Author: Randy McDonough

Randy McDonough is co-owner of Towncrest, Solon Towncrest, and Towncrest Compounding Pharmacies. He is also co-founder/co-owner of Innovative Pharmacy Solutions. He oversees Towncrest Pharmacy’s clinical services including MTM services, wellness screenings, immunizations, and adherence services. He is responsible for development, implementation, and quality assurance for all aspects of the clinic and services. He is board certified in geriatrics and as a pharmacotherapy specialist. Randy has published and presented extensively on the subject of pharmaceutical care and MTM in the community pharmacy setting. In particular he is recognized for his efforts in developing and implementing patient care services. He has co-authored a book on pharmaceutical care and has written chapters for several other texts. He has presented nationally and internationally on pharmaceutical care, MTM services and Performance Measures in the community pharmacy setting. He currently writes a column for Pharmacy Today titled “MTM Pearls” Randy is a member of the American Pharmaceutical Association, National Community Pharmacists Association, American Society of Consultant Pharmacists, American College of Clinical Pharmacy, and the Iowa Pharmacists Association. He has served in various roles in these organizations. His areas of interest include community-based outcomes research, pharmaceutical education, diabetes education, disease state management, student development, and the development of patient care initiatives in the community pharmacy setting.

The System is Broken

For the past month we have been working with one our psychiatrists who is treating a mutual patient of ours. This patient has an intellectual disability, lives in a group home, and has significant history of depression with anxiety and attention deficit hyperactivity disorder (ADHD). One of his mediations that he has been taking for over five years is guanfacine. As we have tried to fill this medication for him, the PBM has rejected the claim because the PBM wants him to try a first line agent for hypertension. Herein lies the problem. The psychiatrist’s office has sent in different prior authorizations (PA) informing the PBM the reason the patient is taking guanfacine. Here, the guanfacine is for the treatment of ADHD, and not treatment of hypertension. Each time the PA has been denied, and each time the PBM directs the psychiatrist to use a first line antihypertensive, such has amlodipine, atenolol, or benazapril. What makes this even more frustrating is the fact that this patient also has hypertension and he is being successfully treated with metoprolol.

So my question is “Who makes these decisions?” First, we have a patient whose ADHD has been stable on a medication—guanfacine, the drug is relatively inexpensive, and it has been proven effective. Secondly, if the PBM is really watching over the patient and their medication profile, then why would they recommend a beta blocker (atenolol) when the patient is already taking a beta blocker (metoprolol). To be honest, this is why providers (prescribers and pharmacists) become frustrated with the system—the PBM is not taking the time to look at the individual case and, in fact, is making recommendations that are harmful to the patient.

The patient is frustrated, the psychiatrist is frustrated, and we are frustrated. We will not withhold treatment for this patient, but we have to trudge through the murk and mire of the system set up by the PBM who “supposedly” hires clinical pharmacists to monitor these situations and make clinical decisions. I am not so sure this is the case and, if so, the clinical pharmacist fell asleep at the wheel with this patient. So we become the one who is left “holding the bill”. The system takes up valuable time from both the prescriber’s office and the pharmacy which is time that is taken away caring for other patients.

It is time for a system overhaul. The current system is broken, does not optimize patient care, and penalizes the providers, in the trenches, who are actually caring for the patients. In fact, the relationship between the PBMs and providers has become antagonistic. If we use the current case as our example, what else can we provide to the PBM with regard to the patient’s clinical record to receive an appropriate clinical decision? As a health care provider, I am liable for the decisions that I make regarding my patients and their drug therapies. I take responsibility for the decisions that I do make, which means that I assume the risk as well. PBMs should also be liable for their decisions, because, as this case example demonstrates, their clinical carelessness can have negative consequences for the patient.

As our health care system embraces quality performance, and providers are being held to certain standards of care. Third party administrators (TPAs) such as PBMs should also be held to the same standards. This requires better systems,  improving the communication between providers and PBMs. A reasonable start might simply be provider access to a live person—preferably someone who is clinically trained, and a reduction in the length of time for decisions regarding medication coverage to be made. We need to remember the adage, “Its all about the Patient” as we look for ways to improve the system. Right now it seems to be anything but the patient!

