The Thriving Pharmacist covers a lot of serious pharmacy topics. But sometimes a little good humor is in order. Recently, on Slate, a great pharmacy related quiz appeared: Is it a Pokemon or a Cholesterol Medication. Be sure to check it out.
For those Pokemon Go! players out there, be sure to catch only the Pokemon. Some of these are tricky!
Okay, maybe it seems that I am obsessed with writing about the 90-day supply. I have long maintained that our ability to care for a patient is directly correlated with the frequency we see them. Only seeing a patient every 90 days is often not frequent enough to enable quality care. But today, I hope, even strong proponents of mail order and the 90-day fill will agree that 90-day mail order fulfillment of narcotics is a really bad idea. Let’s begin today’s edition of Tales from the Counter.
Recently, while working to fill a prescription for generic Percocet (Oxycodone / Acetaminophen), the insurance rejected the claim. The claim response indicated that the prescription was filled by a mail order pharmacy about 40 days ago. Like most mail order prescriptions, it was filled for a 90-day supply.
Seeing this reject made my blood boil. The anger I felt was not because I lost business to an out of state pharmacy that provides a drugs as a commodity instead of providing personalized patient care. We see medications offered as an inexpensive commodity far to often, and getting angry about it doesn’t help. I was angry because of the implications of mail order, 90-day supplies of narcotics.
The most common argument for the use of mail order pharmacy and 90-day supplies is that they are appropriate for maintenance medications. Once a patient’s therapy has been optimized and is stable, longer periods between monitoring by both the prescriber and the pharmacy may be acceptable. Medications for high cholesterol, for example, would be reasonable 90-day candidate. Once the patient has been dosed on the appropriate statin intensity level and labs have been checked (e.g. liver function tests), then it may be appropriate for the pharmacist to assess the patient for adverse drug reactions every few months. Other medications commonly promoted for mail order and 90-day supplies, though, may be less clear cut. Medications for diabetes and blood pressure, for example, certainly can benefit from more frequent monitoring by the pharmacist, and may not fit the 90-day model as well.
But are narcotics maintenance medications? I argue that while a patient might be dependent on opioid pain medications, and chronically using them, the treatment of even chronic pain should always be regularly monitored by both the prescriber and the pharmacy. The 90-day supply, quite frankly, isn’t conducive to this level of monitoring, and the lack of oversight is a significant concern. Also, there are major concerns that opioids are overprescribed and overused and the 90-day supply increases the potential risk of this medication-related problem.
Besides monitoring issues, the potential for diversion also becomes a significant concern. This ties in with the epidemic of narcotic abuse both here, in the United States, and worldwide. Narcotics delivered by the mail or currier services are at significantly higher risk of diversion. Unlike a retail pharmacy, where the patient and their caregivers are often known, a mail carrier or currier is at a significant disadvantage. HIPAA rules mean that the currier cannot know what the medication is or even that this is a narcotic. And while they may have to secure proof of delivery, the person accepting the delivery is generally unknown to the currier. Add to this the large quantities involved with extended day supplies, and the opportunities for diversion become even more significant.
Previously, we wrote about narcotic diversion and the responsibilities of the pharmacist in a blog entitled Pharmacy Street Blues (Link). Most of the methods pharmacists use to detect forged or counterfeit narcotic prescriptions rely on the pharmacists relationship with both local prescribers and the patients. A narcotic prescription doesn’t have to be forged to be illegal, either. There are prescribers writing for narcotics that are not following the DEA guidelines. Being a local provider makes it much easier to recognize this type of behavior. Any pharmacy without a local storefront, is going to be at a significant disadvantage in spotting both forged and illegally prescribed controlled substance prescriptions. Patients with pain issues need to have a team of providers who are communicating closely with each other to ensure appropriate patient outcomes.
The other side of the narcotics epidemic is what is sometimes called fringe prescribing. These are narcotic prescriptions that are legally prescribed but probably not fully compliant with the prescriber’s responsibilities according the DEA. Spotting these problems and addressing them is very difficult when you are dealing with a local prescriber and patient. State run Prescription Monitoring Programs are an important tool, but these documents, which show the patient’s controlled substance history at all state pharmacies and from all prescribers, are difficult to interpret due to frequent inaccuracies. Having a local relationship with the providers makes the process of spotting real and potential issues possible.
