Month: October 2015

Why yes, we ARE are messing with your workflow

During a recent discussion with a pharmacy management systems (PMS) vendor, my business partner was describing our workflow and how we leverage the pharmacist. The goal was to help the vendor understand what we would like to see their software enable: a patient centered workflow. Their immediate comment was “you are messing with our workflow!”

That was the point. The PMS workflow has evolved over the years into a single focused entity: to fill a prescription. The patient, as a focus, is largely gone from every system currently marketed. PMS feature lists are generally focused on increasing efficiency of the dispensing process, tracking the prescription from beginning to end. Every PMS offers an some “clinical” screening for therapeutic duplication, drug and disease interactions, allergies, and compliance, but these are limited in scope to the prescription being filled at the time.

Standard Workflow
Figure 1

Figure 1 above represents a typical prescription focused workflow. The steps typically involving the pharmacist are shown in a brown box, with steps traditionally handled by technicians colored green. This is a traditional assembly-line type workflow, but notice that the pharmacist has to jump-in at several locations. Modern pharmacy management systems minimize work to reduce the impact of this to the pharmacist

The Workflow of the Future Pharmacist

In order to modernize the pharmacist’s workflow, patient-wore clinical information needs to be infused into the final verification step. This includes a summary of addressed and unaddressed clinical issues like drug-drug interactions, drug-disease interactions, therapeutic duplications, compliance issues, clinical outcomes, and monitoring currently being monitored. This information should not be limited to just the drug being checked: modern pharmacists emphasize patient care instead of just checking the prescription.

This workflow might be represented by Figure 2 below.

Modern Workflow
Figure 2

The difference in this workflow is the injection of all clinical data at the final verification step. Unaddressed issues with other medications are presented to the pharmacist to be addressed as necessary. Additionally the pharmacist is given the opportunity to document the intervention(s) at this point. These interventions become a part of the clinical record and are available for the next time the patient is reviewed.

The data injection and the documentation steps–the basis of the commercial product PharmClin (Patent Pending)–are as simple as they are innovative. This expansion of the final verification step creates a patient-focused process that we call MTM-on-the-run. While this workflow might seem daunting to some, with some basic training and a well engineered software package, the process is quite satisfying.

Taking it to the Next Level: An Ultra-Modern Workflow

The truth be told, there is really no reason that technicians could not be used for the entire Intake to Will-Call workflow. In some states, including Iowa, some pharmacies are studying technicians checking another technician’s work (performing the final verification step). The purpose of this type of workflow is to free up the pharmacist to focus more on the clinical aspects of the practice. In this case, the workflow might look more like Figure 3 below.

UltraModern
Figure 3.

Notice above that the pharmacist is still tasked with the data-entry check for new prescriptions. This is currently still required in Iowa under the special rules covering this type of workflow. As a pharmacist, this workflow is very liberating. Instead of being mired in the details of checking between one and twenty prescriptions, the pharmacist can focus on the clinical profile information for each patient represented in the order. They can review previous intervention notes and create new notes. When the patient or their representative arrives at the pharmacy to pick up medications, the register clerk can summon the pharmacist to counsel on any new medications and/or follow-up with interventions flagged by the pharmacist that performed the clinical review.

Change is Coming. Don’t Look Back, We Aren’t Going There…

Giving up participation in the dispensing workflow is a scary proposition for some pharmacists that have spent entire careers performing little more than this function. When we talk to pharmacists at meetings, it is obvious that there are two types of pharmacists: those that look forward to moving to a model like this,and those that don’t know what or how they would perform in a new, modern workflow.

But this much is certain: reimbursement for product (dispensing) is not going to magically return. Maximizing efficiency through a technician driven workflow with added efficiency through robotics or other technologies will free the pharmacist to be a pharmacist. Pharmacists need to apply their clinical knowledge to care for patients. The days of paying a pharmacist to perform final verification of a prescription (a dispensing function) are rapidly coming to an end.

