Tuesday, March 29, 2011

Why are we sicker at a younger age?

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.

Saturday, March 26, 2011

Reply to a question on Twitter

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.


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.

Thursday, March 24, 2011

Insights from a fellow pharmacist

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

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

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

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

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

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

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

Monday, March 21, 2011

APhA 2011- New Business... Mandatory Vaccinations

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.

Sunday, March 20, 2011

Independent MTM business, Part Two

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.

Monday, March 14, 2011

Starting an independent MTM business

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.

Sunday, March 13, 2011

Coming tomorrow.........

My post on starting an independent medication therapy management business.

How's that for a teaser?

Wednesday, March 9, 2011

Blitz on Washington

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.

Monday, March 7, 2011

Medication Therapy Management Benefits Act of 2011

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?

Thursday, March 3, 2011

Journal club- Medication therapy management: Gator style

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.