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!

Pharmer Rex’s Apple Pharm

Meet Pharmer Rex. Rex lives in the country and runs the family apple orchard called the Apple Pharm, just as his father did before him. The local residents of the town regularly visit Pharmer Rex to get their apple-a-day to keep healthy. Pharmer Rex and his family have made a decent living over the years selling apples and keeping the town-folk healthy.

But things on the Apple Pharm have not been as good lately. Down the road, a big-box store opened up, and they too sell apples. Pharmer Rex’s business has declined because the competition is willing to sell their apples below cost just to get the town-folk into their store to buy other merchandise. Farmer Rex understands competition, so he invests in his orchard. Instead of trying to compete on price alone, our savvy pharmer starts growing fancy apple varieties that the competition doesn’t provide. Things once again pick up for Pharmer Rex, but even though profits are still down some, he is happy.

Soon, the competition notices the boutique apple selection up the road, and they don’t see the investment required to get into that business as insurmountable. They bring in their own boutique apple varieties. Like before, the big-box store looks to drive traffic to their store, pricing even their boutique apples much like fallen fruit in the orchard. Pharmer Rex once again sees profits and sales drop. But being a true apple pharmer, he reaches higher into his trees’ better fruit. This time, he invests in ovens and cider presses. Pharmer Rex starts selling fresh apple goods: pies, turnovers, and fresh apple cider. Pharmer Rex’s investment paid off once again. Sales and profits were up. And even though his apples were more expensive than the competition down the road, the town folk still bought some of his apples because they already had come for his other apple-related goods.

No doubt, by now, you recognized this as a thinly veiled parable about independent pharmacy. Independent pharmers, err, pharmacies have long been leaders in identifying and pioneering new fertile grounds for their practices. Each time an independent pharmacy reaches higher in their tree and invests in more valuable fruit, the big-box stores have to decide if they also want to follow the same course and invest. It is a lot like an arms race between the independent pharmacies and the chain pharmacies. Typically, the independent pharmacies forge ahead, but they are soon followed. But as the investment costs increase, the low-cost model of the chain pharmacies will eventually reach a tipping point. When will the required investment be too great to justify the chain store from following along?

We are already seeing signs that this is happening. Consider the Medicare Part D Medication Therapy Monitoring programs, usually referred simply as MTM. This is a significant problem for the chain pharmacies, as their pharmacists are very busy simply checking the high volume of fallen apples, err, prescriptions they are presented. Some chains have dabbled with a central clinical pharmacist to review and complete these cases. They have had varying degrees of success with this, primarily due to patient resistance: If patient doesn’t know the pharmacist cold-calling them to perform the service, they are less inclined to participate. There certainly still appears to be value in the patient-pharmacist relationship.

So how does Pharmer Rex’s story end? The ending has not been officially written. But as I see it, there is one inevitable ending for Pharmer Rex: He becomes a coffee farmer.

Now wait! you think. That makes no sense! Let me explain. Each incremental investment that our entrepreneurial pharmer made in apples was eventually matched by the big box competitor and then discounted. Our hero’s competitor put no value on the apple. Recognizing that the chains were so entrenched in providing low cost apples, to the point of losing money, he came to the conclusion that he had to completely change his focus in order to survive. Our pharmer, therefore, decided to invest in something completely different.

But now our agrarian simile loses some of its cachet. So let’s put some of this this back into pharmacy terms. The PBM industry is only paying pharmacies for fallen fruit, and that is not going to change. So instead of fighting to maintain that dying model by cutting costs and decreasing patient care, our hero instead elects to find payment for clinical services. This is a costly investment, as it necessarily requires more expensive pharmacist payroll and a completely different practice. None of this is easy. Finding sources of revenue requires significant work and investment, sometimes without immediate rewards.

Because Pharmer Rex is a visionary, he started this transition some time ago, he is now seeing the fruits of his labor. Pharmacists are close to receiving provider status with the federal government, and they have already received it in some states. The commercial insurance world is also taking notice of the savings the pharmacists can impact, and they too are starting to pay pharmacists for clinical services. Even Medicare Part D is moving in this direction with new emphasis being made on quality. Working hard, Pharmer Rex has several new opportunities that don’t revolve around the low-price PBM drug model.

But what about the chain pharmacies? Will they change their direction and follow? Because this change is so dramatic, it will take them a long time to decide. Ultimately, I feel that there will be two classes of pharmacy: dispensing operations, dominated by retail chain operations and mail-order, and clinical based pharmacies. Both will be paid (poorly) for product for the foreseeable future. The difference is that the clinical pharmacies will also be paid directly by the insurance plan for the impact they have on total health spend on their patients.