 

“If it’s right for the patient, then its right for pharmacy”

“If it’s rights for the patient, then its right for pharmacy”.  I first heard this statement, or something very similar to this from an esteemed colleague, Bob Osterhaus.  Over the years, I have cited this statement in many venues convincing pharmacists to always put the patient first and do the “right thing” to ensure that they are achieving therapeutic outcomes through safe and effective medications.  This phrase was paramount to my business partner (Mike Deninger) and I as we re-engineered our practice to provide continuous medication monitoring (CMM) for all of our patients.   To put it simply, CMM was a process that we developed and implemented so that we became accountable to our patients.  Filling a prescription becomes more than just a dispensing process, but rather a meaningful encounter with the patient whereby pharmacists are reviewing the patients medications, identifying and resolving drug therapy problems, communicating with patients and prescribers, and documenting their activities in real time.  We firmly believed that this was the RIGHT thing to do for patients.

Since implementing CMM, our pharmacists have improved their efficiencies in their patient care processes so much so that we are documenting approximately 3000 interventions every month.  But how did we get there?  This did require an investment of time, money, and resources.  Early one Mike and I realized that CMM can only be done if there is an effective and efficient documentation system.  Initially we developed a documentation system that allowed pharmacist to do final verification along with patient SOAP notes and we called it our “Quick Clinical” system.  Eventually, it became a comprehensive documentation tool that allows our pharmacist to provide final verification, create on-the-run interventions, identify potential drug therapy problems, and write SOAP notes.  This clinical documentation system is now called PharmClin and we have filed for a patent to the United States Patent and Trademark Office (USPTO).  This system has allowed our pharmacists to better manage our patients drug therapy.  It was the RIGHT thing to do for our patients.

We also hired more pharmacists to ensure that we could provide other clinical services in addition to CMM.  These services include immunizations, medication therapy management (MTM), consulting services for hospice and long term care, medication adherence program (MAP), durable medical equipment (DME) consults, medication synchronization, and health screening/promotion.  We invested in technology (e.g. Parata Pass and Parata Max), participated in the new practice model (tech-check-tech program) initiated in our state, and fully engaged in medication synchronization with the sole purpose to make sure pharmacists were freed up to provide patient clinical services.  Although a sizable investment, it is the RIGHT thing to do for our patients.

Mike and I fully understand that we have a sizable financial investment in our pharmacies, but we firmly believe that we have put our pharmacy on the right path for a bright future.  It is not without concerns, fear, or doubts.  But then I am reminded of the statement by Bob Osterhaus “If it’s right for the patient, it’s right for pharmacy”.  Then I know that we have done the RIGHT thing because our patients are benefitting.

It is time for all of us to critically evaluate our practices to determine if we are doing the “RIGHT” things for our patients.  It begins by creating efficiencies in the practice so that pharmacists are freed up to provide clinical services.  Dispensing should be technician driven.  Medication synchronization services should be the standard of community pharmacy practice as it improves dispensing efficiencies, inventory management, and the provision of clinical services.  Pharmacists need to become “interventionist” by identifying drug therapy problems, providing clinical recommendations to patients and/or prescribers, and documenting their clinical activities.  Pharmacists need to make sure they are practicing to the level of their degree.  If they are uncomfortable and incapable of doing this, then they need remedial education/clinical training.  Obviously this is not easy, nor can it be done without some type of investment (time, money, or resources).  But, ultimately, it is not about what is best for us, but rather what is RIGHT for the patient!

Why Transitions of Care and PBMs Don’t Mix

My step-father, who has been deathly sick for the past 6 1/2  months due to an aortic valve replacement surgery that did not go well, is being discharged from the skilled nursing facility where he has resided at for the past month and a half.  Before this, he was in the ICU for over 3 months, were he required a tracheostomy, gastric tube, urinary catheter, and oxygen.  To be honest, there were several times when we didn’t know if he would make it through the night.  But, he slowly started to make progress, and now he is ready to be discharged to go home.  I am not only his step-son, but I am also his pharmacist, his pharmacy, and his POA for both health and financial matters.  Because I have been a pharmacist for almost 30 years now, I know the challenges that occur during transitions of care, especially as they relate to medications.

