Category: Tales from the Counter

Real stories of clinical interventions made by pharmacies.

Counter-Productivity and the CancelRx Message

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

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

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

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

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

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

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

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

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

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

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

Clinical Mayhem​?


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

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

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

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

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

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

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

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

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

Flummoxed

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

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

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

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

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

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

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

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

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

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

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

Am I a Part of the Problem or a Part of the Solution?

We serve a patient with severe mental disabilities living in a group home. He has full time staff assisting him with his medications. Our pharmacy provides the patient’s medications packaged to meet the rules and regulations for this type of residential care facility. These packaged medications are delivered in monthly installments.

The prescription drug plan the patient uses made some changes with the new year, and one specific change created a problem. With the new year, one important medications now requires a prior authorization. The appropriate paperwork was initiated immediately, with our pharmacy providing much of the basic information directly to the physician to be submitted. This included the quantity needed and the need for a 31 day day-supply as is required for the group home’s monthly delivery of packaged medications.

At this point it is important to note that the medication was delivered to the facility before the first day of the month to the group home. Billing could not be done until the first day of the month and until that point it was not known that a prior authorization would now be needed. We went out of our way to ensure that the patient would not be without the medications they required.

Five days after submitting the prior authorization, approval was granted. When our staff went to bill the medication that had already been delivered and was already being used, they once again received a reject. The insurance, despite the approved prior authorization, would only pay for a 30 day supply of the medication.

For most members of this drug plan, this would not a problem. But in the case of our group home resident, this change creates a logistical issue. Some months, including January, have 31 days in them.

This is where the painful part of the story starts. Talking with the Prior Auth department of the plan we were told that they could not approve more than a 30 day supply. They suggested calling the customer service phone number and asking an exception to be granted. As I was trying to support the group home staff and care for my patient, I did as asked.

During this call I was shuttled to multiple departments. Eventually I spoke with someone that appeared to understand the issue and was going to get me to someone who could help. Once I got there, however, I ran into a brick wall. I wish I could say that this was unexpected.

My request was simple. Put an exception into place to allow a 31 day supply of the drug. I was told that because I was the pharmacist and not the prescriber or the patient that I could not do this. Those that know me will immediately recognize that this upsets me. I continued the call, escalating to a supervisor who simply read off their cue cards the same information. It was not until I mentioned that I was going to complain to CMS that something changed.

After hearing me threaten to complain to CMS, I was put on hold. When they cam back, I was returned to the technician who immediately began to attempt to fix the problem. Her attempt to put the exception in place required her to make some of the same calls I previously made during this process. I noted with some satisfaction that she had difficulty negotiating the same phone tree prompts I have been using over the past two hours. During this process, she was disconnected from both her own company’s phone tree, and from me.

After spending over 120 minutes on the phone I now have to start over: I was back at square one.

Patient care is not only complex from a medication perspective, but also because of the need to jump through arbitrary hoops imposed by the health plans and their benefit managers. We are very aware that in caring for our patients, one size does not fit all. Unfortunately, many healthcare plans and their pharmacy benefit managers do not seem capable of understanding this concept. Our patients are not just faceless nondescript beings. They are living, breathing individuals. We need to ensure that they are achieving their therapeutic outcomes. We need to ensure they are getting the best possible benefit from the healthcare dollars that are being spent on their behalf.

The problem as I see it is that the plans, to a large extent, have failed to comprehend the larger picture. They have allowed the PBMs to describe the benefits of pharmacy only in terms of drug spend. With their focus on the drug product, and not on care and outcomes, the patient and the plan lose.

It is time for the plans and their benefit managers to start working to be a part of the solution, and not be a part of the problem.

Remember, caring for patients is not easy. You may not succeed every time, but don’t give up. Make Every Encounter Count

Sometimes There Isn’t a “Right” Answer

In a modern pharmacy, specialized systems and software assist the pharmacist in identifying potentially important issues important to patients. It is important to recognize that while these aids are invaluable, they also require sound clinical judgement and an underlying knowledge of the disease states and pharmacotherapy involved. I would like to share an example in this edition of Tales from the Counter.

Our patient was just released from a hospital and the History of Present Illness (HPI) was remarkable for:

  • ischemic stroke treated with Tissue Plasminogen Activator (TPA)
  • hemorrhagic complications from the TPA and
  • glaucoma (unspecified) being treated with dorzalamide, timolol and lantanoprost.

