Baby Maximus Arrives

Several weeks ago, this blog discussed our use of a Parata Pass robot and our implementation of SuperSync. At that time, we announced (somewhat like proud parents) that our Parata Pass (named Phyllis) was going to be a big sister. Well Maximus (a Parata Max) entered our pharmacy almost 2 weeks ago and this blog post will address the details of preparing for and implementing automation in our retail pharmacy space. We will discuss the results of the implementation as they relate to improvements in workflow and our MedSync program in a later post.

The Purchase Details

Before finalizing the purchase, several decisions were made with respect to features that would be shipped on the machine. A couple of these decisions were made without a complete understanding of implications. And while a better understanding might not have changed the decisions made, I believe that these questions deserve a bit of discussion as it might benefit someone else down the road.

Vial Sizes. The Parata Max has the ability to label, fill, and cap, and sort prescriptions (start to finish). It is truly a marvelous example of modern automation. The machine can be equipped to use two different vial sizes. Our machine shipped with the standard 13 dram / 30 dram vial size combination. This is well suited for most retail implementations. The other option is the 20 dram / 40 dram vial size combination. This combination may be better suited for pharmacies that deal in a significant 90 day fill business. Be sure your choice of vial sizes matches your needs as changing the vial configuration is not something  that is easily accomplished after the machine ships.

Standard vs. Locking Cells. The second item that was discussed prior to placing the order was the option of locking cells. The sales person emphasized the use of locking cells as being important for scheduled (e.g. narcotic) medications. While locking cells are useful for this, they also offer an additional safety feature. With locking cells in the machine, the user (often a technician) can only have ONE cell open at any given time, minimizing the chance that a mistake is made during the filling process. Proper training, of course, also minimizes this risk, and ultimately the added cost was not worth this for us.

The Delivery Game Plan

Like any major addition to a pharmacy workflow, a lot of work was required after the purchase of the equipment but before the delivery and installation. This is very similar to parents preparing a nursery for a new arrival. A lot of attention is paid to details beforehand knowing that after the delivery there will be a lot going on. Parata, of course, has a detailed handbook of requirements that needs to be followed. These included:

  • Adding a dedicated power outlet on its own breaker for the robot
  • Network access near the installation point
  • proper space around the installed robot (three feet of open space around three of four sides and one foot on the end)
  • consideration of workflow

In our case, a small remodel was necessary to make space for the machine. The delivery crew visited about 1 week before installation to be sure the equipment could be brought into the space and all installation requirements would be done by the time they arrived for installation. I’m not sure they were confident that everything would be done in time, as the “nursery” looked far from complete at that point. Like most remodeling projects, this one finished the night before the installation was to occur.

The Arrival

After much anticipation and preparation, the big day finally came. As this was our second delivery, we were likely a bit more prepared and relaxed. Unlike the delivery of Phyllis 2 years earlier, which involved the equivalent of a c-section, Max breezed into the pharmacy without any problems. It was not until after delivery that a few problems surfaced. The “doctor” in the delivery room (the Parata technician) quickly discovered that Max had a birth defect. He was wired incorrectly at the factory for our installation (the power and network access points were on  the top of the machine instead of the bottom). Dr. Zach, however quickly created a temporary fix and scheduled a minor surgery the next day to fix the problem. Outside of this, installation and training occurred without any significant difficulties, and within a few days we were up and running. Like any new parents, we spent the next several days getting to know our new arrival.

 

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Preparing for delivery

The installation technician taught us how to change the labels, add vials and lids, and (of course) how to “feed it” (load) medications. Boy, can this boy eat! By the time the installation technician left us (three days later), we had only filled about 100 of the 186 different cells. At one week, we were filling about 50% of our total prescription volume on the Parata Max.

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Max in the “nursery”

Coming soon, we will share our experiences with now automation has improved (hopefully!) our workflow and our Medication Synchronization program.

