Eric, Pharmacist

Something to chew on

2012-01-23T23:59:00.001-05:00

I logged on to Facebook the other day and saw a status update from one of the guys from my high school days. He was commenting on the service that he received from a few different pharmacies as he was attempting to find on of the medications that is currently in short-supply.

Would it surprise you to find out that one of the national chains didn't even acknowledge him standing at the drop-off window? Not a "we'll be with you in a moment". Not a nod from a pharmacist or tech to let him know that they spotted him. In fact, two different techs/cashiers walked past him at the drop-off window on their way to the pick-up window to wait on people who entered the pharmacy after he did.

Once he was finally waited on, it took over thirty minutes for the pharmacy staff to inform him that the medication was not available. Needless to say, he was disappointed with the service that he received at the pharmacy. Not one to remain quiet, he addressed the store manager about the "extra care" that he received. Did he receive an "I'm sorry" or any form of compassion from the manager?

Nope.

The manager pointed to a customer comments phone number that was posted on a sign and was told to call the number.

He went to another pharmacy and was able to obtain the medication. In and out, with pharmacist consultation, in under 15 minutes. He was singing praises about the pharmacy that took care of him. Even to the point of giving the address of the pharmacy in the comments after his post.

In my retail days, I never really thought about how people would comment about the care that they received at my pharmacy on the social media sites. We hear about word-of-mouth advertising, but this was the first time that I have seen it play out in the social media. The volume of comments that his update generated was astounding.

If we, as pharmacists, want to be recognized as individual medical providers then the type of service that the first pharmacy provided is unacceptable. Patients aren't going to want to see providers who ignore their presence for 15 minutes. Sadly, this type of service is common from what I've seen of the first pharmacy chain.

If we want to advance the scope of our practice, we need to provide care that exceeds the patient's expectations. We want the social media to have complements about our profession, not complaints.

Isn't there a saying that says it takes 10 positive comments to cancel the effects of one negative one. Maybe we should set that as our benchmark for how we see pharmacy experiences reported in the social media.

Just something to chew on for a little bit.

AMA vs APhA.... looking out for the interests of their members

2012-01-23T16:11:00.000-05:00

Just a quick note on this article that I found on Twitter today.

The AMA pays close attention to the reimbursements that its members receive from third-parties and addresses the issues instantly. Whenever the evening news announces a cut in Medicare reimbursement rates, you can put money down that the AMA will have a statement releases by the start of the next day's news cycle. The AMA understands that without adequate reimbursement, the standard of care will drop and businesses will fail. In the article that I link to, the AMA offers ideas for its members who might be a little cash-strapped.

Let's compare that to the APhA.

The big topics in retail pharmacy over the last couple months has been the Walgreens-Express Scripts drama over reimbursements.

I did a little search on the APhA website to see if there was any commentary on the issue. From the home page I searched for "Express Scripts". Top search result...a 2007 article about drug prices.

So I went over to the APhA CEO blog. With the edit button of my browser I did a "Ctrl+F" (Find on this page) search for "express". Only one match for "express" among the ten blog posts. You probably already know that it didn't match up to Express Scripts.

One of the biggest stories in pharmacy, centering around reimbursement issues, and the APhA has yet to address the issues on its web-site.

Rule #1 for business. You must make money to stay in business. The AMA gets it.

Pharmacists as providers?

2012-01-10T00:05:00.001-05:00

This past weekend marked the six-month anniversary of my transition from retail to hospital pharmacy. It seems like only yesterday that I was behind the pharmacy counter, while it also seems like forever since I’ve been in a community pharmacy.

One thing that immediately jumps out at me on the difference between the two settings is the manner in which I am treated as a pharmacist. In the retail setting, physicians and nurses (or receptionists or whoever the physician allows to represent them on the phone) didn’t seem to respect the knowledge of the pharmacist. I felt that I was viewed as a nuisance. Not so in the hospital setting. On a daily basis I am asked for my input on decisions relating to the care of my patients. A vast majority of the time my recommendations are accepted and implemented.

It didn’t take long for me to realize that hospital and community pharmacy are worlds apart with regards to the practice of pharmacy. I follow what is happening in the retail sector through blog posts and Twitter updates, but for the most part the issues in retail have no bearing on my practice in the hospital setting. And by the same token the issues that hospital pharmacists face don’t mean a whole lot to the folks out in the retail trenches.

The profession is clearly divided and it’s no surprise that pharmacy isn’t represented that well by the national organizations. There isn’t an issue that all of us can get on board with in order to have a united voice. So you end up having several different organizations (NCPA, ASHP, ASCP, etc…) representing their individual interests, trying to talk over each other and in the end nobody’s voice is heard.

The American Pharmacist Association, in my opinion, should be the organization that should be able to speak for all pharmacists. If you pay attention to the opinions expressed on the social media, pharmacists don’t feel that the APhA is doing much, if anything, to address the issues that pharmacists are facing.

The APhA has totally bought-in to the medication therapy management (MTM) practice model. Over the past 18 to 24 months, various articles have tried to sell MTM as the pharmacist’s component of accountable care organizations, patient-centered medical homes, and collaborative practice arrangements. While I believe that MTM-style services are where pharmacy should be heading, I believe that the so-called leaders of the profession missed a key component of the equation when they decided to go all-in on MTM.

Reimbursement.

Sure, some Medicare Part D plans are reimbursing pharmacists for MTM services, such as comprehensive medication reviews. But these are limited to the patients who are selected by the insurers. Rather than accept the practice model no-questions-asked, how about taking a step back to get all of our ducks in a row? How about getting us recognized as providers so that MTM services are reimbursable from all insurers and can be offered to all patients instead of the select few Medicare Part D-ers.

The first issue that should have been addressed is recognition of pharmacists as medical providers. If pharmacists receive provider status and are able to bill for services rendered, the entire MTM practice model will take off. There are innovative minds in the pharmacy world that will revolutionize healthcare, but we need to be sure that the bills will be paid at the end of the day. Changing the practice model today with the hopes of reimbursement tomorrow isn’t going to cut it. We need to become recognized providers now. There is a petition floating around out there to try to get pharmacists recognized as providers. If you haven’t done so already, I suggest that you check it out.

Provider status is the issue that covers a majority of the practice settings for pharmacists and could unite the profession into a strong voice. Over a year ago I wrote on how different practice settings could benefit from being recognized as providers*. Community pharmacists could bill professional fees for DURs, OTC consults, and even calls to insurers (nowhere in my state’s pharmacy practice act does it state that pharmacists must call insurance companies). For each service that we provide, we should bill. The days of counting on dispensing fees to cover the costs of these services are long gone. Pharmacists need to be reimbursed for the professional services that are provided.

On the hospital and consultant side, pharmacists could charge for consults and interventions that occur daily. These are documented at many facilities; we just need to develop a charge sheet to be able to submit to the insurers and Medicare. Services such as anticoagulation clinics, diabetes/asthma/COPD-education, and nutrition education would be areas where pharmacists could make a huge difference if the reimbursements were there.

I don’t know what it’s going to take for pharmacists to unite as one voice. It might be the APhA taking the lead and pushing for recognition as providers. It could be retail pharmacists saying enough is enough and forming a union to get issues addressed.

Whatever the practice setting, I think that we all can agree that we need to be paid fairly for what we do as professionals. Recognition as providers is the first step towards achieving that goal.

*Previous posts of mine that address this issue

Twelve Days of (Pharmacy) Christmas

2011-12-23T13:20:00.002-05:00

Stolen from a Twitter feed from @_RxLauren

Twelve hours standing
Eleven early refills
Ten screaming customers
Nine benzo scripts
Eight a$$hole doctors
Seven drive throughs beeping
Six Plan B pick-ups
Five prior auths
Four cash narcotics
Three fake prescriptions
Two tripping junkies
And a pharmacist who hates her job.

Merry Christmas!

Frogger, RPh

2011-12-06T23:09:00.001-05:00

Have you ever tried to boil a live frog? Just throw the frog into a pot of boiling water. It doesn't work because the frog's survival instincts kit in a it will try to escape. If the water isn't too deep, it will be able to leap out and survive.

But if you put the frog in the same amount of lukewarm water and gradually increase the temperature to a boil, the frog is not able to detect the temperature changes and will be boiled alive.

I've heard this several times over the years without thinking much about it. This past week, the president of our facility shared it during a meeting of our management staff and a thought immediately jumped into my head.

This is the world of retail pharmacy. Pharmacists are the frogs.

If you think about how the world of retail pharmacy has evolved over the past 20 years, I think it's easy to see how the pharmacist is getting slowly boiled. Many factors have come into play that are cranking up the heat on our professionals in the retail trenches.

Let's take a look at some of them. While in and of themselves they aren't necessarily bad (in fact some are good), the combined effects of all of these have turned up the heat on community pharmacists.

Third-party insurers. These initially helped level the playing field for pharmacists since patients would pay the same price wherever they chose to fill their prescriptions. However the ever-decreasing rates of reimbursement have driven many pharmacies out of business. And those that remain must fill more scripts to bring in the same dollars.
OBRA 90. Mandatory counseling, DURs, etc for certain patients. While these are good, there was no increase in reimbursements to hire additional staff to safely fill the prescriptions. Rather than ensuring that every prescription would receive its due attention, I think that it can be argued that the pharmacist has been legislatively forced to have interruptions in their work flow in order to offer the required counseling. And what passes as counseling falls far short of the intent of the law.
Drive-thru pharmacy. One more drop-off and pick-up area. Usually without additional staff (or reduced staff after the first three months).
Gift cards for transferred prescriptions. More phone calls to distract the pharmacists from their primary duties. And one more place where an error in communication can occur.
Pharmacy-initiated refill requests to prescribers. While this may help with compliance for some patients, it adds another uncompensated task for the pharmacist to oversee. I'm sorry, but responsibility for refills should fall upon the patient. It's no surprise that our patients don't take ownership of their health because they aren't asked to do anything other than fork over their copay.
Immunizations are good. The interruption to workflow is bad. Quotas on immunizations (which I have heard rumors of) are unsafe.
Auto-refills (aka predictive refills). Similar to the refill requests. Good intent, but patients need to be responsible for their own health. In my experience, about half of the prescriptions that my retail pharmacies filled through these programs were returned after 7 to 10 days. The process of returning the prescriptions is just as, if not more, labor intensive as the original fill. More uncompensated work for the pharmacists.
$4 generics. Affordable medications can increase compliance, but the amount of staffing hasn't grown to offset the increased workload. More scripts, less help. Not good.
15 minute guarantees. Only to be outdone by 10 minute guarantees. Sure. Why not? While we're at it, let's have corporate call to find out why it's taking so long to get the scripts out the door. One of my friends recently had a corporate person call to inform her that corporate was looking at the video cameras and the pharmacy pick-up lines were too long and wanted to know how she was going to rectify the situation.

The pastor at my church often asks us if we are being a thermometer or thermostat in our community. The thermometer simply is a reflection of the environment. The thermostat sets the environment.

In order to effect any change in the retail environment, we need more pharmacists to be thermostats. Speak up when necessary. Promote positive change for the profession.

Because if we continue to just be thermometers, we're a bunch of boiled frogs.

David Snow U

2011-11-01T00:01:00.000-04:00

Unless you've been under a rock recently, you would know that Medco's David Snow caused quite a ruckus lately with his comments about retail pharmacists. I haven't looked into his comments, and I'm not going to. I think that the reaction that has already taken place gives me a good idea of what he said.

One question comes to mind...if retail pharmacists are so inaccurate, why does Medco have their name on the yet-to-be-accredited college of pharmacy at Farleigh Dickinson University? Do they somehow have the ability to train human to be 23-times more accurate than we currently are?Those are the figures that he quoted when he spoke at the Cleveland Clinic.

The Accreditation Council for Pharmacy Education hasn't accredited the college...yet. Corporate money will help the ACPE turn a blind eye to this slap-in-the-face to pharmacists.

But then again, Farleigh Dickinson could make a stand against Medco as well. Isn't a bit hypocritical for a pharmacy college to accept funding from a company that is trying to decrease the number of pharmacists out there in the retail setting? We know that won't happen either. What college is going to turn away people willing to pay $40,000+ per year for 4 to 6 years to enter a career field that is already saturated?

But then the answer came to me. I know what student the pharmacy college at Farleigh Dickinson is trying to attract. I don't want to stereotype the student who would attend this school, but I will share a picture of what the initial students graduating from this school may look like.

The ideal FDU Medco College of Pharmacy graduate looks like this....

Even if the truth hurts

2011-10-25T00:01:00.000-04:00

Several days ago I stopped by a local pharmacy on my way home from the hospital to pick up an item for my wife. While waiting in the checkout line, I overheard the conversation of two senior women who were ahead of me. One of the women was telling the other about her husband, who was hospitalized due to a diabetic foot ulcer. She said that he had known about the sore on his foot for quite a while, but he had chosen to ignore it. Upon admission, the ulcer had reached through all of his tissue and the bone of his heal was exposed.

Upon hearing this, most people would think “poor guy, hope it heals”.

But that wasn’t my thought.

Maybe my years in community pharmacy have jaded me. Maybe seeing patients admitted repeatedly for the same diagnosis has hardened me since my move to the hospital setting a few months ago. Whatever the reason, my sympathetic side took a backburner to my practical side. My thought was a simple one.

This admission was totally preventable.

Seriously. It is 2011 and we are living in the United States. There is no reason that anybody should be admitted for a diabetic foot ulcer.

We have the best medications to control blood glucose levels. We have at-home testing machines that can tell you what your blood sugar (and hemoglobin A1c) levels are. We even have little mirrors on the ends of poles to help diabetics inspect the bottoms of their feet.

We have home health care companies that go to patient’s homes three, four, even five times a day to help people take their medications. There are social services that come into people’s homes to help with meal preparation and housekeeping.

We have a vast amount of information available to us over the internet. With a few keystrokes we can find out about our medical conditions and how to stay healthy. If your physician is tech-savvy, you can have access to him or her with a few keystrokes on your cellular phone.

With all of the advances in technology and medicine, there really isn’t a good reason that I can think of as to why somebody should be admitted for a diabetic foot ulcer that has reached the bone.

Other than patient apathy.

The hospital administrator side of me started thinking about how, in the near future, hospitals aren’t going to get paid by Medicare for patients who are readmitted within 30 days for certain conditions. Even if the hospital does everything correctly, a patient who doesn’t care about his/her health is going to receive thousands of dollars of care for which the hospital will not be reimbursed. Diabetics who bounce back into the hospital because they can’t manage their disease are going to drain my facility of resources that could be used to treat patients who genuinely desire to get well. It makes me kind of angry.

Then there’s another side of me that wonders why nobody said or did anything. Why did this guy’s wife let the foot go untreated? Has this guy ever been educated about his disease? When was the last time this guy saw his physician? Is he taking his medications correctly? Has he ever talked with his pharmacist about his medications? Can he afford his medications?

These thoughts are running through my mind and I remember a comment that somebody recently left on one of my older blog posts. The jist of the comment centered around a thought that I had shared when a patient asked why they needed to be on a medication. My thought was “because you are fat, lazy, and need to exercise”. The commenter thought it was unprofessional of me to think like that, and who was I to judge.

Maybe I was wrong to think like that (even though I saw the grocery items that were in the cart). But then again, maybe I should have said what I was thinking. So much of our effort in pharmacy is dedicated to keeping the person as a customer rather than speaking to them as a patient. Are we doing our patients a disservice by sugarcoating our message? Sometimes being blunt is what is required to get the point made.

Would this woman’s husband have been better served if somebody had actually said “keep your blood sugar under control or you are going to get a nasty infection on your foot that may require amputation” Most people are afraid of losing body parts so that may have resonated more than “Jim, are you taking your pills right? No? Well you better. That’ll be $4.00.” When I worked for one of the chains offering $4 prescriptions, I didn’t have the opportunity to even have that discussion.

I did have a position at a regional grocery chain (where we filled 120-180 scripts/day) where I was able to talk to my patients. I got to know my patients and their families. And when warranted, I would be blunt with them. They understood that it was coming from somebody who cared for them and wanted to see them healthy. It has been three years since I left that position and I still get stopped at football games and swim meets by my former patients who thank me for how I helped them with their medical conditions.