While I will not claim to know what pharmacy will look like in a few years, I am certain of two things. Firstly, it will be very different than the current dispensing-driven model. Secondly, pharmacists will be increasingly paid for their contribution to patient care or they will be be missing entirely from the flow chart. Make every encounter count today, so you can continue to do so tomorrow.

The Origin of the Voodoo DIR?

 

The DIR fee, a subject of several posts on this blog, can be calculated in a variety of different ways. In 2016, Medicare/CMS directed plans to calculate the DIR at the point of sale (the time of adjudication) whenever possible. A DIR fee doesn’t have to be complicated to save the plan money. Yet after reviewing the 2016 Medicare Part D Prescription Drug Plans (PDPs) and their associated DIR fees, I became distressed to see even more “retrospectively calculated” DIR fees appearing despite the CMS’s direction to simplify the DIR.

So why are PDPs going out of their way to create these retrospectively calculated Voodoo DIR fees? One possible conclusion is that the PDP is trying to hide something. If we agree that this is a possible conclusion, the next question would be: what are they trying to hide, and from whom are they hiding it?

While it might seem logical to assume that the plan is trying to hide something from the pharmacy, I believe that this is in fact not the case. Instead, I believe that this might be a direct result of PBM consolidation. Over the past several years, there has been significant consolidation in the Pharmacy Benefit Manager arena, with only a handful of larger PBMs remaining in the market. I have dubbed the remaining large processors the PBM Titans. This lack of homogeneity in the processor arena has created an interesting dynamic between the PDPs and the PBMs that process for them.

Impact of PBM consolidation on the PDPs

10 years ago, our pharmacies received dozens of remittance advices and checks weekly from different PBMs and plans. Today, it is a very different story. Each remittance from a PBM Titan represents many different plans, both Medicare and commercial. In today’s world, this means that the processor of all of these claims has access to a virtual cornucopia of data.

Remember that the PBM Titans not only process claims for other PDPs, but also run their own commercial and Medicare plans. The Titan PBMs have direct access to the smaller PDP’s claim data, which includes their Maximum Allowable Cost (MAC) for each drug product and the dispensing fee(s). It is not hard to imagine that the PDPs run by the Titan PBMs could leverage their under-the-hood knowledge of the smaller players to match up their plans favorably by comparison and therefore maximize their own PDP enrollment.

The VooDoo DIR Fee

When a major national PDP started using a retroactively calculated DIR fee last year, pharmacies had a very hard time determining exactly how much they were actually being paid for each prescription. The DIR fees for last month’s claims were attached by the PDP to the current claims. This obfuscation not only created confusion for the pharmacy, but is also hid the DIR fee logic and impact from the PBM doing the processing. It is my belief that this is not a coincidence.

The Consequences

Pharmacy is in the midst of a transition. Historically, pharmacies were paid for product, and the services that accompanied the product were essentially given away. The profitability of the drug product will soon be gone. It may already be gone for some pharmacies. The revenue streams for pharmacy service, however, are still in their infancy. It is going to take some time before a pharmacy and pharmacist can run a successful business charging for their services.

The time is now to focus your pharmacy on services. The transition to a service based revenue stream will have to be taken in small steps, so the process must start now. Both pharmacists and their patients will be outside of their comfort zones during this time, and it is going to be a learning experience for everyone. There is not a better time than now to make every encounter with your patients count!

When Therapeutic Duplication Isn’t…

Modern pharmacy management systems screen therapeutic duplication using third party databases, and these systems are not capable of exercising the necessary professional judgement to separate an actual duplication from a rational duplication. Duplication alerts, because they are so frequent, become almost a nuisance, and alert fatigue is a real concern.

Normally, therapeutic duplication alerts in our pharmacy are documented as:

Duplication Appropriate: Different mechanisms of action required to achieve therapeutic outcome(s)

The above is typically added to intervention notes in cases like the use of metoprolol (a beta blocker) with losartan (an ARB). When we create this note, we typically will flag the problem for re-evaluation in 6 months or 1 year.