Letting the Patient Update your Records

Recently I spent several weeks navigating a small health issue that involved outpatient surgery. When checking in at the clinic, the receptionist handed me a tablet and asked me to complete a History of Present Illness (HPI). I did not think too much about this until a week later, when one of my colleagues asked me what our I considered to be the most common intervention our pharmacists made when working with patients. The answer, for us, is a general form of medication reconciliation. We do it every day, though the form the intervention takes varies from case to case.

In our practice, and I am sure many others are not any different, we deal with a significant number of patients that are taking their medications according to the instructions provided by the prescriber. The problem is that these directions don’t necessarily match what was written on the most current prescription. We are routinely the last to know about changes that are made in our patient’s therapies. What starts out looking like an issue with compliance really becomes an exercise in medication reconciliation.

The thought that occurred to me was this: what if we could have the patient review their own medications from time to time and alert us to any changes that have occurred? Using a tablet type device that the pharmacy staff could configure to perform this query would be an excellent use of this type of technology, but even using a simple paper copy of the patient’s profile would be a step forward.

During the time that the patient reviews the accuracy of their profile, they could also be queried about other information related to their drug therapy. Example might include recent lab values (e.g. INR or A1C) or possible Adverse Drug Reactions (ADRs). The possibilities are almost limitless!

The Implementation

Using PharmClin (our clinical software package), a medication snap-shot of the patient’s profile can quicky be printed. By attaching this to a clip board, the patient can review the list while they wait. During the process of generating the medication list, the pharmacist can also review other desired data they wish to collect, and print these for inclusion with the profile. Many common items we use are pre-populated within PharmClin (for many important drug classes) to allow quick data entry by the pharmacist.

The goal is to provide a quick review and data collection period during the patient waiting period. When the medications are ready, the pharmacist can quickly review the information for additional questions and the patient can be on their way.

This workflow would not necessarily work in all situations. If a patient calls ahead, for example, they may be in a hurry to leave (not expecting to review their profile or answer additional questions). The workflow for medication synchronization patients, likewise might need some adaptation. For this reason, any implementation needs to be fluid, and the records to be presented to the patient should be able to be generated quickly and on demand. In cases where the patient is not currently available to perform a review, simply asking them if they might have time for a quick review at a later date (maybe the next time they pick up) could plant the seed and encourage them to make time at their next visit.

Conclusion

Taking the initiative to perform medication reconciliation is a valuable service, and this can be facilitated by leveraging the pharmacists access to the patient. Invariably, discrepancies will be discovered, leading to new interventions with both the patient and the prescriber. An implementation like this one is yet another example of making every encounter with the patient count!

Mondays with Mike

Today’s edition of Tales from the Counter is about pharmacist interventions. Interventions are not a new concept in pharmacy. Pharmacists have been interventionists for decades, and it doesn’t take a clinical pharmacist or a clinical environment to be an interventionist. Our main pharmacy documents several thousand interventions every month. When some pharmacists hear about the number of interventions our pharmacies document, they are often skeptical of either the quantity or the quality of the interventions. I thought that it would be interesting to give an overview of several categories of interventions that I completed during the last Monday morning I worked the counter. During this 5 hour shift I documented 186 interventions. I have picked a few key areas to discuss today as examples of our interventions and processes.

Compliance

Using a Percent of Days Covered (PCD) calculation looking at the last 6 months worth of refills, our PharmClin software alerts the pharmacist to any impending compliance issues (for all patient medications, not just the one being filled). Non-compliance is defined as a PDC below 75% or are above 125%. During my last Monday on the counter, 123 different medications were flagged as non-compliant. As we have stated in previous posts on this blog, compliance is one of the most common issues we see. It also represent the basis of three different EQUiPP pharmacy performance measures. We assess PDC on every medication, and many acute or as needed drugs will eventually fall into a “non-compliant” (or, in the case of a PRN medication, a hyper-compliant) state. Each one needs to be evaluated on a regular basis to ensure there are not any real problems underlying the issue.  Of the 123 compliance issues evaluated:

  • 91 were deemed non-issues because they represented acute drugs or were “as needed” medications. Each of these were flagged as “continue to monitor” and will be re-evaluated in 90 days (to prevent Alert Fatigue)
  • 26 were explained by other evidence (recent dose changes)
  • 9 were flagged for face-to-face questions with the patient. Illustrative examples included:

Propafenone compliance at 72%. The patient was asked if the dose or instructions have changed (and we were not alerted). Patient denied any change and denied any missed doses. The follow-up evaluation for this drug was moved up from 90 days to 30 days to re-assess.