Obviously, controlled substances prescriptions are being mailed, and this practice is legal. Pharmacies participating in this practice are certainly aware of the issues and likely have some safeguards in place to minimize issues. The problem is that distance creates a large impediment to performing all of the necessary due diligence. With the large volume of prescriptions mail order pharmacies process, it is not hard to imagine that problems are more likely to slip through. It is my opinion that the risk associated with mail order narcotics outweighs the convenience of the service. Your comments are welcome below.
One of the more interesting and important findings from a pilot we recently participated in was the financial impact pharmacy can have on a payor’s total health spend. Spoiler alert: it can be very significant. But teasing out exactly what a pharmacy is doing to decrease health spend is difficult, and one of the only ways to do this is to look at what differentiates a high-performing pharmacy from those not saving the payor money. In our case, our pharmacy offers a variety of uncommon and even unique services, and we suspect that this is one of the driving forces of our impact on total health spend, but finding concrete examples requires thinking in a different way. This weekend, while taking care of a patient, I had an epiphany. I realized that what I was doing was saving the system a lot of money.
It was a dark, and stormy Saturday night. Well, not really stormy, just dark. One of our patients was scheduled for an appointment on the previous Friday. The appointment was to administer an injection of haloperidol, a medication used to treat the patient’s mental illness. The patient missed their appointment, and our pharmacist called to remind the patient’s helper by phone that afternoon. By closing time on Saturday, the patient still had not presented to the pharmacy to receive their injection.
So on Saturday night, well after our pharmacy closed, I received a call from the patient’s service coordinator. They had just recognized that the patient missed their appointment and the medication. To make matters worse, the patient’s behavior was becoming a problem. If the patient could not get the dose soon, they were instructed to go the the emergency room where they would have administered the medication. Based on previous history, it was likely that if the patient did go to the ER, they would likely also be admitted for observation or even admitted.
I found myself at my pharmacy after 9 pm giving the patient the medication they required. Sometimes, because we are so involved in what we are doing, we fail to recognize the bigger picture. It was not until later in the weekend, while taking care of another patient after hours, that I had my epiphany; by taking the after hours call, I undoubtedly created a significant savings for the payor. I have since started thinking about the impact of many of the day-to-day activities I do as a pharmacist in a different light. It doesn’t take a lot if imagination to see the value in the services we offer.
At this point, however, pharmacists are not reimbursed for their time. This must and will eventually change. By sacrificing 30 minutes of my Saturday night, I earned the gratitude of the patient and their advocate. My sacrifice also created a significant impact on healthcare costs. I can truly say that I made that encounter that count. I challenge everyone here to start thinking differently, and be sure to make every encounter count.
The term clawback, when used in pharmacy, refers to an adjudicated claim for a medication that includes an extra fee to be paid by the patient above and beyond the cost of the medication. In the most basic form, a clawback looks a little like the following:
In this simple example, the pharmacy will collect $15 from the patient. The payor will then collect $5 from the pharmacy. If this seems complicated, it is. A local television station in New Orleans (WVUE, FOX 8) recently released an investigative piece on the practice Copay or you-pay? Prescription drug clawbacks draw fire. The information in both the video and the text do a good job of explaining this complicated topic. Follow the link to review the materials.
One assertion made by the report, in the Thriving Pharmacist’s opinion, is not completely accurate and merits additional clarification. This has to do with a pharmacy’s cash price potentially being lower than the clawback price. This is never true; a pharmacy must charge the same usual and customary price for cash customers as they submitted to the insurance. This means that the cash price will necessarily be higher than the adjudicated claim plus the clawback. That being said, it does not mean that there are not other discount programs available that could make the same drug potentially less than the clawback price. It always pays to ask, and in my experience, pharmacists generally don’t like clawbacks. If there is another way to help the patient pay less, they will tell you about it.
This month, the EQuIPP platform that pharmacies and pharmacists use to determine how well they are performing added a new measure. The measure is entitled UHC 90-day Fill Rate. The an example of the measure and is shown below.
