Thursday, March 24, 2011

Insights from a fellow pharmacist

The following is an email that was forwarded to me for my thoughts by a fellow pharmacist blogger. I thought that the insights were good and should be shared. I received permission from the original author to post the contents of the email here.

The email touched base on several issues that community pharmacists face. What are your thoughts?

I agree pharmacy schools have dropped the ball but they did that when they transformed pharmacy schools into MTM training schools without finding out whether or not that was a practice model that could be broadly applied to the profession. They were so desperate for a "model" of professional practice, they accepted Hepler and Strand's model without adequetly seeing if it could be accepted and applied in the real world.

Hepler and Strand in the early 1990's brought "pharmacy logic" to its ultimate conclusion. Roughly, it is that since pharmacists have the most formal "drug education" that they therefore should manage drug therapy. If you read their announcement of "pharmaceutical care" on the first page it says pharmacy should "accept" this role and on the third page, it says that nothing they propose, they believe, is or should be infringing on the practices of other health care professionals. The problem is/was doctors were doing the managing already and as we've seen since, they will decide who is to "infringe" on them and who is not. Physicians assistants and nurse practitioners (with a little battling) do much more therapy management than pharmacists. What we now call MTM is an aberration that has been modified to try to fit information available to us. We can't "manage therapy" without lab and examination information--the medical chart.

A recent 'Chain Store News" article featured a K-Mart pharmacist who is "spreading the gospel" of
MTM. One of the things he has technicians do is to call doctor's offices to see if they can find out some lab values before he meets with patients to discuss their therapy. The picture of him conducting MTM was in the foot care isle. The MTM company Outcomes supposedly facilitates MTM by local pharmacists--their "training" that they refer to is one hour of learning how to bill. They also provide what they call "TIPS" (Treatment Intervention Protocol Services) to get the pharmacist to call the doctor to switch therapy to something more cost savings. Since we don't see any medical information nor the formulary, we assume they act in the patients interest. For all we know, we could be acting as drug company shills.

So, why do those recent grads have a pessimistic, unenthusiastic attitude? Perhaps they got a good look at the drive through. Maybe they realize their education isn't really going to be used. You recently wrote that you missed seeing drug reps and liked the concise information they gave--putting aside its inevitable bias toward their product. We don't see them because they now have to invest their time where it counts--with prescribers. Both the drug companies and the physicians are not going to give up therapeutic management to pharmacists. Drug companies support the PBM's and their mail-order pharmacies. They are in direct competition with us. In 2003, the government realized that drugs companies owning PBM's wasn't a good idea so they had to split--at least on paper. Why PBM's now have the right to restrict free trade and mandate using mail order pharmacies and eliminate community pharmacy from the loop makes no sense to me. I know you'd like to see all pharmacists join together but look at recent editorials in Drug Topics magazine. A Drug Topics board member and hospital pharmacist virtually told David Stanley he has no business "complaining" about retail pharmacy and the fact you have to fill 1000 Rx's a day because of squeezes by PBM reimbursements because he "chose the big dollar signs of chain pharmacy." That is a lack of understanding, empathy and unity that I find shocking and divisive. Its no way to treat a patient, much less a colleague. Its a sinister version of "blaming the victim." And I'll bet she hasn't a clue.

Not even the National Boards of Pharmacy give the pharmacist any respect. Doctors, who have the responsibility of prescribing, will be allowed to see who is getting narcotics from who and where--pharmacists will not. We are going to be left out of the information that we had hoped would propel us into an active, contributing member of the health care team. Not just regarding substance of abuse tracking and diversion but the health information that should be available to us to provide real MTM is not going to happen. If we get anything, it will be just enough to shut us up but not enough to be involved in any real decision making. Maybe I'm a pessimist--or a realist. Its hard to tell. Not long ago you wrote that all these new PharmD's coming out of school weren't going to put up with the same old crap as us old codgers had. Did you have a change of mind? Perhaps they were smart enough to see the road ahead and they realized what they were taught really didn't come close to reality. Its hard to instill pride of profession in a group when they realized that. Send a copy to the pharmacy schools who implemented an untested model of practice and get their response. Not their job, I'll bet. Just like it wasn't their job to "sell" MTM to anyone. If that's true, why would you teach it. Another thing Anna said in her response to David was, "there's no money in patient care." That is what MTM was supposed to be about--caring for the patient by a pharmacist. "Reality: Have it your way." Of course there is some truth to that, psychotics do it every day. That is one of the tests for psychoses and apparently for a divided profession. Of course, I could be wrong.


Daryl said...