Omeprazole compliance dropped to 63%. Patient asked if still using or if it was discontinued. Patient reported that the medication was discontinued and that they are using OTC ranitidine with good relief of occasional symptoms.

Omeprazole compliance at 70%. patient reports “as needed” use of this medication. Wanted the Rx to be available in case symptoms reappeared. Note sent to prescriber requesting a new Rx with “as needed” directions.

Sertraline compliance dropped to 63%. When approached, the patient admitted that she had this filled at another pharmacy to take advantage of a new patient program. The importance of a “pharmacy home” was discussed with the patient.

Metformin compliance at 73%. Patient reported that the doctor was doing a 90 day trial. The medication was discontinued

Screening for Adverse Drug Reactions (ADRs)

We routinely look for ADRs on several drug categories including all diabetic medications, opioid pain medications, and warfarin. PharmClin alerts the pharmacist of a new problem or that it time to re-assess an old one. Like other interventions, once an ADR potential has been investigated, the intervention is scheduled for re-assessment in 30 to 90 days (depending on the medication or the seriousness of the potential issues) to prevent Alert Fatigue. This built-in timing also prevents the patient from becoming overwhelmed with constant queries. The periodic nature of the ADR queries also allows us to assess problems that develop with time.

During my last Monday, almost 30 different potential ADRs were noted. Each of these resulted in a face-to-face with the patient. Some examples of these interventions:

  • Patient on Novolog: Confirmed with the patient they understood the signs and symptoms of low blood sugar. Also documented blood glucose testing frequency and date of the last drawn Hemoglobin A1C.
  •  Warfarin patient: Asked about any unusual bruising or bleeding. Also documented patient reported goal INR, draw schedule, and last INR (patient reported value)
  • Patient on Tramadol: Queried patient on possible constipation and confusion / drowsiness from the medication. Patient denies any problems at this time.
  • Patient on Metformin: asked about diarrhea and other potential ADRs. Patient reports that this medication caused them to “fall” and that the prescriber discontinued the medication. Note sent to the prescriber to confirm discontinuation as no other therapy for blood sugar noted in patient profile.

Other Interventions

  • During the 5 hour period, seventeen different new medications were flagged for counseling and patient education.
  • Fourteen new “therapeutic duplications” were evaluated.  None of these were deemed inappropriate.
  • Five prescriptions were flagged as “product is the same but may look different” to alert the patient to a generic product change
  • four different Lab values were recorded in the patient’s electronic chart. These included blood pressure, INR, TSH, and A1C

None of the above examples is above and beyond what an engaged pharmacist does on a daily basis. The primary difference, though, is the documentation done. By documenting what was done, and when it needs to be revisited, we can make every encounter with our patients count.

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.

Search Engines and Pharmacy

One trait of a thriving pharmacy is a good patient base, and a patient base is always in a state of flux. Patient move away, move into nursing homes, or otherwise just evaporate. To continue to thrive, a pharmacy needs to continue attract new customers. Advertising, therefore is important.

The advertising continuum can range from simple to inexpensive. For example, word of mouth and reputation can result in regular referrals from current patients or other health care providers. Other times, advertising is broader (and more expensive), like a television or radio advertisement to let the public know about a new or important service you offer.

Every pharmacy will have a favorite advertising outlet. Some might find newspaper most effective, others might find that television, radio or a medium like a billboard on a busy road are superior. One newer method of advertising is the placement of materials online within search results. Google, Bing and Yahoo! all sell advertising space that matches your advertisement to searches that are likely to be associated with potential patients and customers for your services.