This measure is only displayed by EQuIPP when viewing Goal: Full Measure Set. This is not a CMS measure; it is what is referred to as a display measure or health plan custom metric. Medicare is not using this measure as a measure of plan success–it is an example of a plan creating a measure that it is interested in improving. In fact, it relates directly to the 90-day performance program I wrote about the blog post entitled Is There Anything Special About the 90-Day supply?
The report above is for one of my pharmacies. It appears that I am not meeting the expectations of the plan, with a current score of 50% and their goal of 70%. But in order to really understand the measure, one needs to know what it really means, and how it is being calculated. According to a source at PQS,
This measure tracks the percent of qualifying patients who were last dispensed an extended day supply ( > 60 days). This will focus on the same medications that are included in the PDC adherence metrics for UHC Medicare Advantage.
As I described in my previous 90-day blog post, plans like UnitedHealthcare are looking to improve their compliance (Percentage of Days Covered or PDC) based measures by incentivizing the 90 day supply. But the measure does not actually take compliance into account. The measure is based at the patient level and is calculated as:
Patients with at least one qualifying PDC drug receiving greater than 59-day supplies
the total number of plan patients qualifying for a PDC measure
I should note that a patient needs to qualify for the PDC measure in order to be included. There is a minimum number of fills required during the 6 month period before the patient is included in a PDC measure.
Going back to the PDC basis of this measure, it would be interesting to see how the qualifying patients are doing with respect to compliance without respect to 90 day supplies. Looking at the UHC 90-Day Fill Rate measure details (within EQuIPP), we see:
The details above show 22 total patients reported. The MAPD patients (listed above under Quality Improvement Programs) are a good place to start, because these same patients are broken out by plan in the individual PDC based measures for each PDC drug category. Below are the overall PDC specific details for each drug category.
Looking at the UnitedHealthcare MAPD lines, the total number of patients totals 14, matching the UHC 90-Day Fill Measure. The other feature that stands out is that all 14 patients (100%) are compliant over the last 6 months over every PDC category.
So despite having perfect (>80% PDC) compliance, my UHC measure reads 50% only because my patients prefer to receive their medications in increments of less than 60 days. Our excellent performance on all of the PDC measures is due, in large part, to the high level of engagement we have with our patients, and this engagement is driven primarily by the 30 day fill cycle. Note that there is no penalty associated with not meeting the UHC 90-Day Fill measure. UnitedHealthcare does, however, reward pharmacies for converting a patient to 90-day fills. Participating in this program, however, only decreases the frequency of the opportunities we have to engage with the patient and impact PDC.
This brings us back to the plan’s decision to create the UHC 90-Day measure and reward pharmacy conversions to 90 day supplies. CMS provides incentives to MAPDs if their network pharmacies perform well on the the CMS Threshold measures. If the impetus of UnitedHealthcare’s 90-day measure is to improve PDC measures, then why don’t they simply use the CMS PDC measures already in place? Why create a new, plan specific, measure which is only loosely correlated to the desired outcome? The only explanation I can muster is that, perhaps, improved PDC is not the plan’s actual goal. It would be nice if UnitedHealthcare more clearly communicated its goals to the pharmacies that are providing patient care.
Each pharmacy will have to decide if they wish to take UnitedHealthcare up on its offer to reward them for these conversions. For us, however, losing opportunities to interact with the patient is not worth it. We will continue to make every encounter count.
The other day, I wrote about a case involving a medication for which the plan required to be filled at a specialty pharmacy. This was an example of fragmentation of care. In Pharmacy, fragmentation is often either financial, or the result of contractual requirements imposed by benefit managers or plans. Examples include:
The list could go on, but each example has the same consequence: the complete patient record resides across multiple pharmacies. The record is fragmented. This makes it much more difficult for any one pharmacist or practitioner to have a complete understanding of the patient’s medication therapy, making assessing and monitoring the patient’s therapy much more difficult.
The implications of care fragmentation are significant. If the pharmacist cannot accurately determine if the prescription they are filling is appropriate, inappropriate or even dangerous, problems will arise. Problems, in the context of prescription medications are, at a minimum, undesired. They can be a lot more significant, too; the worst case scenario might death. While the PBMs do pass pharmacies some information about medications filled by other pharmacies, the data is mostly designed to prevent duplicate fills of a given medication. It is paramount, therefore, that pharmacists work combat both fragmentation and its consequences.
