I was just on a conference call with a managed care organization (MCO) that will respond to a request for proposal (RFP) as our state shifts our medicaid administration to two or more MCOs. Unfortunately, the MCO that we spoke with today did not have any idea about the role of pharmacists as care providers. WHAT?!!!! How after all these years, with pharmacy’s movement from product distribution to patient care, can a managed care organization or payer not understand the value of pharmacists as clinical providers.
Part of the reason is because payers are not seeing this type of practice across the board. Also, not all pharmacists are practicing to the level of their degrees–identifying and resolving drug therapy problems, providing recommendations to prescribers, and documenting their activities. Lastly, payers may be looking at the wrong metrics when reviewing pharmacies (e.g. focussing on drug costs and not clinical parameters and patient outcomes, including health care spend).
As a profession, we need to do a better job of selling ourselves to payers and, in particular, our value to the health care team. Our value is that we have access to patients, we are able to identify and resolve drug therapy problems, we can ensure that patients are on safe and effective medications, and most importantly, we can make sure patients are achieving therapeutic outcomes–which will positively affect their total health care spend.
But all pharmacists also need to step up their efforts to develop and implement patient care services if they have not already done so. There is no money in product distribution because there is little value from patients and payers. The value statement is patient care, achieving health outcomes, and the unique role and knowledge of pharmacists to monitor and manage patients drug therapy. So, we need to make this the “norm” of pharmacy practice–not the exception.
Pharmacists, as a group, also need to be more vocal about the clinical roles to payers, legislators, and regulators. We cannot just sit on the sideline hoping that someone can figure this out–each of us has a responsibility to advocate for our profession–to reach out to payers and let them know what you are doing and the value you bring to their clients through your patient care services. If we do not do this, our profession will continue to experience the response that I experienced today–and that is getting old!!!
Pharmacy and pharmacists are navigating uncharted waters. The reason is the many the recent and significant changes in healthcare. Two very different factions emerging within the profession:
Medications as a commodity and
Pharmacists as providers of care
The competition between these factions will shape pharmacy and healthcare for years to come. Will one faction win over the other, or will the profession move in two different directions?
Medications as a Commodity
The mechanics of this faction are complicated, and there are many different parties actively involved. The net effect for pharmacy is a severe reduction in reimbursement for the drug product. Historically, pharmacies and pharmacists have earned their living providing both medication and care, but being paid only for the medication component. The downward pressure on reimbursement has resulted in what we have previously named “the stripped down model of pharmacy.”
The ramifications for the commoditization of pharmaceuticals are significant. Only by ramping up volume can a pharmacy continue to meet overhead costs. Increasing efficiency can take a pharmacy only so far down this path before the bottom line becomes negative. The largest single overhead expense in a pharmacy is wages, and one person can only fill or check a finite number of prescriptions in an hour.
Mail order pharmacy has pushed efficiency to the logical end, where one pharmacist (which is legally required in most states) is “checking” thousands of medications a day. Robotics and automation run the “pharmacy” in these operations. These large prescription mills can deliver an almost limitless number of prescriptions every year without any human intervention. Medications show up in the mail box, and the patient has to contact an unknown pharmacists over the phone if they have any questions or concerns.
Even with a highly efficient operation, retail pharmacies across the country are struggling to maintain profitability given the ever decreasing reimbursement this model provides. Smaller pharmacies across the country are closing at an alarming rate. Many of these pharmacies service more rural areas of the country, creating in interesting dilemma for patients. This Darwinian process of survival of the biggest could have severe repercussions as healthcare evolves. In this faction, efficiency has come at the expense of patient care.
Pharmacists as Providers of Care
On the other side of the battle are the pharmacists working with patients to ensure therapeutic outcomes. In direct contrast to the high efficiency, robotic or automated systems required in the above model, a care oriented practice may have several pharmacists working at any given time. The difference is what is being provided. While the patient ultimately receives a medication (product), they are also receiving service and care. The pharmacists review the patient’s medications, look for and address real and potential problems with the patient and their doctor(s), and work with the patient to ensure that they are obtaining the optimal outcomes. Pharmacists ensure medications are used safely and effectively.