So if you identify with our friend farmer Rex, you need to start now. Invest in your practice. Work to develop the relationships with both payor and patients that will allow you to impact healthcare and be paid for your efforts. Make every encounter count!

Playing to Win, or Playing to Lose?

I don’t know if Drug Channels is simply channeling the Thriving Pharmacist, or maybe its writer, Adam Fein, is wearing a Zoltar costume to trick-or-treat tonight. Either way, his Blog Post Walgreens Plays to Win: Our Exclusive Analysis of 2017’s Part D Preferred Pharmacy Networks is germane to Thriving readers as well. Please head over to read it.

Of course, I cannot help but add some community pharmacy specific perspective. Let’s start with Table 1 from his post. Adam’s take is that Walgreens wants to be preferred. I don’t contest this: they certainly appear to be willing to take more of these hyper-aggressive contracts than others. But sometimes, it is what is unspoken that is most interesting. In this case, we might ask: why would Walmart relinquish their number-one position on the list? Unlike Walgreens, Walmart stores are generally much larger, and contain a broader array of non-pharmacy merchandise. In other words, they appear to be better suited than Walgreens to absorb pharmacy losses by increasing sales in their other departments. But in spite of this, Walmart has contracted its participation, and that is truly interesting! Will we be seeing Walgreens warn of than expected earnings sometime in 2017 like Walmart did in 2015?

Also, while Adam correctly notes that CVS is less willing to play this game, he forgets to mention that some of profits for this company originate on the OTHER SIDE of the ledger: the benefit manager side. CVS may be the smartest one of the bunch because it doesn’t participate in most narrow networks. Likewise, Rite Aid appears to be following in the shoes of CVS, both by limiting their participation and acquiring a benefit manager.

Finally, the independents are not spooked. To the contrary, like CVS and Rite Aid, they might just be smarter than the others. Most independent pharmacies, if given the option, would not sign with any of the preferred or narrow networks. It is only because chains are willing to sacrifice pharmacy profits for store traffic, that independents have to participate in at least one preferred network to prevent significant erosion of their patient base. And this is really the key point. Patients seem to have a lot more loyalty to their pharmacy, both chain and independent, than to their Part D plan. Patients will generally chose a plan both on the overall costs and the ability to maintain access to their pharmacy or pharmacist. It is unusual for a pharmacy to lose a patient when that pharmacy accepts one or more plans that are similar in out of pocket expense to another plan if the patient is forced to change pharmacy providers to gain the advantages offered by the other plan.

Happy Halloween. And I promise that we won’t be referencing Drug Channels in the post tomorrow.

Cost-Shifting

Adam Fein, with Drug Channels, recently posted an excellent analysis of the Kaiser/HRET 2016 Employer Health Benefits Survey. His analysis addresses, among other things, cost-shifting in the employer/commercial prescription insurance realm. See Employer Pharmacy Benefits in 2016: More Specialty Drug Cost-Shifting Means More Problems for Patients for his discussion. It is a worthwhile read.

Often, the analysis of Drug Channels is focused on the distribution chain in the pharmaceutical markets and only pays cursory attention to the end of the chain: providers and patients. But in the article above, Adam makes some great points about the impact of this cost-shifting trend as it applies to patients. Adam observes:

…employers continue shifting the cost of specialty prescriptions to their beneficiaries. Patients taking specialty drugs face economically-debilitating coinsurance—in some cases with no limit on out-of-pocket expenses. These benefit designs essentially discriminate against the very few patients undergoing intensive therapies for such chronic, complex illnesses as cancer, rheumatoid arthritis, multiple sclerosis, and HIV. But isn’t insurance supposed to help when things go really wrong?

In addition to the cost-shifting implications made by Adam, the employer or plan’s classification of many of these medications as specialty drugs forces the patient to use a very narrow pharmacy network that often includes a specialty pharmacy owned and operated by the plan. One might also presume, based on the lack of competition given by the specialty designation, the inclusion of a drug on the specialty list could also be motivated by the profit these drugs might generate for the specialty pharmacy. 

