Month: September 2016

Shall we play a game?

The title above comes from the 1983 movie WarGames. The plot of this movie centers around a young computer hacker that manages to access a Department of Defense computer. That computer asks the hacker, Shall we play a game? That game just happens to be Global Thermonuclear War, and as it turned out, the game was actually very real.

Sometimes, an apparently innocuous event can quickly become very dangerous, not unlike the game our hacker was playing. There are few tasks in the pharmacy world more potentially dangerous than filling controlled substance prescriptions. The risks exists on both sides of the prescription counter. Improper use by the patient can lead to significant morbidity and even death. Pharmacists face significant regulatory challenges trying to balance federal laws and DEA rules, all while assessing appropriate prescribing habits and patient outcomes.

Pharmacies and pharmacists are generally well-versed in complying with federal and laws and DEA regulations surrounding the ordering and managing of controlled substance inventory. A bigger challenge is ensuring prescriptions being filled meet all of the rules and regulations to ensure that it is valid. It is not enough to simply ensure that the prescription is not forged. To be valid, a prescription for a controlled substance must be issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice.  The pharmacy has a corresponding responsibility to ensure proper prescribing of controlled substances.

Recently, the DEA has started conducting audits of pharmacies, and they are not just looking at record-keeping for inventory and ordering. Failure to fulfill the pharmacy’s corresponding responsibility to verify the prescription is valid can result in fines of up to $10,000 per violation. Let’s look at some ways to ensure your pharmacy is not subject to this type of thermonuclear attack. Below are what I consider to be best practice principles for controlled substance dispensing.

Check the PMP (Prescription Monitoring Program) and Document Findings

This should go without saying, but every controlled substance prescription you fill should be checked every time. Even if you think you know your patient, and they have only ever used your pharmacy before, be sure they have not changed their habits. Be sure to document both your search and the results.

Determine and document the indication for the medication

If the pharmacist doesn’t know what the medication is being used for, they cannot assess the appropriateness of the therapy. While a pharmacist may be able to guess the probable indication, it is important to verify and document this information every time you fill a controlled substance. Included in this is the expected duration of therapy. All of this information does not necessarily have to come from the prescription or the prescriber, it may be possible to determine parts of this simply by speaking with the patient.

Understand the accepted guidelines for treatment

In order to be able to assess the validity of a prescription, you need to be sure you understand what the standard of care is for the condition being treated. For pain medications, especially, there is a accepted progression that should be followed. Once this is in the back of your mind…

Document previous treatments used and their outcomes

Did the prescriber jump right to an controlled substance (e.g. an opioid), or did they other medications first (e.g non-steroidal medications)? Is the etiology of the condition treatable with non-pharmacologic vectors, and if so, have they been tried? What were the outcomes? In the case of pain treatments, if the pain is chronic, is the patient being followed by a pain specialist? Do they have a pain contract? Each patient is a story, and without knowing and documenting the story, assessing validity of the therapy is more difficult.

Watch Trends

Every course of treatment will have a natural progression. An acute treatment may flare and wane with time and end. Chronic treatments may slowly escalate. All of these may be normal, but it is the pharmacists job to look for potential diversion of controlled substances. By watching trends and speaking with the patient about them as they occur, you can more easily spot diversion and take appropriate actions.

The reoccurring theme in these practices is documentation. While we use a clinical documentation platform (PharmClin) to document these types of activities, the documentation can be done in a variety of other ways. Having this documentation goes a long way toward satisfying corresponding responsibility.  Be sure to take the time to protect yourself, and make every controlled substance prescription a complete story. Make every encounter count!

Unraveling of the PBM Industry?

The role of Pharmacy Benefit Managers, the PBMs, in the US healthcare system has been detailed on this blog several times. And each time, it seems, the public is able to better understand how detrimental some of theses practices are to our healthcare system. A few days ago, a blog post from Lexology entitled PBMs and Drug Pricing: Congress and Major U.S. Employers Start to Unravel the Hidden Pricing Mechanisms of PBMs describes many of these practices.

The overall of awareness of PBM tactics increasing rapidly. This is a good thing for healthcare in the United States, because these tactics have only emphasized the drug product while completely ignoring patient care. Increased transparency will hopefully put pharmacy back into the pharmacy benefit.

The Crucible 2017

Back in in the 80’s, when I was in High School, I had to read the 1953 Arthur Miller play, The Crucible. The play title references a definition of the word crucible that, until I read the play, was unfamiliar to me.

cru·ci·ble noun \ˈkrü-sə-bəl\ a difficult test or challenge
That definition again came to mind this month as we started to prepare for the 2017 Medicare Part D Open Enrollment, which starts next month. The reason it came to mind is this: unlike the last two years, my pharmacies will not be preferred providers in 2017 for several of the most popular prescription drug plans. This change marks a move away from a focus on access to lives. We will soon have to convince patients to continue to use our pharmacy despite their copays being higher than other preferred pharmacies starting in January.
This will be a significant challenge. Over the last 5 years, Medicare beneficiaries have become accustomed to low, almost non-existent copays for prescription drugs. The plans have essentially made prescription drugs a commodity, and in the process forced the reimbursement paid to pharmacies down to historically low levels. In the process, these plans have also completely ignored the importance of the pharmacist and their role ensuring safety and efficacy in the patient’s medication use.
The reimbursement received by pharmacies under the commodity style reimbursement these preferred plans use has been so poor that many independent pharmacies have been either sold to chain pharmacies or otherwise closed or gone out of business. Even chain pharmacies have felt the impact on their bottom lines, though their business model allows for lower profit margins in the pharmacy by controlling prices in other departments.
Previously I have written that access to lives is important, and I still believe that. Being a participant in these narrow networks has certainly not been sufficiently profitable over the last two years, but we have been able to survive. The real question for 2017 is what happens if we lose access to a large number of our patients. Sure, we will make more money on the prescriptions we do fill, but will it offset a corresponding drop in sales due to a loss of patients?
We offer our patients a lot more than drug product, and many of our customers that are aware of this fact. Others will undoubtedly discover this if they follow the discounted copay to a preferred pharmacy in 2017. Our job starts now: educate our customers on their options, making sure they understand the difference between big box chain pharmacies dispensing medications in a commodity model and an independent pharmacy providing service and care.