My feeling on MTM is it will never be a money maker for pharmacy. Why would anyone want to pay separately for something that is (should be) already included in their doctor visit. This will especially be more the case once med records are all interconnected by Google etc and the doctor can see your chart/meds all combined together from everywhere. And I'm sure the docs software will show lower cost alternatives, therapy choices, and/or interactions right on his/her screen

Pharmacist MTM is a great idea on paper only not in the digital world about to come to life. So those of with with vision go ahead knock yourself out and help people control their med therapy/ drug costs etc. But there is no way they will willingly come in and pay you for this service... of course if you offer to give them monetary rewards such as coupons/gift cards then they will flock in droves.

The Nail Narc said...

Wow! That is the most awesome, cohesive, set of thoughts on the state of our profession I have seen, lately.

Is it just me or does every pharmacist feel as though they are run so ragged, multi-tasking so much, that its a miracle we can even form a complete sentence at all! I find its really tough to even step back and see what is really happening to us! I don't have time for it while jumping all these hoops!

I don't want to say it, because it might come true. Healthcare Reform could mean getting rid of the pharmacist. The physicians are looking at shrinking reimbursement for services and they don't don't want to share the shrinking MTM pie with us. Perhaps, when times were good, pharmacists doing MTM was a possibility, but not in today's current economy. Everyday I'm told, "fill every script! 15 minute guarantee! Shoot as many as you can!" Not a thing about counsel and manage drug therapy. *crickets*

We're being squeezed out, and our crazed, haried, stressed colleagues may never truly have time to see the truck that is about to hit them.

J said...

As a customer? My doc, if I'm lucky - to reference a former post - HAS this stuff on file. It's the case at Oakwood Hospital, and it's the case at Henry Ford too, here in Detroit.

If I'm real lucky he might prescribe something that works.

I'd rather, honestly, have someone who gives out the pills and sees the people and does all the interactions keeping bad doctoring in check.

And, yes, I would pay for it. Pharmacists are not friggin' pill counters, and I'm reasonably certain they ain't monkeys that take as many college courses, and harder ones sometimes, as your average doc.

I think compounding is important. I think pharmacists are overworked to the nth degree and underpaid. I think quality has gone the way of percentile points on a sheet of paper for an equally hard-worn manager.

And this is with people's lives at stake.

As a customer, there ain't much me or mine can do except to quit taking the fancy, chemist approved stuff and die.

I dunno how to fix it. I do try to quietly wait, shrug appreciatively, and as the one-percenter, know that the poor dude on the computer is having a crappy day.

Y'all hang in there.

The Nail Narc said...

@J You're so sweet, thank you for "getting it". I wouldn't stop you from sharing your point of view with friends, family, and the occasional irrate idiot at the pharmacy angry he has to wait 10 minutes. You could also write your Board of Pharmacy, newspapers, and news stations about your concerns with Rite Aid's "15 minute guarantee", in addition to finding other ways for us to accomplish our professional duties. Just a suggestion. Remember, the Board of Pharmacy is there to protect the public, not pharmacy!

My other thought I forgot to include, was, "Well, gee, if I'm not a "real" healthcare professional and I'm not charged with the responsibility of managing medications, perhaps the legal burden of responsibility for that will be lifted from my over burdened shoulders!" Yea.. right!

I know it can't just be me who fears everyday on the job that I'll miss something that someone is going to say I was negligent over and hold me accountable. My computer tells me about contraindicated conditions and makes assumptions about patient's diagnoses based on their medication history. How can I make a professional judgement on these things with no medical history! I have to over ride these crap! I feel totally unarmed to make that judgement.

So.. he less responsibility might be nice. *Flash back to American Beauty* "I'd like a position with the least responsibility possible"

TXPharmguy said...

There is no way MTM is going to work in high-volume chain pharmacy. For instance, my store does about $1M per month in rx sales (over 500rx/day store). We gross 22% or $220K on average. IF, you could get 100 people to come in and do CMR (complete medication reviews) in one month, you'd add a whopping $5K ($50 each)to your gross. Let's break it down further: 100 per month, 25 per week, or 5 per day (weekends excluded). On average each takes about an hour with prepwork and billing, etc. Who couldn't use those 5 RPh hours per day cranking out over 500+? Oh yeah, squeeze in counseling, all the questions, immunizations, compounding, health testing, and all the other crap they want you to do.
FWIW, all medicare part D beneficiaries can get one CMR per year at no charge to them.
From a chain perspective, you'd probably need a person or two and provide phone MTM counseling sessions. You wouldn't make any money on it, but at least you could say you're an MTM provider

TXPharmguy said...

I meant from a chain perspective, have one or two pharmacists for the DISTRICT perform the MTMs via phone