At the present time, pharmacies are still being paid primarily for product, and it is likely that no matter which direction the profession of pharmacy ultimately follows, reimbursement for the drug product will forever be limited. Future support for the pharmacist as a provider of care will have to come from a fee for service model. Medicare and other are starting now recognizing the importance of pharmacists providing care to enhance patient outcomes. Even a single pharmacy has the potential to save a payor millions of dollars yearly by providing quality care (this will be the focus of a future post here).
A fee for service or pay for performance system will eventually need to become reality. Until reimbursement for service catches up to the importance of pharmacists providing care, pharmacies that have embraced the service model are struggling to stay in business. It may not be until Medicare recognizes pharmacists as providers, allowing them to bill for clinical services to the patient’s medical benefit, that the pharmacy as a service model gains widespread traction in our healthcare system.
Winners and Losers
In case it isn’t clear, there are no clear cut winners. Pharmacies and pharmacists will continue to struggle on both sides. What is becoming forgotten is the patient, who has the most to lose.
It is likely inevitable in the current health care system, that medications will become a commodity. Reimbursement for the product in the future will probably only be sufficient to cover basic overhead. It is with the emergence of reimbursement to pharmacists for care that the fate of pharmacy as a profession rests.
If I had to pick a faction to win, however, it would be the pharmacy as a service model. In this regard, the profession of pharmacy has a lot in common with the professional airline pilot. Consider that today’s airplanes can take-off, fly and land without a pilot, much like a prescriptions filled by an automated pharmacy. Now ask, would you want to fly in a plane without a pilot? Who will be there if something doesn’t go as planned, and the automated system cannot land the plane? Similarly, how safe would you feel if there were no one looking over your medications to ensure that there were no potential or real problems? Who will answer questions about the medications and how to best take them, and will they know you? Pharmacists providing care are an important part of the health care system. Until the time when pharmacists are recognized as providers, pharmacists will need play on both sides of the equation: making their practice as efficient as possible while at the same time going the extra mile to make every encounter with their patients count!
One of the most challenging issues facing today’s health care providers is sharing information. Technologically, one might assume that it would be easy to create a system of data exchange between providers. The reality, though, is that providers may be selective with what they will share, who they may share it with, and how they share it. The primary obstacles to sharing of information are security and access, and these barriers are as much a political issue as they are technical obstacles.
Obstacles
Security and privacy of health information is a significant obstacle. Just like breaches in major retail stores that make the nightly news (see Forbes for a list of significant breaches in 2014), health information is also under attack (e.g. Anthem, see CNN). The same technologies that enables modern transactions are also able to be exploited by criminals. Despite recent headlines, however, current technology (when implemented properly) is capable of reliably protecting our personal data, including a digital medical record.
Another significant obstacle is the actual exchange of medical records. All health care providers ( e.g. the physician, pharmacy, hospital and laboratory etc.) maintain some type of patient record. Every procedure, prescription, or visit results in changes in that record. Each change made by one provider (say at the hospital) would, in an ideal system, be updated automatically with the patient’s other providers (e.g. the specialist, the pharmacy and the primary physician). Assuming that security of the data can be maintained without any issue, the remaining problem is a lack of a standardized format for the record. Each repository of patient information is necessarily different because every provider focuses on different aspects of patient care. The format of the records can be very different. At one extreme, paper record (charts) are still in use, while others may leverage electronic medical records (EMRs). In essence, each provider’s records speak a slightly different language.
The Language of Health Care
Among the first organizations to recognize the importance of intercommunication between health care records were hospitals. The laboratory’s electronic records need to communicate with the electronic chart, hospital billing systems, the computerized census system and the pharmacy’s dispensing system. An entire industry was born to help facilitate this data exchange in hospitals, and with this came the creation of several standard languages, one of which is HL7 (Health Level 7).
Using computers as gateways, hospitals use tools like HL7 to link many different systems to provide a relatively seamless transmission of information between systems. But as good as this would appear on the surface, these gateways have significant obstacles of their own. Gateways are labor intensive to maintain and regularly require maintenance to keep them running. Small changes in one system can break down communication between multiple systems. To Make matters worse, there are many different dialects of the HL7 “language” so even if two systems both speak HL7, information can be lost in translation.
Politics
If one accepts that security of the data can be handled by current technologies, and that gateways like HL7 can facilitate the translation of data, one final obstacle exists. The laws that exist to protect the privacy of health information (like the Health Insurance Portability and Accountability Act of 1996 also called HIPAA) also govern the exchange of information between providers. This exchange may or may not require a written release (depending the the relationship between both providers and the patient). The provider’s access to records needs to be limited to only their patients plus any patients. It is also possible that a given provider may still want to control what data is shared, and when it is shared.