I didn’t become a pharmacist to sugarcoat the truth to make people think that they are being healthy. If pharmacists want to impact the health of our patients, we need to be truthful.

Even if the truth hurts.

MTM Workshop

2011-09-29T00:01:00.000-04:00

In an effort to achieve my blog's goal of advancing the profession of pharmacy, I decided to post a link to a workshop that is being provided at the ASCP's annual meeting this November in Phoenix.

I was made aware of the meeting by one of the members of the ASCP Foundation following a recent post about the future of MTM. If you are like me, a mid-November meeting is really kinda last-minute. But if you have flexibility, it may be helpful.

To me, it looks like a "how-to do MTM" session. It does look like it has a little bit of info on developing a business plan. Personally, I'd rather attend a "how-to get your services paid for by an insurance company" session. I live in an area where people don't exactly have a spare hundred bucks of their income to spend on an MTM session with a pharmacist, so I'd like to hear from individual pharmacists who have successfully enrolled as a provider with an insurer.

For those of you who are interested, here's the link to the ASCP's page for the session.

The ASCP wants you.....

2011-09-28T19:17:00.003-04:00

To help them out. Click here to link to a survey for long-term care pharmacies and consultant pharmacists. The results are sent to a third-party, who will in turn submit a report to the ASCP.

Wonder if they will give me a year's membership in exchange for the promotion of their survey and web-site?

Thank goodness for United Healthcare

2011-09-22T19:20:00.002-04:00

I've been hearing this commercial over the radio for the last several days. Each time that I hear it, I get a little bit more pissed off.

Pharmacists are being depicted, at least by United Healthcare, as idiots who can only catch a drug-drug interaction if the almighty insurance company alerts them.

Rather than promote themselves as the ever-present protective force in the prescription drug arena, how about running an advertisement to encourage your subscribers to pick one pharmacy and stick with it? You know, so your records are in one location instead of being scattered between Walgreen's, CVS, and Target?

Oh yeah, because you force your subscribers to use the mail-order service where they never even get to meet the pharmacist who fills their prescriptions. You promote the very practice by which you claim to be protecting your subscribers from.

Don't insult us, United Healthcare.*

*-this post doesn't apply only to United Healthcare, but to all insurers and pharmacy benefits managers who place profits first and patient safety second.

More concerns about MTM

2011-09-14T00:14:00.000-04:00

The internet is an amazing thing. It allows us to share thoughts and ideas with a wide spectrum of people and receive feedback almost instantaneously. This is one of the reasons that I enjoy writing on-line. I receive emails and comments from people who I will probably never meet in real life, but we are able to share our experiences. Hopefully for the betterment of our lives and, since I write almost exclusively on pharmacy issues, our profession.

After my last post, I had a few people contact me to challenge the statements that I made. I appreciate this. It allows me to strengthen my argument if needed. It can also open my mind to points of view that I may not have considered. For today’s post, I’m going to address some of the issues that were brought up to challenge my thoughts on medication therapy management being the future of pharmacy.

First, let me remind you that I believe that pharmacists are not utilized to the fullest extent of their potential in the community setting. Heck, community pharmacists aren’t even being used for ten percent of their potential. That’s why the concept of medication therapy management is appealing. In theory it gives the community pharmacist the opportunity to utilize his or her skill sets to have a positive impact on the health of patient. That’s why we became pharmacists…to help people.

But the reality of the situation is that MTM isn’t going to happen. At least not to the level that pharmacists would like to see. Sure, there may be an individual here and there who is able to generate a revenue stream from MTM-style services. But when it comes down to it, insurers aren’t paying for the services. And if insurers aren’t paying, people aren’t going to use the services.

I’ll use the Diabetes Ten City Challenge to make my point. Now this was to be the national rollout of MTM services following the Ashville Project. I printed off a copy of the article that reported the results of the DTCC from the Journal of the American Pharmacists Association (J Am Pharm Assoc. 2009:49:e52-e60) and did my own analysis of the results.

Firstly, when the results were published, two of the ten cities didn’t have their data included in the results. For whatever reason, Chicago and Los Angeles didn’t get counted. So in effect we have the Diabetes Eight City Challenge.

To be included in the DTCC certain criteria were required:
· Participating groups had to be self-insured with a patient base of at least 5000
· Incentives for insured persons to participate were to be provided
· The insurer had to have strong internal support for the program
· The Ashville model was to be followed

I pulled some information from the DTCC website to see how many people took advantage of the programs. Only six of the reporting cities had data on the number of patients enrolled in the plans that took part in the DTCC. These six cities had approximately 43,200 potential patients. Not diabetic patients, just overall patients. From the eight cities that were included in the final statistical analysis, only 832 patients with diabetes started the program. And from these patients, only 572 completed at least one year and were included in the final analysis. That’s less than 2 percent of the insurer’s patients who took part in the program.

The insurers gave incentives for the people to participate. Things like discounted or free copays on their medications. No out-of-pocket expense for testing supplies or lab work. Credits towards their deductibles.

All of this incentive and less than two percent enrolled in the program. Granted, the data does not say how many patients were actually diabetic, but remember I’m using the number of patient who enrolled from eight cities divided by the number of eligible patients from six cities and I still come in at under two percent. People aren’t beating down the doors for these services like some would have you believe.

When I looked at the final results of the study, I wasn’t impressed. The DTCC did report that there was a savings versus projected costs. Not against a control group, but against the insurers’ projected costs for the patients. My fuzzy math skills calculated that the insurers expected the costs of medical care to increase 13.5 percent, but the actual increase in cost from baseline was only 5.3 percent. That’s how you can report cost savings of 7or 8 percent.

The claims of success for the DTCC were base on improvements on some lab tests. Wanna know what the improvements were? A1c dropping from 7.5 to 7.1. LDLs going from 98 to 94. Systolic BP dropping from 133 to 130. The average patient saw their pharmacist every other month for MTM services and this is the impact that the pharmacists had? Was it really the pharmacists’ interventions that had an impact? Or was it the impact of generic drug prices falling upon the release of Wal-Mart’s $4 list? Or how about some new medications that came out around the time of the DTCC (Byetta/ Januvia)?

We are basing the future of our profession on a couple of studies. Just two. Ashville and the Diabetes Eight City Challenge. Would you agree that the FDA approve a medication based on two studies? But you are banking on the future of your profession on two studies.

Another criticism of my previous post centered on my pointing out that only 27 percent of Medicare Part D plans cover face-to-face comprehensive medication reviews. The point was made that other health care providers are searching for methods to bill for these tele-medicine services. One point was over-looked. The physicians already have an established relationship with the patient. They have met face-to-face previously. They are simply expanding their access and creating another billable service. Billable service? Aside from three CPT codes that offer Level I reimbursements, pharmacists don’t have billable services. And even if we did have more billable services, insurers don’t recognize pharmacists as individual health care providers. After 20 years of pharmaceutical care/MTM, we are still seen as an extension of the building that holds the drugs.

I found an article summary online from the American Journal of Geriatric Pharmacotherapy on the impact of telephonic MTM. In a nutshell, telephone MTM did help resolve medication health-related problems, but did not have an impact on medication adherence or on total drug costs. That doesn’t make the case to me that telephone MTM has an impact on the quality of care delivered.

I receive messages from the APhA listserv for pharmacists who have completed the MTM training session. On July 27th there was a message asking for real-life examples of pharmacists who have been able to incorporate MTM into their business model for inclusion in a guidebook/workbook for MTM. One of the organizations championing medication therapy management has to ask for examples of pharmacists who have been successful at the professions future? Twenty years after Hepler and Strand and we are looking for success stories?

On August 17 the Center for Disease Control and Prevention announced that they were going to award the AphA Foundation a purchase order to “identify and engage a consortium of key stakeholders who have knowledge of, experience in, or can facilitate the adoption and implementation of collaborative medication therapy management policy” and also to educate policymakers. I could save the CDC a lot of money if they float a PO my way. I’d tell them to have CMS give us status as primary-care providers and about thirty billable codes and see the impact that we can make.

As a profession, we’ve sat around for the past twenty years hoping to get reimbursed for services that we can provide. It’s time that organizations that purportedly represent the profession either put-up or shut-up with regards to MTM. In the twenty years since Hepler and Strand advanced the idea of pharmaceutical care/MTM we’ve seen the profession devolve to a three-ring retail circus with a $4 charge.

As always, share your comments either here or as an email to me. I appreciate the feedback. We need to speak up as professionals, while we still have a profession to speak up for.

That's not what the doctor meant

2011-09-09T05:32:00.001-04:00

when he said you needed to bring in a stool sample.

I hope I'm wrong about the future of MTM

2011-08-30T00:01:00.001-04:00

As a pharmacist, it is my duty to be correct one-hundred percent of the time. Correct medication, correct strength, to the correct patient at the correct time. If I am not correct, there may be some serious consequences.

Well today I am writing to say that I hope that I am not correct with what I am thinking, but from what I have been reading and researching, I just may be correct.

What is it that I hope I am incorrect about? It’s the thought that medication therapy management (MTM) is the model for the future of pharmacy. I’m afraid that the profession has gone all-in on this one practice model before the cards have even been dealt. Let me explain.

For the past twenty years, pharmaceutical care/ medication therapy management has been touted to be the future of pharmacy practice. There have been a few projects that have shown how interventions by pharmacists can improve the quality of health care and decrease expenses for employers and insurers (Ashville, Diabetes Ten City). But these have not been able to be duplicated and rolled out across the country.

In fact, after twenty years all we have are three CPT codes that we can bill our services under, but the insurers and Medicare do not recognize individual pharmacists as providers of medical services. We are still viewed by the product that we dispense instead of the services that we provide. It has only been in the recent past that the profession has been able to get language written that provides for grant money for MTM services. No funding yet, just language that might provide funding.

So where does that leave us today? Right now the only MTM that is being provided (and compensated for) is to patients who are enrolled in Medicare Part D Prescription Drug Plans. When the Medicare Modernization Act was passed several years ago, one of the selling points to pharmacists was that we were going to be able to provide MTM services to the Medicare Part D patients. At least with this community pharmacists should be able to provide the MTM services to a segment of the population who should be able to benefit.

The 2011 CMS Fact Sheet on Medicare Part D MTM (dated 6-30-11) provides some insight on how the MTM services are being provided. According to the fact sheet, all of the Medicare D PDPs offer telephonic consultations. And 27 percent of the plans offer face-to-face consultations. Only 27 percent. That is sad. The Medicare D plans are not allowing their patients to receive MTM services from the pharmacists that they know and trust.

The service that is being compensated is a comprehensive medication review (CMR). For those of you who have never provided a CMR consultation, it’s basically a medication reconciliation with a Q & A session afterwards. After twenty years of hoopla, the future of pharmacy is a med-rec and a Q & A?

Since I began writing my blog, I have had the opportunity to talk with several national-level pharmacists who are in the know about MTM. Folks who are higher up the national organizations. From these conversations I have learned that there aren’t any pharmacists who have been able to create a business model that is able to stand on its own financially. I have talked to a couple pharmacists who have been able to bill for their services and collect enough from insurers to cover their salaries and benefits. But these pharmacists have done so using billing codes that are “incident to” physician services, not utilizing the CPT codes that have been established for pharmacists.

If you have paid attention to recent articles, medication therapy management hasn’t been talked about as a service to be provided by community pharmacists. It’s now being thrown in as the pharmacist’s role in the medical home models and accountable care organizations (ACOs). It’s almost as if the national organizations have realized that medication therapy management as it was originally envisioned isn’t going to come to fruition so now they are trying to find a way to incorporate MTM into the ACOs to they can say that they were successful.

Like I said at the beginning, I hope I’m wrong about this. I want to see pharmacists able to bill for MTM services as individual providers. I want to see pharmacists recognized as individual practitioners by Medicare/insurers and not as extensions of the buildings that they work in. I want to see pharmacists reimbursed for the knowledge in their heads, not the pills in the bottle.

By embracing medication therapy management as the future of the profession of pharmacy, it seems to me that the national organizations and the pharmacy educators have gone all-in on this before the cards have even been shuffled, let alone dealt.

Master of Pharmacy Medication Therapy Management

2011-08-28T17:02:00.002-04:00

Online Master of Pharmacy
Medication Therapy Management

If you have questions about the online Master's in Medication Therapy Management, we invite you to join us for a live information session on August 30.

The session will feature program director, Dr. Karen Whalen who will discuss program curriculum, the demand for MTM providers, and the many benefits of earning your specialized degree in MTM. In addition, current students will discuss their experiences in the program, their goals after graduation, and how they are applying classroom skills into their practice.

At the end of the session, you will have the opportunity to ask questions of our panel.

Date: Tuesday, August 30
Time: 7:00 pm EST / 6:00 pm CT/ 5:00 pm MT/ 4:00 pm PT

Register Now!

Best Regards,

Your MTM Admissions Department

******************************

I received this email a few days ago. Anybody else?

I would call to find out the details, but I am already attending a workshop on Tuesday night. If you call in to find out details, please leave a comment here or send me an email to let me know what was said.

As an editorial comment, I find it interesting that a university is offering a Masters program in medication therapy management. Especially since insurers are not recognizing pharmacists as individual providers of MTM services.

MTM... The future of pharmacy?

2011-08-16T20:07:00.002-04:00

Keep your eyes open. If you've read this blog long, you know that I believe in the concept of MTM.

But is it the future of our profession?

I'm working on a post that examines where we are with regards to medication therapy management. With my new position as director of pharmacy, I have kept busy with the duties of my position so I haven't been able to keep up with the blog entries.

But I'm still working on posts, just not getting them typed up. Like I said, keep your eyes open for my future posts.

I need counseling...seriously

2011-08-10T00:01:00.001-04:00

Last week I developed a condition with my right eye. I had spent the weekend working in the yard, trimming the trees, pulling weeds. All kinds of landscaping/gardening activities. As Sunday evening rolled around I started to feel something in my right eye. I assumed it was some sort of allergic reaction since pollens typically cause me problems.

So I took some loratadine on Monday morning and assumed all would be well by the end of the day. After finishing a round of golf after work, my eye wasn't better. By the time I returned home, the upper eyelid of my right eye was swollen.

In between rounds and meetings on Tuesday, I was able to run over to one of the nurse practitioner's offices to have my eye looked at. The diagnosis wasn't an allergic response. It was cellulitis. The nurse practitioner decided to e-scribe an antibiotic for me.

Since our facility doesn't have an outpatient or employee pharmacy, I had to decide where to have my prescription filled. This was the first time in my career where I wouldn't be using my own pharmacy to fill a prescription. I decided to use the grocery pharmacy that I had managed a few years ago.

Being the responsible patient, I called the pharmacy to give them my new insurance information ahead of time. It would be four or five hours until I would be picking up my medication. The pharmacist on duty was one of my partners from ten years ago. We've always joked around when we run into each other. As we finished the call, I told him to make sure he had his whole counseling bit together because I needed to know how to store my medication and what to do if I missed a dose. We laughed and hung up.

After finishing at the hospital, I drove to the pharmacy to pick up my prescription. After paying for my prescription I asked about the counseling. Steve informed me that when I signed for my insurance, I was also documenting that I declined the offer of counseling. I remember that about that system. We laughed again and I went on my way.

Fast forward to Saturday. My family decided to do some school shopping and see what was left at the local Borders. It was getting to be late in the afternoon and hunger was starting to set in. As we drove to the Italian restaurant, a storm kicked up. I dropped my wife and kids at the door and ended up parking a considerable distance away from the door. I hopped out in the rain and hurried in. The only part of my body that the umbrella protected was my face and hair. Everything else was soaked.

By the time that we finished eating, I was still pretty damp. The storm had passed so we decided to hit another store.

While in the store I put my hand in my left front pocket. That's when I realized what had happened.

You see, I was going to need a dose of my antibiotic while we were out shopping. Rather than bringing along the prescription vial, I just shoved a capsule in my pocket.

What happens when the gelatin of a capsule gets wet? You know, like when it sits in a damp pocket for a couple hours.

That's right the gelatin dissolved to the point to where the contents of the capsule were now lining my left front pocket. I was half mad, half amused at what happened. Over the sixteen years of my career I have preached and preached and preached about not storing medications in humid environments. And look what happened to me, the pharmacist.