Computers were becoming mainstream in the late 70’s and early 80’s, and those that grew up in that time period (Generation X) are generally very computer savvy and now in their 40’s and 50’s. Generation X is also starting to required medications as they enter middle age. In other words, Generation X’ers are prime targets as new potential pharmacy customers. Online advertising (e.g. Google AdWords and other programs) is a very appealing way to target these individuals to get your pharmacy’s message across. Internet advertising has real potential to a business like a retail pharmacy. Internet advertising, however, is still in its infancy, and its effectiveness for pharmacy is largely unknown.

Putting an advertisement to appear in search results from providers like Google, Yahoo! or Bing is not straight forward if you are a pharmacy, though. All of the major search engine companies have policies on advertising pharmaceuticals or pharmacy services, and these policies state that internet pharmacies must have a VIPPS or e-advertiser credential (both available from NABP) in order to advertise.

The VIPPS Program is designed to identify legitimate internet pharmacies from the plethora of illegal internet pharmacies that exist. NABP describes the benefits of certification  as:

With thousands of rogue sites illegally selling prescription drugs, VIPPS offers a way for legitimate sites to set themselves apart.

A NABP VIPPS endorsement will set a pharmacy back $6000 initially and up to $5000 annually. The endorsement involves an on-site survey and verification of licensure along with verification of compliance with a host of policies that lend credibility to an online pharmacy. Internet pharmacies often do not cater to walk-in customers, and may not even have a storefront. The site survey to verify the legitimacy of the business is an important part of this certification.

Welcome to Pharmacy Jeopardy

Alex Trebek: “The answer is: A brick-and-mortar store with a simple website selling prescriptions to local customers in for in-store pickup.”

You: “What is a retail pharmacy, Alex?”

BZZZZZT!

Alex: Sorry, that is incorrect. The correct question is “What is an Internet Pharmacy”

You see, if…

  • your customers pick up in store, or receives home delivery from your own employee, and
  • only rarely do you have to mail a prescription (then and only into areas you are licensed already) and
  • your store also has a website of any type, and
  • your current customers can request refills from this website…

Your pharmacy is categorized as an internet pharmacy by the search engines.

The sticking point, as far as the search engine companies are concerned, is the ability to request refills online. This is a service that is critical in today’s pharmacy world. Even patients with little aptitude with computers regularly use online refill pages at their pharmacy website (independent and chain alike). They have come to expect and demand this of their pharmacy. Unfortunately, this one service makes every brick and mortar pharmacy, in the eyes of the search engines, an internet pharmacy. And internet pharmacies have to have a certification in order to advertise on the search engines.

A VIPPS certification is overkill in this respect, and NABP recognizes this. NABP also offers an e-advertser certification that will allow the pharmacy to advertise on the search engines if it only offers online refills on its website. This certification does not involve an on-site survey; the emphasis is on a review of the pharmacy’s web site. This makes a lot more sense for actual pharmacies in established communities, but astonishingly,  NABP charges $2000 per year for this certification. When asked how they justify this cost, NABP officials referred to the “extensive website review” that they do to ensure that the pharmacy meets their criteria.

I am not sure who is doing the review of the website at NABP. I have personally reviewed hundreds of pharmacy websites over the last 10 years while involved with an pharmacy accrediting organization.  Most websites took between 5 and 30 minutes to thoroughly explore and evaluate for compliance with stringent accreditation rules. Few were exceedingly information dense> The worst of these were not difficult to review in less than 60 minutes. It doesn’t take a Ph.D. in mathematics to calculate that this works out to more than $2000/hr to review a website.

Advertising ROI

Every dollar spent on advertising is supposed to bring in profit to offset the costs of advertisement. This return on investment (ROI) is often difficult to calculate, as bringing in one new patient to a pharmacy might result in a anywhere from a few dollars per year to thousands of dollars per year in sales.

But this yearly certification is not advertising. It is only a license that allows you to spend money advertising with the search engines. One still has to purchase advertising space. The yearly tax (in the form of a certification) effectively makes each advertising campaign with a search engine substantially more expensive. The high expense, coupled with the unknown ROI on an unproven advertising medium, makes the proposition dubious for all but the most aggressive pharmacies.