In my step-father’s example, he is being discharged on a Sunday.  I had been working with his social worker, nursing supervisor, and prescriber to make sure that I have an updated medication list.  I reviewed this list, noted the discrepancies, and sent a follow up note to all three providers.  They indicated that they will only fill the medications that he has been taking while in the facility and, if there are any discrepancies, I should follow up with his PCP and specialists that he sees (which include a pulmonologist, neurologist, and cardiologist).  So I did this, and received new prescriptions for the medications that they want him to take following his discharge.  Obviously, this was a multi-step process that occurred over several days.  Now that I have his prescriptions, things should go smoothly, right?  Wrong!  When we went to fill the prescriptions, they, of course, got rejected as “refilled too soon” because the long term care pharmacy that fills for the facility (not our pharmacy) has already filled and billed medications.  I confirmed with the facility that they will not be sending him home with any mediations, so,  next step was to call the Pharmacy Benefit Manager (PBM) to get an override. This is where the frustrations and problems escalated.

I explained to the PBM representative that my step-father is being discharged on Sunday and that I am not only his step-son, but his pharmacist and pharmacy.  I want to be proactive and have all his medications filled so when I pick him up on Sunday, he has all his medications there.  Sounds easy, right?  Wrong again?   The representative said that we cannot be proactive and that he cannot get an override until he is discharged.  I said that our pharmacy is closed and that I will be busy getting my step-father home, but she said there is nothing she can do.  I asked for the representatives supervisor, and this person reiterated said the same information.  The supervisor stated that they are “only the processor” for the plan, and that I would have to contact the plan to get an override before his discharge date. The supervisor was unable to give me a phone number to contact the plan, and said to look on the back of his card. I don’t have that information readily accessible.  The supervisors solution was to have me come into my pharmacy early on Sunday, fill the prescriptions, call the PBM to get overrides (one by one for 8 to 10 medications), fill the medications, then go see my step-father.  I asked her why we cannot be proactive, since we are only talking about 2 to 3 days and the supervisor said the plan will not allow them.  So, now instead of focusing on helping my mother (who is also ailing) and my step-father (who’s health is very fragile), I have to figure out how to fill his medications on the day of discharge–are you kidding me!

That is why I titled this blog “Why Transitions of Care and PBMs Don’t Mix”.   Supposedly payers are concerned about the quality of health care and that readmissions for the same diagnosis are frowned upon.  So, when you have a pharmacist proactively working closely with prescribers to get an accurate mediation list and making sure the medications are ready when the patient is being discharged, this should be a good thing, right?  Wrong, yet again.  Plan and PBMs are so worried about the kind and timing of the override that they have totally forgotten about the patient.

It is time to change the system.  Pharmacists are frustrated with the limitations that insurance plans and PBMs have place on patient care.  Doesn’t it make sense to ensure the patient, who has been hospitalized, should get their medications seamlessly to prevent a bad outcome?  And doesn’t it make sense that it should happen prior to the discharge?  I was unable to get the appropriate override, but it did move me to action, as I am writing a letter to my step-father’s insurance plan and the plan’s PBM to express my concern that their limitations will end up hurting patients.  Perhaps, they need to be educated about the challenges of transitions of care from a patient and caregiver perspective because, from my perspective, they know very little.

The New Community Pharmacist

In the past three years, I have seen more changes occurring in healthcare and, in particular, pharmacy, then I have seen in my entire career which now spends almost 30 years.  The changes are coming rapidly and frequently to the point where it is becoming scary, challenging, and intimidating to pharmacists in all settings. One of the more significant changes is in how healthcare is being reimbursed.  The old fee-for-service is no longer the standard.  We have quickly moved to a system that utilizes value-based purchasing as the new standard.  In this system, payers purchase services based on value and the performance of providers.  Payers are looking to reduce their overall healthcare spend while simultaneously improving healthcare quality.  This includes sharing the risk of healthcare costs with providers, including pharmacists.  This also means new opportunities for pharmacists, including community pharmacists.  With these opportunities, though, will come new responsibilities.  Community pharmacists will have the responsibility to ensure that their patients are achieving therapeutic outcomes through the use of safe and effective medications.  This is not a responsibility to be taken lightly, nor is it one that will allow community pharmacists to stay passive.  We must change our practice setting, and what we do day-to-day for our patients.

