISTS, need to take action. This morning, as soon as my Congressman (Zack Space D-OH) opens his office, I'm calling to talk about the House bill. I'm going to tell him to support getting the bill through committee and onto the floor for a vote. But I'm going to see what he can do about the language of the bill to see that pharmaCISTS are the entities that can contract with the PDPs and get reimbursed for the professional services that are provided.

PharmaCIES are buildings from which prescription medications are dispensed. PharmaCISTS are the professionals who provide medical care to patients who enter our pharmacies. It's time for all of us, as pharmaCISTS, to get off of our collective asses and start contacting the elected officials in Washington DC to get something done.

We can't count on the APhA to lobby the House and Senate, it's up to us to stay on their backs to get these bills out of committee, voted on, and on the President's desk to be signed into law. Just remember to push for the reimbursement to go to the pharmaCISTS who are providing the MTM services, not to the pharmaCIES.