Duplication Appropriate: Different courses of acute therapy.

This designation is often used for antibiotics or other acute therapies (prednisone, NSAIDs etc) that have been completed before the next course is started. These are typically flagged for re-evaluation with the next fill of the medication.

Case Study (An Exception)

Today’s Tales from the Counter story starts with a therapeutic duplication; sotalol 120 mg in the AM / 80 mg PM with metoprolol ER 25 mg QD in the AM. One prescription was ordered by the patient’s primary care provider and the other a cardiologist. Both of these drugs are in the same therapeutic class of beta blockers. In this case, the duplication alert is not necessarily a nuisance; it represents a potential problem.

In the case of this patient, the refill history made the problem more difficult to evaluate. Metoprolol was filled in April for 90 days, sotalol in June, and both filled in August. At first glance, it appeared that the medication was changed from sotalol to metoprolol and then back again. To be sure, the patient was approached and asked if they were taking both. The unexpected response was that they were taking both medications (they had just accumulated an excess of sotalol and did not need to refill it until that supply had been depleted).

At this point, we let the patient know that we were going to contact the prescriber to clarify the therapy. A SOAP note was created and faxed that day to the primary care provider. The note simply stated:

Subjective / Objective: KB came into the pharmacy today to pick-up her meds. Pharmacist noted patient is taking both metoprolol ER 25mg QD (Dr. One) and sotalol 80mg 1.5 tabs QAM and 1 tab QPM (Dr. Two).

Assessment / Plan: 

Should KB be taking both metoprolol and sotalol? ___Yes ___No

If not, should metoprolol be D/C’d? ___Yes ___No ___N/A

Less than 24 hours later a reply was received. The response was unexpected by this pharmacist: KB should be on both medications — confirmed with cardiology.

Therapeutics Revisited

I was not expecting this response, and took some time to investigate the possible rationale for this decision. Sotalol is somewhat unique in the class of non-selective beta blockers as it also exhibits cardiac action potential duration prolongation (Vaughan Williams Class III) anti-arrhythmic properties. It is well documented that beta blockade can significantly decrease mortality and improve outcomes in several types of cardiac disease. In the case of a patient with an implantable cardioverter-defibrillator (ICD) and or a biventricular pacemaker, the combination of anti-arrhythmic and betalocking properties of sotalol can be beneficial, making it an excelent choice. Sotalol, being non-selective, may not offer enough beta blockade by itself, and the addition of a low dose selective beta blocker like Metoprolol Succinate 25 mg is therefore rational therapy.  For a good review, see Chaki AL, Caines AE, Miller AB. Sotalol as adjunctive therapy to implantable cardioverter-defibrillators in heart failure patients. Congest Heart Fail. 2009 May-Jun;15(3):144-7.

This is a great time to re-emhasize the importance of documentation. This intervention was addressed as Duplication Appropriate – an exception to the normal “like mechanisms” duplication that would normally be a problem. The intervention and SOAP note, including the physician’s response, was documented and linked to the problem. The next time this problem is assessed in 3 months, the pharmacist will already know the story.

Monitoring

Just because the duplication problem has been addressed does not mean that the pharmacist’s responsibility is complete. In this case, the patient is at risk of the effects of too much beta blockade. This would manifest as a low resting pulse rate. The pharmacy should now regularly ensure that the patient’s pulse is being monitored and/or monitor the patient’s pulse periodically. Both activities should be documented in the patient’s record.

Every day I worry about the future of pharmacy as a profession. The current reimbursement climate continues to resemble a walk through Death Valley, California, without any water in sight. Despite some of the grim realities pharmacists face daily, finding problems (and even non-problems like the one above), and managing the care of patients still excites me. It makes my days enjoyable. And the added benefit of the patient’s gratitude for taking the time to look into the potential problem doesn’t hurt, either. It reenforces the fact that every encounter really does count.