From a practice setting perspective it means several things.  First, community pharmacies need to make sure that they are being freed up to provide patient care services, and not just dispensing a product to the patient.  This may require additional staff, and training of existing staff.  Community pharmacists should move to a technician-driven, pharmacist-managed dispensing process.  Also, it may require investment in technology whether it be a “state of the art” pill counter, or a more sizable investment in a robot for automated dispensing.  Another area to look at is what is allowed under state board of pharmacy rules in regards to a tech-check-tech system.  As mentioned previously, the intent of these changes is to make sure the pharmacist is freed up to review patient medication profiles, identify and resolve drug therapy problems, and document their activities.

Community pharmacists may need to make an investment in clinically oriented and/or residency trained pharmacists, especially if the current practice does not have a clinically oriented pharmacist on staff.  Being responsible for therapeutic outcomes is an extremely important role for pharmacists.  It requires current therapeutic knowledge, clinical skills, problem solving, and critical thinking.  Pharmacists need to become interventionist, meaning that once the drug therapy problems is identified, they also provide solutions to resolve these problems. This requires communicating clinical recommendations regarding drug therapy changes to other providers.  Community pharmacists should ask themselves the following questions with each patient, and every medication the patient is taking:

  • Is the patient achieving their therapeutic outcome?
  • Is the patient’s medication effective?
  • Is the patient’s medication safe?

If the answer to any of these questions is no, then a drug therapy change may be warranted.

Re-engineering a practice also means critically evaluating the physical layout of the practice.  Community pharmacists need to think about where they will counsel patients during the dispensing process, and if the space provides some level of privacy.  Also, a patient care area to perform Medication Therapy Management Services (MTMS) and other clinical services is important.  This space should allow a more intimate discussion where the patient does not feel rushed or concerned about privacy.  These patient care areas are where patients and pharmacist can have more in-depth discussions regarding the patients medication regimen, questions/concerns the patient may be having, or providing clinical service such as immunizations.

Lastly, the new community pharmacists needs to be documenting their patient care activities including the drug therapy problems found during the dispensing process when pharmacists are performing their prospective drug utilization review (pDUR) now referred to as continuous medication monitoring (CMM) services, or while providing MTMS or other clinical services.  This documentation needs to be completed real time. Drug therapy problems identified should be documented along with an action taken, and the results of the actions taken.  Patient charts, electronic or hard copy, should be kept for all patients, and these charts should includes all interventions pharmacists have made to improve their patients’ therapy.

The new community pharmacist has a lot of responsibility, but also becomes a more integrated healthcare team member.  With healthcare change will come a plethora of new opportunities, but community pharmacists need to by ready to accept them. The new community pharmacist needs to make every encounter with their patients count.

Who’s Paying Pharmacy to Resolve Insurance and PBM Issues?

Recently, I  spent over one hour to resolve an issue that should not have taken nearly as long as it did, nor should have been a problem from the start.  It had to do with a patient who needed blood glucose strips filled.  This patient uses an insulin pump, so she must check her blood sugars 7 times per day.  The patient’s physician had completed the prior authorization paper work and the patient did receive a letter from the PBM indicating that the strips had been approved for coverage.  And yet, when we went to fill the prescription, it got rejected because the product is an OTC.  The PBM was called and their representative basically read to me the rejection that I was already seeing on the computer screen.  So when I explained that the patient received a letter from them specifying that the strips are covered, the representative put me on hold and had to check her sources.  After some time had passed, the PBM representative came back on the phone to tell me that they cannot provide this override as it has to come from the plan because it is an OTC (Over the Counter) reject.  She then proceeded to tell me that I had to call the plan specifically as they would have to approve the override and she gave me the plan’s toll free number.  WHAT?!  The letter came from them (the PBM) to the patient, not from the plan!  The PBM representative insisted that this type of reject has to be overridden from the plan.  I repeatedly asked the PBM representative if the information on the strips could have been coded wrong, but she said, “No, it had to be overridden by the plan.”  So I proceeded to call the plan.

The plan representative was confused by my call.  She asked me if I had reached out to the PBM, and my answer was YES!  I told her what the PBM employee told me, and this just added confusion to the plan representative who said she would have to put me on-hold.  After some time she came back on the phone and she asked me to re-run the claim so she and another plan representative could see the reject.  Once I ran the claim, both representatives were now perplexed on why the claim would not go through.  The plan representative put me on-hold again and said she needed to do some more checking on why this claim was rejected.  After some time, someone at the plan hung up on me.   After some more time passed, I did get a call back from the plan representative who was very nice and helpful.  The plan representative informed me that the error was on the PBM side; they had coded the information incorrectly from the start.  Hmmmm!!! This is what I asked the PBM representative previously.  So either the PBM representative was lazy, misinformed, or not trained properly to check or identify if the transaction was miscoded.  Luckily, the plan representative was able to get into the PBMs system and make the necessary correction, and the claim did go through.