The Implications
Because of the obstacles above, providers and patients struggle to seamlessly communicate. The fax, which became widely available in the 1980’s, is still one of the primary means of communication between providers despite the proliferation of communication options available today. The ramifications are significant, and examples of the problems created by the lack of real-time communication are easy to find. From a pharmacy perspective, four common issues are:
A patient admitted to the hospital. The admit process requires the hospital staff to document an accurate medication history. Hospitals do not have access to the current the prescription history for the patient maintained by the patient’s pharmacy, creating a chance possibility for errors, adverse drug events and improper therapy.
Therapy changes made in the hospital. These changes need to be communicated to other providers (e.g. the primary care physician and the pharmacy). The lack of standard communication between hospitals, the primary care physician’s EMR, and the pharmacy’s records can lead to discrepancies.
Routine changes made at a physician office. Patients are often instructed by their physical to increase or decrease doses of drugs they take without a new prescription being issued.
Medical information related to drug therapy. A pharmacist managing a patient’s drug therapy requires a significant amount of medical and laboratory data to ensure optimal outcomes. Without seamless access to a patient’s relevant laboratory results, relevant diagnosis and pertinent history and physical, pharmacists are limited in their ability to perform Continuous Medication Management (CMM)
Jumping Thru Hoops
Many electronic medical records and other health care provider systems have made their way to the internet. Using secure web portals, providers can access their patient’s records from a variety of locations (office, hospital, home etc). The internet has become an enabling technology for providers trying to share information. If two different systems do not communicate (e.g. the physician’s EMR and the Hospital EMR), at a bare minimum, the provider can access both systems from a single computer to update and check records. Many providers find that they maintain accounts with multiple internet enabled medical records.
A pharmacy with good relationships with several providers might be able to gain access to a variety of records to enable productive collaboration. Besides having access to their own clinical record system, a pharmacy might have access to a hospice’s EMR, multiple nursing home EMRs, and access to records from one or more laboratories. This creates a chaotic environment where information must be gleaned from multiple sources and documentation made across many different records to ensure proper communication between all providers.
Even with great relationships between providers, gaining access similar to that described above is difficult. A pharmacy might serve 10% of a medical practices patients, and access has to be limited properly to prevent improper access. Likewise, a pharmacy would only want grant records access to a provider’s patients.
Today in healthcare, communications between providers is more important than ever before. And today, the fax still dominates communication between providers. It will likely be take a long time before all providers can come to and play in the same sandbox.
A key factor in performing continuous medication monitoring (CMM) is knowing the indication of each medication a patient is taking. Sometimes this is easy to decide, and other times it can be challenging. The important step, however, is documenting the information once it is known. This article will discuss strategies and workflows that we use to collect and document diagnosis information.
Certainly of Diagnosis
When documenting a diagnosis in a patient record, it is important to state the level of certainty associated with the diagnosis. For example, the indication for some drugs is often easy to guess. Statin medications (HMG-CoA reductase inhibitors) are rarely used for anything except hyperlipidemia. We refer to the pharmacists best guess for the indication as a inferred diagnosis. Sometimes a pharmacist may consider a likely indication but recognize that the possibility exists that the medication is being used for something else entirely. An example of this might be the drug metformin. While this medication is used primarily for diabetes mellitus type 2 (formerly noninsulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes), it can also be used “off label” for Polycystic ovary syndrome (PCOS). In the case of a female patient without other evidence of diabetes in their profile, assigning a diagnosis of PCOS would be recorded as a suspected diagnosis. When the indication is specified explicitly, either by the prescriber or on a prescription, the diagnosis would be considered confirmed.
Diagnosis Source
Similar to the documentation of the certainty of a diagnosis, it is important to note the source of the information in the patient record. We use three categories to refer to the source of a diagnosis.
Pharmacist — This is used to indicate that the pharmacist, using clinical judgment, has assigned a diagnosis based on their knowledge of therapeutics.