Conclusions

I generally try very hard to put a positive spin on everything covered on the Thriving Pharmacist, and it is difficult to spot a silver lining for pharmacies. Even so, I will try not to disappoint.

First Conclusion: if one really wants to advertise using this method, consider disabling web based refills. This should enable an exception to be made with the search engine provider (though this is not a promise). For those patients wanting access to easy refills on the go, look into companies that offer cell phone app based refills instead. This might allow you to maintain a balance between online advertising and convenient refills.

Second conclusion: Look at search results using terms like “local pharmacy” on several search engines. Chances are that your competitors (even the chains) are suffering from the same restriction. This means that you are not at a competitive disadvantage. In my case, our pharmacy appears above local chains every time (for what reason I really don’t know). If you feel like becoming the first one to test the uncharted waters of this advertising forum, go back to the first conclusion and read it again.

Third conclusion: It would take a very large response to search engine based advertising to break even after one includes the up front and annual certification costs to advertising. That does not mean, however, that a positive ROI is not possible. With great risk, comes great reward…maybe.

Finally, if being labeled an internet pharmacy by Google, Yahoo! and Bing bothers you, let them know. Contact their advertising departments and explain why you are not an internet based pharmacy and lodge a complaint. If you would be willing to spend money advertising on their site (without a NAPB certification), ask them why they don’t want your money. With enough traction, maybe the rules will relax and allow brick-and-mortar pharmacies to avoid the NABP “internet pharmacy” tax.

Should the Tail Wag the Dog?

Here at the Thriving Pharmacist, we often write about where we believe the practice of pharmacy should going, and given the feedback we receive, there are more than a few pharmacists that agree with our direction. In a nutshell, we believe that pharmacists and pharmacies should be documenting patient care, evaluating outcomes of therapy and working with patients and prescribers to optimize medication use. There is evidence already available (some discussed on this blog previously) that pharmacists, when used in this manner, can benefit the healthcare system in significant and meaningful ways. This includes financial benefits to the healthcare systems, with significant savings realized in total health spend.

But healthcare today is very fragmented, and this creates the potential for inefficiency. The companies paid to manage the prescription benefit (Pharmacy Benefit Managers or PBMs) often have no stake in the total health spend. The primary mechanisms used by the benefit managers to save the healthcare systems money are downward pressure on the cost of medications and (more recently) DIR fees taken from member pharmacies and shifted back to the health plan. The health plans appear to be mostly unaware that pharmacists, used properly, can positively impact their bottom line in other ways.

This myopic doctrine manifested when Congress handed the Medicare Drug Benefit (Medicare Part D) over to the PBMs to run. The PBMs are only responsible for drug costs. The accountability for total health spend falls to Medicare Part B, so any programs under Medicare Part D that leverage pharmacists to increase medication compliance and improve medication related outcomes come at the expense of the PBMs with no return on the PBM investment. It comes as no surprise, then, that Medicare Part D MTM programs have been mostly non-starters, with very few patients eligible, and plans using internal resources instead of the patient’s own pharmacist to implement them. The PBMs appear to view these programs as added expense without a return on their investment.

This fragmentation is allowing the tail to wag the dog. The Medicare Part D benefit has become a “success” from the prospective of congress, with the savings the PBMs have shown. These savings have largely come at the expense of the bottom lines of the actual providers in the trenches, though. One only has to look as far as Medicare’s own reports to see that the PBM industry is doing quite well, quite possibly making as much money managing the benefit (charging a spread on each prescription) as the pharmacies actually caring for the patients. The recognition by the government that the current problem is a success further propagates the currently popular PBM strategies that have forced down the price paid to pharmacies for medications without looking at the bigger picture: medications (when used correctly) are an incredibly cost-effective way to save total healthcare costs. It is not always the least expensive medication that is going to save the system the most money in the long run, but the tail continues to argue cheap is better, and the dog doesn’t seem to be complaining.

