Month: February 2024

Do We Need Pharmacists?

If the title of this article makes you uncomfortable, it should. This is the exact question my business partner, Randy McDonough posed to our pharmacists at a recent clinical meeting. The profession of pharmacy is literally at a precipice. The future of pharmacy depends on how every pharmacist answer this question.

The issue facing the profession is one of initiative, or the lack thereof. For years, thought leaders in pharmacy have been pushing pharmacists to perform at the top of their licenses. We have been asking our staff to do more than simply count, pour, and label drug product. We need our pharmacists to leverage their relationship with the patient to help them active their drug therapy goals. We need pharmacists to monitor outcomes. We must have pharmacists that take the initiative to act as health care providers, not simply drug dispensers.

Yes, there are pharmacists that are doing some or even all of this. The problem for the profession is that these outstanding individuals are in the minority. Today, many pharmacies are struggling to keep their doors open. I am not just talking about independent pharmacies. Even the larger players are having difficulty maintaining enough profitability to continue to provider pharmacy services.

The key to the next generation of pharmacy is getting paid for clinical services that pharmacists can, and in some places, are already providing. The problem is one of timing. Pharmacy owners and pharmacists desperately went to be paid for their services. But many, even most, are not providing the services, nor are they even ready to start. This is a classic chicken / egg problem. Pharmacies have to prove themselves in order to be paid for the services, but many pharmacy owners won’t make changes until they are already getting paid.

Additionally, even if a pharmacy owner is committed to making these changes in order to be ready for future of clinical revenue, finding pharmacists that are willing to put forth the effort required is unbelievably difficult. Far too many pharmacists have become complacent. They are being paid very well to do very little outside of dispensing functions and they are far too comfortable with their limited responsibility. The thought of putting their clinical skills to work is both scary and daunting.

The answer to the question posed at the beginning is actually easy. Yes! Hell yes! Pharmacists are definitely needed. But the pharmacists that are needed are not those that are simply dispensing. Dispensing will eventually become extinct. Healthcare is evolving, and these skills don’t require highly paid professionals. Where we are headed, like it or not, is going to make a lot of pharmacists and pharmacy owners uncomfortable. Change is hard. Change is inevitable.

So if you are a pharmacist, ask yourself this tough question: Am I ready to take on the new challenges of healthcare? Am I going to evolve to become a clinical interventionist? If the answer is yes, and I hope that it is, then you need to start now. Be ready to prove your importance in healthcare. Learn new skills. Advance your practice site. And above all else, Make Every Encounter Count.

Bait-and-Switch?!?

Pharmacy is a difficult business for a lot of reasons. The PBM industry, years ago, turned the profession upside down by transitioning from selling a service to pharmacy (processing claims) to selling access to their pharmacy networks, and later also selling patients of those networks as a commodity. This pivot made pharmacies essentially dependent on the PBM industry for access to their own patients.

When a PBM is involved, pharmacies do not have any real control over what they are paid for product or work. If a PBM wants to pay a pharmacy less than the product costs, a pharmacy has few alternatives. The only way to take back control is to cancel contracts with a PBM network. Of course, this also carries the risk that patients using that insurance will go to a different pharmacy to use their insurance. A serious Catch-22.

There are examples, however, when pharmacies do cancel contracts. I have seen pharmacies drop major payers due to poor reimbursement. The question becomes, if I am being reimbursed so poorly that I will go out of business if I continue to take the insurance, then the loss of that bad business might be enough to keep the doors open. This is akin to amputating a leg with gangrene. Tough choices need to be made in order to survive.

Some contracts that are bad for a pharmacy have less draconian implications. A good example is a discount card with high transaction fees leaving little or no margin for the pharmacy. These cards may advertise themselves to patients as a good option, but they are bad business for pharmacies. As there are many options for discount cards, cancelling an egregious contract for a discount card is not as risky to the pharmacy as cancelling a network based insurance contract.

Pharmacy is also a very dynamic industry. One cannot become complacent as things are always changing. The PBM industry has a new trick up its sleeve: piggyback discounts. The PBMs claim that they need to offer their clients (businesses and insurance providers) better copays. Never mind that the PBM completely controls the copay structure. They want to reduce copays but not impact their own pocketbook or cost their customers more money. And they have found a way to achieve this.

Today, when some PBMs receive a claim electronically from the pharmacy, they then submit the claim to one or more discount cards. If the discount card offers a better price than the PBM’s logic, it uses that instead. This all happens outside of the normal claim response loop. In other words, the claim is sent to and returned from the insurance, but it also took a stop elsewhere. Essentially, a bait-and-switch tactic on the pharmacy.

This extra (and secret) hop can create problems. For example, some of the discount card partners being used by the PBMs are the same one that many independent pharmacies went out of their way to cancel. The PBM, with this new program, has essentially overridden the pharmacies preference to not do business with what they perceived as a bad player by piggybacking the discount plan’s contract onto the PBM’s contract with the pharmacy. The PBM contract has vastly more significance to the pharmacy if it wanted to opt-out.

