Drug Topics wouldn't touch this idea

The following is the article I submitted to Drug Topics. I asked them to give me a response to see if they would consider using it and they haven't responded yet. Rather than sit and wait for weeks or months for a reply, I'm publishing it here. They can put it in Drug Topics as well, but I feel that this article may help pharmacists to view themselves as individual health care providers instead of as employees of some corporation.

So here, enjoy the post that Drug Topics might be afraid to publish.



Recently I had to take my daughter to the local emergency department for a nasty cough. It was on the weekend and in the middle of the night, so her pediatrician was not available and the urgent care centers were closed.

It’s been a few weeks and the insurance EOBs are starting to arrive in the mail. While reviewing these I had what may be an epiphany.

For our hour or so in the ED, we will be receiving bills from the emergency department, the ED physician, the radiology department, and the radiologist. Two bills from the facility and two bills from the health care professionals.

That got me thinking. On-line and in the pharmacy publications I see pharmacists wanting to be reimbursed for their professional services. Some pharmacists are able to generate an income stream through Coumadin clinics and medication therapy management services, but for a lot of community pharmacists the populations we serve can barely afford their medications, let alone these additional services.

Then it hit me. Why aren’t pharmacists billing the insurance companies for our professional services each and every time we fill a prescription?

We’ve allowed the reimbursements for pharmacy services to be lumped into the reimbursement formulas for the drug product. Guess what people? Those contracts are with the pharmaCIES to provide the product. PharmaCIES are businesses or departments where medications are stored and sold. (A July 12 article by David Witmer on the ASHP blog echoes this thought)

PharmaCISTS are medical professionals who review medication orders for accuracy, perform drug utilization reviews on each and every prescription, and educate patients on the proper use of their medications. The pharmaCY can’t do this, only the pharmaCIST. But only the pharmaCY has a contract with the insurer.

I believe that if we, as pharmaCISTS, want to show our value to the health care system, we need to actually try to get reimbursed for each time that we perform a professional function. Physicians do it every time they take a blood pressure; it increases the complexity of the visit. Why not us? Why aren’t we billing for our services each and every time.

We’ve allowed our professional services to be lumped in with the dispensing fee that is tacked on to the MAC or AWP-minus formula that the insurers set. I don’t know about you, but I feel that my professional expertise is worth more than $2.25 per prescription (0.00 on three month Medicare D orders). Well actually less than $2.25 when you factor in costs of vials, labels, technicians, utilities, etc…

As pharmaCISTS, we need to find a way to bill for our professional services each and every time we fill a prescription. The insurers need to contract with the pharmaCISTS, as well as the pharmaCIES, to provide the entire prescription product (medication, consultation, education). They do it for both the hospital and the physician. Why not pharmaCY and pharmaCIST?

I suggest that software be designed to send the NPI of the dispensing pharmacist to the insurers and that the insurers send reimbursement for professional services directly to the pharmacist of record. If we, as pharmaCISTS, truly want to be reimbursed for our professional services, we need to get serious about it and approach it on a wide-scale.



I don't know if this idea has been proposed before. I don't care if it has been or not. It needs to be discussed now. Right now we, as pharmaCISTS, need to get our act together before it's too late. Don't count on the corporations to look out for the well-being of the pharmaCISTS. They are doing everything they can to get tech-check-tech and other legislation passed so they can decrease pharmacist payroll, if not the pharmacist position completely. Don't count on the pharmacist organizations to do anything for you.

It's up to you.....the PHARMACIST.

I need some duct tape (a small rant)

I just read the APhA statement to the FDA about REMS in reference to extended-release opioids.

In a statement to the narcotics advisory board at the FDA, the APhA continues "to advocate for a standardized system-based approach that is feasible and scalable to accommodate the growing number of REMS programs".

I'm underwhelmed. Way to step out there and lead pharmacy by advocating. And for a standardized approach.

Wow.


Then the APhA statement has to mention that pharmacists give flu shots.


OMG!

My head is going to explode.


I'm sorry, but WTH?


