Author: Michael Deninger

Mike graduated from the University of Iowa with a BS in Pharmacy in 1991 and completed his Ph.D. in 1998. He has over 20 years of practice experience, over half of which is as a pharmacy owner. Areas of expertise also include technology in practice, including integration with data sources.

Tales from the Counter 

Sometimes I lament that, as a pharmacy owner, I don’t get to spend as much time on the prescription counter working with patients anymore. I still enjoy the challenge of working on the counter and working with patients, and every day I spend in this capacity I see examples of how pharmacists bring real value to healthcare. I also regularly find examples demonstrating the importance of taking time with each patient to be a clinical interventionist. I wanted to share a recent encounter I had the other day, because it emphasizes one of the core tenants of the Thriving Pharmacist: making every encounter with the patient count.

Today, while doing routine CMM (Continuous Medication Monitoring), I noticed that a medication had not been filled in several months. Our clinical checking system (PharmClin) helps our pharmacists easily spot these types of problem in two ways. First, the system calculates compliance (as a PDC — percentage of days covered). When the PDC drops below a pre-set level (around 75%), the software creates an alert for the pharmacist. It is important to note that this is done for all medications each time the patient record is visited and without regard the the medication(s) being filled and checked on a given day. The second feature of PharmClin that is immensely helpful is the ability to document if problem (like compliance of a medication) has or has not already been addressed. It also allows the pharmacist to set a follow-up date for re-evaluation of the issue.

In the case today, this medication had dropped to a compliance rate of 75 percent three months ago. The PDC was low due to one late refill, the pharmacist note on that date indicated that we would continue to monitor the compliance and revisit it in 3 months. It is not uncommon compliance to rebound, and 90 days is a reasonable amount of time to observe and re-assess. Today the software once again alerted me to the compliance issue (the three months had now elapsed). Given both the worsening PDC and the previous course of action (simply to monitor), I generated an intervention and attached it to one of the prescriptions being picked up today. The note simply asked if the dosage of this medication had changed or if this medication had been discontinued. The pharmacist speaking with the patient at the register would then be able to collect any important details (why, side effects, ineffective etc.).

When the patient arrived this morning, the technician (seeing the intervention tag) called me over to the counter to speak with the patient. During the course of discussion, I was able to ascertain that while the medication was indeed working for him, he was not currently taking it due to a drug interaction. Not seeing any drug interactions noted in his profile, further inquiry was made. It turned out that the patient was receiving a mediation from the local university teaching hospital. This medication (Harvoni) did indeed have an interaction with the medication in question.

At this point, I was able to speak to the patient about the importance of a single pharmacy home, and making sure that that pharmacy home has a complete profile. As it turned out, the patient had simply assumed that we would know what the other pharmacy dispensed. If a new medication was prescribed that also interacted with Harvoni, we very likely would not have been aware of the potential for an interaction. After the patient left, I added Harvoni to his profile for inclusion in future screening during our CMM activities.

The intervention that I had with the patient today was not uncommon to pharmacy. Pharmacists around the country take the initiative to be clinical interventionists. It doesn’t take board certification, a residency, or a fellowship to be a successful interventionist. It takes a sound workflow and an desire to think and ask questions. The biggest difference for me, though, is the documentation being done by our pharmacy. Documentation, like the previous note and the alert for a follow-up, allows the pharmacist to continually refine the clinical picture for each patient and the plan of care. Software is an important part, and can enable the pharmacist perform and document meaningful CMM activities.

Creating a Slack Based Workflow

Whenever visitors tour our pharmacy, one of the most common comments has to do with the level of our staffing. We typically have a minimum of 4 pharmacists working on any given day, with as many as 7 on select days. The use of extra pharmacists (what we call our slack resources) allows the flexibility to accomplish many ventures other “stripped down model” pharmacies cannot. This article will describe our workflow and the benefits it brings to a pharmacy practice.