Another important distinction is that cost-shifting has not been leveraged solely on high-priced medications. This same strategy is also routinely leveraged with less expensive maintenance medications. In both commercial and Medicare Part D plans, a very large number of generic maintenance medications are dispensed to patients for less than $4 per month. This is often lower than the copay the plan might have for the medication. At this point, the plan has essentially cost-shifted the entire prescription to the patient. The plan contribution for the medication is often near, or even equal, zero. During the course of the year, many patients taking only a few of these low-cost maintenance medications will not even satisfy their plan deductible, further minimizing the plan’s risk exposure. All the while, the plan continues to charge the member a monthly premium for the plan.

The implications of this trend are far-reaching. The focus of many plans is now squarely on low price. There is absolutely no focus on outcomes and patient care. This, in my opinion, is the biggest problem with the cost-shifting phenomena.

The Price of Being Preferred

Open Enrollment started Saturday, and we got our first look at how our customers’ medications will be priced in 2017 under Medicare Part D. There are several interesting observations to be made.

Preferred, Non-Preferred, and Mail Order

With the release of the 2017 data, we can actually calculate patient-cost and pharmacy reimbursement for one of the more popular plans last year. The object is to recompare the plan while using a preferred pharmacy, a non-preferred pharmacy, and the plan’s mail order pharmacy. For reference, I have also included the 2017 version of another preferred plan popular last year. It also happens to be the only 5-star plan available to my customers in 2017, and one in which I am included as a preferred provider in 2017.

The data below is arranged in columns by plan. This is actually data from a patient I worked up today, and represents their actual drugs. The columns show the Total Adjudicated Amount to the left of the “/” and the patient copay to the right of the “/” mark.

Drug Name A
Using a Preferred
Retail Pharmacy		 B
Not Using a Preferred
Retail Pharmacy		 C
Using The Plan’s
Mail Order Pharmacy		 D
Preferred Retail
5 Star Plan
Amlodipine 10 mg $1.62 / $1.00 $7.24 / $7.00 $2.63 / $2.63 $1.96 / $1.00
Atorvastatin 40 mg $1.62 / $1.00 $7.28 / $7.00 $10.32 / $3.00 $7.65 / $1.00
Furosemide 40 mg $1.60 / $1.00 $5.05 / $5.05 $2.54 / $2.54 $2.20 / $1.00
Gabapentin 300 mg $4.00 / $2.00 $43.00 / $15.00 $26.60 / $6.00 $22.15 / $6.00
Copay Total $5.00 $34.05 $14.17 $9.00
Pharmacy Total
reimbursement		 $8.84 $62.57 $42.09 $33.96

The example above is obviously not representative of all possible drug therapy combinations, but it does demonstrate several tendencies that appear to be reproducible with many different drug combinations I have run so far. For the sake of simplicity, it also is limited to only generic medications that are regularly subject to MAC (Maximum Allowed Cost) pricing. These types of drugs represent a majority of drugs dispensed in most non-specialty pharmacies.

Preferred Retail  vs. Non-preferred Retail

Looking at Column A and Column B, we can readily see the difference in both copay and reimbursement based on preferred status. The patient’s copays are significantly lower at the preferred pharmacy for this plan, saving the patient about $30/month or $360/year over a non-preferred pharmacy. The pharmacy, on the other hand, sees only $8.84 per month for these four prescriptions if they are preferred and $61.00 if they are non-preferred. Note that these numbers are not the profit made by the pharmacy, but rather the total reimbursement for these drugs. Given that the published national cost of dispensing, the amount that it costs a pharmacy to dispense a drug on top of the cost of the drug product, is between $9 to $12, the preferred plan does not come close to paying the pharmacy what it costs to dispense the drug. The non-preferred pharmacy, on the other hand shows a profit for its work. This alone explains why there are very few pharmacies in 2017 that accepted the Preferred Status for this plan.

The plan is essentially driving a wedge between the patient and the pharmacy by trying to move a patient to a preferred pharmacy. This access to lives strategy is hard to justify for the pharmacy unless it plans on making up the losses on prescription drug sales by increasing prices elsewhere. This may or may not work for big-box chain pharmacies or grocery stores with pharmacies. It is not even possible for independent pharmacies, and it is therefore no surprise that few independents elected to participate in this plan in 2017. Even a few chain pharmacies declined participation, leaving us with the question: exactly what is the point of this tactic?

Preferred Retail vs. The Plan’s Mail Order

This comparison (Column C vs. Column A) is a real head scratcher. The plan is forcing any preferred pharmacy to accept $30 less in total reimbursement than it pays itself to mail the prescriptions to the patient. Likewise, the plan makes the patient pay more for the same thing. One possible explanation for this is that in some areas, including mine, there are few pharmacies with preferred status. This means that the plan can try to coax these customers to their own mail order pharmacy, arguing that they are “saving” the patient compared to the non-preferred rate, all the while making an excellent profit using the pharmacy they own and operate.