Patient — indicated that the patient has identified the diagnosis
Prescriber — is used when the prescriber has stated the diagnosis
A Diagnosis Workflow
At our pharmacies, CMM is performed at the final verification stage of the prescription workflow. After the pharmacist verified that the new prescription or refill has been filled with the right drug and is labeled correctly, they evaluate the profile a look for potential or real drug therapy problems. The clinical workflow screen displays the diagnosis associated with the drug being checked. If no diagnosis is specified, the system may suggest possible indications for the drug (see Figure 1 below). The pharmacist can assign an inferred indication to the patient quickly at this point. Here, the source of the diagnosis would be the pharmacist and the certainty would be marked as inferred. If a new prescription includes diagnosis information, this too can be added to the profile with the appropriate source and certainly indicators.
Figure 1. A clinical documentation system making a suggestion for a possible diagnosis for the drug.
If a diagnosis is uncertain, the pharmacist has the opportunity to engage the patient when the mediation is picked up. At this point, the pharmacist could create an intervention (Figure 2) and flag the prescription for counseling, including a note (Figure 3) to clarify the diagnosis with the patient. When the patient arrives, the pharmacist has the opportunity to consult with the patient and determine if the inferred or suspected diagnosis is correct. Information received from the patient can then be used to further update the pharmacy record.
Figure 2 Documentation of an Intervention by the pharmacist to clarify a diagnosis
Figure 3 Example of a will call tag to be placed with the prescription order to aid the pharmacist in collecting information at the point of sale.
Often, a patient confirmed diagnosis is sufficient for the needs of the pharmacy. Sometimes, however, the patient may not be a reliable source. In these cases, the workflow should include a method to send a short SOAP note to the prescriber requesting clarification of the diagnosis (Figure 4). Once this information is returned, the diagnosis information for the patient can be completed.
Figure 4 Example of a short SOAP note requesting confirmation of the diagnosis.
Collecting accurate, relevant patient drug-diagnosis combinations is an important step in the CMM process. Leveraging the patient at the point of sale is yet another example of making every encounter count.
As co-owners of two community pharmacies, a compounding pharmacy, and a consulting company, my business partner and I have created practices that have developed and implemented value-added services. The services we have implemented include immunizations (flu, pneumonia, shingles and TDaP), health screenings, disease state management, medication therapy management, medication adherence program, medication synchronization services, consultations for CPAPs, ostomies and wound care, and continuous medication monitoring. Although I described these services as “value-added”, it is not the service in and of itself that is of value to patients, but rather the pharmacists’ knowledge and their ability to problem-solve for the patient. As I write this blog today, I am reminded of a statement made by one of my pharmacy colleagues when asked what makes a good pharmacist and his reply was “It’s about the therapeutics, stupid!”
My colleague was absolutely dead-on. We can offer many value-added services, but if pharmacists do not have the clinical knowledge and skills to ensure that patients are achieving their therapeutic outcomes with safe and effective drug therapy, then these services are just a shell with no real value. As our health care system moves to a value-based system and providers are evaluated based on their performance, then it will be those pharmacists who keep up with the literature, keep their knowledge current and relevant, and are capable of identifying and resolving drug therapy problems who will thrive in this new system.
Unfortunately, there is not an easy way for pharmacists to keep their knowledge current and it requires a lot of work and energy. It requires that pharmacist keep up with the guidelines, read and understand landmark studies, be involved in professional organizations, and apply their knowledge consistently in the practice setting. For some it may require some remediation, whereby they may need to take a series of courses on therapeutic topics that they need to further their understanding. But it does not end there, because to become comfortable with new knowledge, it is important that it is applied to everyday situations until it becomes entrenched in memory. Perhaps purchasing an updated therapeutics textbook as a guide will help, along with a case study workbook to apply new knowledge and therapeutic skills. Another approach is to connect with a faculty mentor who can provide you with reading material and cases to help you become a better clinician. Employers should invest in their employees and encourage them to attend local/state/national conferences, which would help increase their value as employees to better the practice. Even with employer support, it still is up to the individual pharmacist to read, assimilate, and apply new knowledge. In other words all of us need to become life-long learners.
At the end of the day, those pharmacists who keep their therapeutic knowledge current and relevant will be of great value to the health care system. More and more payers are recognizing the value of good and effective pharmacists in reducing total health care spend and improving patient outcomes. I am convinced that the future of our profession lies in our ability to affect patient outcomes, collaborate with other providers, and improve the bottom line of payers. Now is the time to prepare yourself for the this future which is coming fast and furious. It will all serve us well to remember our value to the system is all about our therapeutic knowledge and how well we can apply it to our patients!