Technician Driven

The most important part of our workflow is freeing the pharmacist to focus on the patient. This is accomplished by leveraging excellent technicians to do all data entry and filling processes. In our case, our pharmacy is involved in a pilot project allowing technicians that have received additional training to check refill orders without a pharmacist final verification of the product.

The Pharmacist Belongs on the Counter

Another important philosophy in our workflow is that the pharmacist needs to stay in the dispensing workflow. Even if the pharmacist is not doing the final verification step (for example, in the tech check tech pilot program above) the pharmacist is still reviewing the patient’s profile and clinical record in real-time. The pharmacist is tasked with creating and documenting interventions that need to be addressed with either the patient and / or the prescriber. By being on the counter, the pharmacist is accessible to gather information directly from the patient as needed to make clinical recommendations.

The pharmacist on the counter has one of the more difficult jobs in our practice. Their responsibilities include:

  • Final Verification of the drug product (all prescriptions, or for new prescriptions if a tech-check-tech program is in place)
  • Clinical profile review. Each patient’s records are reviewed any time a prescription is filled or a patient contacts the pharmacy with a concern or question.
  • Identify issues that need to be addressed at the point of sale (compliance, high risk medication use etc) and flag these for follow-up with the patient
  • Gather patient information specific to any issues identified
  • Document the additional information gathered
  • Schedule appropriate follow-up as required
  • Contact the prescriber by phone or fax regarding any problem(s) identified as needed

This is a significant amount of work to put on one person, and when the pharmacy becomes busy, this pharmacist needs a resource to delegate work. This is our slack pharmacist.

The Slack Pharmacist

It is important to develop a workflow that leverages this person to maximize their impact. It would be inefficient to have this resource sitting and waiting for the hand-off from our prescription counter. Our slack pharmacist’s responsibilities also include medication reviews for our patients residing in nursing homes we service, and our assisted living community patients. They are also involved in vaccination programs and other clinical services like cholesterol screenings, site visits and our medication sync program.

Our slack pharmacists are located a few feet from our prescription counter, in semi-private cubicles. This workspace allows the slack pharmacist to work individually with a patient, and to have ready access to the clinical records system and many of the other tools they use (blood pressure cuff, Cholestec machine, immunization supplies, injection supplies, patient charts etc). This proximity means that the counter pharmacist can easily hand-off patient care activities, SOAP note completion, physician calls and faxes during a busy time on the counter.

Pharmacists Enable Care

If it isn’t obvious by now, our practice places a significant emphasis on the talents and capabilities of our pharmacists. What visitors notice immediately after they count the number of pharmacists at our practice is that every single pharmacist is quite busy.  Taking care of patients is not possible if you don’t have the resources available, and simply filling prescriptions is not patient care. The pharmacist has excellent access to their patients, and they need to capture every encounter and make it count.

Medicare Part D and Clinical Opportunities

On a recent conference call, we learned that a significant Medicare Part D plan would NOT have any clinical opportunities for pharmacists in 2016. This is disappointing on many levels. The fact that Medicare will allow a plan to do this is troubling, especially with the increased lip service being paid by Medicare with respect to quality measures.

Pharmacists should be upset by this, but there is another facet to this that is equally troubling: Medicare Part D plans are not searchable based on clinical services offered. While the Medicare.gov plan discovery tool does display the presence of an MTM program it is not prominent and does not adequately describe the program’s context or extent (see the example below). These omission are significant, especially given the emphasis on quality being touted by Medicare. If a patient considers their local pharmacist to be an important part of their care, and desires to have clinical services (locally provided by their pharmacy) included in their drug plan, they are adrift with little guidance.

