Tuesday, November 30, 2010

CTP codes. How about CPS codes?

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

A change in thinking

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

Personal cancer story

Ring, Ring

It’s 5 o’clock on a Tuesday morning. Who’s calling.

Ring, Ring

Oh crap, I better get that before it wakes everybody up.

Ring, Ring

I stumble into the kitchen to answer the phone.

Ring, Ring

Eric: Hello

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.

Ten seconds.......

fifteen seconds.......

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

OTCs and OB/GYNs

Fifteen years ago, my wife and I were preparing for the birth of our first child. As part of her obstetrical care, the OB/GYN provided my wife with a list of over-the-counter medications that were deemed to be safe to use.

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
The only combination products you will find are Mucinex-DM and generic Codimal-DM (the only product that works for my asthmatic son's non-asthma coughs).

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.

Coming soon

Responses to comments from the State of the Profession series. Hopefully the series got you thinking about how we can advance the profession moving forward.

Wednesday, November 10, 2010

Policies and procedures

Through my years of being a pharmacist, I've heard of many policies and procedures that don't seem to make much sense. Either from being an asinine idea in and of itself, or because it requires attention from the pharmacist-only when it is a non-professional function.

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

Open enrollment begins soon

Medicare Part D open enrollments start in a few days. Aren't you excited?

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

Belated breast cancer awareness

It's a little late, but I thought I should do my part to help on the issue of breast cancer awareness. After seeing all of the emails and Facebook updates and so-on and so-forth, I thought that I would share a picture of some of my favorite boobies....

C'mon, it was just Halloween a few days ago. Have a sense of humor.

Monday, November 1, 2010

Tonight's heroin

I'd like a pack of insulin syringes. Thirty-one gauge. One-hundred cc's.

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.