If only I had agreed to my counseling.

Senna + bisacodyl + docusate + PEG =

2011-08-06T00:05:00.001-04:00

I've kept this photo saved on my computer for a while, not sure when the appropriate time to post it would be.

Well a couple weeks ago, we had a couple incidents on our med/surg floor that made me think of this picture. We had people (on back-to-back days) produce BMs after 5+ days of constipation each. The hospitalist's words "it was all over the room".

Nursing and housekeeping earned their pay on those two days.

Have a great weekend.

Fellow pharmacist's lament

2011-08-02T00:01:00.000-04:00

I don't think I can do this anymore.

I'm tired of the customer's word weighing more heavily than mine. Then, after they take the trouble to call in a complement on my behalf...

It's more or less disregarded or soon forgotten.

I'm tired of being asked to do more and more and more, and given practically no incentives whatsoever.

I'm tired of being talked down to by grocery personnel. I'm tired of being resented. I'm tired of pharmacy being mis-understood/appreciated.

I'm tired of being surrounded by incompetents and maniacs, then getting hammered whenever I happen to screw up something.

I'm tired of having to be a customer service kiss-ass to some of the worst scum and biggest jerks. And if they complain, I get rear-ended.

I'm tired of corporate breathing down our back telling us to increase flavoring, give more flu shots, take this training on your off day, et

I'm tired of catering to everyone else and then being treated like a drone in return.

I'm tired of getting lectured and scolded for petty things that aren't even my fault or that big of a deal

Where's the respect? Where's the appreciation? Where's the benefit of the doubt? Why are we never cut any slack?

I'm almost 40 and I hate my job. What the hell am I gonna do now?

Those are a series of tweets from a fellow pharmacist on Twitter several days ago. Sadly I can relate, as can many of you. In fact, I imagine that just about every chain pharmacist feels the same as this pharmacist.

I'm waiting for a member of management, somebody at the district manager-level, to grow a pair and stand up for their pharmacists. If you have such a DM, praise them. They are your voice.

Don't wait for the national organizations to speak up for you, it's not going to happen anytime soon. You invested the time and money to earn your degree. Don't sit back and let some corporate officer ruin YOUR profession.

Speak up.

Anti-meth PSA

2011-07-27T00:02:00.000-04:00

Writer's block. So today I'll share a few photos to serve as a public service announcement in the battle against methamphetamine.

I'm not advocating meth with the above photo. It just allowed the Star Wars geek in me to include Chewbacca in a pharmacy blog.

This next one kinda reminds me of a certain actress who has some substance issues. Last name rhymes with Rohan (for the Lord of the Rings fan in me).

And the most compelling argument against meth:

I'm scared about this last one. I think my six year-old daughter might be on meth.

Oath of a Pharmacist

2011-07-20T05:33:00.000-04:00

At this time, I vow to devote my professional life to the service of all humankind through the profession of pharmacy.

I will consider the welfare of humanity and relief of human suffering my primary concerns.

I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve.

I will keep abreast of developments and maintain professional competency in my profession of pharmacy.

I will maintain the highest principles of moral, ethical, and legal conduct.

I will embrace and advocate change in the profession of pharmacy that improves patient care.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.

I found a copy of the Oath of a Pharmacist that was provided to each member of my graduating class by the AACP while searching for something in my basement a few days ago. The ideas expressed in the oath are the ideal. Let's compare the ideas with reality in the community pharmacy.

I will consider the welfare of humanity and relief of human suffering my primary concerns. Not a 15 minute guarantee. Not playing insurance agent. Not dealing out gift cards. Pharmacists want to help those who are hurting and impact the health and well-being of the patients who come in to see us. Trying to do this while filling 300+ prescriptions per shift is difficult at best.

I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve. Um...yeah. With less than two minutes per prescription, "optimal drug therapy outcomes" means that the patient isn't going to die from the prescription. Community pharmacists are simply not given the time to do this. DUR. In retail/chain pharmacy? Other than glancing at a pop-up window for drug-drug interactions, what DUR is being performed?

I will keep abreast of developments and maintain professional competency in my profession of pharmacy. Community/retail/chain pharmacists are actually able to pull this point off. At least a majority are able too. Sometimes I wonder about the competency of the floater pharmacists who come through. And I've always been concerned about the competency of management. Seriously. But so has every other pharmacist.

I will maintain the highest principles of moral, ethical, and legal conduct. Pharmacists...yes. Manufacturers...no. But somehow pharmacists are lumped in with pharmaceutical manufacturers. And the insurance companies. For some reason people think it's the pharmacist who decided to increase their Lipitor copay from $15 to $45. But we'll take the blame. And give you a $25 gift card for your trouble.

I will embrace and advocate change in the profession of pharmacy that improves patient care. Advocate change. Most pharmacists are afraid to speak their minds to management. Until more pharmacists speak up, all the changes that are implemented won't be for better patient care, but for better earnings reporting to Wall Street. But don't hang your hat on the changes that are being proposed by academia. You have to remember that the bills still need to be paid. Before rolling out major changes to how pharmacy is practiced, we need to make sure that we will be reimbursed for the changes. Too many times the profession has started doing things for free, with the hopes of getting reimbursed when it becomes mainstream. You know where we are now, right?

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public. Pharmacists are aware of the responsibility that we are entrusted with. Maybe some members of management need to spend a week behind the counter, shadowing pharmacists to see what responsibilities we have to the public rather than handing down additional tasks that benefit the corporate.

Chains...what are they good for?

2011-07-12T00:01:00.000-04:00

I'm a huge fan of the social media. It gives me a chance to throw ideas out and see the response of others who are active in the social media. I try to share my thoughts at least once a week on my blog, but life gets hectic and sometimes I have trouble sitting down to put together a post.

As a result, I have become a huge fan of Twitter. I can share quick thoughts and get feedback almost instantaneously. Recently I made a comment about chain pharmacy ruining the profession of pharmacy. A fellow Tweep asked me to explain. I was going to send him an email, but then it struck me that the topic could be something I could use for a blog post, so here it is.

Let me start out by saying that chain pharmacy has put a lot of food on my table and made a lot of house payments for me. I have worked in the chain environment for the first sixteen years of my pharmacy career. I have learned a lot from these experiences. When I started, the chains weren't too bad to work for, but over the years I have witnessed the profession of pharmacy devolve into its current state.

What is now accepted as pharmacy practice in the chain pharmacy setting is a far cry from what it once was. Marketing ploys have changed the profession of pharmacy into simply a retail job. This post will focus on some of these ploys that have taken pharmacy to unprofessional place that it is today.

First up... insurance contracts. I can assure you that an independent pharmacist wasn't the first person to sign an AWP - 17% + $1.50 contract. It was the big boys. The ones who are able to withstand the lower reimbursement rates because they get larger discounts by buying in bulk. Smaller operations were forced to accept the low rates or risk being dropped from a PBM's network. Now the PBM's have developed multiple reimbursement formulas that capitalize on multiple reimbursement formulas. AWP, WAC, GEAP, FUL, and MAC may look like alphabet soup to you, but to the PBMS it's a means to guarantee that they will pay the least amount for a medication that they can. Some insurers have gone as far as to establish their own MAC lists. Good luck getting a copy of that list. In the take-it-or-leave-it world of PBM contracts, most pharmacists sign the contract without even reading the reimbursement rates. And we can thank the chains for starting us down that road.

Next on the list... gift cards and coupons. Pharmacy is a medical profession, not a marketing ploy. But rather than growing pharmacy business by offering superior medical care the chains decided to start bribing patients to come to their establishments. Transfer two prescriptions and get 25 bucks in gift cards became the norm. These days the chains use the gift cards to handle complaints from customers. That's right, I called them customers and not patients. Patients have relationships with their medical professionals. How many district managers have ever used the term patient counts? It's always customer counts. That's how they view the phamracy patrons.

Next up... 24 hour pharmacies. Other than emergency departments, what medical professionals are open 24/7? Let's expand the question to professionals in general. How many lawyers have 24/7 hours? Or accountants? Yet pharmacists are working in these conditions all over the country. And if you've been paying attention to the news, you'll see that there have been a number of pharmacy robberies lately. Should medical professionals be putting their lives at risk so that Henry can pick up his Vicodin at 4:00 AM?

Ever see on of these... drive-thru pharmacies? Some will argue that drive-thru pharmacies offer a convenient alternative to people who may have difficulty walking back to the pharmacy department. Ask a person in retail pharmacy who actually utilizes the drive-thru. Rather than helping a very small segment of the patient population, drive-thru windows have advanced the notion of fast-food pharmacy.

Speaking of which... 15 minutes guarantees on prescriptions? Thank you Rite Aid for that wonderful idea. While I have worked at pharmacies that have been able to have wait times of less than 15 minutes, it was never guaranteed. The guarantee puts an extra level of stress on the medical professionals who work in the pharmacy. Can you imagine your dentist promising root canals in 15 minutes or less? You would question how professional the service would be. Enough said.

These are just some examples of what the chains have done. There are many other things that the chains have promoted that have helped to devalue the profession of pharmacy. Feel free to share them with me.

One of my favorite songs

2011-07-10T00:01:00.000-04:00

Florida pharmacists and the PCMA

2011-07-06T00:01:00.001-04:00

A few weeks ago I came across an article that talked about the state of Florida's employee prescription benefits. The jist of the story was that state employees and retirees were being forced into using the mail order option for certain medications. This isn't anything new. Employer groups force their enrollees into mail order all the time.

But the article quoted an organization that I had not heard of previously. The Pharmaceutical Care Management Association (PCMA).

The name of the organization sounds like it has the best interests of the patients in mind. I mean pharmaceutical care is in the name of the organization. But is that really the case. On June 16 and 17, the PCMA came out with guns blazing, attacking independent pharmacies for wanting to protect their profits instead of caring for the patients.

I don't see it that way.

Anybody who has worked in community pharmacy knows of the problems that occur when patients are forced to use mail order options. Hours are wasted every week in efforts to get a two-week supply of medication covered for patients whose mail-order prescriptions haven't arrived.

When community pharmacists are filling prescriptions for medications used for acute situations, we are dependent on the software at the insurance company to flag potential drug-drug interactions since the entire history is not available to the community pharmacist. The PCMA tries to assure us that their software catches all potential interactions and that complete insurance claims history is available to both the mail order and retail pharmacy to screen for interactions.

Did you catch that?

The PCMA says that the insurance claims history is available to both the mail order and retail pharmacy. I've never been provided with a patient's claims history in order to conduct a thorough DUR, but that's not the point.

I don't know about where you work, but in my area a lot of people bypass the mail order mandate and just pay cash for their maintenance medications. Over the last five years, there has been a huge uptick in this practice since four dollar prescriptions have rolled out.

The so-called safety check that the PCMA touts is actually being bypassed. Complete DUR evaluations are not being performed and patients are being put at risk. Pharmacists are not given an accurate picture of a patient's drug therapy.

The PCMA knows, as do community pharmacists, that the best pharmaceutical care is provided when a patient gets all of their prescriptions filled at one pharmacy. The PCMA is just afraid to admit it out of fear of losing money.

I applaud the pharmacists who have spoken out against the state of Florida and the PCMA. Your voice is being heard. Don't give up the fight.

Curbing the narcotic problem

2011-06-29T00:01:00.001-04:00

By now you have probably heard about the Father's Day incident on Long Island that left two pharmacy employees and two customers dead, victims of an armed robbery. Apparently the gunman was trying to obtain controlled substances for his wife.

If you run over to Google and search for "pharmacy" in the news, you'll get a steady stream of stories about robberies and thefts at the pharmacy. A few weeks ago, up until the Long Island incident, the pharmacy stories revolved around the murder conviction of an Oklahoma pharmacist who emptied his gun into a man who had attempted to rob his pharmacy.

Around the same time there were stories floating around about a Michigan pharmacist who fought back against some robbers, unloading his weapon during a middle-of-the-night robbery. He was subsequently terminated for his actions.

These aren't the headlines we want to see for the profession of pharmacy. But the reality that we face today is that there are many addicts in this county, and they are becoming bolder in their attempts to obtain controlled substances. Pharmacies are the places who the controlled substances are, therefore pharmacies are the targets.

What are the reactions to these events? New York Senator Chuck Schumer has come out with a plan to require prescribers to undergo additional training before being able to prescribe narcotics like Vicodin and Percocet. His plan also calls for increased penalties for people who rob pharmacies.

Prior to the Long Island incident, the APhA (in Pharmacy Today) was reporting on the White House's plan to curb prescription drug abuse. For the last several months we've heard about the opioid REMS (Risk Evaluation and Mitigation Strategies) requirements that have been in the works.

The opioid REMS program calls for voluntary physician training when it comes to prescribing opiates (although there is talk of linking training to DEA registration). It also calls for pharmacists to distribute a MedGuide along with each prescription for the affected products.

Other projects/programs that are being used to help curb the abuse of narcotics include prescription drug monitoring programs (the one in my state is not real-time, it has a two-week lag), prescription drug take-back days, and Cephalon's when good medicines become bad drugs program.

As a practicing pharmacist, these programs do absolutely nothing to stop the abuse of narcotics. Anybody who works in community pharmacy knows how people will do or say anything to get their drugs. I honestly don't think handing a patient an extra sheet of paper telling them how the opiates might be bad for them will really affect their efforts to obtain morphine. A coloring book for kids isn't going to keep an addicted mom from deceiving a clinic physician in an attempt to score some hydrocodone. These programs may make non-practicing pharmacists feel good about doing something to curb the narcotic problem, but do they really do anything? In my opinion, the answer is no.

So what is the solution?

There isn't one. But that doesn't mean that steps can't be taken to attempt to slow things down. The solution isn't one that falls strictly to the medical and pharmacy professions. It includes law-enforcement and the federal government. I won't go into the details of what the cops and feds should do, let's just say that they needs to be involved even more than they are.

For those of us in the medical professions, we need to have real-time information provided to us, as well as having security measures in place for the protection of the employees at the pharmacy.

When a patient visits a prescriber, there needs to be a means to relay to the pharmacy what was actually prescribed. We've all had somebody present a prescription for Percocet or Vicodin from the ER late on a Saturday. In your gut you know that there was a second prescription issued, but somehow it was lost between the ER and the pharmacy counter.

As much as I hate the thought of a centralized database, I propose a centralized database that records everything that has been prescribed as well as what has actually been filled for a patient. The process is simple... any time that you visit a prescriber you must present your identification card. The prescriber swipes the card thru a reader and is able to see what meds you have been prescribed, who prescribed them, what you actually had filled, and where you had it filled.

Before releasing you with your prescription, the prescriber would record what medications they were prescribing and upload it to the database. When the patient visits the pharmacy, they would hand over both their prescriptions and the identification card. The pharmacist would be able to see what the patient should be having filled and compare it to what is actually being filled. If you don't present all of the scripts or only request the narcotics, the pharmacist records it in the database. That way future prescribers and pharmacists have a better picture of the behaviors that a particular patient has used. Ideally diagnosis codes would be included as well, so all of the health care system would know what the patient's chief complaints have been.

I would like to see the diagnosis code be a required part of the prescription, similar to Medicare B testing supplies. When a prescription is filled, the DEA number, NDC number, quantity, and diagnosis code would be transmitted to the DEA. That way the DEA could track (in real time) which prescribers are ordering which medications for particular diagnoses. A family practice physician who suddenly starts prescribing 720 oxycodone 15s, 120 Percocets, and 60 Oxycontin 80s to every third patient for chronic lower back pain could be stopped before they draw every addict in a fifty mile radius to their practice.

Those steps may help to lessen the chances of creating addicts, but the pharmacies need to be protected from the current addicts. This is where it gets a bit dicey. Pharmacists wear it as a badge of honor that we are the most accessible health care provider. But I don't think any of us want to see our accessibility lead to the death or injury of another pharmacy worker.

I have absolutely no problem with the thought of working behind bulletproof glass. Heck, I'd work out of a bank vault with drawer (similar to a drive-thru set-up) if it means keeping my staff safe. Time-delay safes for narcotics...absolutely. No narcs after 6 PM...sounds good. I've had armed guards escort me from the pharmacy lab to the front door before, then watch me from the door as I've crossed the parking lot to get to my car. If it keeps me safe, I'm for it.