While it is possible that Medicare may eventually include clinical opportunities as a searchable term, and / or make differences  in how the services are provided more obvious to the end user, it may come down to companies like iMedicare to fill this void in the near term. This company can be used by pharmacies to quickly help their patients choose a plan based on the same information used by the Medicare.gov website. If iMedicare supplemented the information already being provided by Medicare with a description of MTM and clinical opportunities for the given plan, it would allow pharmacists to explain which plans include this important feature. These details on how each plan handles MTM are very valuable, as some plans do not use local pharmacists to perform these clinical services, or severely restrict the number of patients that are eligible. Given this additional information, patients would have a more complete understating of plans and could then make better decisions about their Medicare Part D plans

Why PBMs May Become an Extinct Species

The PBM Industry

The Pharmacy Benefit Manager (PBM) industry has gone from being a claims processor (simplifying paying claims for the insurance payor) to a manager of the entire pharmacy benefit for hundreds of millions of patients. Is not uncommon for a PBM to tout the savings they garner the system thru their management of the drug formulary, restrictions on expensive medications, and a variety of processes that come close, or even cross the boundary, between the PBM being a “manager” and the PBM acting as a physician or pharmacist.

The PBM industry generally takes credit for saving the health care system billions of dollars yearly. But being a pharmacist, I often have wondered how much of these “savings” are due to the PBM itself, and how much is directly attributable to the actual care providers. I find it interesting that the PBM industry is a pure middle-man in the health care industry. As an industry, they have very little on the line as they are not generally responsible for the total health spend. Manufacturing savings for the PBM may be as simple as creating downward pressure on the price paid for product and services. The PBM can effect savings in this manner without actually jeopardizing their own bottom line significantly. While the above characterization is certainly not complete, it does represent the essence of the entire industry.

Quality emphasis

CMS and others are beginning recognize that the current system places too much emphasis on product and not enough on service. Recent initiatives are starting to emphasize quality of service in the equation, and these measures are NOT something that a manager can do themselves. They require the providers (and in this case these are pharmacists) to accomplish. Pharmacists are key because they actually can see, speak to, and evaluate the patient and their medication use. Recently, some PBMs have even taken steps in the right direction and initiated programs to reward pharmacies for high quality work. While these initiatives emphasize metrics that are simplistic (mostly measuring compliance), and the actual financial rewards are not at levels that could sustain high quality performance in a pharmacy, they are steps in the right direction.

Pharmacist Impact

Pharmacists can have significant impacts on savings in healthcare. Our own pilot study that included 600 patients with a local payor is showing significant savings effected by pharmacists acting as clinical interventionists. These savings, calculated by the payor using a rigorous statistical analysis, show that a pharmacy can save the health care system several thousand dollars per patient per year.

Now the US Army is reporting similar results; using pharmacists as interventionists can create significant savings and a positive return on investment. And this type of evaluation is starting to catch the eyes of payors. In Iowa, the payor involved in our pilot is looking to create a network of high performing pharmacies by next year (2016), and that network would be paid using a different model than the one currently used in the industry.

Changing Times

The current iteration of the Star Measures are simplistic, but they are a good starting point. We fully expect that the Star measures will evolve to include actual disease state outcomes and measures that better reflect the savings in total health spend. These changes are not compatible with the current PBM centered “manager” model. A PBM cannot manage patients in this manner, only a provider with face-to-face access to the patient can do this.

Increased emphasis on outcomes means that the PBM, who does not have any skin in the game currently, will either become less important, or will need to shoulder more responsibility for the outcomes of the patient. Either way, the days of easy profit as a middle-man may be numbered.  The current methods leveraged by the PBMs to create a stripped down model of pharmacy will not improve outcomes. The cheaper  drug does not necessarily mean better healthcare outcomes and a lower total healthcare spend.

These changes have significant implications to pharmacists and pharmacies that have adopted the stripped down model of pharmacy. Going forward, it will not be enough to simply fill a prescription. It is what is done after the prescription is filled, that time spent with the patient, that will become important. Pharmacists need to rediscover their inner clinician. Those skills learned in pharmacy school will need to be polished and practiced once again, for many, for the first time since graduating pharmacy school. Pharmacists need to start stepping up their games now. Start making every encounter with your patients count!