The discharge orders included a prescription for methylphenidate 5 mg daily without any diagnosis information provided. After reviewing the HPI, it was determined that the methylphenidate was being used off-label to treat post-stroke depression.

Because we put diagnosis information in our pharmacy management system, automated screening performed by our system includes drug-disease interactions. In this specific case the following warning appeared:

This medication is contraindicated in patients with glaucoma.

Other drug-disease interaction sources list the same contraindication. Facts and Comparisons Interactions, for example, labels this issue with a severity level of Not Recommended.

Whenever any type of automatic screening alert presents, the pharmacist needs to pay attention. The reason, however, is not necessarily what many might expect. A health care provider can be sued for negligence for ignoring a warning, but they can also be held negligent for heeding the warning and withholding or delaying treatment.  The pharmacist needs to pay attention to the provided information and document what they did with the information and why they decided on their course of action.

The first step is understanding exactly what the computer generated warning actually means. A quick search of the literature revealed that this contraindication is poorly documented. The use of methylphenidate in patients with glaucoma has the potential to increase intra-ocular pressure. The increase appears to be dose dependent: most of the reports in the literature cite doses more than 30 mg of methylphenidate

If one wanted to avoid this interaction, they would consider another treatment option for the depression. However, alternate drugs that could be used to treat depression also have their potential issues in this patient. Tricyclics like nortriptyline must be used with caution as they also interact with glaucoma (severity is listed as Extreme Caution by Facts and Comparisons). Drugs like escitalopram are associated with an increase the risk of bleeding events; a drug-disease interaction with the hemorrhagic stroke recently treated. This interaction’s severity level—Extreme Caution.

The alternatives to treating the depression are therefore somewhat limited by the patient’s HPI. The alternatives really boil down two options:

  1. Do not treat the post-stroke depression
  2. Treat the depression and manage any associated risk

There is no right or wrong answer here. We elected to dispense the methylphenidate along with documentation to the prescribing physician that included a recommendation to monitor the response of the patient’s intra-ocular pressures. The rationale was that the low dose methylphenidate was less likely to create problems with the glaucoma and would not further increase the risk of hemorrhagic stroke. There are certainly other possible answers, but the others also involve some level of associated risk. The important part is the act of documenting.

Does a Pharmacist Represent the Insurance or the Patient?

I recently had a discussion with an angry patient. At the center of the interaction was the allowable day supply of one of his diabetic medications. The patient was questioning why I was only able to give them 7 vials of insulin instead of the 8 vials they wanted. To me, the answer is simple: 8 vials exceeds the allowable day supply as defined by their insurance benefit.

The patient asked me if I was taking care of him or his insurance. That is a fair question. I would always claim that I am a patient care provider first and pharmacy manager second. But limiting his medication supply based on arbitrary insurance rules does seem to contradict that assertion, given that his request was far from unreasonable.

The current healthcare system is a lot more complicated than the patient would admit. The insurance is paying for large parts of his medications, so they are entitled to have input as to the quantities they are willing to fund. And by that same argument, the patient has paid the insurance premiums for decades without utilizing the benefit significantly until now: why is the insurance unwilling to allow him a little flexibility now that he needs the care he has purchased? Complicate this with by considering that a motivated diabetic patient actively managing their disease and having adequate supplies of medication could save the insurance on claims over time, reducing healthcare expenditures and even patient premiums. This only begins to scratch the surface of the complexity!

Those of us working in health care, and being served by health care systems, are subject to an imperfect and complex system. It is important to keep an open mind and listen. This goes for both providers and patients.

During our discussion it became evident that the patient did not completely understanding the concept of day supply. He was under the assumption that the 7 vials would have to last him 90 days. I explained to him that in fact we were submitting the actual day supply the 7 vials would last. He would be able to refill the insulin as that day approached–before he would run out.

This was some consolation to the patient. Yes, they were being inconvenienced by having to come to the pharmacy more often than every 90 days, but he now understood that he would not be without his medication. The patient was still frustrated, and I believe that in his eyes I am still appeasing his insurance at his convenience and expense.