Re-Blog: Companies you’ve never heard of are making a killing off high drug prices

Business Insider recently put out an excellent article that deserves the attention of legislators and consumers alike. After reading  Linette Lopez’s article  Companies you’ve never heard of are making a killing off high drug prices, you will better understand many of the convoluted facets of this industry.

Don’t Treat the Number, Treat the Patient…

During my senior year in pharmacy school, one of the most important lessons drilled into me was to look at the bigger picture. As a young professional, I naturally tended to look at individual data points like lab values and then make recommendations. Generally speaking, this is a not seeing the forest for the trees type problem. With time, practice, and maturity, I have become much better at evaluating the patient as a whole and not just seeing them as a group of numbers.

This skill is applicable to many different arenas in life, and a gentle reminder is sometimes needed to refocus our priorities. I was participating in conference call discussing the implementation of a new high performing network that launched in Iowa. The discussion was centered on the various metrics being used to assess the performance of pharmacies when the Vice President of Pharmacy Operations for the sponsoring payor made an astute observation to the group of pharmacists. He noted:

[custom_blockquote style=”red”] I am concerned that the pharmacies here are focusing too much on the metrics and not enough on transforming their practices.  [/custom_blockquote]

He could not have been be more succinct. Today, pharmacists and pharmacies are being pushed to perform, and are being evaluated using arbitrary metrics like the EQuIPP measures. But actual performance in the context of healthcare is not easily measured using simple metrics. Too often pharmacists are looking for ways to move a number in the desired direction. Doing this risks losing sight of the ultimate goal, optimizing each patient’s drug regimen. But by simply moving a measure does not equate to a patient receiving better care.

So it is time for pharmacists to take a step back. Take in the vastness of the forest around us. Focus on transforming your pharmacy practice. Instead of simply filling prescriptions, work to understand your patients’ disease states, their therapeutic outcomes, and goals, and the issues they are having. Working with together with your patients in this way will result in both a more satisfying practice and improved outcomes. Take care of the patient, and the numbers will follow. Make every encounter count starting today.

Pharmacy is Being Corrupted by Big Business

Recently, I was reviewing a new prescription for a patient. It was not the clinical ramifications of the newly prescribed Humolog and Lantus that caught my eye. What caught my attention was the fact that on one of the prescriptions I was making money and on the other I was losing money. At issue is the arbitrary nature of pharmacy-PBM contracts. A pharmacy is often reimbursement at a different rate for medication based only on the day supply it represents for the patient.

The PBM industry is operated by businessmen, and not pharmacists. Their contracts are written by lawyers, not pharmacists. It is not surprising, therefore that most of its focus is on regulatory issues and product cost, and not patient care. To wit, PBMs regularly reimburse pharmacies less for dispensing an extended-day versus 30 day supply. This is a business assumption that a practicing pharmacists would not make. Outside of the drug cost, the overhead, time, and materials vary little with the day-supply. And, if the pharmacist is doing their job, the pharmacist will have fewer opportunities to work the patient between long-term fills. This means that they may actually need to spend more time with the patient receiving long-term fills in order to monitor and evaluate the safety and effectiveness of the therapy. It is not surprise, therefore, that a pharmacist views pharmacy in a very different light than a manager at a PBM.

The problem does not stop at the PBM level, either. Most large pharmacy chains have few practicing pharmacists in their management teams. These pharmacists representing the profession at the corporate level, and look at the business of pharmacy in a very different way. They often have very different and conflicting priorities when compared to pharmacists working in the pharmacy department. The fact that so many chain pharmacies willingly sign contracts that devalue the contributions of their pharmacist clearly demonstrate this. This problem is not seen only in the corporate office, either. In a chain, the pharmacy is usually a department within a larger store, and while the pharmacy manager is hopefully, but not always, a pharmacist, the department managers typically report to non-pharmacist store managers who have their own, non-pharmacy priorities.

Finally, big business does not stop at the corporate level. Often, those successful in business gravitate to politics, and work to influence our politicians and government officials. Our elected officials often understand business much better than they understand healthcare and specifically pharmacy practice. When asked how they would characterize Medicare Part D, my senators and representatives have always been very positive, considering it a smashing success. This is because they are looking only at the costs associated with the drug spend, and not the bigger picture of care and how it impacts the bottom line in Medicare spending.

Do not mistake my description above as doom and gloom. While the Big Business is working hard to corrupt pharmacy practice, the pharmacy profession has long been lead by independent pharmacies and pharmacists in this country. And independent pharmacies are constantly innovating and demonstrating the power of patient care delivered by pharmacists practicing at the top of their licenses. This is slowly gaining the attention,  both regional and national levels, with commercial insurers being the first to take notice. Even Medicare is slowly beginning to recognize that quality pharmacy care can help save money outside of the traditional drug spend.

Like a boulder perched on a hill, eventually it will make the journey down. Every pharmacist practicing at the top of their license helps drive the momentum of the boulder. Make your encounters with your patients count. Help us push pharmacy away from big business and back to patient care.