So, for those pharmacists who deal with these type of issues on a daily basis, they know exactly what I am talking about and the frustrations with these type of calls.  This happens way too often and provides no value to anyone. The complexities of the system created by the PBM are even beyond the PBM’s help desk employees, and even they could not help us correct the issue they created.  And who’s paying us to correct errors like this for them?  Community pharmacists are being bombarded with underwater MACs, DIR fees , clawbacks, and insufficient reimbursement for many medications.  And yet we are the ones who not only provide clinical services for our patients, but also resolve these claim processing errors.

If pharmacies are charged a fee by the PBM for each and every claim they submit to be processed, should not the PBM’s have to pay pharmacies for their work helping patients achieve their therapeutic outcomes–even if its to resolve processing errors made by the the PBM?  Indeed, if it were generally known how much time pharmacies spend working on PBM generated problems like this, they would likely be appalled. If the federal government has rules to reduce burdensome paperwork, should not the contracts signed by pharmacies (and on their behalf by their PSAO) have language that covers time wasted by the phararmacy on the behalf of the processor. In this case, a pharmacy technician would have cost the pharmacy about $30 in time. Where should we send the bill?

This is a open call out to all contracting organizations representing pharmacies (chain and independent). As our partners, stand up for us. Emphasize the value of pharmacies in assisting patients navigate the difficult world of the pharmacy benefit. Help the PBM industry respect our time and efforts. In the past, reimbursement for product helped offset pharmacy hours spent working these types of problems. Current reimbursement no longer allows pharmacy this luxury.

Remember, from the beginning, this was a clinical issue.  A patient with diabetes, with an insulin pump, requires testing above “normal” test strip usage.  All of the obstacles were administrative, and in no way helped the patient.  It took the pharmacist to uncover the convoluted mess created by administrative policy and clerical error.  It is always about the patient–let’s not forget this, and this needs to be emphasized to payers and PBMs!

Access to Lives: What does that mean and to whom?!

The other day, my business partner and I had a conference call with our wholesaler and our PSAO about the impact that DIR fees were having on our bottom line.  The representative from our PSAO kept emphasizing that the reason why they signed the contracts with some preferred networks (with very low pharmacy reimbursement) is because they wanted to make sure that their network of pharmacies had access to lives.  We do not disagree with this statement, but where our priorities began to diverge from our PSAO is when the PSAO representative described ways to increase revenue for those patients in the store. The emphasis was on selling them other items to make up for the losses on the drug product. The emphasis was not on clinical services, but what other products you may be able to offer patients coming to your practice.

What?!  We were in disbelief! From our perspective, access to lives means that we have an opportunity to provide clinical services that impacts the care of these patients.  If clinically we did our job, then patients should attain their therapeutic outcomes through safe and effective drug therapy regimens.  Those patients who achieve their therapeutic outcomes should be healthier and have less health care spend than those patients who do not achieve their therapeutic outcomes.   It is our contention that pharmacists SHOULD be paid a FAIR fee for high performance.  Obviously, with underwater MACs, DIR fees, claw-backs, and other PBM business practices, the payment for product has rapidly become insufficient to cover the costs associated with dispensing. Product reimbursement certainly leaves nothing to pay for a pharmacist’s clinical activities and cognitive services.  To add insult to injury, the performance payment from one PBM for our performance on pharmacy performance measures was extremely anemic.  This is unacceptable, and as a profession we should demand more from our strategic partners, which include our wholesaler, our PSAO, our network, our buying group, and the PBMs themselves.  At this point, the partnership seems to be benefiting everyone but the community pharmacist who is in the trenches taking care of patients (and who is getting paid less to do this).  It makes no sense.  But to have one of the strategic partners verbalize that we have to do more than just offer clinical services and look at other products that we can sale to patients as a way to enhance our revenue was enough to put us over the edge.