The solution for health care, however, is just waiting to make it through congress. By giving provider status (with Medicare) to pharmacists, the real benefits of pharmacy can grow beyond Medicare Part D’s emphasis on cheap drug product. Paying pharmacists to make interventions that ultimately save the provider (Medicare part A and B) in total health spend makes significantly more sense than the current model focusing almost exclusively on drug cost. In effect, provider status for pharmacists will ultimately use pharmacists where they can save the most for the system.

Today’s assignment is for every pharmacist to have an encounter with their elected officials in Washington DC. Refer them to some of the examples discussed previously on this blog (things like the Army’s own reports, and studies looking at savings by improving compliance and other examples) where pharmacists can save the payor money. Help them understand that pharmacists are an important asset to help Medicare survive. Make your encounters count. Get help them understand the importance of Medicare acknowledged provider status to pharmacists. If they have not already signed on in support of the current bill, encourage them to do so. Help stop the tail from wagging the dog.

DIR Analysis (The Bottom-Ten)

The previous analysis of narrow network DIR fees generated significant attention, and several people were interested in more details about the medications that were severely underwater.

Notes

It is important to note that the 10 drugs listed below represent 10 drugs our pharmacy dispensed during a 3 month period to patients using one specific narrow network with a DIR fee. It is unlikely that these 10 medications are the only severely underwater products, but without a broader sample of claims data, this is unknown. Below I have established an estimate of best current (July 2015) available price using a variety of alternative generic wholesaler vendors for the drugs. Because the analysis was initiated retrospectively, determining an actual historical best available price was not feasible. For each drug, I have calculated a ratio of the approximate best net acquisition cost (after DIR fees were applied) to the product reimbursement. For example, if the best acquisition for drug X is $10 / tablet and the net payment after DIR is $2 /tablet, the ratio would be 5:1. These ratios are rounded, as contracts prevent a pharmacy from disclosing actual acquisition costs of items.

Drugs in the Trench

Amphetamine Salts XR 20 mg Caps (generic Adderall XR 20 mg) 

This medication has long been subject to underwater issues and represented 3 claims during the analysis period. Based on acquisition cost (before any rebates are applied) our pharmacy system shows losses of hundreds of dollars for this high dollar generic.  Unfortunately, because this is a Schedule II (C-II) controlled substance, buying from other sources is more challenging for a variety of reasons. It is also possible that some pharmacies could have better contracts on this medication than others. Based on our best acquisition price (after rebates): Ratio 4:1

Brimonidine 0.15% Ophthalmic Solution (10 ml)

There were only two prescriptions for this in our 3 month data set, but each one resulted in more than a $100 loss. A check of alternate generic wholesalers did not reveal any currently available product below our net (after rebate) acquisition cost. It should be noted that the other strength of this medication (Briminodine 0.2%) is significantly less expensive, possibly alluding to the basis of the ultra-low reimbursement. Ratio 6:1

Cefdinir 300 mg Capsules

This drug represented only one claim in the data set. Currently, there is a product available at a price significantly less than we paid back in March, 2015, but even with this lower priced product available today, the claim would remain underwater. It would take an acquisition cost of about $0.50 per capsule to break even. Ratio of 1.2:1

Chlorpromazine 50 mg and 100 mg Tablets

These two strengths of the drug represented ten claims during get test period and resulted in a loss of more than $2,800 by themselves. The product saw price a significant price increases back in September of 2014: the price increased by over 300%. The price has been falling slowly over the last couple of months, but remained steady during the analysis period. Reimbursement, after DIR fees were removed, were around $1/tablet (50 mg strength) and $1.40/tablet (100 mg strength). It is worth observing that the current reimbursement is in line with the pre-increase acquisition costs of the medication. Even given the best price today, losses for this drug would still be very significant. Ratio 3:1

Divalproex ER 250 and 500 mg Tablets

Our pharmacy serves many seizure patients, and because of this, we have a policy to minimize unnecessary changes in manufacturers for seizure medications that might result in the deterioration of seizure control of our patients. Reimbursement considerations make this infinitely more difficult, as the third party payor doesn’t have any stake in ER visits and hospitalization costs. This being said, our current divalproex ER products have remained stable for quite some time and have (thankfully) been the least expensive option available to us. Looking around for the best available price today (without respect to changing generic manufacturers) does alleviate some of the losses, but does not move the profit indicator out of the red. Ratio 3:1