Anyhow, it's getting late for me. I thought I'd share some of my thoughts on the narcotic problem that is affecting our profession as well as offer up some solutions. What are your thoughts?

Test post

2011-06-28T14:05:00.001-04:00

This is a test of the feature that allows me to publish posts by simply sending an email to a specific address. This could come in handy if I have the desire to develop and type an entire entry from my phone.

There is no content related to the profession of pharmacy in this post. I am working on a few ideas and should have an actual, substantive post in the near future.

As an aside, I have been busy getting ready for my change from community pharmacy to hospital pharmacy. Only six more retail shifts remain after today. I am excited for the move, especially since the main medical practice group at the hospital wants me to get an anticoagulation clinic up and running in the near future.

This concludes today's test post.
Eric Durbin

Thoughts on prescription volume and liability for errors

2011-06-22T00:15:00.000-04:00

Imagine if you will the following scenario... district manager calls the pharmacy to speak with the pharmacy manager. A short conversation ensues where the pharmacy manager is speaking in a hushed voice and starts to look frustrated. After the call, the pharmacy manager pulls the other pharmacist(s) aside and tells them that corporate has determined that the pharmacy volume isn't high enough to support the pharmacist staffing and, as a result, pharmacist hours are going to be cut.

Imagine that at the current staffing levels, each pharmacist is verifying an average of twenty prescriptions per hour. That is on top of counseling patients, making OTC recommendations, talking to physicians and nurses on the phone, resolving third-party issues, evaluating DURs, etc... Three minutes per prescription without those distractions isn't that much time.

Imagine that the new staffing algorithm calls for pharmacists to verify (on average) twenty-five prescriptions per hour. Two minutes, twenty-four seconds per prescription. Not counting the distractions. If I look up the word disaster in the dictionary, I might see this as an example.

In the sixteen years that I have been a pharmacist, the profession has devolved from what was once a medical profession that took care of patients to a fast-food operation that wants to see how many customers they can get thru the doors. Pharmacists who work in this environment are afraid to speak up out of fear of losing their jobs.

What has led our profession to this? Several factors come into play.

Corporate ownership of pharmacies is a biggie. When the people who make decisions about the operations of the pharmacy don't actually work in a pharmacy, there is a major disconnect. It's even worse when the managers making these decisions aren't even pharmacists. I've had managers who have been pharmacists and managers who aren't pharmacists. At least the pharmacists have some idea of the realities of the profession, even if they have sold out as they have moved up the corporate ladder.

Declining third-party reimbursements. The argument is that declining margins mean that more scripts must be filled to make the same profits as before. There is a simple solution... stop signing contracts that don't reimburse at a respectable level. Everybody seems to be afraid of turning away people if we don't accept their plan. Hoping to make up for the horrible reimbursements on the prescriptions by selling a extra tube of toothpaste as an impulse buy. I was able to obtain a copy of a third-party contract at my previous employer. The terms for generic medications were AWP- 25% + 1.75 for 30 day supplies. AWP- 50% + 0.00 on 90 day prescriptions. And the employer was pushing us to get the people on 90 day prescriptions. ???

Four dollar/free prescriptions. Apparently the corporates offering these programs aren't afraid of telling you exactly how much they value your training and expertise. Nuff said.

Surplus of pharmacists. Remember 15 years ago when there was a pharmacist shortage? Then all the new pharmacy schools opened up. And now the job market is flooded. Remember how companies used to treat pharmacists well in order to keep them? Now pharmacists willingly accept being treated as highly-trained monkeys in order to remain employed.

Pharmacists need to stop being so timid when addressing issues with the members of management who are making the decisions that are destroying the profession. It's not their license and livelihood that is on the line if a mistake is made. It's yours. If you won't speak up for yourself, who will?

We need to remember that we are medical professionals first and foremost. We are liable for any and all errors that may occur in the pharmacy. Some pharmacists are lulled into a false security when employers say that they will carry a liability policy to cover the pharmacists. The policy that stipulates that all policies and procedures must be followed exactly or else the coverage is not valid. I'm guessing that it takes longer than two minutes, twenty-four seconds to follow the policies and procedures on each prescription.

This is just a thought on the subject, but the next time there is a major error that occurs due to a pharmacist being required to fill too many prescriptions per hour/shift, I'd like to see some other defendants in the courtroom. Instead of just the pharmacist and maybe the corporate being named in a lawsuit, I'd like to see the district manager, regional manager, and everyone up the corporate ladder all the way to the CEO being named in the case. Maybe if the members of management who make these staffing decisions are held just as liable for errors as the pharmacists in the field, we may see some changes.

2011-06-15T01:04:00.000-04:00

Here is more from my conversation with a fellow frustrated pharmacist. I find some of his insights very interesting. Again, what are your thoughts? Please share them here for everybody's benefit. I appreciate the emails, but more people see your thoughts when they are in the comments and not my email inbox.

I just read part of your note to Jim. Anybody that says they are an expert in MTM is not being entirely straightforward, in my opinion. If there were such a person and he/she knew how to do it and make it meaningfully profitable, they should be shot if they keep that information to themselves. People may be experts in "MTM" if they have charts available but they are still not managers of drug therapy in the sense Hepler and Strand meant it. We are not given and don't have the right to be responsible to the patient for drug therapy. That still rests with the doctor--we would need an OK from each MD and that's not what Hepler and Strand meant. But what they meant is extremely unlikely to ever occur (my opinion). The Ashville Project was and is such an artificial situation, I'm not surprised they can't give you an exact amount the pharmacists were paid. It was something that evolved over time. At first, the pharmacists spent varying amounts of time and their documentation was very sloppy as to what they actually did. They were also assisted by a diabetes nurse educator who did alot of what we would hope to bill as MTM. They also had a leading community physician running as a front man for them to help get physicians reluctant acceptance and several hospitals, as I recall, were also involved. I'm relying on memory of articles I read about 7 or 8 years ago that I have since thrown out (along with my hope of MTM ever being a working model). I don't know that academia and APhA are actually keeping anything from you so much as they probably really don't have precise figures and the services/types, records, etc varied over the years. Pfizer is now a major sponsor of Ashville and I wouldn't believe anything Pfizer had input on anyway. They back the PBM's and we know what the PBM's think of retail pharmacy. We are fighting against billions of dollars and some of those dollars have been used to compromise APhA. In my opinion, APhA tries to sound like pharmacists is who they represent, but the real money comes from large pharmaceutical corps. that they must feel they can't afford to piss off. Look at the response Tom M. (APhA exec. VP) gave to David Stanley's editorial, "You Talkin' For Me?" in Drug Topics. He barely hid his hostility. He brushed aside David's points and essentially accused him of not knowing how to use technology or technicians. He referred to him as "Stanley" every time he mention David's name except the first time when he called him "David Stanley." I got no sense that he felt he was talking to a colleague but to someone that pissed him off by telling the truth.

Frustrated with pharmacy

2011-06-10T05:58:00.003-04:00

There are times when I get frustrated with my profession, as I'm sure you do too. This blog has enabled me to make connections with pharmacists from all over the world. A few months ago I had an email conversation with a fellow pharmacist who is frustrated. I was actually looking into other career options at that time.

The following is copied/pasted from one of the emails. I have permission to share this from the other pharmacist.

What are your thoughts? Are you as frustrated with your profession as this pharmacist is?

My quest is to get out of pharmacy too. I went back to graduate school at age 53 and got a Masters in Mental Health Counseling with an AODA concentration. I graduated 3 years ago and have had to stay in pharmacy to pay the bills for graduate school. My wife is about to start a job as a nurse and if I could find a job at $60,000 per year I'd be gone tomorrow. I've done AODA counseling as part of our graduate training. The satisfaction I get from working with alcoholics and addicts is way beyond any satisfaction I have gotten from pharmacy. Plus, we actually use much of what we were taught in school. What a novel idea. With the economic downturn, finding an AODA job in my area (NE Wisconsin) is tight but I keep looking and hoping. Good luck in your quest. Do you know why they call it the "Asheville Project"? OK, neither do I but one of the reasons has to be because it never ever came close to reaching the controls necessary to qualify it as a study. That pharmacy would trumpet it as "evidence" of anything is further proof of how little proof MTM has as a viable model. In graduate school, I had to take a stats course and several research courses. "Asheville" as a study would have little internal or external validity because there were so many variables that were not controlled (confounders) and its widespread applicability (generalizability or external validity) to other practice types is extremely low. To answer your question as to where the MTM model came from, it was a paper Hepler and Strand wrote in approx 1990 about pharmaceutical care and its application, MTM. Only someone in pharmacy would consider it even a remotely possible practice model. Unfortunately, all pharmacy schools subsequently did. Now we have Doctors taking orders from Med Techs--they had to come up with a degree appropriate to all the new responsibilites pharmacists would have--hence, the 6 yr. PharmD. If I was a PharmD, I'd be pissed.

Prescriptions per hour

2011-06-07T09:30:00.000-04:00

I recently posted a poll that asked the following question:

How many prescriptions can a pharmacist fill safely per hour (including counseling)?

The results did not surprise me:

0-10 (10%)
11-15 (44%)
16-20 (30%)
21 or more (16%)

The majority felt that 11-15 scripts per hour was the safe level. At that rate, you have 4 to 6 minutes per prescription to verify the accuracy of the prescription label, check the patient profile for duplications/interactions, contact prescribers if any issues arise, call the insurer if needed, verify that the contents of the prescription vial are accurate, and counsel the patient on their medication.

Not included in this 4 to 6 minute span are the interruptions that a pharmacist must deal with. A patient asking for an OTC recommendation. Phone-in prescription from a prescriber's office. Phone ringing from a patient phoning in refills (I actually think that there is a rule somewhere that requires a pharmacy to have two more phone lines than people working in the pharmacy).

But back to what we actually do. We rely on the DUR software to help us check for interactions, but a recent study from the University of Arizona found that the software systems are flawed (link here). That means that we, as pharmacists, should dig through a patient's profile each and every time that we fill a prescription to check for interactions. That takes time.

Another part of the prescription process that take time is counseling. From my experience and observations, pharmacists fail at this horribly. I watch how pharmacists counsel patients on their prescriptions. 95% of the time "counseling" is simply the pharmacist reading the label to the patient. OBRA '90 gave us specific points that we are to cover when we counsel the patients.

OBRA ’90 Counseling Points:

Name of drug.
Intended use and expected action.
Route, dosage form, dosage, and administration schedule.
Common side effects that may be encountered,including their avoidance and action required if they occur.
Techniques for self-monitoring of drug therapy.
Proper storage instructions for the medication.
Potential drug-drug or drug-food interactions or other therapeutic contraindications.
Prescription refill information.
Action to be taken in the event of a missed dose. (source)

To inform a patient on all of these points, time is required. Two or three minutes, per prescription, is what I feel is adequate to ensure that the patient understands what I am saying. Then you need to allow time for questions from the patient.

* * * * *

So I found it amusing recently when upper management decided to change the guidelines for the number of prescriptions a pharmacist should fill on an hourly basis. I'll just say that, prior to the change, we were at the higher end of the volume spectrum of the poll. The new guidelines call for an increase of 25 percent.

I contacted my state board of pharmacy, whose mission statement states that it is to act...in the public interest to pursue optimal standards of practice through...legislation, licensing and enforcement to see what their take on my employer's changing guidelines were. The response from my pharmacy board was that no prescription volume limits have been or are being considered. Apparently my pharmacy board believes that a maximum time of two minutes, 24 seconds per prescription is the optimal standard of practice.

Eric Cropp lost his pharmacist license permanently due to a dispensing error. He was in a situation where there was too much work to be done with inadequate staffing. The little girl who was undergoing her last chemo treatment ended up dead from the error. So when he speaks about the rapid pace of pharmacy and the potential for error, I'm paying attention. He was quoted in a recent internet article as saying "We want to stress the fact that everybody's got to slow down and treat each patient like they're a member of your family...Healthcare is so fast and crazy sometimes we start to miss the fact that we're taking care of a human being, not running an assembly line."

If only the management of the pharmacy chains would think the same way.

Summer safety

2011-06-03T06:31:00.004-04:00

I posted this on Twitter a couple days ago. After mulling it over in my head, I decided that these Tweets were worthy of their own blog post.

This will be short and to the point. And it may save suffering for your patients over this summer.

Feel free to print this out and post it at your pharmacy for your patients/customers to read.

* * * * *

This is the sun. If you can see it, put on some sunscreen.

For the folks who get poison ivy every year. This is what it looks like. DON'T TOUCH IT!

Now that I have said that, go outside and enjoy the summer.

Twitter exchange

2011-05-31T18:38:00.001-04:00

Recently I had a brief exchange on Twitter about HR 891, the Medication Therapy Management Benefits Act of 2011. Somebody had posted that another Congressman had signed on as a cosponsor of the bill.

I commented that we don't need any more cosponsors, we need action from the committees. Their response was "The former fuels the latter. Onward!"... meaning that more sponsors will get the bill moving out of committee.

I don't agree. The MTM bill has been introduced previously, only to die in committee. We can have dozens of representatives cosponsor the bill, but if it doesn't leave the committees it dies.

Here are the names of the members of the committees where the fate of the MTM bill rests. Lobby them, and if/when the bill makes it out of committee we can work on our individual Congresspersons.

House Energy and Commerce Subcommittee on Health:

Joe Pitts, PA Chair
Michael Burgess, TX Vice Chair
Ed Whitfield, KY
John Shimkus, IL
Mike Rogers, MI
Sue Myrick, NC
Tim Murphy, PA
Marsha Blackburn, TN
Phil Gingrey, GA
Bob Latta, OH
Cathy McMorris Rodgers, WA
Leonard Lance, NJ
Bill Cassidy, LA
Brett Guthrie, KY
Joe Barton, TX
Fred Upton, MI
Frank Pallone Jr, NJ
John D. Dingell, MI
Edolphus Towns, NY
Eliot Engel, NY
Lois Capps, CA
Jan Schakowsky, IL
Charles A. Gonzalez, TX
Tammy Baldwin, WI
Mike Ross, AR
Anthony D. Weiner, NY
Henry A. Waxman, CA

The bill is also sitting in the Committee on Ways and Means.

Dave Camp, MI Chair
Wally Harger, CA
Sam Johnson, TX
Kevin Bradley, TX
Paul Ryan, WI
Devin Nunes, CA
Pat Tiberi, OH
Geoff Davis, KY
Dave G. Reichert, WA
Charles W. Boustany Jr, LA
Peter J. Roskam, IL
Jim Gerlach, PA
Tom Price, GA
Verne Buchanan, FL
Adrian Smith, NE
Aaron Schock, IL
Lynn Jenkins, KS
Eric Paulsen, MN
Kenny Marchant, TX
Rick Berg, ND
Diane Black, TN
Sander Levin, MI
Charles Rangel, NY
Fortney Pete Stark, CA
Jim McDermott, WA
John Lewis, GA
Richard E. Neal, MA
Xavier Becerra, CA
Lloyd Doggett, TX
Mike Thompson, CA
John B. Larson, CT
Earl Blumenauer, OR
Ron Kind, WI
Bill Pascrell Jr, NJ
Shelley Berkley, NV
Joseph Crowley, NY

These are the people who we need to lobby. If we want more cosponsors, work on these Congresspersons.

Regardless, if the bill doesn't make it to the House floor it dies. Stop sitting on your hands, hoping somebody else does the dirty work.

Do something for your profession. Contact these Representatives.

Memorial Day

2011-05-29T05:25:00.006-04:00

New poll....prescription volume

2011-05-22T23:17:00.003-04:00

Recently my pharmacy manager has been instructed to decrease the pharmacist staffing at our location by 0.5 FTE. Corporate has guidelines on how many prescriptions a pharmacist can check per hour.

I am not in agreement with corporate guidelines. I'm curious to see what pharmacists in the field think are SAFE volumes of prescriptions that can be filled.

Please take a moment to vote on the poll located on the right side of the page.

Thanks.