This is only one example of an underlying problem in healthcare: the lack of professional autonomy. Artificial constraints like day supply imposed on the provider completely ignore the needs and situations of the individual patient. Often they are a roadblock standing in the way of successful patient care.

If the provider does their job well, or the patient does not have any special concerns or issues, the patient is usually blissfully unaware of the complexity of the system in which they participate. Unfortunately, more and more patients are impacted by these system-imposed constraints. Our system has a long way to go to put the care back into healthcare. Our job is to do our best to care for our patients, Making Every Encounter Count.

Major Interactions

Recently, pharmacies failing to address significant drug interactions has made national headlines. But while the pharmacists that failed to address these interaction are certainly at fault, to some degree we all share in the fault. Today’s healthcare world is regularly pushing providers to do more for less. The payor and the patient both want low cost, and with respect to pharmaceuticals, they often getting what they want.

The public’s frenzy for low cost pharmaceuticals has fueled the fire. Pharmacy reimbursement is almost exclusively based on the drug product dispensed, and reimbursement today often barely covers drug cost. Pharmacists are generally not paid for their clinical expertise.  In order to stay competitive, pharmacies have to increase prescription volumes while using fewer pharmacists. Instead of using a pharmacist to perform continuous medication monitoring or drug utilization review, pharmacies are increasingly relying on computers to help the pharmacist identify problems with drug regiments.

Today, pharmacies almost exclusively use a type of software generically referred to as pharmacy management system. Besides handling the record keeping for dispensing prescriptions, the package also includes screening for drug interactions, therapeutic duplication, drug allergies, and drug / disease issues. The problems identified by a software package like this will range from trivial issues with no clinical relevance to life-threatening problems. Because of the enormous volume of alerts generated by these systems, alert fatigue is a real concern.

But while computers can generally find problems, at this point they still lack the clinical expertise to make the important judgements required. A pharmacist still needs adequate time to evaluate the implications of the sometimes lengthy list of potential problems. Given the time, pharmacists can help ensure a patient will have positive therapeutic outcomes while minimizing the associated risks. To emphasize this, let us look at a brief tale from the counter.

We start out with a patient taking Oxybutynin and Nortriptyline. They have been taking this combination for some time now. Looking at the most recent refills, the only item noted by the computer based screening is a late refill on one of the medications. No drug interactions were flagged by the computer, but as it turns out this is not necessarily accurate. If the pharmacist looks at these two medications in a dedicated drug interaction reference, they find that there actually is an interaction:

Pharmacologic effects and plasma concentrations of Nortriptyline HCl Oral may be decreased by Oxybutynin Chloride ER Oral

The interaction is considered a MODERATE risk, with a delayed onset. The reference also notes that there is not a lot of documentation to support this interaction. In this case, the pharmacist recognized the interaction without the aid of the computer screening. The interaction poses minimal risk as the nortriptyline dose is generally titrated to the desired effect. The intervention might involve a brief discussion with the patient explaining the issue.

But the plot thickens: more recently, the oxybutynin was discontinued and a newer medication started. Myrbetric does flag as a drug interaction in the pharmacy management system, but again the system did not display an alert because it was set to only display moderate and severe interactions. The reference used by the software classified the interaction as minor.

But when using a dedicated interaction reference, the story is quite different: the interaction significance is classified as major.

Pharmacologic effects of Nortriptyline HCl Oral may be increased by Myrbetriq Oral. Elevated plasma concentrations with toxicity (e.g. QT prolongation/Torsades de Pointes) may occur.

Note that the effect on the nortriptyline is opposite that of the other drug. The overall risk is much higher for this type of interaction, and one of the listed consequences is Torsades de Pointes, a rare but very significant heart arrhythmia that can be fatal. Fortunately, the pharmacist was given adequate time to consider the new therapy, spotted the interaction, and addressed it with the patient and prescriber.

So the national headlines decrying pharmacists missing important interactions also serves to highlight how important having a pharmacist exercise their clinical judgment is to patient care. Perhaps the there is another interaction that needs to be addressed:

Interaction: poor reimbursement decreases pharmacist staffing.
Significance: Major
Onset: Delayed
Documentation: Strongly suspected

Effect: Ability of pharmacists to perform clinical activities is negatively impacted by current pharmacy reimbursement model focused on inexpensive drug product.

Be sure you make every encounter count!