I'm beyond words. I'm speechless. All I can think is "?????????"




Let's follow this statement with the APhA recommendations to the FDA:

1. Outreach and educational materials for pharmacists about REMS. The only outreach I need is my hand reaching out to attempt to slap some sense into the APhA headquarters. You send a letter to the FDA that basically says "more MedGuides, please".
2. Recognize the role that pharmacists play as the medication experts.... The same crap that goes on every APhA statement.

WTH?

Apparently the APhA isn't doing a very good job in getting pharmacists the recognition for the role that we play as medication experts.

I will give the APhA a little credit. They do challenge FDA and sponsors to continue to evaluate the potential impact, need for, and ability to compensate for patient care services at the point of dispensing as part of a REMS program.

Did you see the key word in there?

Compensate. Well evaluate the ability to compensate for patient care services.

I can see the results of the evaluation. Nope. Can't compensate pharmacists. Why don't you go run off now and give a flu shot or two.

I may need two rolls. Better make it Gorilla tape.

Why PBMs suck

And believe it or not, this post has nothing to do with our friends over at CVS/Caremark.

Quick question- how many of you pharmacists out there are aware of the terms of your contract with the PBMs?

I already know the answer... not many. And that makes perfect sense given that a majority of pharmacists are not owners, but mearly employees of a pharmacy. Only the owners know the terms are. Well, as long as the owner is reviewing the contracts and not leaving it to a third-party service.

I'm going to share a story from my recent past to illustrate exactly how pharmacy benefits managers screw over pharmacies on reimbursements and how pharmacies go along for the ride.

At my previous job, working for a regional grocery chain as pharmacy manager, I was brought in for a little discussion with both my store manager and the director of pharmacy operations for the chain. The subject... declining pharmacy margins. I'm not talking a percent or two. I'm talking big time declines, the kind that make your P&L statement dip into the red.

Let's take a step back, to let you know the climate that I was working in. I was working for a high end grocery chain. Exceptional customer service was the minimum acceptable level of performance. A majority of our pharmacy patients had insurance thru a local insurance company (XYZ Insurance). XYZ Insurance only operates in about five counties, and they are the major insurance carrier for all of the counties. At my pharmacy, the accounted for 35 percent of our business. Our business lived and died on XYZ's reimbursements.

Our original contract with XYZ had your typical reimbursement structure:

• Brand: AWP - 15% + 2.25 dispensing fee
• Generics: MAC + 2.25 (MAC being the HCFA MAC*, or the GEAP MAC* if there was no HCFA MAC)
• or AWP - 30% + 2.25 if the medication was on neither the HCFA nor GEAP MAC lists

Pretty standard reimbursements. We made a nice little profit from them. Then XYZ Insurance stuck the screws to every pharmacy it was contracted with.

Quick history lesson, who can name what blockbuster products have gone generic over the last four years? If you answered every one of them, you are right.

Well right before all of these products went generic, XYZ changed the reimbursement structure ever so slightly. The people signing our contract with them didn't pick up on it, not until I asked for a copy of the contract and saw the change XYZ had made.

The contract language now stipulated that MAC means Maximum Allowable Cost as determined by the lessor of the Federal Upper Limit (FUL)... or the XYZ Insurance MAC. Then it had the same language about GEAP and AWP - 30.

That's where they screwed us. They could put any freakin' drug on their MAC list and we agreed to take it. You know how the acquisition price for the first generic manufacturer is usually about 15 percent less than the brand name price? During this period they were XYZ MACing us. Nothing like losing 15 bucks on each and every prescription. The best part...they wouldn't release a list of the XYZ MAC drugs. Proprietary information.

That's what happens when you don't read the contracts and just accept whatever the insurance company throws out at you. When you figure that you can't reject the terms because you can't afford to lose the customers/ script count, that's when they nail you.

How long until XYZ decides to MAC brand name medications? Wait, I better not say that. It might give them an idea.

*if you don't know what HCFA MAC s, GEAP MACs , or FULs are, you shouldn't be signing any contracts