We want to be good community pharmacists.  We offer an extensive list of clinical services. We have partnered with a local payer, who has stayed committed to us because of the outcomes we have been able to generate with their clients (our patients), and we consistently achieve a high performance on our pharmacy performance measures on the EQuiPP platform.  We own two professional pharmacies that have small front ends.  We only sell medical related items and we already have a flourishing DME business.  So if our strategic partners are suggesting that we are suppose to sell paint and hardware or milk and eggs as a way to generate new revenue, then question if they are truly our partner.  It should be about patient care.  It should be about the services we provide.  It should be about the outcomes we achieve.  We have worked hard to change the paradigm of our practice, but now we are working just as hard to change the paradigm on how community pharmacist are paid.  It seems everyone within the drug distribution system is “making their money” including the all the strategic partners that have been mentioned previously, but the community pharmacist is left to provide the care, identify and resolve drug therapy problems, take calls from patients 24/7, be responsible for patient outcomes, and not paid sufficiently for any of it.  Access to lives should not be about finding new ways of selling products to improve the bottom line, but rather it should be about quality patient care, fair reimbursement for that care, and bonus incentives if expectations are met. How can anyone rationally look at the current system and say that it is fair and that pharmacist are reimbursed sufficiently?  The financial viability and survivability of independent community pharmacist is on the line.

As we move forward, we will continue to fight for what we believe is fair reimbursement for services rendered.  We will continue to put pressure on our strategic partners to help us in our quest for fair and equitable reimbursement.  In the short term, we also will continue to put pressure on our strategic partners to make sure that we are receiving the best price for our costs of good sold, including rebates.  We will continue to communicate with our legislators about fair reimbursement for pharmacists.  And we will continue to support our local, state, and national professional organizations as they continue to fight for pharmacists recognition as providers.  It has been a tough year, and next year looks to bring the same.  We also realize that we are not alone, as other owners have expressed similar concerns.  All of us can make a difference,  but we have to be willing to challenge the status quo and our help strategic partners to change.

Creating the Capacity for Patient Care

We are often asked how our practice evolved into what it is today with it’s diverse service offerings, a significant staff of pharmacists and technicians, and our ability to generate revenue beyond just dispensing medications.  It started almost a decade ago when Mike and I decided to change our model of community pharmacy practice.  Creating the capacity to provide patient care  services was not an overnight fix, rather it was an evolution based on trial and error, feedback from staff and patients, and market forces.  This is not saying that our practice developed out of random happenings, but rather we had laid a foundation for which we could easily adjust, improve, and add services as deemed necessary.

To create a capacity for patient care, we began by moving our practice to a technician driven dispensing model, repurposing pharmacists so that the majority of their time was spent evaluating patients’ medications, resolving drug therapy problems, and communicating with both patients and providers.  This required changes in job descriptions and responsibilities, new positions being developed, and staff training.  We put a lot of our focus on the dispensing pharmacist. Pharmacists traditionally focused performing final verification. In our practice, the pharmacist was asked to becoming a clinical interventionist–identifying and resolving drug therapy problems “on the run” in which we now called continuous medication monitoring (CMM).  To make this transition, we had to develop a different documentation system, because our dispensing system, much like all the others, is great for making sure we have all the information needed for dispensing a product, but very limited in terms of documenting patient care.  The system we created is now called PharmClin, and it leverages the information from our dispensing system and creates a clinical record, making it easier and more efficient for the dispensing pharmacist to provide CMM.   Moving the pharmacist into this new role also required education and training on how to quickly clinically assess patients’ medications, develop an intervention to resolve medication issues, and document their patient care activities.  Obviously, creating the technician driven dispensing process helped to free up the pharmacist more to focus their activities on patient care.  We saw the need to create a new position for a pharmacist to oversee the operations of our dispensing system.

In addition to the changes in dispensing, simultaneously we remodeled our pharmacy to include two patient care areas.  These areas are used to provide clinical services beyond the CMM process.  Services included immunizations, medication therapy management services (MTMs), adherence programs, health promotion services, and case management.    As our services continued to expand and more and more patients enrolling in them, it was time about adding some new positions.  We created a community pharmacy resident position, but quickly realized that we also needed to hire another pharmacist to oversee all of our clinical services.  Not only do these pharmacists manage our clinical services, but they serve as a resource for our dispensing pharmacists providing us with “slack resources” for more in-depth problems uncovered by the dispensing pharmacists, or providing more in-depth counseling to patients as needed.