The Future

Imagine a future where it is the pharmacy that has negotiating power. A payor will negotiate with a high performing pharmacy to have them included in their network. Pharmacies and pharmacists are paid for the care they provide based on real clinical outcomes. Savigs effected by pharmacy and pharmacist are shared with the  pharmacy and pharmacist. A vision like this is possible, and it is a far cry from where pharmacy stands today, begging to be included in narrow networks with impossibly thin margins. In order to get there from here, pharmacists need to start now.

Large Pizza and the 90 day Refill

The other day I sat contemplating the pricing of a large pizza. Yes, I am a bit of a math geek, and I was having trouble wrapping my head around why the price of a 16 inch pizza was only a couple of dollars more than a 12 inch pizza despite the exponential nature of the area as pizzas get larger (113 sq inches for a 12 inch pizza vs 153 sq inches for a 16 inch pizza, almost a 40% increase in size). I am sure someone has looked at all of the variables( ingredients needed, time required to assemble the pie, pizza oven space requirements, baking time etc.) and justified the discrepancy, but it still bothered me.

As I thought about this some more, it occurred to me that pharmacy (and more specifically the pharmacy benefit managers or PBMs) are doing the same thing. The emphasis on the 90 day refill is high in the industry, even to the point of incentivizing the patient with a lower copay (just like pizza) to “upsize” their prescription. Like the pizza industry, I am sure someone has measured all of the variables and come to the conclusion that, like the large pizza, 90 day fills are better.

But is this wisdom actually accurate? Whom does this benefit? Remember that the PBM industry has, by and in large, made this judgment using their variables. Is it good for the payor,  the patient, or the pharmacy? What is the goal or outcome that is being sought? To a pharmacist, the goal should be improved outcomes and a decrease in total health care spend. For some reason, I doubt that these are the outcomes cherished by the PBMs.

Benefits of a 90 day “Super Size” Rx

The Patient: 

A super size Rx may result in fewer trips to the pharmacy. This assumes that the patient doesn’t visit the pharmacy for other reasons, of course. Patients also pick up necessities at their local pharmacy (think OTC items), receive vaccinations, have their blood pressure checked or cholesterol tested, or to ask questions or advice from their pharmacist. Even after implementing a medication synchronization program, many of our “sync” patients still come the the pharmacy just as often as before. Indeed, fewer trips to the pharmacy may actually be a bad outcome for patients.

Compliance is often touted as a benefit of a 90 day refill. This, however, turns out to be somewhat difficult to prove. Claims data may show better compliance, but it is impossible to know if the patient is actually taking the medication properly and achieving the optimal outcomes with claims data alone. When a pharmacist takes time to talk with a patient, they can actually assess both compliance AND outcomes. Super size refills creates fewer interactions with the pharmacist to assess the patient and can actually delay the pharmacist’s ability to address compliance and intervene to improve outcomes.

Cost is used an incentive for Super Size refills. The patient will often pay less for a 90 day supply than they would for three 30 day supplies. For many patients, this savings, over multiple prescriptions and over the course of the year can be significant.

The Payor:

Insurance companies are the ultimate payor. In the case of Medicare Part D, the payor is Medicare. To the entity holding the purse strings, 90 day fills offer little real advantages. While it is possible that a supe rsize refill costs the payor less than a 30 day refill, drug costs are only a fraction of the costs that the insurance has to consider. Any savings, in the form of improved outcomes from medications can far exceed any savings for 90 day prescription fills. A recent program between a pharmacy in Iowa and a major insurance payor demonstrated that pharmacists can impact total health spend for their patients, and the degree of this impact can be very substantial. Overall, the payor may benefit more from an increase in patient-pharmacist interactions rather than a decrease.