Recent encounter of the MTM-type

2011-05-17T00:01:00.002-04:00

Well, it has been a while since I've sat down to offer some thoughts here on the blog. Over the last month or so work has been extremely hectic. One of the other pharmacists has been on medical leave and corporate has decided that it's not necessary to replace a full-time pharmacist with equal hours. We're lucky if we get 20 hours of floater pharmacist each week. With that, after any given day of work I haven't been feeling like sitting down with the blog.

I took a week off to attempt to recharge. During this time off, I tried to think about pharmacy as little as possible. If you follow me on Twitter, you would have seen very few pharmacy-related comments. Not thinking about pharmacy is relaxing, but when you are attempting to land clients for a medication therapy management business, that's not necessarily a good thing.

Especially after having discussions with pharmacists at the national level who are promoting the MTM side of pharmacy. After talking with these people, I get recharged on the MTM front. But then I return to my employer where I get beaten down with the dispensing side of the profession. With the lack of pharmacist hours, I haven't been able to offer even basic counseling to my patients let alone even think of the advanced level of patient care that is required with MTM-type services.

All that being said, at the end of my week off I was able to have an exchange that renewed my passion for educating patients and offering MTM services.

Every other week, my wife and I meet with four other couples from our church for our small group. We attend a large church that doesn't offer traditional Sunday school classes for adults. Instead, we meet in small groups to have, for the lack of a better description, a Bible study. It's not just a Bible study though, we are a support group for each other as we go through life.

When we were wrapping up Sunday night, one of the women in my group approached me with a question about her father's drug therapy. He has been having episodes lately where he has been passing out and falling and she was wondering if a change in his medications a few months ago might be contributing to the falls.

We talked for about fifteen minutes as she shared what had been happening and I questioned her further to get more information. She had contacted her father's cardiologist and primary care physician, but they were not able to determine a possible cause of the fainting spells and falls.

Then she said the magic words that may have helped us figure out what the cause of his falls might be. About two months ago, her mother decided that he needed to eat healthier. Instead of a sandwich, fruit, and pretzels for lunch, she was now feeding him chicken breasts and salad.

Now this would normally be good, but they didn't factor in one thing.....he has been on a fixed insulin dose (Novolin 70/30) for about 30 years.

Factoring in the time of day that his spells have been occurring (mid-afternoon) and his recent change in diet, our working hypothesis is that he is basically having hypoglycemic episodes every afternoon. I made a couple suggestions for her to relay to her parents and we'll see where things go from here.

This is an example of how pharmacists can have an impact on the lives of our patients, if we are able to take the time to talk with our patients. Recently some of the chains have started making moves that appear to be advancing the cause of MTM. I would like to remind these chains that the single-most important thing that they can do to allow pharmacists to provide these services is to give the pharmacist TIME to talk with the patients. Verifying 30+ scripts per hour does not allow the pharmacist the opportunity to have these discussions that can impact the lives of our patients.

Quick...smile

2011-05-04T06:15:00.000-04:00

Quick post

2011-04-27T14:10:00.002-04:00

It's been busy for me over the last few weeks, so I haven't had the time, and quite honestly, the energy to put up any blog posts. Between a screwy schedule at work (thanks to corp only replacing a portion of the hours of a pharmacist who is on medical leave), trying to sell our house, talking to other pharmacists across the country, and focusing on developing my MTM business, there just aren't enough hours in the day to be able to sit down and deliver a solid blog.

Plus I haven't really had any good ideas to write about. I do have a few ideas rolling around inside my head, I just need to grab a legal pad to jot down my thoughts so I can organize them. But as it is right now I've lost my mojo and can't seem to find it. If you have seen my mojo, please send it back to me at ericrph /at/ msn.com.

Thanks.

For the folks in Camp Hill

2011-04-12T09:52:00.005-04:00

Dear

executives/board of directors,

When you decided to implement the

which of the following were you high on

or

And did you happen to consult with ANY pharmacist who currently works in pharmacy about this before rolling it out?

Sincerely,
A pharmacist who does NOT work for you

APhA House of Delegates actions (YAWN)

2011-04-09T06:52:00.003-04:00

"Of the six new business items proposed during the meeting, three were ultimately accepted. The final text will be forthcoming, but the approved statements support requiring influenza vaccination of pharmacy personnel, adding pharmacists as providers under the Social Security Act, and encouraging collaboration with the American Public Health Association. A statement addressing the legalization of medicinal marijuana in certain states was referred to the Board of Trustees for consideration in 2012." from the APhA Newsroom

Just some quick thoughts on the three new business items that were approved by the house of delegates at APhA 2011. Here's a link to who comprises the house of delegates.

#1- Influenza vaccinations for pharmacy personnel

I opposed this and still do. A comment following my post said it well... "No reason for this in a community pharmacy. Are they going to force all the cashiers, managers, etc.. too? How bout the cashier at the bank or the grocery store? STUPID!"

#2- Adding pharmacists as providers under the Social Security Act

This is the one item that I can get on board with. The APhA has been advocating for expanded roles for pharmacists in direct patient care. But we need a revenue source to cover the expenses associated with the expanded roles. Medicare is the starting point. Private insurers will follow once Medicare recognizes us. Medicare was created 46 years ago. It's time we get recognized as providers. This should be the sole focus of the APhA until we receive the recognition.

#3- Encouraging collaboration with the American Public Health Association

OK. Whatever. I'm sure somebody is patting themselves on the back for getting this one through.

Ponderings following last week's post

2011-04-05T00:02:00.000-04:00

Part of the inspiration (if you would call it that) behind my sicker at a younger age post was a recent article I linked to off of Twitter that showed a region of the country that was termed "the diabetes belt".

I live in the area that would be considered the "muffin top" of said diabetes belt. Which actually surprised me because I can't imagine an area that has more young patients with diabetes than my area, but there are.

I addressed some of the issues that I believe play into the development of chronic medical conditions at younger than expected ages. Things like fast food, video games, nutrient-poor food, and apathy/laziness. I had some enlightening conversations with people who look at these issues from a societal point-of-view.

But there was one thing that I didn't think about until I sat down to figure out what my next post would be.

Are some of these conditions caused by our society pumping medications into our kids at younger and younger ages?

One of my friends is an orthopedic surgeon. He always likes to refer to medications as "controlled poisons", and he is right. There's a reason why they are called dangerous drugs.

So why are we, as both parents and medical professionals, so willing to put these chemicals into the bodies of our children? Remember, the manufacturers don't conduct large scale studies on kids because they really don't know if the kids could be harmed.

I wonder if putting these controlled poisons into our youth at such young ages somehow alters the immune (and other) system(s) of the children, causing their bodies to develop these conditions decades before they would otherwise.

Case study... I have a 17 year old patient who has been visiting the local counseling center. Over the past 18 months, s/he has had a steady diet of atypical anti-psychotics. S/he has packed on the weight over this same time period. Now S/he has been diagnosed with diabetes and is learning how to use insulin on a sliding scale because his/her pancreas doesn't work now.

My casual observation of the age group that my last post focused on (the under 32 crowd) seem to have significant histories of antidepressant use.

Coincidence?

Or has our pill-crazy society brought this on ourselves?

Just some thoughts that have come to my mind since last week. What are your thoughts? Leave a comment here or shoot me an email.

Why are we sicker at a younger age?

2011-03-29T00:01:00.000-04:00

As a community pharmacist, one of the things that you notice are trends in prescribing. Years ago, drug reps would ask the pharmacist which physicians are writing for their particular product. These days, the trends that pharmacists seem to pay attention to involve controlled substances. Which prescribers seem to write for them more often and in greater quantities. That's not what I'm going to discuss today.

Instead, I'm going to talk about something that I have observed over the last six or seven years. You see, right now I'm in my late thirties. I'm getting close to the age where chronic medical conditions have traditionally been diagnosed and people start treatment. I pay attention to what medications other people my age are taking. I compare my health with theirs. Right now, people my age are still in pretty good health.

But something that stands out to me is the medical condition of people who are younger than me. When I see the medications that people who are at least six years younger than me (we're talking the 32-and-under crowd), I am amazed.

The volume of people who are on blood pressure and cholesterol medications blows my mind. And the number of people on diabetes medications is even higher. I just saw a link to an article a couple days ago about using statins in children. ???

What is going on that has caused our younger generations to develop these chronic conditions at an early age? Well I have a theory or two about the causes. I have no data to back up these claims, it's just my observations and opinions.

Theory #1: Video games

I was in junior high when Nintendo brought out their gaming system. Super Mario and Duck Hunt were all the rage.

Ever since that system came out, video games have become the national past-time. Forget going outside to play baseball or football, we can stay inside and play it on the television and be a star. The activity level of our younger generations is virtually nothing compared to thirty years ago. Coincidentally, the 32-and-unders that I reference earlier would have just started elementary school when these systems were introduced. Our twenty-somethings have never known life without video games.

At least Mario is running around and jumping. Click here to see what would happen if Mario didn't do all of that running/jumping.

Theory #2: Fast food

I grew up in a small town in a rural area. When it was suppertime, we ate a full meal at home. McDonalds was a place that my family only saw when we were traveling on vacation. In my county, there were only a handful of fast food restaurants. For the longest time, there was only one McDonalds and one Burger King in the county that I grew up in. Both in the county seat which was 15 miles away.

During my high school years, Taco Bell moved in and another McDonalds opened up. Still, not a lot of fast food outlets. But Ronald McDonald had a trick up his sleeve. He started super-sizing the meals. What once were a large order of fries are now the small order. Sodas jumped from 21 ounces to 44 ounces. Fast forward to today. Can you drive through a town anywhere without passing at least one fast food outlet?

I stopped at a Wendy's with my daughter after preschool one day a year or so ago. There was a parent throwing a fit with the manager because her son didn't get the right toy with the kid's meal to complete the current promotion's collection. Just my opinion, but if your kid has had enough kids meals from a fast food joint to have the entire collection, you're eating fast food a bit too much. I wonder what the kid's lipid levels are.

Theory #3: Nutrient poor "food"

This ties in with the fast food a little bit, but I'm talking more about what people are buying at the grocery store. I worked at a regional grocery chain for four years. It was in an affluent community where the residents were concerned about their health. Best produce department in the county. The carts that passed in front of the pharmacy would have the produce in them, as well as a bag or two of chips, maybe some Ho-Ho's.

Contrast that to what I saw at another grocery in my county, one that has a higher proportion of customers utilizing food stamps. Do I even need to describe the items in the carts? Frozen pizzas, cases of soda (a "luxury" item), beef jerky, Doritos, Froot Loops... do I need to go on?

It was sad to see some of the younger (under 30) generation riding on the Mart-Karts because they are too fat to walk unassisted through the store. But you know what foods the carts were carrying.

I'm not going to blame Walmart for the low nutritional content of the food. It comes down to the FDA allowing food producers to distribute products with little to no nutritional content. Couple that with the food stamp programs that allow these foods to be included as covered items (luxury items) and you can see why we are getting fatter. This is just my opinion, but if the government is going to offer food assistance to people in need, let's not give them diabetes while doing so.

I went through the Express checkout at my local Giant Eagle a week or so ago in the middle of the morning. The person in front of me had three items: a bottle of Sprite, a single serving bag of Fritos, and a 24 ounce energy drink. Paid for by the Ohio Directions Card (aka food stamps). Check out the nutritional content of those items next time you are at the grocery store.

I read somewhere that your body will continue to crave food until the nutritional demands are met. That's why people can sit down and eat an entire bag of chips in a single sitting. Since the body is not getting enough nutrients, it tells you to eat more. And more. And more. Eventually the nutrient demand may be met, but it might be 3000 calories later.

I always get a kick out of this picture, but it does illustrate how your body is a reflection of the foods that you put into it.

Theory #4: Laziness/apathy

Ehhhh.... It will take too much effort to type my thoughts on this.

Besides, there's probably a medication that will take care of it. Why should I put in thirty minutes a day exercising to keep myself healthy if I can just pop a pill and chase it with a Mt Dew?

Heck, people are now to lazy to even walk their dogs.

It's sad to say, but those look like Ohio plates (my state) on that car.

Three weeks ago I put the following on Twitter:

I had a pt ask why they had to be on a med today. I wanted to say b/c you are fat, don't exercise, and won't watch what you eat.

Pretty much sums it up.

Reply to a question on Twitter

2011-03-26T07:19:00.008-04:00

Saw this tweet from @Ron_Jordan yesterday:

If pharmacists are the most accessible medication therapy expert, what happens when so many are in Seattle for #APhA2011?

I wanted to reply with a tweet of my own, but I figured that my response would be over 140 characters. Plus you can't format tweets, at least I don't know how. So here is my response.

Total attendees at APhA 2011
- Students
- Pharmacists in industry
- Federal pharmacists
- Pharmacists working for national/state organizations
- Academics
- Hospital/clinical pharmacists
- Lobbyists
- Pharmacists in managed care
- RPhs working for publications
______________________________

appox 250-500 "accessible medication therapy experts" at APhA 2011

That's not a lot of real, accessible medication therapy experts at the convention. I would like to see a breakdown of the background of the attendees at the convention. I sent an email to the APhA last year to see if I could get that information. Never received a reply. But that's okay.

I attended the convention in Washington DC last year to attend a session on MTM. If the people sitting at my table were a cross-section of the attendees of the entire conference, then community pharmacists aren't represented real well. The folks at my table, starting across from me and moving counter-clockwise, were:

call center pharmacist who does over-the-phone MTM
pharmacist at a Medicare D plan learning how to implement MTM
pharmacist at university that provides MTM to university employees
me
another community pharmacist
dean of a college of pharmacy

The people at my table were amazed at what the other community pharmacist and I shared about our practice settings. They couldn't believe the issues that community pharmacists deal with on a daily basis.

Hello???

That's what a majority of pharmacists deal with every day. And that's why there are only about, by my totally unscientific calculations, about 250-500 of the most accessible medication therapy experts actually in attendance in Seattle.

The rest of us are back home enjoying a day or two off with our families/friends, trying our best to not think about pharmacy -OR- we are in the pharmacy, providing direct patient care even though we are understaffed by our employer and under-compensated by the prescription drug plans. We don't have four or five days where we can put off work to go to the conference.

We have patients to take care of.

Insights from a fellow pharmacist

2011-03-24T05:34:00.002-04:00

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.

APhA 2011- New Business... Mandatory Vaccinations

2011-03-21T06:00:00.001-04:00

Cruising around the APhA site a couple days ago, I found this proposed policy on the House of Delegates portion of the site. The subject: Requiring Influenza Vaccination for All Pharmacy Personnel.

After all of the proposal-y language, this is the policy that is being introduced:

APhA supports an annual influenza vaccination (unless a valid medical or religious contraindication precludes vaccination) as a condition of employment for all persons employed by, completing education and training within, or volunteering for, an organization which provides pharmacy services or operates a pharmacy or pharmacy department.

I have issue with five words in the proposal. As a condition of employment. Excuse me. I'm an adult. I believe that I can make my own decision about if, when, and against what I will be vaccinated. And to make my employment conditional on getting a vaccination... I don't think so.

I understand the rational behind the proposal. Health care providers should try to keep from getting sick. And health care providers should do what they can to prevent transmitting disease to our patients.

The policy is calling for mandatory influenza vaccinations, yet the background information on the policy lists several more potential things that we could pass to our patients. Why not include hepatitis B, meningococcal, varicella, pertussis, measles, mumps, and rubella shots to the list of vaccines and boosters that pharmacy staff should receive in order to stay employed?

I looked at the sources that were cited to back-up the policy. The most recent article was published in 2000. I would like more current information. Eleven years is an eternity in health care. Plus, two of the cited articles looked at health care workers in the long-term care setting. Usually patients in long-term care see the same caregivers multiple times, creating multiple chances for disease transmission. Down at the local CVS, the patient sees the drop-off tech for a couple minutes, might see the pharmacist for two minutes, and the cashier for a minute or two. Not the same as a nurse who may spend 20 or 30 minutes continuously with a patient in a long-term care setting.

In the real world pharmacy setting, there are more practical steps that can be done to prevent the transmission of infectious diseases. Things like using disinfectant on surfaces that the patient comes in contact with. Think of all the patients who walk up to the pharmacy counter, cough/sneeze into their hand, then rest their hands on the counter/grab the pen on the signature pad. Next patient comes up and touches those same surfaces. We can't Lysol after every patient, but regular disinfecting will do a lot to prevent disease transmission.