Divalproex Sprinkle 125 mg

This product is an immediate release variant, and changing manufacturers is less of an issue. Looking at the best available price today does show one product (from a company I have never seen before) priced around $0.04/capsule. If one were inclined to trust this product (and if it was even available at this price in the first quarter of this year) one could have made a small profit on the product after the DIR fees. Therefore, this product was ignored for the purpose of ratio calculations.  Ratio 5:1

Donepezil 23 mg Tablets

There was only one prescription for this medication in the data set, but based on our best price at the time, we lost over $270. Back when the prescription was filled, only one product was available at a cost of more than $10/tablet. Today, with the a product now available for closer to $3/tablet, the loss would still not be eliminated. Reimbursement is closer to $1/tablet. Ratio was: 10:1 (would be 3:1 today)

Methylphenidate ER 18 mg Tablets (Generic Concerta 18 mg)

Back in November of 2014, the FDA determined that two of the three available generic versions of Concerta were did not meet FDA Orange Book guidelines for rate and extent of absorption, and therefore could not be considered generically equivalent (AB rated). This meant the product effectively became single source. The reimbursement, after DIR fees are accounted, hovers around the acquisition cost of the non-substitutable, less expensive product. Ratio: 5:1

Equity in Pricing

Note that contracts prevent pharmacies from disclosing their actual acquisition costs for products. It is safe to assume that larger groups of pharmacies (chains and large independent buying groups) may receive better pricing than smaller groups. By participating in a large buying group, independent pharmacies should be able to receive prices similar to large chain pharmacies, and this is mostly true. There are reports, however, of a few medications that are deeply discounted to individual groups. This is sometimes referred to as corporate contracted rates for a drug. Some of the drugs in the analysis above may be subject to these contracts, and the pharmacies receiving that special pricing may not actually lose any money on the prescriptions.

It is likely that the PBM industry leverages these deeply discounted contracts in their MAC price calculations, and this may explain some of the severely underwater reimbursements seen by pharmacies not receiving this special rate. The “black box” nature of MAC prices (the PBM considers their MAC pricing formula proprietary and a trade secret) makes it impossible to determine the reason behind underwater prices. DIR fees simply make the situation worse. Requests to the PBM to update the MAC price for a drug to account for real-world acquisition price often receive a “no adjustment required, product available at a lower price. MAC Price justified” type response. This is of little consolation to the pharmacy that cannot purchase the product at a rate even close to a break-even price. There is no “request to review” a DIR fee.

There are, however, reports that some wholesale drug companies and buying groups are looking at ways to help pharmacies (especially independent pharmacies). Currently, the wholesale drug companies and buying groups do not have skin in the game. There is talk, however, of these two groups offering pharmacies a form of price protection from severely underwater products in the form of rebates, thereby offsetting some of the losses. Without some for of safety net, pharmacists have to make some difficult choices in what to stock and not stock in their stores.

Follow-up on Performance Payments

Last week, one of the Medicare Part D plans using Mirixa for Medication Therapy Management (MTM) “dropped” a new batch of “Star Measure” alerts to our pharmacy. These have been previously discussed here on this blog.

This “drop” was not unlike previous iterations our pharmacy has seen; the patients highlighted for possible compliance issues were exclusively patients residing in group homes. Each of the patients have staff working with them to ensure that they take their medications, and all of their medications are in compliance packaging (either OPUS cassettes or other systems to enable the staff to make sure that all doses are given). Every time the patient misses a dose, the staff report the incident to us, and we document the pertinent details in our clinical documentation system (PharmClin). Needless to say, if a patient is severely non-compliant, we would know quickly (because we would be receiving calls several times a week).

If it is not obvious by now, every one of these Star Measures cases were a false positive. Each patient was, and continues to be, nearly 100% compliant (as a percentage of days covered or PDC). So why were these cases brought to our attention? The answer relates workflow.