There is no way to completely eliminate fragmentation as long as our system puts its emphasis on reducing cost, and not on patient outcomes. While an outcomes based system may be something that will eventually become prominent in our country, we cannot afford to wait. We need to combat this problem, and the weapon of choice is communication.
The first problem for the pharmacist is identifying fragmentation. Patients don’t just walk in and announce that they use four different pharmacies. Using tools like electronic claim notifications and rejects can alert you to the existence of some forms of fragmentation. Communicating with the patient, however, is the best way. Regularly ask the patient what other medications they are taking that your pharmacy doesn’t provide. Any time you discover the potential for multiple pharmacy use, it is important to document your findings in the patient’s pharmacy record. More to the point, communications need to be initiated to ensure that all pharmacies involved have a good understanding of the patient’s therapies and outcomes. Once the problem is identified and information exchanged, the immediate crisis is over. It is now time to address the root cause of the fragmentation.
I always start the discussion with the patient. It is important to understand exactly why they are using more than one pharmacy provider. I always emphasize the importance of having a single pharmacy home, but I am always watchful for circumstances that will prevent this from occurring. Once I understand the reasoning, I look for solutions.
Mis-information is also a problem, and education is a part of the this solution, as well. I have personally observed prescribers sending patients to multiple pharmacies for a variety of reasons. Mostly, though, they are simply trying to help the patient get the best value for their healthcare dollar. Prescribers understand that the medication doesn’t do any good for their patent if they cannot afford it or fail to take it regularly. This is a great place to educate the physician on the value of the pharmacist in the equation. Spend some time visiting with prescribers. Let them know what a good pharmacist does to ensure good compliance. Talk about medication synchronization and compliance packaging. Make sure they understand that a single pharmacy home may have a larger impact on outcomes than price alone. If they have an open mind, you may change their habit. What is more, you might actually receive additional referrals for your efforts.
Ultimately, fragmentation comes down to choices. Our job is to be sure that people making choices do so with the best information possible. If we do our job well, everyone benefits. Make your encounters count.
I am seeing more and more drugs that are being moved from traditional retail status, meaning that you can get them from your local pharmacy, to specialty-drug status, available only from a designated pharmacy. According to Specialty Pharmacy Times:
specialty drugs or pharmaceuticals usually require specialty handling, administration, unique inventory management, a high level of patient monitoring, and more intense support than conventional therapies.
If one accepts the definition above, cost alone should not be enough to limit the product’s availability in the retail sector. However, the assignment of specialty status appears increasingly arbitrary, regularly focusing on drug cost. The arbitrary nature of the specialty moniker is most apparent when comparing different insurance plans. The same drug can be considered specialty in one plan, but not special in another.
The state of Iowa recently switched its Medicaid recipients from a fee-for-service program to a for-profit managed care model. Originally, these plans were not going to be allowed to limit mediations to specialty status, but this stipulation was dropped in the 11th hour before implementation. It took less than 24 hours for one of our patients to be affected by this change.
One of our Medicaid patients has been receiving Invega Sustenna from our pharmacy. This patient was switched to one of the three MCOs now managing our Medicaid population. Like many of our patients receiving medications by intramuscular injection, our pharmacy actually administers the medication to the patient. The prescribers in our area, for a variety of reasons, often do not want administer medications in their offices. These practitioners rely on us to administer the medication. We order the medication, schedule the administration appointment, and administer the injection.
On April 1st, however, the new MCO returned a rejection for the Invega Sustenna. They require that the medication be filled at a specialty pharmacy. Going back to the definition above, the medication exhibits few, if any of the attributes listed. Cost alone appears to be the primary consideration.
A call to the MCO simply confirmed that they required the medication to be filled at a specialty pharmacy. When asked what was special about this medication, they replied that it was an injection. That answer did not impress me; I dispense a lot of not-very-special medications that just happen to be in an injectable form. When asked how they can provide the medication in a timely fashion, they offered to overnight ship it to the patient. I asked the MCO who was going to give the medication. They told me the patient would self-administer it or that a doctor would give it in their office. It is at this point I broke the bad news to the MCO representative: giving oneself a deep IM injection is not something most want to do, and the prescriber doesn’t give these injections in their office. I informed him that our pharmacy gives the injection to the patient.
