Month: December 2018

Clinical Mayhem​?


Today, there are many forces encouraging patients to use more than one pharmacy. Physicians are directing patients to chain pharmacies with $4 prescription options. Grocery store chains are offering discounts on gasoline for each prescription transfer. Some patients that simply shop around for convenience, price or both. When a patient elects to use multiple pharmacies, commonly referred to as polypharmacy, there are several significant implications, including a few less obvious possibilities, to be considered. Today’s edition of Tales from the Counter describes a few of these gotcha’s.

Like many of our Tales From the Counter, our adventure begins with a clinical intervention. In our case, our workflow identified a patient that was a candidate for an additional drug therapy. Current guidelines suggest patient would benefit from initiation of a statin to lower cardiovascular risks. Our pharmacist took the time to initiate a discussion with the patient about the possibility of adding a statin during their next encounter.

Like a lot of our recommendations, we always make sure that the patient is aware of any possible suggestions we would like to make to the prescriber. This helps the patient maintain a modicum of control over their own healthcare. The success of any therapy change is inherently dependent on the patient’s willingness to participate.

In this case, the patient wanted to discuss the recommendation with their doctor at their next appointment. Our pharmacist indicated that she would send a note to the patient’s physician outlining the discussion that they shared, the recommendation, and the patient’s desire to discuss the possible new therapy with the physician.

The physician reviewed the note our pharmacist sent and their response included a notation indicating that they were sending a new prescription. Because our pharmacist knew that the patient wanted to speak with the doctor about this before initiating any change in therapy, our pharmacist put a hard-stop on the filling of any new prescription for a statin on the patient.  She also took time to call the patient to alert that a prescription was expected and to let her know that we would not fill it until she spoke with her doctor and gave us the green light.

This is where polypharmacy unexpectedly creeps into our story. We did not receive a new prescription for a statin on the patient. Another pharmacy, the one the patient chooses to use for one of their medications based on out of pocket costs, received, filled and called the patient to pick up their new prescription.

The unexpected call about a new medication upset the patient. Our attempt to leave the patient in control of their healthcare failed. We did not anticipate that the prescriber would write the prescription. Nor did we anticipate, or even consider, that the prescription being sent would go elsewhere. We failed our patient on multiple levels despite our best efforts.

The TV commercial character Mayhem, played by Dean Winters, is associated with unexpected and sometimes even catastrophic events. This portrayal also works well for the healthcare clinician. It behooves us to always be on the lookout for the unexpected. Recognize that often we will miss something that later will seem obvious. Our job is to mitigate these challenges. Remember that everything we do should be in the best interest of the patient, but also with their knowledge and permission as well. Our miscommunication could have been prevented. And even our attempt to intervene was thwarted by an unexpected twist.

As you work to make Every Encounter Count, be sure you also stay on the lookout for mayhem lurking around the corner.

Will CMS Mandate Point-of-Sale DIR?

Drug Channels published a nice summary of some proposed changes to DIR fees being considered by CMS. Adam Fein’s commentary does a good job summarizing the current challenges faced by both CMS, the patient. and pharmacies. Among the more interesting data he presents:  while manufacturers’ rebate payments to Part D plans are the largest component of the DIR pie at $29.5 billion in 2017, pharmacy price concessions (as DIR fees) have increased significantly as a share of total DIR pie, from 1.7% in 2013 to 11.4% in 2017. Of course, this comes as no surprise to anyone running a pharmacy.

Adam’s conclusion to the impact of the proposed changes if enacted:

The outcomes—higher government costs and lower manufacturer payments—create political challenges for point-of-sale pharmacy DIR. Pharmacies will cheer the change, while plans will criticize it. Meanwhile, the patient impact is mixed. An unknown number of patients will benefit from lower out-of-pocket costs, but a possibly larger number of patients will see slightly higher monthly premiums.

Jump to CMS Considers Point-of-Sale Pharmacy DIR: Another Prelude to a World Without Rebates? to read the whole article.

 

Flummoxed

I have seen a lot in my years as a pharmacy owner. And while I often discuss the sometimes questionable tactics of prescription drug plans, sometimes I encounter something so disheartening that it gives me pause. So starts this episode of Tales from the Counter.

Several times now, I have had patients question an increase in their copay upon picking up their prescription. One patient noted that their first fill cost her a $23.54 copay while this second refill returned a copay of $71.02. The patient is often surprised to find that the pharmacy rarely dictates the price of the prescription: pharmacies are contractually bound to accept the authorized amount the payer returns. Because of this, I have to refer the patient to their prescription drug plan for any questions about copays.

One consequence a plan’s contract with pharmacies is that the plan can rein in costs. The plan generally will set a generic drug’s reimbursement price to reflect the least expensive product available. This is reasonable, as not all generic products cost the same. And pharmacies work hard to purchase a product that prevents them from losing money. The result: pharmacies must periodically change manufacturers for any given generic product based entirely on the purchase price.  Ironically, in almost every case we see of disputed copays, the discrepancy is related to a change in the manufacturer of the product that we dispensed.

Let’s look at what is going on with a concrete example from a recent patient. Here, between Claim 1 and Claim 2, we changed to a different product (identified by a different National Drug Code or NDC) based on a cost difference to us of about $0.01 per capsule when contracts changed. You might be wondering why we would change manufacturers over a penny per capsule. In the case of our prescription below,  $0.01/capsule differential equates to a $1.80 difference in our cost to dispense.  That represents almost a 14% difference based on the plan’s $12.99 allowable reimbursement.

Let us take a close look at both claims side by side. Theoretically, the plan would treat both generic manufacturers the same and the allowed price and the patient copay would not change.

Claim 1 Claim 2
Product (NDC) A B
Qty 180 180
PBM Authorized $ $12.99 $80.20
PBM returned Patient Copay $ $12.99 $60.00

This is obviously not the case, as the second claim was paid at a much higher rate and the patient’s copay was significantly higher as well. In the case of Claim 1, the prescription drug plan appears to have used a different price schedule than in Claim 2.

It is very disappointing when a prescription drug plan blames the pharmacy for this type of situation, and I have been disappointed several times, with one specific plan regularly and unfairly shifting blame to the pharmacy. The general solution that a plan gives the pharmacy is for the pharmacy to use a different manufacturer’s product (NDC) so the patient will get the correct copay. This leaves me flummoxed. Shouldn’t the plan instead simply correct their price schedules so that the claim processes correctly?

At times I wonder who is actually running my pharmacy. Prescription drug plans tell me what I will get paid. By doing this, they force me to purchase the least expensive products. Now, they are telling me to use a more expensive manufacturer’s product so that our mutual patient will get the best price? This puts the pharmacy in a difficult situation. The plan is quick to tell the patient that if your pharmacy doesn’t use the specific manufacturer’s version of the medication to go to another pharmacy that will, maybe even the plan’s own mail order pharmacy.

Ironically, up to this point, the problem has only manifested with one specific Medicare Prescription Drug Plan. And each time, the plan’s customer service representatives do not mention the patient’s other choice: choose a different Medicare Part D plan.

When faced with challenges like this, it is important for the pharmacist or pharmacy owner to intervene. Work the problem and be sure the patient understands all of their options. Work to overcome the inane obstacles being thrown at the pharmacist, and above all else, Make Every Encounter Count.