Apples and Orange Books

Darrel Huff’s How to Lie With Statistics is an excellent overview of using mathematics and statistics mislead things that may not actually be true. At the beginning of his book, Huff starts with a quote popularized by Mark Twain and attributed to British Prime Minister Benjamin Disraeli:

There are three kinds of lies: lies, damned lies, and statistics.

The art of statistical malfeasance is regularly practiced in the realm of drug development and marketing, and today’s Tales from the Counter is a common example.

Our patient was being treated for glaucoma with latanoprost. Unfortunately, mono-therapy was not achieving the desired goal for our patient’s intraocular pressure. The ophthalmologist wrote a prescription for a second drug,  timolol maleate, in hopes of better controlling the pressure in the eye. The prescription, however, was not  written for generic timolol. It was written for Istalol 0.5% drops, and this is where statistics and science enter into the equation.

Istalol is a brand name version of Timolol Maleate 0.5% drops. Also available are generic Timolol Maleate 0.5% solution and Timolol Maleate 0.5% Gel-Forming Solution (GFS). In the eyes of the Food and Drug Administration, each of these drugs are scientifically and statistically different. Because of this, the pharmacist cannot substitute any of these three for another without getting a new prescription from the prescriber.

The rules of substitution enumerated in an official publication of the FDA called the Orange Book: Approved Drug Products with Therapeutic Equivalence Evaluations. This compendia of equivalent and non-equivalent dosage forms  (bioequivalence) is governed by a science called pharmacokinetics. In the most basic terms, bioequivalence is achieved by statistically demonstrating similar rate and extent of absorption into the body. Bioequivalence has two opposing uses: matching rate and extent to create a substitutable generic equivalent, and purposefully modifying rate and extent to prevent equivalence, creating a non-substitutable drug entity. This last use is commonly used to create a marketing advantage.

Note that equivalence, or the lack thereof, are not inherently relevant in a clinical sense. Bioequivalence is not a measure of clinical outcome. Instead, it ensures that a given clinical outcomes should be observable using any equivalent product. Differences in rate or extent do not mean that one product is necessarily better than another.

This is the key point. Some bioequivalence differences statistically demonstrate better disease control or fewer side effects. More often, bioequivalence differences are associated with patient convenience: once-a-day dosing offering potentially better patient compliance than twice-a-day dosing. If taken properly, either will achieve the desired clinical outcomes.

It is creation of a non-substitutable drug entity that creates some of the most interesting pharmacy stories. When faced with the impending loss of patent protection, it is common for the pharmaceutical manufacturer to re-formualte their product to create a non-substitutable version of their product. This helps them extend the profitability of their product. But often these tricks offer little  in terms of actual clinical advantage.

This brings us back to our timolol prescription. Istalol is non-substitutable timolol with once-a-day dosing. The Timolol Maleate solution requires twice-a-day dosing to achieve the similar therapeutic effects. Interestingly, the Timolol GFS can also be dosed once daily to achieve the desired outcome. A brief search of the literature did not reveal any obvious clinical advantages of Istalol over the other two products. Because our patient has not, as of yet, tried any timolol formulations, we have no reason to believe that they would not achieve their therapeutic goals on any of the available timolol formulations. So how do these products compare with respect to price?

  • Istalol 0.5% Solution, 5 ml: $270 (Copay $135)
  • Timolol Maleate 0.5% solution,  10 ml: $10 (Copay $0)
  • Timolol 0.5% GFS, 5 ml: $70 (Copay $0)

Given that the Timolol GFS is dosed once-a-daily like the Istalol, and it is $135/bottle less expensive to the patient, it would be a much better first choice. Because the prescription was written for non-substitutable Istalol, the prescriber was contacted to request a new prescription. This is called making every encounter count!

Night Shift…

Recently I received an after-hours call from a rehabilitation facility. One of my patients was recovering from surgery and they were out of one of her medications.  Normally, a call like this would be a routine delivery and the story would end here. Instead, this call transformed in my latest adventure in Tales from the Counter.

The trouble began when the prescription was refilled: it was too early according to the plan. Either the patient had an additional supply, or something else changed. A call to the facility confirmed that the patient was now taking 2 tablets a day compared to the one tablet daily the written in the original prescription. As evidence, the facility pointed to the discharge summary the received from the hospital at the time the patient was admitted to their care.