The biggest challenge with the new tactics is that it is essentially transparent to the pharmacy. Unless you are looking closely at the claims, you will be unlikely to notice that it happened. We have also been told that patients and payers are also unaware that this switch is taking place. So how can a pharmacy ascertain if this is happening? There are a few things you can do to flag these claims in your pharmacy system.

  1. Ask your switch to capture any of these types of claims and then return a soft-reject, essentially giving you an alert that something has happened. At this time, our switch is working on an implementation, and expects that it will be ready to deploy in April of 2024. If this is not soon enough for you (and it isn’t for us), then continue below.
  2. Create a filter or restriction on claims based on an ingredient cost paid field returned by the insurance. Look for when the returned value is less than $0. This is NCPDP D.0 field 506-F6. Discount cards in general return a negative value here (this is the claw-back or fee the card takes). This is a very GENERAL test for claw-backs and discount cards.
  3. Finally, and most specific, create filters or restrictions on claims based on the Network Reimbursement ID field. This is NCPCP D.0 field 545-2F. What you look for here depends on the payer. The values and their affiliated plans to capture in the field are:
######GDRX for GoodRx where the ###### are numbers (often a BIN number) *  
######SSRX for SureScripts with the ###### like above again *
CNTRCT5001 for the Caremark internal discount card
CASH for Cigna patient not covered anymore discount card
NET=9185 for the Humana OTC discount / not covered item
OPTPRP is the Optum Patient Relief (no longer covered)

*Because the ###### component may change, you will need to look for the static part by using logic like "Contains GDRX" Alternatively, you may find PBM published payer sheets that outline the actual numbers. In my state, for example,  the insurance using GoodRx returns 999999GDRX in 545-2F.

Most of the above programs have very high fees. These fees fall on the pharmacy, and not the PBM or the patient! The list above is not guaranteed to be complete, and values can change.

Personally, I consider this tactic unethical. As the tactic is just now appearing in our area of the country and we don’t have enough data at this time to fully comprehend the implications nor the significance of the change. One expert on pharmacy contracting indicated that the strategy was used in other areas of the country in the fall of last year. That plan phased the strategy out, apparently using what it learned from the discount card partnership to lower their own Maximum Allowable Cost (MAC) pricing.

Assuming that this practice is here to stay, what can a pharmacy do? A pharmacy refusing to run these claims has to understand the contractural implications. Refusing to run claims might put your pharmacy in violation of a network contract and run the risk of being terminated from the network.

At this point, our pharmacies are collecting data: we have implemented filters to flag these claims as they occur. Our staff has been instructed to document the information and forward for analysis. Until we understand how this strategy is being used in our area, we cannot formulate our response. With more information, we can decide what our response might be going forward. Your assignment this week: put these types of flags into place in your pharmacy and prepare to make Every Encounter with your claims Count!

Footnote: If you are not sure how to implement a restriction or alert on your pharmacy system based on returned claim information, contact your pharmacy management software vendor. I am familiar with two common systems being used by independent pharmacies, Pioneer and Liberty. Both allow this type of implementation. Others undoubtedly have similar features.

Comparison: Strip Packaging workflows

Recently, our pharmacy revisited our strip packaging robotics: our current packager was getting long on the tooth, and we were interested in either upgrading or investigating other options. Ultimately, we added a new product to our arsenal.

Target Market

There are a few different strip packaging options available in the market today, and while they all create a similar end-product, their design and operation might influence the type of practice they best compliment. For simplicity, I divide the market into two groups — Long Term Care (LTC) focused pharmacies, and Community / Retail focused practices. The difference between these two groups, for my purposes, are primarily centered on the duration of packaging provided. A LTC pharmacy supplying medications for facilities will provide strip packaging frequently: the day supply provided to facilities generally ranges from 1 to 14 days at time. In contrast, community pharmacies doing compliance packaging would package no more frequently than every 14 days with most patients receiving 28 to 30 days’ worth of medication at a time.

The packaging machines that are required to support these two examples are designed very differently. Machines designed for the LTC style of practice ideally can house hundreds of medications at time. An example is the Parata Pass family of devices. The RxSafe RapidPakRx was designed with community pharmacy compliance packaging in mind. Both machines could technically be used in either environment, but their operation outside their focus space would less than optimal.

Canisters

The volume driven Parata machines house a large number of small containers (208 to 576 drugs) that contain a carousel optimized for a specific size and shape of medication. There are thousands of possible cassette wheels available. For a given canister, even small changes in tablet or capsule size mean that the canister will either work poorly or not at all. Without a canister, the efficiency of the packaging operation drops precipitously. 