The PBM:

Extended day supplies benefit the PBM in several ways. Many extended day contracts feature both decreased pharmacy reimbursement and decreased dispensing fees (the two places pharmacies are actually paid for their effort). This directly benefits the PBM by decreasing their cost. Another potential benefit is for the PBM to emphasize their own mail-order pharmacy. Extended day fills are really the only way this type of pharmacy can exist. Any emphasis on extended days supply creates opportunity for the PBM owned mail order pharmacies to extend their business.

The Pharmacy:

The pharmacy stands to loose the most from extended day supplies. While the PBM argues that extended day supplies are easier for the pharmacy (only having to fill a prescription 4 times a year versus 12 times a year), this benefit is negated by a myriad of negative economic impacts on the pharmacy, including decreased front end sales and diminished reimbursement of the prescription itself. A prescription, to a pharmacist caring for the patient, is a lot more than just a bottle, label, and drug product. It is a chance to make that encounter with the patient count. Pharmacy is a profession, not a product.

The Real Pharmacy Benefit: Pharmacists

In the end, the PBM industry has pushed its own agenda by forcing down reimbursement for drug product and emphasizing its own metrics. It is time for the patient and the payor / plan to start recognizing the importance what the pharmacist does and how it impacts patient care. It is also imperative that pharmacist step up, if they are not already working as a clinical interventionist. Every pharmacist should be working to make every encounter with their patients count!

DIR Fees–Why Are Pharmacies in the Middle?

DIR fees are a hot button item for many pharmacies and pharmacy owners. These fees are not well understood and their impact on the health of pharmacy as a profession is significant. Recent conversation with both our PSAO and (surprisingly) representatives from a major PBM have me questioning why pharmacies are even being involved with DIR fees.

Medicare created the concept of the DIR fee as a way to capture rebates that PBMs were receiving from pharmaceutical manufacturers. The DIR fees are not kept by the PBM, but instead are passed back as a savings to the payor (in this case, Medicare). The format of these fees, however, involves not just the PBM and Medicare. Pharmacies have been dragged into the equation, and the equations are complicated. Trying to understand the logic behind a DIR fee and how it is calculated has become very challenging.

I have been told that Medicare would prefer that DIR fees not come thru pharmacies, but they do not enforce this, allowing PBMs to create complicated logic on how these savings are directed back to the payor (Medicare). In their simplest form, a DIR fee is calculated in one of two different ways:

  • A flat fee per claim (say $3)
  • A flat percentage (say 3%)

If a contract without DIR fees read Average Wholesale Price (AWP) – 18% + dispensing fee, the DIR contract would read AWP – 15% + dispensing fee. The DIR fee would be the difference between the first and second calculation. This seems simple enough, but many pharmacists are still scratching their heads, you would not be alone. The use of MAC prices hides the AWP logic completely from the pharmacy. Remember that the PBM industry does not publish how it calculates MAC rates, and retains the right to change these rates at any time for any reason.

Example DIR fees from a Medicare Part D PDP

Consider a generic drug claim and the AWP for the 90 day supply of the medication is $100. The plan will typically invoke a MAC rate for this drug. MAC rates have been estimated by some PSAO’s as averaging about AWP – 79% across the industry. Given this estimate of MAC, the claim would adjudicate at $21 plus a dispensing fee (which is almost universally trivial, often $1 or less).

At the end of the month, the PBM would then apply the DIR fee schedule to this claim. If the DIR schedule for generic drugs was agreed to be AWP – 84.5%, an the pharmacy would have an additional 5.5% withheld from its payment as a DIR fee for this prescription. As an aside, it is possible that the DIR could be negative if the MAC price is actually below AWP – 84.5%, and in this case, the pharmacy would receive credit in the form of a DIR. This may have the potential protect pharmacies from some overly aggressive MAC prices, though the significance of this unknown.