Sneeze shields are a must. I can tell you the number of times that a sneeze shield has stopped droplets from a cough or sneeze from making it to my face. It's sad to say, but at least half of the people who come to the pharmacy don't even attempt to cover their coughs or sneezes.

My pharmacy is usually too warm in the winter, so we have fans running to keep us cool. Orienting them to blow air out of the pharmacy creates a pseudo positive-pressure environment that keeps germs from getting to our staff. Then we are not the vectors for transmission.

We have also considered wearing gloves and masks to keep our staff from becoming infected. If there is an influenza outbreak in our area we may put that into play. I have a physician at a local urgent care center who wears a mask from November until April. I don't think that pharmacy needs to be that drastic.

But, if the APhA is going to enter the workplace with policy, how about something like this.

Community pharmacists are allowed to have sick days.

And there will be pharmacists available to cover the sick pharmacist's shift. I've been offered positions at five different chains over the years, as well as several hospital positions. The hospital positions always included sick days. Not one retail position has had sick days included as part of the job offer.

How difficult is it to have an extra pharmacist or two available in a district to cover an ill pharmacist's shift? Apparently it's very difficult because whenever a pharmacist gets ill, it usually falls on their partner to cover the shift. Even if the partner just finished a five day stretch and only has one day off before starting another three or four day stretch. And the pharmacist who was ill is expected to make-up the missed shift.

This is just my opinion, but having the option to call-off with the knowledge that the shift would not need to be made up would keep sick pharmacists from working. As it stands now, pharmacists tough it out because they don't want to inconvenience their partner or make-up the missed day.

If the APhA is going to address the issue of transmitting disease from the pharmacy, workplace sick day policies are where the focus needs to be. Not injecting a vaccine into every pharmacy staff member in the hopes of keeping three or four strains of one particular illness from being passed to our patients.

Again this is just my opinion, but APhA resources are better spent addressing the issue of getting pharmacists provider status with Medicare and getting CPT codes so we can bill for our services. If we want to expand our practice, we need to get paid for it. Recognition from CMS is the first step.

APhA delegates, think about this before voting on the mandatory vaccination policy proposal.

Independent MTM business, Part Two

2011-03-20T07:08:00.002-04:00

When I wrote the post on starting an independent MTM business, I kept thinking to myself "don't forget to include this".

Well, I forgot to include one of the most helpful things that you can get to help you your ducks in a row for the business.

The Pharmacist Society of Wisconsin has an MTM CD that has all kinds of useful stuff on it. Look into it.

Starting an independent MTM business

2011-03-14T00:01:00.000-04:00

One of the most common email topics that arrives in my inbox is "how do I start my own independent MTM business?". I've tried to reply to these messages, but there just aren't enough hours in the day to adequately reply to all of them. So I thought that I would share everything that I have done, with the hope that it will help any other pharmacist who is trying to start.

First and foremost, you should apply for your own NPI if don't already have one. This will uniquely identify you as a provider. If you are going to operate your MTM consulting as separate business entity, you will need an NPI for it as well. Note: wait until you have a registered business name before applying for the business NPI.

Which brings up the next thing that I did... I registered my MTM business as an LLC. Once that was done, I applied for the NPI for the MTM business. Why wait until after the business is registered? That way you can make sure that the name is available. For me, my first two choices for a business name were already registered. I want my business name and NPI to be the same.

All of this so far took about a week or two.

Now for the part that we all really want to know about.

How do I get patients for my business?

This is the point where you need to decide what your MTM business focus will be. Are you going to go after the Medicare Part D patients? How about self-pay patients who might be looking to decrease their out of pocket expense? Corporate clients? Who are you trying to help with your MTM services?

Me...My target market is self-insured, small to mid-sized businesses. My thoughts are to get to these patients before they hit retirement age and help improve their health and save their employers on health-care expenses. I want to go on-site to provide my company's services. But this is a tough market to break into because, surprise, companies don't want to do business with individual pharmacists who are not recognized as health care providers by their insurance company.

The APhA is working on getting the legislation in place to get us the recognition, but it's going to take some time. So I have spent the last two years contacting the medical insurance companies in my area, attempting to get my business recognized as a provider within their networks. My thoughts are that if my company is listed as a provider, the small to mid-sized businesses will be more likely to enter into a contract. If nothing else, the employees could seek me out on their own and bill it to their insurance.

It's been tough going. I've done some direct marketing to my target market and have had some meetings and phone calls with benefits directors. But so far no contracts.

As for getting recognition as a provider with the medical insurance companies, the first two years have been rough. I submit provider applications, only to be turned down with "try back in six month" messages. But recently I have had two insurers request additional information about the services that my company provides. This is promising and I will share what happens at a later time.

I have attempted to become an MTM provider for the Medicare D plans that operate in my state. I have contacted every plan in both 2009 and 2010. The plans that respond usually give me the "we provide MTM services with in-house staff" responses. In my state, there is only one plan that will contract with individual pharmaCISTS to provide MTM services. Outcomes Pharmaceutical Health Care provides MTM services to Humana patients in my state. So I have my business set up as an alternate site provider. I am also currently filling out my application to become a provider in the PharmMD network. Until the medical insurers recognize pharmacists as providers, I am getting access to some patients through the Medicare D plans.

As for training and such, I went to the Delivering Medication Therapy Management Services in the Community session at APhA 2010. It reinforced what I was already thinking that I needed to do. I also bought a couple books from the APhA. Nothing earth-shattering there either. But they did have some good stuff. My previous management experience has done more for me than the books with regards to developing a business plan, etc...

There are several companies that have MTM software programs. I have blogged about them previously.

Hopefully this helps answer some of the questions that you have. Please contact me if you have a specific question. Or leave a comment so that others can benefit from or answer your questions. The more information that we share, the better patient care we can deliver.

* * * * *

If my employer (a chain) wanted to provide MTM services, I would embrace it. But I would want compensated above and beyond my regular wage for providing these services. I don't want to see MTM become simply another ploy to get people in the store to buy over-priced dog biscuits. I'm afraid that as chains enter into the MTM arena it will be another area where they expect pharmacists to provide top-notch patient care without providing adequate support.

As pharmacists, we need to be active politically as individuals. Right now we have MTM legislation sitting in two House committees. The bill needs to make it to the House floor, then to the Senate, then to the President. Remember the old I'm just a bill ditty from Saturday morning cartoons? We need to be active to make the bill become a law.

You can follow the bill at the Library of Congress to see where it is in the process. We need to contact the Congressional committee members who hold the future of MTM in their hands.

Coming tomorrow.........

2011-03-13T11:19:00.001-04:00

My post on starting an independent medication therapy management business.

How's that for a teaser?

Blitz on Washington

2011-03-09T06:57:00.002-05:00

In my last post, I encouraged pharmacists to contact our elected officials in Washington about the MTM bill. I did so without realizing that there was a pharmacist blitz going on this week.

To use a football analogy, I hope we are blitzing the right people. As it sits now, the House Ways & Means and Energy & Commerce Committees hold the MTM football. They control where the bill, the football, goes. They are the quarterback.

These are the people who need blitzed.

In football, you don't blitz the water boy. So don't waste your time on Congressmen who are not part of these committees. When the bill reaches the House floor, that's when you blitz them.

Let's not waste our efforts on the water boy. Let's get to the quarterback.

Medication Therapy Management Benefits Act of 2011

2011-03-07T08:00:00.000-05:00

Well, it's happened again. The legislation to expand the pool of patients who have access to medication therapy management benefits has been introduced to the current Congress. The Medication Therapy Management Benefits Act of 2011 is now in the hands of the House of Representatives.

On cue, a couple pharmacy organizations (NCPA and NACDS) have come out with the canned response of how beneficial MTM is and how MTM can save the health care system a lot of money. These two groups have also come out in support of the Medication Therapy Management Empowerment Act of 2011.

Unfortunately, I see both of these pieces of legislation finding their way to committee where they are never heard of again, at least not until the next Congress is seated and the legislation is introduced again. That is, unless pharmacists take action and call the members of the committees to which these bills are assigned.

And that's why this legislation will fail. I don't know why, but pharmacists are afraid to take action on issues that directly affect their profession. I guess the reason is that it's a lot easier to complain after the fact than make the effort to create the fact (if that makes any sense).

It's time for pharmacists to take some action. Step out of your comfort zone and call/ write/ fax the committee members to advance this legislation to the floor for a vote.

For those of you who decide to take action, the MTM Benefits Act is in both the House Energy and Commerce Committee and in the Ways and Means Committee.

Me, I sent a message to Speaker John Boehner to encourage him to advance the bill out of committee and onto the floor.

What are YOU going to do for YOUR profession?

Journal club- Medication therapy management: Gator style

2011-03-03T00:01:00.000-05:00

I'm a little bit late on this, but better late than never.

The February issue of Pharmacy Today has an article about a project going on down at the University of Florida. Quick summary- pharmacy students are conducting comprehensive medication reviews with WellCare patients over the phone.

After reading the article over lunch today, I can only think one thing: Why in the hell is the University of Florida giving away pharmacist services?

I say that because there was no mention of reimbursements for the MTM services that were provided. Articles like this do absolutely no good for practicing pharmacists who are trying to develop a business model for medication therapy management because reimbursements are not discussed.

Maybe WellCare is reimbursing the Gators. Maybe not. The article doesn't say. But if the article doesn't say that pharmacists are getting paid, then I assume that they aren't.

The article discusses how, over the course of a standard day at the call center, a total of 25 MTM calls are made by 12 pharmacy students. That's two calls per day, per student.

Now this is just my opinion, but two MTM calls per day per pharmacist is not going to pay the bills for any operation. Based on the reimbursements I've personally seen from Outcomes, those 25 calls wouldn't even cover the costs of labor and benefits for two licensed pharmacists.

Doesn't look like the type of business model that we should try to recreate in the real world.

Maybe it's time for pharmacy to stop looking at academia for ways to advance the profession. Academia doesn't need to make a profit. In the real world, no profit means no more business.

APhA...how about featuring a real business that is successfully billing for MTM services? That's what real pharmacists want to see. Not all of us are fortunate enough to have 12 students to provide the labor for an operation that still can't operate in the black.

Just some thoughts from a frustrated pharmacist out on the front lines.

* * * * *

As a side note. Today I received a letter from a local medical insurance carrier that said that they were denying my application to be a provider for their company. The reason... they don't cover the type of services that I offer (medication therapy management and pharmacotherapy consults).

Instead of promoting happy-go-lucky-yea-for-us-we-do-MTM-for-free stories, how about getting an insurer or two to recognize us as providers straight up? Forget trying to show how pharmacists can save money and enhance patient care.

Get us recognized as providers so we can prove it.

Thoughts on health care reform

2011-02-24T00:22:00.000-05:00

Well why won't the insurance cover it?

It was a prescription for an oral contraceptive. I explained that the pharmacy benefits manager might cover the medication if the prescriber submits documentation that the medication is being used for something other than the prevention of pregnancy.

But isn't it less expensive for them to cover the birth control pills instead of the cost of a pregnancy and delivery?

Well, you think that the answer would be yes. But your medical insurance company and your pharmacy benefits manager are two different companies. The company that handles your prescription coverage has no vested interest in keeping you from becoming pregnant. They don't handle your hospital bills. Why should they worry about it? Their only job is to keep medication costs down.

That was a conversation I had with one of my patients a few weeks ago. And it's a conversation I'll have dozens more times over the remainder of this year. And next year. And the year after that.

With the passage of the Affordable Care Act and the recent court ruling that held parts of the act to be unconstitutional, we have no idea where health care reform is going. But I think we can all agree that something is going to be done. It's just that none of us know what that will be.

I don't have the answers on health care reform, but I wanted to share a few of my thoughts on the issue.

In my opinion, one of the largest obstacles to care is the segmentation that occurs between the different companies that insure the patients. One company covers visits to the physician and hospital, another company covers dental health, and a third company covers the prescription medications. There may even be another company that handles vision care. There is no coordination of care since the insurers are separate companies. Each company is primarily interested in minimizing their costs. Patient care may not always be at the forefront of each company's thought processes.

Rather than continuing down the road we are on, I think that insurers should cover all aspects of patient care. Not just one segment of it.

Patients would have one company looking out for their total health care. Medical, dental, vision, and prescription coverage all from the same company. Then maybe little Johnny won't need to try three different medications before his Singulair is covered to control his asthma and allergies because the insurer knows that little Johnny will most likely have three ER visits in the meantime and run up enormous bills that could be avoided simply by covering the medication in the first place.

At the same time, the insurer would be able to track patient compliance because they would have all of the patient records at their hands. Let's say Mr Smith is diagnosed with asthma by his physician. The physician orders a steroid inhaler and a rescue inhaler. This information is transmitted to the insurer when the physician submits their bill. The insurer is able to see if Mr Smith is filling his prescriptions for both medications on a regular basis.

If Mr Smith runs to the ER with difficulty breathing and hasn't filled his prescription for the steroid in a while, the insurer can contact the prescriber and the issue can be addressed. If the patient continues to not fill his prescriptions and keeps running to the ER or urgent care center, then the patient runs the risk of having his coverage dropped or having his premiums increased because of the non-compliance issues.

Combining coverage for all aspects of health care would let the patients know that they must adhere to the treatment plans that are designed by their providers. The days of running to the doctor, only to decide not to follow the doctor's orders are over. If a patient wants to continue to have their condition covered, they must show a little responsibility for themselves.

IRON PHARMACIST

2011-02-19T08:44:00.002-05:00

A few days ago I had a fun exchange with another pharmacist blogger on Twitter that set the gears in motion for today's post.

Coming to APhA 2012 in New Orleans.........

IRON PHARMACIST AMERICA

Based off of the hit show Iron Chef America, IRON PHARMACIST AMERICA will pit two pharmacy teams against each other to see which team can handle the issues that face community pharmacy on any given day.

Now initially, this may seem totally boring. Who wants to watch pharmacists work? That's where we bring in the competitors. The sitting IRON PHARMACISTS will be everyday pharmacists who face the public on a daily basis. I would personally like to see pharmacists who blog as the IRON PHARMACISTS, but that's only because I would like to hear some of the commentary that may go on.

The challenger would be selected from a pool of pharmacists who seem to be the ones directing the path of pharmacy, but who don't actually see the insides of a pharmacy. Somebody from academia. Maybe one of the pharmacy organizations. Or my preferred challenger... a member of management from one of the pharmacy chains. The challenger will select which IRON PHARMACIST participates in the challenge.

Each team would have a second pharmacist, a cashier, a few techs, an intern, and a non-pharmacy manager who checks in from time to time. After a ten minute organizational meeting, each team will enter Pharmacy Stadium (located in the exposition hall so attendees can view the proceedings) and take their places inside the typical community pharmacy.

Setting for the competition is simple. Friday afternoon/evening at the pharmacy. The contest will last three hours and be recorded to be shown at a general assembly session.

During the competition, each lead pharmacist will be required to conduct one comprehensive medication review with a patient. During the competition, the pharmacy teams will conduct business as usual in a typical community pharmacy.

Of course, there may be some issues that pop-up that require the pharmacist's attention. Things like:

Forged prescriptions for controlled substances
Medicare B billing issues
Family emergency requiring second pharmacist to leave early
Medicare D eligibility issues
Visit by the board of pharmacy, FDA, DEA, or local law enforcement
Unannounced Medicare audit
Non-pharmacist manager sending staff home for budgetary issues
Discovery of a dispensing error
Prescription that requires compounding

These issues would present themselves as the pharmacy team goes about their normal tasks of filling the prescriptions, counseling the patients, making OTC recommendations, and dealing with third-party issues.

After the competition is over, the edited video would be shown to the general assembly and a discussion would follow. It would allow for a discussion of the conditions faced by your typical community pharmacists on any given day, along with the opportunity to address these issues with the people who are "leading" the profession. If this idea is successful, a health-system edition may follow.

Because, face it folks, there is a tremendous disconnect between the pharmacists who are "leading" the profession and the pharmacists who practice the profession. It's time for the pharmacy practitioners to be heard.