Over the years I have been asked by many pharmacists why Towncrest Pharmacy gets such a good response from physicians and other prescribers when we send them a SOAP note and recommendations. My response to them is that it took having many conversations with different physicians, creating easy to use physician communication forms, and learning how to write succinct, clinically relevant notes that matter to physicians. This experience has helped me to develop a set of criteria that I use to teach pharmacists, residents, and pharmacy students on how to write an effective SOAP note.
Criteria for Physician Communication.
Keep it succinct and clear. It is important that our SOAP notes are not lengthy nor convoluted. The information needs to read easily and be understandable. By using the SOAP note format (S = Subjective, O = Objective, A = Assessment, and P = Plan) pharmacist create a note in a format recognizable and understood by prescribers. Subjective information is information that the patient has told you, objective information is something that was measure (e.g. labs, vitals, etc), assessment is the pharmacists evaluation of the subjective and objective information to identify potential or actual drug therapy problems (DTPs), and the plan is the pharmacists recommendations to resolve the DTPs. It is important to keep the SOAP note to one page, if at all possible, and include an updated medication list.
Provide the prescriber with information they do not have. What I mean here is that pharmacists need to look at their patients and their drug therapy with a critical eye. Pharmacists need to be asking themselves how their patients are taking their medications, if they are adherent, if they are achieving their therapeutic goals, and if they are experiencing any adverse drug reactions (ADRs) including side effects and drug interactions. By systematically reviewing each medication in this way, pharmacists can communicate information to physicians that may be otherwise unknown to them.
Describe the problem. The assessment part of the SOAP note is where pharmacists use their critical evaluation skills to identify the drug therapy problems that patients may be experiencing. The categories of drug therapy problems that we use to describe the problem is what has been used extensively in the literature including:
Untreated indication
Need for additional therapy
Adherence
Dosing issues (dose too low and dose too high)
Unnecessary drug therapy
Adverse drug reaction (side effects and drug interactions)
Provide concrete recommendations to prescribers. Over the years I have learned provide recommendations that are answered with a yes or no by theprescriber. Also, I make it clear on the form that I use thatprescribers understand that the recommendations become a prescription if approved and signed by the physician. For example, I recently provided the following recommendation to aprescriber.
Patient is taking both sertraline 25 mg QD and trazodone 150 mg QD. She has a PMH signficant for dementia with behavior disturbances, depression, and anxiety. Her last depression evaluation indicated minimal depression. Due to concerns about CNS ADRs with trazodone, can we attempt a trial reduction of her trazodone to 100 mg QD, #30 tablets, 11 Refills? _____Yes _____No
Be evidence based. It is important that pharmacists keep current with their therapeutic are are aware of the literature to support their recommendations. This does not mean that you have to cite a particular study, but it does mean that you are able to do this if questioned and challenged. If prescriber become confident in your knowledge and clinical skills they will more likely become more accepting to your recommendations.
Knowing and applying these criteria will help community pharmacists impact their patient’s care and help to develop collaborative working relationships with prescribers. It is our responsibility to ensure that our patients medications are safe and effective, but we need to effectively communicate with other providers if we are to be successful in helping our patients.
[dropcap color=”white” background=”black” style=”rectangle” size=”big”]A[/dropcap]t Our pharmacies, we put a great deal of emphasis on performing clinical services while working on the dispensing counter and we call this process continuous medication monitoring (CMM). By this, I mean that the pharmacist, while verifying that the prescription was filled correctly, is also responsible for an in-depth look at the patient’s medication profile each and every time the patient has a prescription filled. To accomplish this, we have developed a software platform for our clinical pharmacists to work with while on the counter called PharmClin.
While the PharmClin package contains a comprehensive array of features including documentation for the clinical pharmacist, one of its core features is the patient profile. The single most important piece of information that a pharmacist has to make clinical assessments is the patient’s medication profile. The remainder of this post will look at the importance of the profile and how a logically formatted profile can aid the pharmacist in CMM on the fly.
A dispensing profile
Before looking at a clinically oriented profile, consider that a PMS (Pharmacy Management System) also maintains a patient profile. The user experience when trying to use most PMS profiles to perform CMM, however, quickly deteriorates. A Pharmacy Management System (PMS) is designed to facilitate dispensing. The PMS profiles are, therefore, optimized for dispensing activities, and not CMM. Consider a PMS like McKesson’s Pharmaserv below (click to enlarge).