It is important to recognize that the basis of the MAC price is unknown to the pharmacy, so in order to know what it actually made at the point of sale, the pharmacy would have to be able to identify each DIR eligible claim and apply a corrected calculation to the sale in the ledger each time.

Another problem with this methodology is that nowhere in those calculations is the ACTUAL COST of the medication considered. With an effective generic discount rate of AWP – 84.5% many pharmacies are seeing over a third of prescriptions being reimbursed underwater after the DIR is taken into consideration at the end of the month. This is primarily on generic drug products, but the same thing also occurs with some brand name drugs.

When a pharmacy or PSAO evaluates a narrow network / preferred provider plan, they need to be able to assess the impact of the overall contract on both. Given the above logic, this is certainly possible, though challenging (because MAC price is not explicitly defined). To make matters more complicated, plans are calculating DIR fees retroactively. In other words, the DIR fees for January are being assessed in February. Not complicated enough? Some plans document retroactive DIR payments by attaching the DIR to a different prescription and fill date in the current remittance document for the DIR being charged for another prescription filled during the previous remittance period. Think about this for a moment. There is no way for the pharmacy to double check the DIR calculation because the prescription it is attached to is not actually the prescription that the DIR fee represents. Pharmacies now have to simply trust that the DIR fees being levied are accurate. In our case, DIR fees for one plan are easily exceeding $5000 every month. This is not inconsequential and is having significant implications to the bottom line for the pharmacy.

Pharmacy Should Not be in the Middle

In the end, it makes no sense to include pharmacies in DIR calculations. Pharmacies are providers. They are not in the middle like the PBM. If savings are to be passed on to the payor (Medicare) then they should be transparent. They should not involve the pharmacy at all. The pharmacy should expect to be paid the adjudicated amount, and that amount should be specified directly in the contract. Anything else infers that he PBM is trying to hide something in the shell game of transactions.

 

SuperSync: the Super Hero of Adherence

To say that Medication Adherence is a hot topic in many pharmacies is an understatement. With the Proportion of Days Covered (PDC) being the focus of three of the five CMS performance measures for pharmacy, medication synchronization services are being adopted by many pharmacies. Synchronization is one strategy to improve patient compliance, making it less likely that the patient runs out of medication.

At our pharmacy, the synchronization is often referred to “not-so-simplify my meds” because of all of the details that have to be managed by the pharmacy to successfully synchronize, and maintain synchronization, of a patient’s medications. Companies like Prescribe Wellness, and Ateb (and others) offer cloud based software solutions to help pharmacies manage what turns out to be this less than trivial task.

But synchronization only address one aspect of patient compliance by making it less likely that the patient will be without one or more medications. The patient still has to remember to follow their mediation regimen, and sometimes this obstacle is daunting. Pharmacist can coach patients to improve their compliance or even suggest changes of therapy to the prescriber to simplify the patient’s medication regimen (e.g. changing a person from simvastatin, that has to be taken in the evening, to atorvastatin, that can be taken with the rest of the patient’s medications). When these types of interventions steps fail to improve a patient’s compliance, however, it is time to call in a super hero: SuperSync.

Med Planners

One of the best ways to help a patient take their medications correctly is the make the job of taking the medications less burdensome. An easy way of doing this is to recommend the use of a medication planner. Filling a planner, however, is a fairly tedious process for some patients. The pharmacy can assist (though it does need to abide by state and federal regulations with respect to labeling if applicable). Depending on how this service is managed, it is even possible for the pharmacy to charge a fee for this service.

SuperSync: Synchronization plus Packaging

One novel way to approach medication packaging for the synchronized patient is to do away with the prescription vial entirely. Packaging systems like the Parata Pass system create a prepackaged, commingled, multi-dose strip package with each day and time divided into a perforated strip of bags. The patient’s next doses are always the next bag on the strip.

Methods like this work very well in combination with medication synchronization. The patient’s medication are simply entered in the pharmacy management software and sent to the robot for packaging. The pharmacy trades vials, caps and labels for the disposables used by the packaging system.