At this point, I had to set my pharmacist hat aside and put on my detective hat. The job now is to track down who made the change, get an updated prescription, and then get a dose-change override from the plan. Not knowing where the change originated, I drafted and sent notes to three different physicians:

  1. The primary care provider
  2. The specialist for the medication
  3. The surgeon discharging the patient from the hospital to the rehabilitation facility

I was fortunate to get quick responses from all three. Incredibly, none of the prescribers acknowledged making the change. The surgeon wanted nothing to do with the change, and the primary care provider deferred to the specialist, who indicated they did not make any changes.

So where did this change come from? It is likely that the change was made erroneously during the hospital admit process. Possible explanations might include the patient relaying incorrect information or the staff member erroneously transcribing the information. Perhaps the patient misunderstood something their specialist or primary care provider told them at a recent appointment and conveyed incorrect information that they understood to be true. There are numerous possibilities, but if this was the origin of the change, the admitting staff recording the medication history did not spend the time necessary to reconcile the profile.

We regularly receive requests from local hospitals for a copy of our patient’s med profile. Our clinical software make is easy to create a list and send it off. Likewise, we request the discharge summaries for our patients whenever available. These help us ensure we are aware of changes before they become an after-hours emergency.

This story happens far too often in today’s health care environment. There are too many silos, with different groups not taking the time to communicate efficiently. In some ways, the current laws regulating health care and privacy are a part of the problem, making providers reluctant to volunteer information to other providers. In other cases, it is politics and money.

In the end, though, it is the patient and their care that counts. Yes, it can be a chore to tie up the loose ends. It took the better part of 5 hours to resolve the problem above, but in the end the patient was returned to the correct dose and the best possible care was given. When opportunity calls, even late at night, be sure to make every encounter count!

Dealing with High Risk Medications–Zolpidem

This week’s tales from the counter deals with the high risk medication Zolpidem. The other day, I received a call from a patient concerned with their copay for zolpidem. The patient’s copay increased to over $90 for a 2 month supply. This was up by 200% compared to the previous refill, and she had concerns about being able to afford this in the long term. The price increase appeared to be a deliberate attempt by the plan to financially pressure the patient away from using the high-risk medication. The approved claim even included an attached note suggesting trazodone as a possible alternative.

This tactic of financial pressure to change the patient’s behavior in interesting. Unfortunately, this pressure is somewhat shortsighted. A real possibility exists for the patient to not switch medications, but instead to switch to a different discount prescription program instead of using their Medicare Part D plan. While such a switch might improve the Medicare Part D plan’s star rating (by removing the medication from their records), such a change would not actually reduce the patient’s risk.

A better way to handle high risk medication is by working directly with the patient. In fact, we had already spent time working with this patient to reduce their use of this high-risk medication. While on the phone with the patient, I read the notes we had created in their electronic chart. Here, there were several interventions regarding this same medication. Most recently, several months ago, one of our pharmacists worked with the patient and the prescriber to try a dose reduction and conversion to a different medication with lower risk. The patient did not tolerate the change, reporting several adverse drug reactions to the new drug, and reverted back to the zolpidem after a few weeks.

The increase in the patient’s copay, however, did allow us another tool to revisit this problem. Using the opportunity this financial tactic presented, we were able once again to approach the patient and attempt another conversion. The patient, like before, was open to the suggestion, and another note was sent to the prescriber.

My point is not to criticize the plan for using a financial incentive to discourage behavior in the patient, but to point out the missed opportunity. Instead of working alone, perhaps the plan would be better off partnering with the network pharmacy providers. If the plan and the pharmacy were on the same page, the potential synergy would be tremendous. Pharmacists could have discussions with the patients on high-risk medications. The patient can be informed of the risks associated with the medication and financial impact continued use will incur. Working together, the patient, the pharmacist, the prescriber and the plan could more easily persuade patients away from using high-risk medications.

The other implication to this collaboration is that there are always going to be some patients that have good justification for their continued use of a high risk medications. With the recent expansion of the Beer’s List of high-risk medications, this is even more pronounced. The plan should also allow the pharmacy to provide documentation justifying continued use of the medication. A patient with justifiable use should not, then, be counted against the plan and pharmacy’s EQuIPP scores.