Example Profile from Pharmacy Management System
This screen grab is fairly typical of most any commercial PMS in that it shows the history most current at the top. The level of detail visible, though is limited, and one has to select a prescription to see the previous dates (in the split window below). In all, the information visible is related primarily to dispensing.
This begs two questions: 1) what information displayed by the PMS do we not require when making clinical determinations and 2) what is missing that we would want to see? Taking these questions in order, our clinical pharmacists were less interested in:
Original Date (because it does not related to the first date the patient started taking the drug)
Refill number
Strength and form (because it is duplicate information)
Price
Facility
NDC
Coverage / Insurance
RPh and Tech
Keep in mind that almost all of these have significant value when considering the dispensing aspects of pharmacy, they just are not relevant to the most common clinical issues.
Our clinical pharmacists were interesting in seeing a few other details without having to drill down into the record. These included:
Days Supply
SIG or directions
Recent Refill Summary
A selective profile representing only the most recent therapies
Our clinical pharmacists were also interested in being to quickly spot
Specific therapeutic drug categories (e.g. those in the EQuIPP measures)
Drug interactions
Compliance Issues
A Clinical Profile
With this in mind, we pared our clinical profile view down to the following (for sake of comparison, this is the same profile as listed above): (again, click to view the image)
Example profile from a clinically based system
Besides some small differences in sorting and the scale size of the screen capture, the profiles represent the same exact data. One of the first things you might notice is that the profile is narrower (taking up much less space across the screen). The changes represent most of the important items on our clinical staff’s wish list for the profile.
Some things in this profile may not be initially obvious, but are exceptionally helpful to a clinical pharmacist performing rapid CMM on the counter. To simplify the profile , only the last three dispensing incidences for each given drug are displayed, and these are all displayed together, without respect to Rx number, NDC or other drug product changes. This saves the clinical pharmacist time as they do not need to hunt thru the profile. One advantage to this method is that the pharmacist can review compliance over the last three dispense occurrences quickly.
Other simplification were made to the profile. To reduce the amount of data to be interpreted, only the last 180 day are displayed, significantly reducing clutter in the profile. If a clinical situation requires a complete history, that option is available.
Another key difference is the addition of color. While the color-key is not visible in this screen capture, the drugs are color coded as follows:
Statins in GREEN
ACE / ARBs in RED
Diabetic medications in BLUE
Drugs listed as high risk (Beer’s List) in PURPLE
Drugs that precipitate drug interactions in ORANGE
All of the above color-coding relates directly to the current CMS 5-STAR rating guidelines, and allow our pharmacist to quickly make 5-star related determinations on compliance, high risk drugs, and drugs that are known to precipitate interactions.
Besides color-coding drugs that are known to precipitate drug interactions, the profile has drug interaction column that highlights any interactions flagged by the PMS. This column is kept minimal and does not show the details of the interaction by design. We decided that if we did not know what was going on, we could click to look, but for the most part, knowing that an interaction was flagged was enough for our clinical pharmacist to make their assessment. Interaction pairs are easy to spot this way. Drug – Alcohol and Drug – Food interactions sometimes create an ODD number of interactions, but after a bit of practice, spotting problems becomes very easy.
The profile above is not perfect, and has changed with time as we work thru our CQI process. One of the things that would be most helpful to us would be an accurate listing of medical conditions. Unfortunately, while PharmClin and our PMS do have the capability of entering this information, we often do not have documentation of actual diagnoses. For the purposes of “on the fly” clinical work, therefore, we use implied diagnoses, and the color coding is helpful in this.
I should point out that our clinical system does a lot more than just show the pharmacist a patient profile. The patient profile is important to start the process, but once the pharmacist has identified a problem, they have to document it efficiently. Once the pharmacist notes something worth documenting, they can document an intervention system for the next pharmacist or even write a quick SOAP note to send to the prescriber. Interventions and SOAP Notes can be flagged for follow-up.
Notes on PharmClin
PharmClin (patent pending) was developed as an in-house documentation tool for a clinically oriented retail pharmacy. The product currently integrates with McKesson’s Pharmaserv, but integration with other PMS vendors is being pursued. More details about PharmClin are available on the Innovative Pharmacy Solutions website. Web demonstrations can be arranged from that website.
