Tuesday, October 26, 2010

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

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.


A few years ago, several pharmacy outfits decided that it would be a good idea to offer generic medications at rock bottom prices. Four bucks for a month's supply of pills.

One of the consequences of these programs is a decreased profit margin on prescriptions. In order to maintain a profitable department, pharmacists have been forced to fill an increased volume of prescriptions in order to cover the costs of operating the prescription departments.

When you look at a pharmacy's P & L statements, the largest expense (after medication costs) is the pharmacist salary. You can hire four to six technicians for the price of one pharmacist. Don't you think that the non-pharmacist members of management are looking for ways to decrease or eliminate the need to pharmacists?

I'm not saying that we need to worry about this over the next year or so, but if you are not prepared for this we may see ourselves phased out of our own profession. Pharmacists need to start speaking up to our legislators and boards of pharmacy in order to make sure that the corporations don't phase us out. I hope I'm wrong on this issue.


In 1996 the APhA House of Delegates decided to push for pharmacist immunizations. After 14 years, pharmacists are able to give vaccinations in all 50 states.

So flippin' what?

How has this advanced the profession?

Pharmacists are now able to provide the same service that physicians and nurses have been doing forever. Doesn't really differentiate us, does it?

In fact, the beauty of pharmacist immunizations is that we can't bill for the act of giving the shot. When a physician gives a shot, they bill the insurance for an administration fee. Do pharmacists?

For the increased liability exposure, pharmacists receive absolutely nothing.

Medication Therapy Management

This is my pet project. I see this as the future of pharmacy.

MTM actually utilizes our unique skills as medication experts. But how do we market this? How can we get patients to want to pay us for these services.

Our profession has been tied to a product for so long that people are almost shocked when we say that we want to bill for the information that we possess. They think that the cost of the medication entitles them to all of the information that we can provide. Maybe if we actually made a decent profit on the product. But $1.85 profit on a script is going to get you $1.85 of info from this pharmacist.

We need to promote the informational side of what we do, but not give it away. OBRA 90 requires us to provide specific information during a counseling session. Anything above and beyond that should be compensated by either the patient or their insurer.

So far, I have not seen a successful model to follow in developing MTM services. I hope to be able to report back in five years and say "this is how I built my successful MTM business". We need to share our successes so that all of us may benefit.

Corporate ownership of pharmacies

North Dakota has it right. Pharmacists should be in control of the profession, not companies.

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.

Thursday, October 21, 2010

Quick question

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

Anybody know where to get them?

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

Tuesday, October 19, 2010

State of the Profession...Marketing

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.

Tuesday, October 12, 2010

State of the Profession......PBMs

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.

Thursday, October 7, 2010

Addiction and abuse

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.

Tuesday, October 5, 2010

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

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.