The RxSafe RapidPakRx, on the other hand, takes a very different approach. Instead of hundreds of canisters, the RxSafe product has only 20, 30 or 40 canisters. The mechanism in the canister is also much more elegant–it is capable of dispensing a wider range of different sizes and shapes, including half-tablets. The dispensing wheel used in the RxSafe product comes in just 5 variants that optimize efficiency for very small to very large dosage forms.

The RapidPak canisters are large, accommodating larger quantities of medications needed the longer day supply used in the community setting. They are also easier to clean, which is important, as the canister is not typically dedicated to one medication. While you can assign a few canisters in the RapidPak to be fixed — staying on the machine between batches like a Parata canister, most of your stock remains in the manufacturer’s stock bottle, optimizing product shelf life and limiting overall inventory. Infrequently used Parata canisters can go weeks to months between refills, meaning the drugs spend extended times outside of the sealed, desiccated bottle. Inventory management is more difficult when product stays in the machine.

Smarter

The difference in canister design also ties in another important feature. A machine like the Parata uses an optical sensor to register the drop of the medication. If the cassette was loaded incorrectly but the dosage form fits the canister, it will drop the wrong medication into the pouch. I have had this happen more than a few times, and it is as scary as it sounds. The RapidPakRx uses a very different, and much smarter and safer mechanism.

The RapidPakRx canister wheel picks up the tablet or capsule and it rides up the wheel until it is deposited onto a platform. Here, a camera inspects what was presented by the canister. It first checks that only one item was dropped, emptying the platform, and trying again if it did not receive a single unit. With one unit present, it inspects the size, shape, color, and markings to ensure that the correct medication is on the platform. If it doesn’t match with a very high level of certainty, it rejects the unit and tries again. If it fails multiple times in a row, it will alert the operator so the drug can be corrected, or the canister size changed (wrong canister size results in poor drug capture — too many or two few reach the platform). Once the product is correctly identified, it is then dropped into the awaiting package pouch.

In practice, this mechanism is nothing short of amazing. If one accidentally put the wrong medication in a canister, or even a different generic manufacturer version of the right medication, it will almost always know (and flag an error). If one or two tablets of a different medication are introduced into the canister accidentally, it will reject them. Only in a case where the medications that are virtually identical to each other might the machine logic fail to notice the change. Using this mechanism, you have a very high degree of certainty that the right medications made it into the medication packs, despite any introduced human error.

Workflow and Speed

The RapidPakRx was designed with a retail / community pharmacy workflow in mind. With only 20 to 40 canisters, you load each canister every time you package. At first glance, this might appear to be a large inefficiency compared to a Parata style machine with hundreds of medications loaded, but the difference is not as significant as you might think. Working with the Parata, you typically replenish multiple cassettes before a given run, and if the inventory number is off, you may end up having to replenish them during the run as well. For volume runs (large numbers of patients for short time frames), the Parata still has an edge, but the RapidPakRx is respectably efficient if the drug storage shelves are located close to the robot.

The RapidPakRx also comes with an optical tablet counter: we opted for the GSE EyeCon device (spoiler alert, the parent company of the EyeCon also purchased RxSafe). In a community / retail setting, the pharmacy management system integrates tightly with the EyeCon, documenting the initial product verification. The EycCon saves the images of the count (including NDC and a check on the size and shape of the product) back to your pharmacy system: there is a robust electronic paper-trail. After the initial verification, the RxSafe software collects additional information on the product (like Beyond Use Date), the product is dropped directly into the cassette and placed on the robot. The workflow on a Parata is similar but counting is done by weight (less accurate) and the audit trail is not quite as robust.

Packaging Materials and Cost

On the subjective side, my patients are almost completely in agreement: they prefer the RapidPak pouches. This is due to their stiffer paper backing and the exceptional quality of the printing. The Parata strip packs are all cellophane. Parata offers a white / clear cellophane that offers similar readability, but it in my judgment, it is less legible than that RxSafe. The Parata cellophane is also more prone to wrinkling, making them harder to read after they have been rolled up and boxed. Here the edge goes to the RxSafe product.

Cost of materials for the RxSafe is also better. When we did a cost analysis of the packaging materials used versus standard prescription vials, the Parata packaging was roughly the same. The RxSafe packaging supplies are less expensive, creating a net savings versus rx bottles with time.

Integrated Checking

When we first started with our Parata packager, we did all checking by hand. This was a tedious process and was prone to fatigue. Eventually we purchased a Parata Perl imaging workstation. This allowed us to image each envelope and use the images to do the final verification more quickly. This was a significant added cost as the device is not included with the robotic packager.

The accuracy of the Perl’s integrated verification (where it flags things it doesn’t recognize as correct) drops significantly as the number of doses in each pouch goes up. We found that if we had more than 4 or 5 tablets in a pouch, the accuracy dropped quickly. While the pharmacist had to look at every pouch, the pre-check (when it worked) would dramatically decrease the time required to check the product.