After spending some time explaining these realities to the plan, I was able to secure a one time override for the medication because the injection was already scheduled and due to be given. This bought the patient some time, but it does not solve the problem. The medication is still arbitrarily designated as specialty-only. The plan, after learning that our pharmacy both provides and administers Invega Sestina to nearly a dozen similar patients, promised to follow-up and offer us a specialty pharmacy contract. I am not holding my breath. I expect to have the same problem again in a few short weeks.
Specialty pharmacy should be about more than the medication cost. As ASP’s definition states, it should require special equipment, expertise, or something above and beyond simply dispensing the medication. I have no doubt that for some drugs, the designation is warranted. Here, however, I am skeptical. Compared to a standard retail pharmacy, what the plan’s specialty pharmacy could do differently is not immediately apparent. There is nothing special about Invega, it is just an expensive, injectable medication. On the other hand, what we are providing is special. We are providing care.
With the FTC considering the pending merger of Walgreens and Rite-Aid, the consequences of pharmacies owning PBMs may once again be considered. It has been several years since FTC approved the CVS / Caremark merger, and the changes and consequences of that merger are now visible. It is imperative that these issues of potential conflicts of interest are revisited. For an excellent overview, read:
Big pharmacies are dismantling the industry that keeps US drug costs even sort-of under control
Some of the most difficult problems pharmacists face are not clinical. The problems I am referring to are generally related to dealing with insurance plans and their corresponding Pharmacy Benefit Managers. Consider an example: We have a patient taking an older, single source medication. This patient is stable and responding well to this therapy. I should point out that this was not the drug the patient started on, and it took a lot of time to find therapy that worked well for the patient.
In early January, the prescription was adjudicated, and a MAC price was applied. The MAC based reimbursement resulted in a loss of about $1000 based on our invoice cost. The loss was still very significant after our rebates from our buying group. Shortly after this claim was adjudicated, I sent an appeal to the plan to have them revise the MAC price of 20 products, including this medication.
Before continuing, I want to warn you: this story doesn’t end in a typical manner. Much like Frederick Forsyth’s The Day of The Jackal, I am going to tell you how the story ends before embarking on the rest of tale. Not only does plan / PBM corrects an underwater MAC price for the drug, but they actually over-correct, resulting in extreme overpayment.
When I received my response about 10 days later, the MAC price was doubled. The response also contained a reminder:
We would like to remind you of your overall GER guarantee with [Part D Plan]. While some MAC prices may be under your acquisition cost, [Part D Plan] will ensure that you are appropriately reimbursed overall, according to agreed-upon overall generic effective rates.
Note that the patient’s drug (and most of the other 20 drugs) would still represent significant losses going forward at the new, updated rate. Not being deterred, I responded to the MAC increase notification:
To whom it may concern:
Please note I understand the contracted GER. It is my understanding, however that the contract also does not explicitly state that I can be reimbursed for product below the prevailing acquisition cost. Severely underwater MACs are never acceptible, even in the context of this contract’s terms. I require supporting documentation each of these decisions, including source and availablilty of a lower priced product on the market. Please forward these promptly. Before these MAC appeals were sumbitted, a comprehensive search was preformed revealing no available products that would support the current MAC price. Your statement to the contrary should be accompanied by supporting documentation.
The February and March claims continued to show significant losses. I did not hear back from the plan, and frankly did not expect anything more. At this point, I had done what I could, and was resigned to continue to provide this drug at a substantial loss to the patient. It would not be ethical to withhold the medication or, to refuse to stock the medication: our patients depend on us.
Unexpectedly, last week, I received another correspondence from the plan. I do not know if the response was to my initial, or follow-up correspondence. The letter informed me that MAC price was again increased. This time, the increase was much, much higher. Reimbursement at the new rate went from abysmally low, to stratospheric levels.