There is only one question that needs to be asked.

Do you have what it takes to be the next

IRON PHARMACIST

Staffing

2011-02-15T21:11:00.001-05:00

Nope. Today's not going to be a diatribe on how pharmacies should be staffed. I'm not going to go off on how short-staffing a pharmacy leads to errors. Maybe another day.

Today I'm going to share how oblivious some members of upper management are when it comes to the business of pharmacy.

At one point in my career, I was the pharmacy manager for a Wal-Mart SuperCenter. The pharmacy was open 12 hours Monday thru Friday, 10 on Saturday, and 6 on Sunday. Do the math... 76 hours per week.

We did anywhere from 1900 to 2400 scripts per week. Usually on the lower end but we would get busy from time to time.

We had three full-time pharmacists (only because we had two outstanding applicants at the same time, and this was an extremely hard to staff store... otherwise we would have had 2-1/2) and six technicians (actually five plus a summer-only intern). We were staffed well. On a typical day we had two pharmacists and 4 techs in the store.

For those of you not familiar with Wal-Mart's dispensing system, it is very labor intensive. The first step involves scanning the hard-copy prescription and entering the data into the computer. This takes one or two techs, depending on the volume at the moment. The data then goes to a pharmacist for a 4-point check where the RPh checks the tech's work.

From there the prescription gets transmitted to the third-party. If the claim is rejected, either a pharmacist or technician can resolve the issue. Once the claim adjudicates, it goes to the filling stage. We usually needed two techs to be working on this. Then back to the pharmacists to be visually verified. From there it went down to the will-call bin by the cash register, which was manned by another tech. If a patient needed counseled, we had two privacy windows for the patient to speak with the pharmacist.

At our store, to make the pharmacy run smoothly we needed to have two pharmacists and four techs in the pharmacy at any given time. During lunch breaks it was a little more hectic, but we could manage. A pharmacist would usually help out with some of the tech duties.

Well the powers-that-be from higher up the corporate ladder determined that we were overstaffed. We needed to eliminate two technician positions and split one of our pharmacists with another store. Well the one pharmacist was pregnant and had the baby so we lost her. I let the intern go and released one of the other techs, the one who usually covered the pick-up area. So now we were down to two full-time pharmacist and four technicians to cover the 76 hours that the pharmacy was open.

Wal-Mart had a couple policies that made staffing very difficult. First... no overtime. Period. Second, no hourly associate could work more than five consecutive days, even if the shifts were less than four hours.

You can imagine how much fun it was to try to schedule 4 technicians to adequately staff the pharmacy. 160 tech hours per week to cover the 76 hours that we were open, on a system that requires 4 technicians to function smoothly. We were able to grab a floater pharmacist for 10 hours per week, so we did have some overlap.

I don't know how I did it, but I was able to put together a schedule that somehow covered the pharmacy. I actually broke down the day-by-day volume and determined where we could get by with only three techs. Of course the pharmacists were doing more of the tech duties, but we were a team and it worked. I set the schedule up so that I rotated on a four week rotation. That way the techs could plan on which days and weekends they would have off. Everybody was happy.

Until one day when I went to the office to write the next week's schedule.

You see, Wal-Mart's scheduling software would schedule associates based on when the cash registers were busy. The assumption was that you needed to have more associates on hand when the customers were handing their money over to the cashiers. That works great for the general merchandise aspect of the business, but pharmacy is different.

Over my time at the store, there was never a schedule that was generated that covered the pharmacy anywhere near adequate. That's why I created my four-week rotating schedule. It covered our busy times in the pharmacy and accounted for the lulls that happen during the day and week.

On this day, I walked back to the office to enter the schedule into the computer. As I sat down, the DM for the entire store walked into the office. He saw that I had my hand-written schedule and was starting to enter it into the computer.

He came back and asked me what I was doing. Of course I told him that I was putting in the pharmacy schedule. He questioned me why I wasn't using the computer generated schedule. After all, the computer knows everything.

Except the business of pharmacy. The only factor that the computer used in determining pharmacy staffing was when the prescriptions were actually rang out of a register. We all know that mornings are hectic in the pharmacy, mostly from the overnight refills. Then the evening rush happens as everybody comes in to pick up their medications that either they or their physician called in.

For this particular schedule, the computer said to staff the pharmacy with 5 technicians (remember I only have 4 now) from 6:30 PM until 8:30 PM on Monday. We closed at 8:00. It also said that I only needed one technician on Monday from 11:30 AM until noon. Zero techs for the rest of Monday, at least until 4:00 PM. Aren't Monday mornings usually a little busy? But since the actual sale didn't occur until the prescription was rung thru a register, the computer didn't know how to schedule.

The store's manager and two assistant managers were with the DM. They knew that I had turned in my resignation the previous Monday and that this was the last schedule that I would write. But we sat there and let the DM go on for 45 minutes about how awesome the scheduling program was. When he finished, I told him that the next day was my last day with Wal-Mart.

When I returned to the pharmacy department, everybody questioned me why it took so long to put in the schedule this week. I told them what the DM had done.

We had a good laugh. This DM could be the worst one that I ever had.

MTM opportunity?

2011-02-08T07:03:00.002-05:00

When you hear the words medication therapy management, what do you think of? I imagine that a majority of us think of the comprehensive medication review that occurs in a community pharmacy setting. The patient brings in brings all the medications and herbal products that they put in/on their body and the pharmacist goes over them with the patient, looking for any issues that may exist.

Others may think of disease state management programs when they think about MTM. Programs where the pharmacist works with the patient to treat a specific disease...diabetes, asthma/COPD, hypertension, or hyperlipidemia.

Most of the talk that I see about medication therapy management revolves around the community pharmacy setting. But what about in the hospitals?

I write this with a specific case in mind. A case where pharmacist involvement could have saved the patient, the community pharmacist, and several nurses a significant amount of time on a weekend.

First the details of the case. Patient is admitted and has several stents placed. Patient does not tolerate clopidogrel, so the patient is started on prasugrel. The patient is insured by a government-funded program that does not cover prasugrel without a prior authorization. After spending a few days as an inpatient, the patient is discharged on Saturday afternoon.

For those who work in a community pharmacy, you know what happens next. The pharmacy processes the claim for the prasugrel and receives the "Prior Authorization required" message. Now the community pharmacist gets to tell the patient's spouse that the medication is not covered, knowing that it will take several days for the prior authorization to be approved. The labeling of the prasugrel states that it must be stored in the original container with the desiccant. We inform the patient's spouse that they can pay the retail price now, then get a refund once the claim is approved.

That didn't go over well. About ninety minutes later the pharmacy receives a call from a nurse case manager who is fairly hot over the issue. The patient neeeeds this medication. I don't doubt that one bit, but it requires a prior authorization. So the nurse case manager says that she will take care of the PA.

Another hour passes and the nurse case manager calls back. The PA desk is closed for the weekend. That doesn't surprise me one bit. The nurse case manager calls back. What are we going to do? The patient neeeeds this medication. The patient just had several stents placed.

This is where I want to throw the lack of preparation on your part doesn't constitute an emergency on my part back in the nurse case manager's face. But I have a patient who needs their medication. I don't want a couple hundred bucks of medication go out the door without having some sort of arrangement set up, just in case the prior authorization isn't approved. In the end, the patient went home with the prasugrel after the financials had been worked out.

* * * * *

I intentionally used the title nurse case manager during the story for a reason.

Where was the pharmacist in this case? Did the hospital pharmacist have any role in the discharge planning for this patient? If they did, did they do anything other than glance at the chart a few times during the time that the patient was admitted.

I've said this before and I'll say it again. A medication regimen that the patient can afford and will take regularly is far more effective than the clinically superior regimen that the patient can't afford and won't take. That's one of the keys to my view of medication therapy management.

As soon as it was determined that the prasugrel would be the patient's home-going medication, somebody at the hospital (pharmacist) should have checked to see if the medication would be covered by the patient's insurer. It took me under 15 seconds to see that the medication would be covered with a prior authorization, and I was able to see what the copay would be once approved.

That's part of the practice of medication therapy management. Making sure the patient can afford the medications. It's a place where the hospital pharmacists can impact the care that the patients receive, but it may be beneath the duties of a clinical pharmacist.

I practice community pharmacy in a very rural area. The closest major teaching hospital is over sixty miles away. There are five cities with major teaching facilities within two hours of my pharmacy. These cities have eight hospitals that I would say are top-notch. Of these eight hospitals, only two of them regularly have prior authorizations taken care of prior to the patient being discharged.

Hello hospital pharmacy directors. If only two of the eight major teaching facilities take care of PAs prior to discharge, you can imagine how well the local city/county hospitals take care of PAs.

MTM pharmacists....maybe this is an area where you can expand your practice.

A calming environment

2011-02-01T00:25:00.000-05:00

We have a yellow lab as our family pet. He's about ten years old. He started as an indoor pet, but my wife and one of my sons started having allergy symptoms so the dog was moved outside.

He remained outside for the past seven years, but a couple weeks ago we decided to bring him back inside. Actually, our daughter cried and cried until we caved in. A trip to the groomer to get a haircut and the dog is back inside.

When he was younger, he was rambunctious. Now he just lays around. When I'm sitting in my chair, he will come over and put his head on my lap. After petting him for a little bit, he will lay down again. The kids will go over and use him as a pillow and watch the television.

He likes it. He's getting the attention that he has missed over the last several years. Since he has come back into the house, he has been a calming influence. The boys aren't arguing as much. I find that I'm not yelling at the kids as much either. It's like the dog is our family tranquilizer.

Makes me wonder if having animals around the pharmacy department would have the same type of calming effect.

Maybe not dogs.

Maybe some fish.

A couple larger fish tanks. Some color schemes that bring tranquility to the pharmacy instead of the bright white paint with fluorescent lights that gives the pharmacy a bleak appearance. I see blues and greens around the fish.

Perhaps a Tuscan color scheme could be brought to the pharmacy. Canned lighting. Maybe artwork on the walls that has some accent lighting.

Anybody works in a place like this? What's it like?

Back online

2011-01-29T23:10:00.002-05:00

Had to take my computer to the shop the other day to get it checked out. Every since our house was struck by lightning in September it had been acting up.

The initial work was to take three days. Ended up being eight. Had to do a restore on the hard drive to get things operating again. Not too happy with the place that worked on it, but they reduced the price of repairs by 33 percent to make up for the inconvenience.

Once the computer returned home, it has taken me several days to reinstall the various programs that were removed during the restore. This process was drawn out over several days due to swim meets and gymnastics practices filling up my evenings, plus a work schedule that hasn't been the most kind recently.

But now I'm back up and running. Posting should get back to normal very soon.

Getting paid for MTM services

2011-01-25T00:19:00.003-05:00

Getting paid for MTM services.....page 42. That was on the cover of the most recent Pharmacy Today. When I saw that, I heard the angels singing.

Finally, an article about getting reimbursed for medication therapy management services. Perhaps some insight in how to sign up as a provider with a medical insurance company. Personally, I've been trying to get contracted with the major insurers in my area for over a year with little success.

This article could be the holy grail for those of us who want to attempt to provide MTM services as a stand-alone business. Finally something from the APhA that tells us how to make some money, rather than just telling us that our services are valuable and save the health care system in the long run.

I sat down to read the article during my lunch hour, legal pad at my side to jot down notes. I had been looking forward to reading this since I received the Pharmacy Today issue in my mailbox a couple days ago.

After reading the article I can tell you this... don't bother reading it.

Not a darn thing.

False advertising.

Medicare Part B

2011-01-17T09:45:00.000-05:00

When I started at my current pharmacy, we had a certain physician who didn't want to cooperate and provide valid prescriptions for Medicare B covered items. Well maybe it wasn't the physician...the nurse would not let us speak to the physician to explain what we needed. The nurse would phone-in the orders for testing supplies and leave them on the voice mail.

Which would cause us to call back and say that phone-in orders are not valid for Medicare B diabetes supply claims. We would explain that we needed a hand-written or fax order that had:

the patient name
the product(s) being ordered
the quantity to be dispensed
the testing frequency
refill information
and the ICD coding appropriate for the patient's condition

You would think that we were asking them to fax over the patient's entire medical history in triplicate.

This went on for months. Patients were receiving substandard care because some nurse was having what she believed to be a turf issue. The last thing I want to do is keep a patient from being able to test their blood glucose levels, but I'm not going to circumvent the regulations that are in place.

I think it finally came down to one patient who was able to get the physician's attention on this matter. The patient asked me what I would do if I were in their shoes. I told them that if my physician wasn't willing to provide a valid prescription for my testing supplies, I would assume that they really didn't care about my condition and that I would change physicians. I handed the patient a leaflet that said what was required on the Medicare B prescriptions. The patient was on their way to the physician's office. I don't know the details of the conversation, but whenever we call now, we get what we need from that office.

We could have just fudged the information in the computer. Hope that we wouldn't get audited. Take care of the patient and not really worry about it. Good thing we didn't because...

We've been receiving Medicare B requests for additional information fairly regularly over the last few months. It's not too big of an issue because we follow the rules.

Most of the requests are for copies of the original prescriptions and signatures showing that they were picked up. That takes about five minutes to get together.

But then they want the pharmacy to provide copies of the testing logs and physician progress notes. That's a bit more time-consuming. Especially getting the physician notes. But we do it. And get it back to Medicare by the due date (which isn't too long).

The audit process wastes pharmacist time. Diverts pharmacist attention.

It makes me wonder if my pharmacy is being singled out, or are all Medicare B suppliers getting hit with audit requests. Given that Medicare has been burned by some of the fly-by-night businesses that bill for a couple million dollars of prosthetics, collect payment, then close up shop I can partially see the reason for auditing. But we only bill about 10 claims per week, and we have been doing this for years. It's not like we've suddenly quintupled the number of claims that we are submitting.

It also makes me wonder if Wilford Brimley and the folks over at Liberty Medical are being served with a proportionate amount of audits. Especially since I have had patients come in and tell me that they have over 1200 diabeetus test strips on hand because Liberty won't stop sending them.

Mastercard

2011-01-13T06:19:00.001-05:00

She came in a couple days ago. Mrs. Crow. We knew that she was going to be in, just not when. She had called ahead to make sure that her husband's insulin needles were the correct ones (BD 328411).

So we had braced ourselves.

Well I saw her first, walking across the front of the pharmacy to go to the pick-up window. So I grabbed the phone and started dialing. The local time and temperature line can be a life-saver some days.

And one of my techs saw her as well. She was getting ready to punch-in on the time clock, but decided to wait a few extra minutes to clock-in.

Which meant that my other tech would get to wait on her.

Fortunately we were not real busy at the moment, so Jeff was able to take care of her. Besides her normal routine of opening every bottle, requesting that the medications be bagged separately, etc... she now wants certain medications to be put in certain sized vials. Jeff complied with her requests and was able to get rid of her in about 20 minutes. During that time, I was able to handle about 7 phone calls and 5 fake phone calls.

Overall her visit was uneventful, but it made me appreciate Jeff even more.

Sure, he will get some overtime for efforts, but that's the best money I've spent on payroll in a long time.

Total price of prescriptions... $45.00
OT for Jeff to wait on her... $15.00
Seeing her first and weaseling out... PRICELESS

And even better, our cash register was acting up so we had to send her to a register in the front of the store to check out....... another PRICELESS.

I don't (heart) the Weather Channel

2011-01-10T22:39:00.001-05:00

Tomorrow's forecast is for snow, snow, and more snow. Lots of it. All day long. Yep, that's what the Weather Channel says.

Of course the last four times that the Weather Channel has predicted this, all we have received is 40 degree temperatures and a light mist, if any precipitation.

But that doesn't stop the onslaught at the pharmacy. Everybody needs to have everything refilled now because, as we all know, a little ice and snow on the road means the end of the freakin' world.

So today, in anticipation of the storm to end all storms, we'll get hammered. Then tomorrow it will barely do anything and I can resume my hatred for all the folks at the Weather Channel for scaring my patients and causing me to work way too hard for a storm that only exists to get you ratings.