Another Plan’s version of Preferred

While we were preferred in the plan represented in Column A in 2016, our pharmacy dropped the plan for the 2017 plan year. The reasons should be obvious: we cannot survive on such meager reimbursement. On the flip side, our contracting arm did sign a new preferred network, which includes the region’s only 5-star plan. I included this plan as an alternative way preferred networks can work with their pharmacy partners. In this plan, the patient would again pay more for going to a non-preferred pharmacy. I did not include a column for this, but its omission is not the point. The point is that a preferred plan can treat both the pharmacy and the patient fairly. Comparing the patient’s copays for this 5 star plan (Column D vs. Column A), we see that the patient would have lower copays with the 5 star plan. At the same time, the pharmacy is more often paid fairly for its contribution. Yes, reimbursements are lower than those to a non-preferred pharmacy. A more comprehensive analysis will be needed to determine if this contract is more actually more pharmacy-friendly than other preferred networks.  Note that some of the reimbursements are still too close to $1, but average reimbursement may be closer to the cost of dispensing and therefore easier for the pharmacy to recoup with other services and methods.

The Bottom Line

Now that we can see the 2017 landscape, my concern over not being preferred with the same plans as last year are somewhat alleviated. If my customers using the 2016 version of the plan in Column B have more loyalty to that plan than to us, their pharmacy, they will either switch pharmacies or start using mail order. But the Access to Lives argument cuts both ways. While plans certainly want to lure patients their way, I have found that patients actually have a lot more loyalty to their pharmacy and pharmacist than their plan. Because my pharmacy is preferred in at least one preferred network (the 5 star plan) which offers basically the same or better value to the patient, the real winner will be the 5 star plan. I have already seen many patients that plan on enrolling in this plan in 2017.

Perhaps, with time, that the whole paradigm could invert. Instead of plans trying to lure patients to them with lower copays, they will instead try to lure patient by enrolling the best pharmacies. That would be a very interesting change. So take time educating your patients during this 2017 Medicare Part D enrollment period. Be sure your patients know which plans you participate in and which ones you dropped in 2017. Let them choose their allegiance: the plan or the pharmacy. Support them, and they will support you. Make every encounter count!

Shall we play a game?

The title above comes from the 1983 movie WarGames. The plot of this movie centers around a young computer hacker that manages to access a Department of Defense computer. That computer asks the hacker, Shall we play a game? That game just happens to be Global Thermonuclear War, and as it turned out, the game was actually very real.

Sometimes, an apparently innocuous event can quickly become very dangerous, not unlike the game our hacker was playing. There are few tasks in the pharmacy world more potentially dangerous than filling controlled substance prescriptions. The risks exists on both sides of the prescription counter. Improper use by the patient can lead to significant morbidity and even death. Pharmacists face significant regulatory challenges trying to balance federal laws and DEA rules, all while assessing appropriate prescribing habits and patient outcomes.

Pharmacies and pharmacists are generally well-versed in complying with federal and laws and DEA regulations surrounding the ordering and managing of controlled substance inventory. A bigger challenge is ensuring prescriptions being filled meet all of the rules and regulations to ensure that it is valid. It is not enough to simply ensure that the prescription is not forged. To be valid, a prescription for a controlled substance must be issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice.  The pharmacy has a corresponding responsibility to ensure proper prescribing of controlled substances.

Recently, the DEA has started conducting audits of pharmacies, and they are not just looking at record-keeping for inventory and ordering. Failure to fulfill the pharmacy’s corresponding responsibility to verify the prescription is valid can result in fines of up to $10,000 per violation. Let’s look at some ways to ensure your pharmacy is not subject to this type of thermonuclear attack. Below are what I consider to be best practice principles for controlled substance dispensing.

Check the PMP (Prescription Monitoring Program) and Document Findings

This should go without saying, but every controlled substance prescription you fill should be checked every time. Even if you think you know your patient, and they have only ever used your pharmacy before, be sure they have not changed their habits. Be sure to document both your search and the results.

Determine and document the indication for the medication

If the pharmacist doesn’t know what the medication is being used for, they cannot assess the appropriateness of the therapy. While a pharmacist may be able to guess the probable indication, it is important to verify and document this information every time you fill a controlled substance. Included in this is the expected duration of therapy. All of this information does not necessarily have to come from the prescription or the prescriber, it may be possible to determine parts of this simply by speaking with the patient.

