Out of the Box

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

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

Closing the Medicare D gap

Well, two minutes ago the deadline passed. Drug manufacturers were supposed to have signed an agreement with both CMS and third-party administrators for Medicare D plans by 11:59 PM on September 1 in order to have their medications covered for the 2011 Medicare D benefit year. (link to story here)

It's part of the Affordable Care Act, which is supposed to eliminate the doughnut hole for Medicare D beneficiaries by 2020.

Here's how the system is supposed to work. It is my analysis of the information presented in the link above.

Manufacturers must agree to discount the price of medications for selected beneficiaries once they reach the gap (or doughnut hole) in their Medicare D coverage. If you don't discount the price of the medication, it will not be covered by the third-party administrator.

The bulk of the responsibility for the program falls into the hands of the third-party administrators. By the design of the Medicare Coverage Gap Discount Program, the third-party administrator will:

• Determine which beneficiaries are eligible for the discount
• Determine if the drugs are discountable (should be all drugs since CMS says only drugs that will be discounted will be covered under Medicare D)
• Calculate the amount of the discount, depending on doughnut hole status
• Send the discount information to the dispensing pharmacy as part of the on-line adjudication process
• Reimburse the pharmacy for the discount within 14 days of the online claim

Call me a cynic, but I see all kinds of potential problems with this. Maybe I'm just a tad jaded from working with third-parties for the past fifteen years. Maybe I've actually read a third-party contract and understand how the third-party will nickle and dime the retail pharmacy on this. Maybe I can see what is going to happen to drug prices as a result of this program.

Before renewing any contracts with Medicare D plans, a smart pharmacist should carefully read the contract. Look for changes in the reimbursement rates. I can foresee terms for brand name medications to read something like AWP-18% + 1.75 or the MCGDP* + 1.75, whichever is less.

* Medicare Coverage Gap Discount Price, I just made it up but I can see it as a new formula to join FUL, MAC, WAC, and GEAP.

Right there, the plans will attempt to reimburse at the lowest rate possible. And I can guarantee that many pharmacies will sign without even looking. There will also be some terms that allow the plan to delay payment for discounted prescriptions pending audits. Of course every claim will be flagged for an audit. Again, this is just the cynic in me speaking here.

But let's assume that the third-party administrators will be on the up-and-up. Let's think about what the manufacturers are going to do.

Over the last week or so on Twitter, I have seen several links to stories that talk about how the brand name medications have seen price increases of about 8 percent over the past year.

Now we have CMS requiring that the manufacturers discount prices for people who are in the doughnut hole. The manufacturers never discount prices, they pass the cost of the discounts on to others. That means that the non-Medicare D plans and self-paying patients will see prices skyrocket.

The $180 bottle of Nexium that we see on our shelves. Medicare D patients in the gap will see the discount. Let's be nice and say they will only have to pay $120. That sixty dollar discount isn't going to be written off. It's going to drive the price up to $250 per bottle for everybody else. Classic move. The manufacturers aren't going to see any change in profits. Heck, between now and January I wouldn't be surprised to see the big-name medications to see hefty price increases.

In an effort to help out the Medicare D patients, CMS has screwed everybody who is not on a government funded prescription drug plan. Like I said earlier, maybe I'm just cynical but I see multiple places where the system can be hijacked. And in just about every instance it will be the pharmacist who gets the short end of the stick.