The RxSafe has integrated product imaging and verification included in the cost of the robot. As mentioned earlier, the verification taking place when the product is dropped dramatically decreases the chance that a wrong product is dropped. It also decreases the chance of extra doses falling, something that was common with the Parata device. After the pouches are sealed, a photo is created of the commingled product. Like the Parata Perl, the RxSafe verifies what is in the pouch and flags issues.

Both units have decent software interfaces for checking. The Perl relies on many camera tweaks and once set properly it does a decent job. The RxSafe’s software is newer, and suffers a few minor annoyances, mostly because I have seen both and like some things and miss others. The checking experience on the RxSafe is marginally better than the Perl, but the Perl’s software is probably a little more refined. 

If your pharmacy is doing packaging and looking for a strip packaging solution, both devices deserve your consideration. Depending on your workflow and your market niche, one product may serve you better than the other. For community pharmacies doing compliance packaging, the RxSafe product is probably the winner. If you are servicing many different facilities with frequent med exchanges, the Parata would win hands-down. When you are considering purchasing a robot that costs as much or more than a nice house, it is important to understand the niches the machine services best. 

Counter-Productivity and the CancelRx Message

Today’s topic will not be new to the pharmacists that read this forum. The purpose today is to give pharmacists a chance to share this information with providers and patients with the hope of increasing the awareness of some of the more challenging aspects medication therapy management: how to reconcile medications when the pharmacy doesn’t know a change has occurred.

Let’s look at a scenario that came up today. We received a call from the hospital looking for a current medication list for a patient who was being admitted. This is fairly routine: medication reconciliation is a staple of the admit and discharge process from hospitals. During the call, the pharmacist doing the reconciliation questioned one medication we were providing: they recalled reading a clinic note that referenced the medication being discontinued. Our records did not show this change.

Often, the patient’s own pharmacy is the last to know when a change is made, and sometimes, we are never informed of changes. How can this be? Many hospitals and doctors give the patient a post-visit summary. This might include changes in how they are to take a medication, new medications to start, and old medications to stop taking. Sometimes the patient will share this with their pharmacy. This is ideal, and we train and encourage our patients to provide us with a copy when they receive one so we can reconcile their medications on our side as well.

If the patient doesn’t share this, some of the changes will still become apparent. For example, a new medication will result in a new prescription being sent to the pharmacy. In the other scenarios, though, there isn’t any communication of the changes made back to the pharmacy. The change may eventually come to light when the patient requests a refill early or doesn’t need a refill when we expect. Both of these scenarios depend on the pharmacy being very proactive.

Independent pharmacies like ours are proactive. We leverage Medication Synchronization (MedSync) and make calls to patients a week or so before they are due to get refills to ask about changes and confirm what needs to be filled. Changes may become apparent at this point. Pharmacies that do not have these types of program may completely miss these changes.

When a pharmacy packages patient medications, the lack of communication could result in changes not being made promptly. There really should be a better way to communicate. As it turns out, there is. SureScripts has supported the CancelRx transaction for quite some time now.

The CancelRx message is a message to the pharmacy to discontinue one or more prescriptions that the prescriber previously sent. This message, when used, alerts the pharmacy of changes that they otherwise might not be alerted to in a timely manner. Unfortunately, some providers don’t use this message, or their electronic health record (EHR) doesn’t support the message.

This message is not without its own caveats. We routinely receive CancelRx messages from providers to cancel the old Rx at the same time we receive a new Rx for the same item. If the doctor, however, forgets to send the new Rx, the medication might be instead be just discontinued. Today we received a host of CancelRx messages for seizure medications without new prescriptions following. This resulted in a call to the provider to ascertain their intent.

It should be apparent by this point that communication between the patient, prescriber and the pharmacy is exceedingly important. With our without the CancelRx message, the pharmacy needs to be in the loop on any changes being made. The patient can help by providing their after-visit or discharge summaries to the pharmacies promptly. The prescribers can make judicious use of the CancelRx messages, as well as other communication avenues.

The pharmacy has a job in this as well. The pharmacy should be documenting and providing regular feedback to the prescriber, including the current list of medications. Every message, SOAP note, and request that our pharmacy sends to a provider includes a current medication list as we have it documented. This includes supplements and medications that may come for other providers. This helps close the loop of communication between the provider(s), patient, and pharmacist.

The take-home lesson today: Patients — provide your pharmacy with a copy of the information you receive from your visit or hospital discharge. Prescribers — be sure to communicate changes not only to the patient and their caregivers, but also to their pharmacy. Finally, pharmacies need to provide feedback to the providers, both with respect to current medications and supplements the patient is taking as well as any issues, side effects, or concerns the patient voices to the pharmacy staff. In short: Make Every Encounter Count!