Understand the accepted guidelines for treatment

In order to be able to assess the validity of a prescription, you need to be sure you understand what the standard of care is for the condition being treated. For pain medications, especially, there is a accepted progression that should be followed. Once this is in the back of your mind…

Document previous treatments used and their outcomes

Did the prescriber jump right to an controlled substance (e.g. an opioid), or did they other medications first (e.g non-steroidal medications)? Is the etiology of the condition treatable with non-pharmacologic vectors, and if so, have they been tried? What were the outcomes? In the case of pain treatments, if the pain is chronic, is the patient being followed by a pain specialist? Do they have a pain contract? Each patient is a story, and without knowing and documenting the story, assessing validity of the therapy is more difficult.

Watch Trends

Every course of treatment will have a natural progression. An acute treatment may flare and wane with time and end. Chronic treatments may slowly escalate. All of these may be normal, but it is the pharmacists job to look for potential diversion of controlled substances. By watching trends and speaking with the patient about them as they occur, you can more easily spot diversion and take appropriate actions.

The reoccurring theme in these practices is documentation. While we use a clinical documentation platform (PharmClin) to document these types of activities, the documentation can be done in a variety of other ways. Having this documentation goes a long way toward satisfying corresponding responsibility.  Be sure to take the time to protect yourself, and make every controlled substance prescription a complete story. Make every encounter count!

Unraveling of the PBM Industry?

The role of Pharmacy Benefit Managers, the PBMs, in the US healthcare system has been detailed on this blog several times. And each time, it seems, the public is able to better understand how detrimental some of theses practices are to our healthcare system. A few days ago, a blog post from Lexology entitled PBMs and Drug Pricing: Congress and Major U.S. Employers Start to Unravel the Hidden Pricing Mechanisms of PBMs describes many of these practices.

The overall of awareness of PBM tactics increasing rapidly. This is a good thing for healthcare in the United States, because these tactics have only emphasized the drug product while completely ignoring patient care. Increased transparency will hopefully put pharmacy back into the pharmacy benefit.

The Crucible 2017

Back in in the 80’s, when I was in High School, I had to read the 1953 Arthur Miller play, The Crucible. The play title references a definition of the word crucible that, until I read the play, was unfamiliar to me.

cru·ci·ble noun \ˈkrü-sə-bəl\ a difficult test or challenge
That definition again came to mind this month as we started to prepare for the 2017 Medicare Part D Open Enrollment, which starts next month. The reason it came to mind is this: unlike the last two years, my pharmacies will not be preferred providers in 2017 for several of the most popular prescription drug plans. This change marks a move away from a focus on access to lives. We will soon have to convince patients to continue to use our pharmacy despite their copays being higher than other preferred pharmacies starting in January.
This will be a significant challenge. Over the last 5 years, Medicare beneficiaries have become accustomed to low, almost non-existent copays for prescription drugs. The plans have essentially made prescription drugs a commodity, and in the process forced the reimbursement paid to pharmacies down to historically low levels. In the process, these plans have also completely ignored the importance of the pharmacist and their role ensuring safety and efficacy in the patient’s medication use.
The reimbursement received by pharmacies under the commodity style reimbursement these preferred plans use has been so poor that many independent pharmacies have been either sold to chain pharmacies or otherwise closed or gone out of business. Even chain pharmacies have felt the impact on their bottom lines, though their business model allows for lower profit margins in the pharmacy by controlling prices in other departments.
Previously I have written that access to lives is important, and I still believe that. Being a participant in these narrow networks has certainly not been sufficiently profitable over the last two years, but we have been able to survive. The real question for 2017 is what happens if we lose access to a large number of our patients. Sure, we will make more money on the prescriptions we do fill, but will it offset a corresponding drop in sales due to a loss of patients?
We offer our patients a lot more than drug product, and many of our customers that are aware of this fact. Others will undoubtedly discover this if they follow the discounted copay to a preferred pharmacy in 2017. Our job starts now: educate our customers on their options, making sure they understand the difference between big box chain pharmacies dispensing medications in a commodity model and an independent pharmacy providing service and care.

Re-Blog: Companies you’ve never heard of are making a killing off high drug prices

Business Insider recently put out an excellent article that deserves the attention of legislators and consumers alike. After reading  Linette Lopez’s article  Companies you’ve never heard of are making a killing off high drug prices, you will better understand many of the convoluted facets of this industry.