Other features of our practice that help support our patient care services a marketing plan that we review monthly.  Every month we determine which services or practice areas we want our marketing efforts to focus on and what media we will use to “spread the word”.  We hired a marketing professional who oversees our marketing efforts.

We have remodeled our pharmacy several times in the past decade with each remodel planned to improve patient care processes. We created two patient care areas which also serve as offices for our clinical manager and our community pharmacy resident.  We expanded our dispensing counter to give our dispensing pharmacists more room for their CMM activities.  We also created a patient counseling area at the end of our dispensing counter.

We have implemented tech-check-tech services as part of a new practice model program in Iowa to free up our pharmacists to provide clinical services.  We also have implemented new technologies in the practice to improve our efficiencies including using a Parata robot, the Eyecon medication counter, an interactive voice response (IVR) system,  and automated programs that help with our medication synchronization program and help with patient selection into medicare plans.

With all of these changes, the following list provides the current patient care services we offer at Towncrest Pharmacy

Clinic Services: Med Check Program, Medication Adherence Program, Influenza and Pneumococcal Vaccinations, Zostavax Vaccination, Tdap Vaccination, Pharmaceutical Case Management (PCM), Medication Therapy Management (MTM), Nursing Home Consulting, CPAP service/Education, Ostomy Consultations, Drug Information Service, Compounding, Employer based health screenings

–Wellness Center: Cholesterol screening, Blood glucose screening, BP screening, Height and Weight, BMI

Specialized Focused: Mental Health, Wellness, Geriatrics, End of life/palliative care

As we have mentioned before, our practice has evolved to have this type of capacity to provide patient care services to all of our patients. Although it didn’t happen overnight, we realized that we had to make the initial changes to provide the foundation.

We Have to Stop Apologizing and Just Do It!

Recently, I was at a multidisciplinary meeting to discuss how pharmacists and prescribers can work more effectively together to identify patients with certain risk factors and ensuring that they receive appropriate drug therapy.  As I discussed our continuous medication monitoring process (CMM), the prescribers in the room indicated that they were not familiar with pharmacists in their communities doing anything like what I was describing.   Sadly to say, their own experiences  going to a pharmacy as a patient did not help my argument.  The other providers described the situation, that is all to common, that they seldom talked to a pharmacist and if they did, they had to wait 25 minutes.  Now I realize that this may not be the actual case, but we have to remember that their perceptions are their realities.  After some heated discussion about the roles of pharmacists and turf issues, I finally said to one of the physicians who was sitting next to me questioning how pharmacists can do what I was describing that he should change pharmacies and go to one that does provide clinical services.

Unfortunately as we have written in previous blogs, too many community pharmacies (chains and independents) have settled for a “strip-down” model of practice where there is little to no overlap between pharmacists and just enough technician help to ensure prescriptions can be filled efficiently–but little thought to clinical services.  This “strip-down” model evolved out of profit motives and not what was best for patients and as reimbursements dwindled over the past decade, the “strip-down” model became even more prevalent and accepted.  Because of this, patients, providers, and payers get mixed messages.  They hear what I and others are talking about, but they experience something totally different when the go to a pharmacy.  It is time to change the paradigm of community pharmacy practice.

The paradigm change that I am talking about will change the perceptions of all who come to a community pharmacy.  First, we have to stop using the word “retail” when talking about community pharmacy as it gives a much different description then if you say community pharmacy.  Secondly, pharmacists need to become interventionists identifying and resolving drug therapy problems, counseling an educating patients, consulting with other providers, and documenting their activities.  Thirdly, pharmacists have to stop being passive in the dispensing functions.  We need to make sure that we engage patients to collect information that will help us better manage their medications.  Lastly, we need to make sure we have sufficient staff so that pharmacists are freed up to provide clinical services including CMM during the dispensing process.

For the past twenty something years we have been pushing community pharmacists to move from distribution functions to patient care.  One would think, after all these years, that we would have a critical mass of community pharmacists providing ongoing clinical services.  But given the response I received from the other providers at this meeting obviously they have not been exposed to it yet (and these providers were from around the country).  We have to stop apologizing and making excuses for why we are not providing patient care services and just be doing it!

Why Don’t Payers Get It?