Cost Analysis

One significant question, however, is if a program like this will save a pharmacy money, or cost them more in time and materials. The analysis below represents reasonable approximations to the cost of this type of program.

Traditional Prescriptions

The cost of a typical prescription vial with a lid varies by size, with the more common small 8 dram vials / lid costing roughly $0.25 each. Larger vials can cost upwards of $1.00, though these are much less commonly used in most pharmacies. Label costs add about $0.02 to $0.08 each, depending on stock and size of the order. Overall, each prescription filled costs the pharmacy about $0.30.

Disposable Costs: Traditional
Approximate monthly cost for vials, lids and labels for patients receiving 6 to 12 chronic medications.

The cost per month for vials, lids and labels, given a typical patient being synchronized in our pharmacy is about $3 per month.  When dispensing 90 day supplies, the cost per month is reduced only marginally, as the more of the larger vials are required, adding expense.

Strip Packaging (commingled)

The primary costs associated with this method are packaging paper (the cellophane that becomes the bag) and the ribbon (which creates the printing on the package). The cost of the robotic equipment is not being included in this discussion in a similar way that labor costs were not included in the cost analysis of a traditional prescription. The per-bag cost for a strip-package is about $0.021 (the decimal is important as there will be numerous bag in any given order).

The number of bags in an order will depend on the number of medications, and the number of times each day a patient takes a medication, and the number of days being packaged. Each bag is capable of holding up to four different medications (this is a practical limitation based on the size of print and the amount of information that has to be included on each bag per pharmacy labeling regulations) and seven tablets/capsules (this being limited by the volume each bag can contain).

Strip package costs.
Monthly cost of cellophane bag stock and ribbon based on the total number of bags required per day.

Because each bag can hold any combination of 4 medications and 7 tablets / capsules, the typical day will include 1 to 4 bags. For example, a patient taking 6 medications (representing 7 tablets), all in the morning, would require 2 bags per day to allow for the printed requirements to fit on the packaging. If one of those medications were twice a day, they would require 3 bags per day. Patients with medications taken three or four times a day will have as many as eight bags a day. This means that the average cost to the pharmacy in disposable overhead is about on par with traditional prescription vial based packaging for most patient needs.

Kryptonite for SuperSync

The biggest disadvantage to a packaging system like the Parata Pass being married to a synchronization program is the potential for therapy changes. If a patient has a medication change, the entire strip is potentially rendered incorrect. It would need to be re-packaged, adding additional costs in labor and overhead. It is important to keep this in mind when selecting patients for a SuperSync type program. Policies and procedures also have to be developed to handle this type of change, as even the most stable patient can have a change that effects their meds when they are packaged in this manner.

Workflow and Equipment

The two biggest challenges with using a SuperSync process are:

  1. Purchasing the equipment and
  2. creating a workflow that is efficient and seamless.

Equipment like the Parata Pass are capital purchases involving many tens of thousands of dollars both in up front costs and reoccurring maintenance fees. Traditionally, this type of packaging has been used mostly in nursing home type pharmacies. The congruence of packaging and synchronization, however, makes it appealing for retail pharmacies as well. I am aware of more than a few pharmacy practices that are adopting this type of packaging for all of their ambulatory patients. Workflows that leverage both synchronization and robotics like the Parata Pass have the potential be extremely efficient.

Pharmacists in Washington State Receive Provider Status (Commercial Insurance Plans Only)

It will be interesting to watch as recent legislation in Washington State has given pharmacists provider status for commercial (non-medicare) health plans. This is a step in the right direction for pharmacy as reimbursement for drug product reaches record lows. Pharmacists need to step up to this challenge and utilize their clinical knowledge to advance patient care and enhance outcomes. With success, this baby step will help propel the 600 pound gorilla in the room (Medicare) into a similar direction. Click thru to read the release from APhA.