Happiness is a 16 dram bottle away

2011-01-07T00:02:00.001-05:00

During the next to last week of the NFL season, Pennsylvania governor Ed Rendell was quoted as saying "I think we've become wussies" with regards to the Eagles-Vikings game being rescheduled due to the winter weather that hit the Philadelphia-New York-Boston area.

I thought about his words. He's right. We are a bunch of wussies.

But I'm not thinking in the same terms that he was. I'm looking at it from the pharmacy counter.

I worked the first three weekdays of the new year. Looking at the scripts that have crossed in front of me, Americans really need to suck it up. Somehow the American public has turned from being able to suck it up when faced with adversity to running to a little amber bottle any time adversity shows its face.

I'm not going to touch on narcotics with this post. We all know how narco-happy the United States is.

But based on the volume of other medications that I have checked this week, we've got a serious pill problem going on here. Rather than addressing the issues causing their problems, Americans are running to us to supply them with the means to solve their problems.

Drinking too much alcohol or caffeine? Don't cut back, just take a proton-pump inhibitor or H2-receptor antagonist to fix your problems.

Feeling a little bit nervous or anxious? Take a benzo. You'll feel better. A lot better. Go ahead and mix it with some alcohol and a stomach pill.

Is your life so hectic that you can't wind down in the evening? Don't even think about looking for ways to de-clutter your schedule. Just start taking this pill before bed for a month, oh what the heck let's give you five refills and let's see how you are doing in six months.

And while we're at it, don't worry about trying to lose weight. Let's just try some muscle relaxers to settle down those back muscles that are strained from carrying around an extra eight pounds.

Better living through chemistry....the American way.

Lobbying and communication

2011-01-02T15:47:00.005-05:00

As I was watching my favorite collegiate football team go down in defeat during their bowl game on New Year's Day, a commercial came on that caught my eye. It basically told the story of a father and daughter as they went through life. The spot was titled "You Can Let Go" and (to me) showed the daughter letting her father know that he didn't need to fight against death any longer. He had raised her and she was letting him know that she was grown up now and that she would be fine if he passed away.

It was a touching commercial. Both my 5 year-old daughter and 6 year-old niece commented on how sad it was.

But my inner conspiracy-theory detector started going off. You see, several days ago I heard some commentary on the radio concerning the Affordable Care Act. When the bill was signed into law, a provision that called for end of life counseling every five years was not included. Some argued that the section that included this lead to "death panels".

Well now the end of life counseling sessions are back in the bill. This time through the rule-making process. And on an annual basis. The new rule says Medicare will cover “voluntary advance care planning” to discuss end-of-life treatment, as part of the annual visit.

My brain started playing a little game of Coincidence or Conspiracy. I thought it was funny how, shortly after the rule was made, commercials saying that it was alright to die started airing. Especially during an event (college bowl game) where there would be a large viewing audience.

I did a little checking, and from what I found it turns out to be coincidence.

Then I started thinking... this is just another example of the influence of the lobbying efforts of the different physician groups. Somehow they were able to get the advanced care planning changed from every 5 years to every year. They can bill for this service each and every year that their patient stays alive.

I thought a little more. Pharmacy has a lobby in Washington DC. But we seldom hear what is happening with the pharmacy lobby. We hear plenty about the lobbying efforts of Big Pharma, but not pharmacy.

I think it comes down to a communications issue.

You see, I like to gripe about things such as not being able to contract for my pharmaceutical care/ medication therapy management services with insurance companies. It turns out that there are a lot of barriers to this for pharmacists. Recently some changes were made to rules and regulations that will help pharmacists get contracted.

But I had no clue about this. I actually stumbled upon it as I was linking around on the APhA website. And I haven't been able to find the story since then.

As much as we like to rag on the APhA for being out of contact with the average pharmacist, I think that they might have our best interests at heart. But they need to communicate everything that they are doing on our behalf in a better manner.

I would love to see several tweets every day on issues that affect the profession of pharmacy. I'm not talking about clinical trials and new drug approvals. I'd love to know what is happening in DC and how the APhA is working for us. Perhaps if this information were to be pushed to us via the social media (as opposed to being buried in the APhA website or in a weekly email), more pharmacists would become more active in and less critical of the APhA. The AMA blasts emails and tweets on issues affecting their members several times each day, why not our organization?

Like I said, it's a communications thing. If the practicing pharmacist knows how the APhA is working for them, the pharmacist would be more inclined to support the organization.

As always, I'd love to hear your thoughts on this. Comments and emails are always appreciated. Comments get seen by everybody, emails only get seen by me.

Pharmacist blogging

2010-12-28T00:01:00.000-05:00

Recently, both the Journal of the American Pharmacists Association and the American Journal of Health-Systems Pharmacy have had articles that have discussed the use of blogs by pharmacists. After reading the articles and their conclusions, I decided to share my thoughts on the topic.

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.

Today, take a minute

2010-12-25T00:01:00.002-05:00

Take a minute and say a little prayer for the members of the United States military who are deployed all over the world. You don't have to agree with the politics that have sent them where they are, but they joined voluntarily to serve our country. For that they deserve our gratitude and prayers not only today, but every day.

Remember those who have fallen

And the families they leave behind

Christmas story

2010-12-24T00:01:00.003-05:00

Here's a few pictures that I stole from The Chive to look at while listening to one of my favorite renditions of the story of Christmas.

Merry Christmas.

End of the year insurance tips

2010-12-22T06:11:00.003-05:00

It started yesterday at my pharmacy. Medicare Part D patients started bringing in their new cards and wanting us to bill their new prescription plan for their prescriptions. Of course, all of the claims came back to us saying that the coverage was not in effect yet. And then the pharmacy staff had to spend a minimum of five minutes explaining to the patient why the claims would not go through. Then another five minutes telling the spouse/son/daughter the same thing.

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.

Tip #1

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.

Tip #2

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.

Tip #3

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.

Tip #4

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.

Tip #5

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.

Bad Pharmacist

2010-12-18T00:33:00.000-05:00

It looked a little odd. It was written on the prescription blank as a transfer in to our pharmacy, but it only said from CVS in a town on the other side of the state. No prescription number. No pharmacy phone number. Prescription was for Stadol NS. Plus, it was for the other pharmacist's husband. Hmmmm.

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!

Reimbursement for OTC consults

2010-12-15T00:01:00.002-05:00

One my last post, I proposed a means by which individual pharmacists can be reimbursed personally for the professional services that they provide on each and every prescription. By including our personal NPIs on claims, insurance companies would reimburse us for DUR review, interventions, etc...

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.

Why?

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.

It's time.

* * * * *

In case you've missed it, this past March a little bill was passed and signed into law that basically provides health care to all Americans. Like it or not, it's now the law. Even with the Virginia ruling on the constitutionality of one of the provisions, the law is still in effect. One of the provisions of the bill is the implementation of electronic health records.

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.

* * * * *

So how does this apply to pharmacy and pharmacist reimbursement?

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.

* * * * *

This idea may seem a little far-fetched, but we (as pharmacists) need to start looking out for the economic survival of our profession. The AMA just had the cuts in physician reimbursement delayed because they pay attention to the money. We need to do the same.

Your thoughts?

Pharmacist reimbursement for professional aspects of dispensing

2010-12-09T22:26:00.003-05:00

By now I think that anybody who reads this blog knows that I believe that pharmacists should be getting reimbursed for all of the professional activities that we engage in. In the community practice setting, a dispensing fee just doesn't cut it any longer, especially when the drugs are being reimbursed thru WAC, MAC, and GEAP-minus formulas.

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?

Take a moment to smile

2010-12-03T09:55:00.002-05:00

One of the issues I face writing this blog is finding the time to sit down and actually post. And when I do have the time to sit down, I sometimes get writer's block.

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.

CTP codes. How about CPS codes?

2010-11-30T00:15:00.000-05:00

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?

A change in thinking

2010-11-23T00:52:00.000-05:00

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.

Personal cancer story

2010-11-18T00:01:00.002-05:00

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.

OTCs and OB/GYNs

2010-11-15T23:50:00.000-05:00

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

2010-11-15T18:40:00.001-05:00

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.

Policies and procedures

2010-11-10T14:13:00.003-05:00

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.

Open enrollment begins soon

2010-11-09T00:05:00.000-05:00

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?

Belated breast cancer awareness

2010-11-03T23:37:00.001-04:00

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.

Tonight's heroin

2010-11-01T23:59:00.001-04:00

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.

State of the Profession......The Future

2010-10-26T00:03:00.000-04:00

Over the past few weeks, I've tried to present the profession of pharmacy as I see it. You may or may not agree with my views and that's fine. Depending on our practice setting and the patients we see, we will have differing views on where the profession stands currently.

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.

Tech-check-tech

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.

Immunizations

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.

Pharmacist prescribing

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.

Quick question

2010-10-21T06:09:00.003-04:00

Today's topic... Marketing materials for MTM services.

Anybody know where to get them?

Shoot me an email. ericrph (at) msn (dot) com

State of the Profession...Marketing

2010-10-19T00:20:00.001-04:00

When you think of pharmacy marketing, what do you think of?

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.

State of the Profession......PBMs

2010-10-12T04:25:00.001-04:00

A couple month ago I had a little post on pharmacy benefits managers and some of the tactics they use in the course of their business. The post focused on how PBMs use any and all means at their disposal to pay the absolute minimum for medications. From a business standpoint, I would expect nothing less from them.

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.

Addiction and abuse

2010-10-07T00:01:00.000-04:00

I decided to take a break from my state of the profession series for today's post. In our profession we (unfortunately) see people who are addicted to drugs on a daily, if not hourly basis.

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.

State of the profession.....Reimbursements Part II

2010-10-05T00:01:00.000-04:00

A couple years ago I was working for a regional grocery chain. That was back when NPIs were just starting to be issued. Our director of pharmacy operations encouraged each pharmacist to get their own NPI.

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).

* * * * *

We pharmacists provide many services for our patients at no charge. On any given weekend I consult with at least four patients every hour. Either to recommend an OTC item or triage an injury that they have sustained. With the way that the current system is set up, I can't bill for these services because pharmacists are not recognized as medical providers. The recommendations that I make on the weekends may save the insurer the costs of an unnecessary ER visit, but there is no system to document these interventions for the insurers.

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.

Delay in series

2010-09-23T22:08:00.002-04:00

Due to a lightening striking the chimney of my house and zapping several electronic devices, the next installment in my state of the profession series will be delayed until next week.

Sorry.

State of the Profession.... Reimbursement Part I

2010-09-21T00:15:00.000-04:00

For years, we've seen declining reimbursements for the product that we dispense. I've addressed that in a previous post and I don't really want to discuss that in my state of the profession series. I'll just say that pharmacy benefits managers should select one reimbursement formula and stick with it for the term of a contract.

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.

State of the Profession, Part Two...Organization

2010-09-16T00:01:00.000-04:00

A couple days ago, I addressed the topic of UNITY within the profession of pharmacy. As a follow up to that topic I want to look at part of the problem we have in achieving unity within the profession of pharmacy.

ORGANIZATION

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

At their core, each of these organizations is trying to advance the profession of pharmacy. However, each organization is trying to advance aspects of their portion of the practice of pharmacy, not the profession as a whole. As pharmacists, we need to have one voice that represents the entire profession.

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.

State of the Profession.....Unity

2010-09-14T00:01:00.000-04:00

For the past nine months, I've been writing this blog to attempt to get pharmacists to look at where the profession has been, where it is currently, and where the future lies. I've shared my commentary on some issues that have popped up, thrown in some posts for a laugh, and griped some.

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...

UNITY.

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.

Starting tomorrow...

2010-09-13T09:06:00.001-04:00

State of the Profession series.

Out of the Box

2010-09-09T00:10:00.000-04:00

There's a nice discussion going on over at the MTM e-community portion of the APhA website about pharmacists being recognized as providers by medical insurance companies in order to be reimbursed for providing MTM services.

I read the first few comments on the thread and decided that I had to share my two cents. Since that section of the pharmacist.com site is members-only, I thought that I would share the comments that I left. I believe that my comments should be considered for every new venture that pharmacists pursue.

My comments were the following:

We, as pharmacists, have grown accustomed to being contracted with insurance companies as a result of the dispensing function. We are comfortable having that contract with the insurers. It gives us security.

Over the years, the insurers have chipped away at the reimbursements to pharmacies. So pharmacists have looked for alternative methods to generate income. MTM is one method where we can utilize our professional expertise and see the impact that it has while getting reimbursed at a decent rate.

So why are we in a rush to get contracted with an insurer?

The insurance companies have people whose sole job responsibility is to reduce costs for the insurer. Don't you think that they will reduce payments to MTM providers? They are doing it to physicians. Do you think pharmacists will get treated any better?

Maybe we need to take a step back and talk to physicians about how the insurance companies have treated them over the past 10 years. Maybe we don't want to jump into bed with the insurance companies right away. Just looking at the EOBs that I receive from my medical insurance company shows me how much the providers discount their professional services. I'm not sure that I want to do the same. I'm not willing to bill an insurer my U&C only to see them discount it 40 percent.

Maybe we should take a look at how dentists have set up their contracts. They seem to be sitting pretty on the reimbursements.

I just think that if we are going to pioneer a new practice in the field of pharmacy, we need to be careful to not give away the farm in order to say that we are a provider for XYZ Insurance Company. I like what Don has said that he does...bill the patient directly and take payment, then provide the patient the form to submit to their insurer. We protect our fees this way. As insurers see more people seeking reimbursement for our services, they may approach us about being providers. We can control the reimbursements better this way. I don't like the idea of submitting claims and hoping to be reimbursed. Collect from the patient and let them worry.

* * * * *

I started pharmacy school twenty years ago. I didn't have an internship until late in my schooling, so I only have about sixteen years behind the counter. In those sixteen years, I really haven't seen too many new ideas for pharmacy. Immunizations and MTM are the only new things.

The sad thing about this lack of change is that most pharmacists that I talk to really don't care to see the profession evolve. They are there to collect a paycheck and go home. Get up tomorrow and repeat. They are literally trapped inside the box.

Pharmacists need to get out of the box. One of the other comments on the thread was the following: Many times our biggest obstacles are other resistant pharmacists who can only think of why we shouldn't expand our cognitive services and recognition for those services or colleagues who cannot visualize us as anything other than what we have traditionally been in the past professionally (i.e. the "in-the-box" thinkers).

As a pharmacist (or student), you need to step back and do a little self-evaluation. Are you an in-the-box pharmacist? Are you okay with allowing your professional practice to be dictated to you by others, many times non-pharmacists?

Or are you going to step out of your comfort zone and start to think outside of the box? There are limitless opportunities to expand your practice if you take a look outside of the box. Are you going to be the pioneer to lead pharmacists into a whole new world of pharmacy?

I fear that 99 percent of the people who read this will think it sure would be nice to see the profession evolve, but then do absolutely nothing about. I encourage the other one percent to voice their thoughts and ideas, preferably as a comment (so everybody can benefit) rather than as an email to me.

We, as pharmacists, need to set the agenda for the pharmacist organizations. Rather than follow along with (or gripe about) whatever the organizations are proposing, we need to get our own ideas out and discussed. If we get enough chatter going, it might, just might, get heard by the organizations and get acted on.

Even if the organizations don't listen, that doesn't mean that we can't share our ideas about the profession of pharmacy and how we can expand the roles of pharmacists.

Personally, I'm aiming big. I want to build a self-sustaining medication therapy management business that is not affiliated with a dispensing pharmacy. I want to be recognized for the medical services that I provide, not the product that I put in a bottle. It's going to take some time, but I believe that the effort is going to pay off.

I hope to see other pharmacists join me in taking the profession to another level. I'm tired of dealing with third-parties and junkies and ungrateful people. That's the stuff I've seen from inside the box for the past sixteen years.

Come join me outside of the box, it's going to be fun.

End of summer........sigh

2010-09-07T06:14:00.000-04:00

Summer is officially over, at least in my neck of the woods. The last of the school districts have started up classes.

The volume is starting to pick up as kids are getting each other sick.

There's hardly any eye candy running in and out of the store as classes at the local university have started back up and the students are dressed more conservatively. Plus the weather has been a little cooler than normal for this time of year.

It's only been a week or so and I already miss seeing the chicks show off their belly buttons.

HAHAHAHA