I was just on a conference call with a managed care organization (MCO) that will respond to a request for proposal (RFP) as our state shifts our medicaid administration to two or more MCOs.  Unfortunately, the MCO that we spoke with today did not have any idea about the role of pharmacists as care providers.  WHAT?!!!!  How after all these years, with pharmacy’s movement from product distribution to patient care, can a managed care organization or payer not understand the value of pharmacists as clinical providers.

Part of the reason is because payers are not seeing this type of practice across the board.  Also, not all pharmacists are practicing to the level of their degrees–identifying and resolving drug therapy problems, providing recommendations to prescribers, and documenting their activities.  Lastly, payers may be looking at the wrong metrics when reviewing pharmacies (e.g. focussing on drug costs and not clinical parameters and patient outcomes, including health care spend).

As a profession, we need to do a better job of selling ourselves to payers and, in particular, our value to the health care team.  Our value is that we have access to patients, we are able to identify and resolve drug therapy problems, we can ensure that patients are on safe and effective medications, and most importantly, we can make sure patients are achieving therapeutic outcomes–which will positively affect their total health care spend.

But all pharmacists also need to step up their efforts to develop and implement patient care services if they have  not already done so.  There is no money in product distribution because there is little value from patients and payers.  The value statement is patient care, achieving health outcomes, and the unique role and knowledge of pharmacists to monitor and manage patients drug therapy.   So, we need to make this the “norm” of pharmacy practice–not the exception.

Pharmacists, as a group, also need to be more vocal about the clinical roles to payers, legislators, and regulators.  We cannot just sit on the sideline hoping that someone can figure this out–each of us has a responsibility to advocate for our profession–to reach out to payers and let them know what you are doing and the value you bring to their clients through your patient care services.  If we do not do this, our profession will continue to experience the response that I experienced today–and that is getting old!!!

It’s About the Therapeutics!

As co-owners of two community pharmacies, a compounding pharmacy, and a consulting company, my business partner and I have created practices that  have developed and implemented value-added services.  The services we have implemented include immunizations (flu, pneumonia, shingles and TDaP), health screenings, disease state management, medication therapy management, medication adherence program, medication synchronization services, consultations for CPAPs, ostomies and wound care, and continuous medication monitoring.  Although I described these services as “value-added”, it is not the service in and of itself that is of value to patients, but rather the pharmacists’ knowledge and their ability to problem-solve for the patient.  As I write this blog today, I am reminded of a statement made by one of my pharmacy colleagues when asked what makes a good pharmacist and his reply was “It’s about the therapeutics, stupid!”

My colleague was absolutely dead-on.  We can offer many value-added services, but if pharmacists do not have the clinical knowledge and skills to ensure that patients are achieving their therapeutic outcomes with safe and effective drug therapy, then these services are just a shell with no real value.  As our health care system moves to a value-based system and providers are evaluated based on their performance, then it will be those pharmacists who keep up with the literature, keep their knowledge current and relevant, and are capable of identifying and resolving drug therapy problems who will thrive in this new system.

Unfortunately, there is not an easy way for pharmacists to keep their knowledge current and it requires a lot of work and energy.  It requires that pharmacist keep up with the guidelines, read and understand landmark studies, be involved in professional organizations, and apply their knowledge consistently in the practice setting.  For some it may require some remediation, whereby they may need to take a series of courses on therapeutic topics that they need to further their understanding.  But it does not end there, because to become comfortable with new knowledge, it is important that it is applied to everyday situations until it becomes entrenched in memory.  Perhaps purchasing an updated therapeutics textbook as a guide will help, along with a case study workbook to apply new knowledge and therapeutic skills.  Another approach is to connect with a faculty mentor who can provide you with reading material and cases to help you become a better clinician. Employers should invest in their employees and encourage them to attend local/state/national conferences, which would help increase their value as employees to better the practice.  Even with employer support, it still is up to the individual pharmacist to read, assimilate, and apply new knowledge.  In other words all of us need to become life-long learners.

At the end of the day, those pharmacists who keep their therapeutic knowledge current and relevant will be of great value to the health care system.  More and more payers are recognizing the value of good and effective pharmacists in reducing total health care spend and improving patient outcomes.   I am convinced that the future of our profession lies in our ability to affect patient outcomes, collaborate with other providers, and improve the bottom line of payers.  Now is the time to prepare yourself for the this future which is coming fast and furious.  It will all serve us well to remember our value to the system is all about our therapeutic knowledge and how well we can apply it to our patients!