[dropcap color=”white” background=”black” style=”rectangle” size=”big”]M[/dropcap]ore and more, we are hearing that MTM is the future of pharmacy. And while there is some truth with this statement, the reality is a lot more complicated.
MTM, as it has evolved under Medicare Part D’s parentage, is a poorly conceived service. The separation of the medication costs and the medical costs that exists within Medicare Part D gives PBMs (who manage the Part D benefit) little financial motivation to give patients access to the MTM service. This results in fewer MTM opportunities for community pharmacists. Additionally, many PBMs have brought significant amounts of MTM activities in house, using their own nurses or pharmacists to perform the minimum number of required by law. When local community pharmacists in the trenches do get an opportunity to perform MTM, they often end up spending far too much time completing the intervention and are reimbursed too little to cover their expenses. With the recent changes in Medicare Part D and CMS’ adoption of completed patient cases for comprehensive medication reviews (CMRs) as a performance measure for community pharmacies, this may potentially boost pharmacists access to MTM opportunities. Unfortunately, the amount of reimbursement for a CMR will continue to be a significant challenge unless pharmacists find a way to streamline their MTM processes.
The pharmacists approach to MTM needs to change. Consider that each refill picked up by the patient is an opportunity to assess the patient’s medication therapy, identify and document problems, and take action.
Today, pharmacists need to re-train themselves to complete MTM type activities in real time. This means upgrading their clinical knowledge, leveraging documentation systems, and optimizing workflows. Once pharmacists stop thinking about MTM as a sit-down encounter that takes more than 45 minutes, it opens up a host of possibilities.
Using a bite size approach to MTM allows the pharmacist to create, over the course of a few months, a complete medication therapy management description for a large number of patients. The pharmacist gradually collects and documents the information required in a traditional MTM encounter. This collection takes place on the counter, while checking prescriptions. This efficiency means that when a pharmacy is called upon to perform MTM services for a payor, they already have documentation and results in their pocket. The MTM intervention can be done in a matter of minutes.
It should also be point out that MTM does not need to exist only in the context of Medicare Part D. Pharmacists can look to group homes, assisted living centers, and others as potential MTM customers. Once shown the benefits of MTM groups and individuals often become quite interested in this service. Cash based MTM can become a real revenue stream for a pharmacy without requiring hours of desk time to complete.
[dropcap color=”White” background=”black” style=”rectangle” size=”big”]M[/dropcap]anaging a small business is a challenge. Pharmacy is no exception to this rule, and because it is one of the few (possibly even the only) retail business that has virtually no control over what it charges for most of what it sells. Watching the bottom line often resembles an event at the X-Games.
Being savvy when it comes to money is important. A great example is the satellite radio that may be in your car. Experience has shown that the company selling the subscription for this service is willing to take less than their advertised rates for the service, so why pay more? One only has to ask (and maybe it doesn’t hurt to threaten to cancel the service along the way) to be offered a better rate. Pharmacy owners can, and should, leverage this approach with a variety of venders. Consider some of the successes seen by my stores over that last few months:
When approached by a software vender for a required upgrade on my almost new (2 year old) system, the vendor wanted almost $3000. Asking the appropriate questions and escalating the issue resulted in a very substantial drop in the price to update.
When my prescription vial supplier cold-called me and asked how things were going, I was honest: things are hard. I then immediately asked for a larger rebate based on my volume. While the sales rep was not expecting this, I was able to secure real savings (in the form of additional rebates) within a few months of starting the conversation.
Secondary wholesalers regularly call with offers of pharmaceuticals at prices lower than my primary wholesaler offers. Why accept their first offer? Asking “how low can you go?” regularly results in better opportunities.
The employees wanted a water cooler for the break room. They presented a single quote to us. A few calls later, we had both companies bidding for our business, resulting in a much lower overall cost for the service in the end.
Buying groups provide rebates that help a pharmacy’s bottom line. Things in pharmacy change so rapidly, with prices dropping and soaring for products seemingly every minute. If a buying group contract has not been updated in a while, it cannot hurt to approach them for a better rebate rate, at least until the buying group updates it contracts to keep up with changes.
Overall, in business, it cannot be reiterated enough: “If you don’t ask, you won’t receive.” In today’s business environment, one cannot simply accept the first offer for any service or product. One needs to leverage competition and loyalty with vendors to enhance the bottom line. Not asking for better pricing means possibly not being in business this time next year.