Now don’t get me wrong: I have no problem making money on a prescription. In this case, however, we went from the bottom of the Mariana Trench (about 10,000 meters below sea level) to the top of Mt. Fuji. (3,776 meters high). At this rate, my losses for this drug (year to date) would quickly evaporate. Despite my elation at recouping my losses and not losing money going forward, the updated price makes as little sense as original underwater price for this drug.
What does this story say about the state of our current system? Instead of retroactively updating the previous claims to represent reasonable reimbursement going forward, the company instead overcorrected the price. It is also unfortunate that a provider had to point out the price problem in the first place. As a pharmacist, I am supposed to be focused on the patient, their drug therapy, and their therapeutic outcomes. The Plan and PBM are in charge managing reimbursement. If they were doing their job, reimbursements would not be so askew, in either direction, in the first place. Also remember, this one drug was corrected. There are still a large number that have not been addressed satisfactorily to date.
This is yet another example of our broken system. Providers have to spend time with problems outside their expected role of patient care in order to ensure they are reimbursed fairly. Reinbursement, is either feast or famine: more recently is is more famine than feast. It is a lot like climate change: we have far too many extremes and too few nice days.
The other morning, before my staff arrived to work for the day, I took a phone call from one of the group homes we service. They wanted to know if we had received an order for a dose change on a patient’s sertraline. I looked in our systems and concluded that we had not yet received an order. It turns out that I was mistaken. Deconstructing my mistake illustrates a time honored saying: If you didn’t document it, you didn’t do it!
Like any busy work environment, knowing where to look for information is the key to success. There are limited ways the order in question, a prescription, can arrive:
Once an order has been processed, documentation should be found on the pharmacy management system (PMS). At our pharmacies, the old prescription would be discontinued, and a new prescription would be entered with the new directions. This is what I expected to find if we had processed the order.
Our pharmacy also uses a clinical documentation system, PharmClin, to document all activities as they relate to drug therapy. Any notes or pending issues related to a dose change should be documented in this system. This additional documentation is very valuable to us as it allows us to document many of the important details that complete the clinical story as they relate to the patient’s drug therapy. PharmClin makes this information easily accessible and retrievable.
I went searching. I found no unprocessed orders. The original order on our PMS still active, and no new prescriptions for sertraline were present. There were also no notes in PharmClin related to a dose change of sertraline. In other words, I did not find Waldo. Based on a lack of evidence, we did not appear to have the order yet.
When my staff pharmacist arrived, I mentioned the call and was informed that she was aware of the order and that it had already been addressed and picked up. I was flummoxed! How could this be? As it turned out, the situation was a lot more complicated than the phone call suggested.
The patient was taking 200 mg of sertraline daily. The previous day, prescriber decided to switch the patient to escitalopram. My pharmacist correctly identified that the patient should not simply stop taking the sertraline without some attempt to taper the dosage over time and contacted the prescriber’s office. She was told that the prescriber did indeed tell the house staff to taper the dose of the sertraline and provided a flow sheet of the taper. In other words, there was no prescription written to decrease or taper the sertraline. As Homer Simpson says, DOH!
Multiple mistakes were made here. My first mistake was not asking additional questions of the house staff that called. I made the assumption that we were looking for a dose change for sertraline and failed to see the new Rx for the escitalopram. The other omissions were made before I received the call: the sertraline order was not discontinued in the PMS, and the communication with the prescriber was not documented in PharmClin.
The scenario above an epidemic in today’s healthcare environment. The patient is told something by a primary provider, and other providers do not receive notice. The communication from the prescriber to the pharmacy, a form of documentation, was missing. Despite this, my staff pharmacist who dealt with the problem discovered all of the details after they spent time on the problem the previous day. But like the first omission, her documentation was incomplete and largely missing.
Having an tool like PharmClin to document clinical interventions is a great asset to a pharmacy. But if the tool is not used, the benefits are lost. Pharmacists across the country make outstanding interventions every day. The fact is, however, that they largely fail to document their work. In a small pharmacy with few employees, mentally keeping track of issues like this might be manageable, but eventually the system will fail. In a larger pharmacy with many more employees and patients, a systematic documentation system is a must. Remember…Do It. Document it. Done! This is how you can make every encounter count!