The workflow required to handle the large number of prescriptions dispensed on the same day each month to a large group home population requires a fairly involved process that is mostly automated by our pharmacy dispensing system. Even with this automation, billing may be delayed by up to 10 days for some prescriptions*. Keep in mind that it is the billing that is delayed, not the delivery of the medications.

Discussion

What is surprising is how quickly the plan and Mirixa identified what they perceived as compliance issues. We received the notices just short of 2 weeks after the due date of the prescriptions. That is just short of amazing, and some of our patients would consider this type of “short leash” offensive (and even an invasion of their privacy) if they were aware of how tightly the benefit manager is tracking them.

In this case, the delay in billing within our workflow resulted in sixteen “opportunities” to document and collect some “clinical” reimbursement from the program. Each of these cases is an opportunity to earn $12 by responding to the case (without respect to outcome). There are, however, two caveats about this program that should be noted.

  1. Each of these $12 interventions will be withheld from the performance incentive paid to the pharmacy (by the plan) at the end of the year (assuming we exceed drug specific patient compliance metrics). In other words, each $12 is effectively just an “early” performance payment.
  2. The Mirixa system for addressing these issues is time-consuming. If a pharmacist completes the intervention completely (updating each medication and answering all prompts), it takes a minimum of fifteen minutes to complete the intervention (not counting any patient contact time). This is not cost effective, as it does not come close to covering the time spent by the pharmacist.

The Pearl

These Star Measure interventions (or SSI Performance Network Program) are a much more focused intervention than a complete Medication Therapy Management Program encounter (MTMP). The reimbursement level (at just $12 per incident) reinforces this statement. To handle these interventions efficiently, make a call to the patient (this does not merit a face-to-face) and ask some open-ended questions. Patients can become defensive when approached about compliance, so it is wise to deflect this initially, noting that there are many possible reasons for this (like physician samples, dose changes, side effects etc) and let the patient fill in the rest of the story. For example:

We have noticed that your refills of lisinopril have not been as frequent as we expected. Often, changes are made by the prescriber, and the pharmacy is the last to know. How are you currently taking the medication? What difficulties, if any, are you having with the medication?

At $12 per intervention, break-even time (at a pharmacist salary of $50/hr) for this case is 14 minutes, so this phone call has to be efficient. You need only to establish if there is a real problem and a brief explanation. The phone call might take three to five minutes to complete.

Data entry must also has to be efficient. A tip for pharmacists working this type of problem in Mirixa: do not spend time updating the medication profile. It is not obvious, but leaving this portion of the intervention unfinished will not prevent (at least for now) the intervention from being completed.  By omitting this information (and only addressing the fields that relate to the compliance issue at hand), a pharmacist should be able to complete the Star Measure intervention (call and data entry) in less than 10 minutes. This is much more in line with the actual reimbursement being offered.

Footnotes

* July 2015, with the observed holiday of Friday July 3rd, is a worst case scenario of delayed billing.

Computer ADR Screening and Real Life

Today’s post is yet another edition of  “Tales from the Counter.” This one is somewhat less clinical sciences and a bit more pharmaceutical sciences, with a measure of soapbox thrown in for good measure.

The other day, while performing CMM on a nursing care center patient being admitted, my technicians asked about a DUR Warning our pharmacy system flagged on the patient. These warnings are generated by software licensed from a third party vendor and are designed to bring possible issues to the attention of the pharmacist. The warning here read:

Prior Adverse Reaction Report

Prescribed Drug: Triamcinolone Nasal Spray

Adverse Reaction(s) have been reported with prior MORPHINE SULFATE 20 mg/ml.

Ethylenediamine Class Monograph

Essentially, the above warning is stating that the patient has had a prior adverse drug reaction (ADR) to morphine, and the newly prescribed drug (triamcinolone nasal spray) may also, therefore, cause problems with the patient.

I will let that sink in for a moment. Any pharmacists that immediately know why this was flagged are encouraged to comment below (giving yourselves a little pat on your own back), because this one is a little obscure (though there is a hint in the general description above).

The warning continues on as follows:

Discussion: Aminophylline is the ethylenediamine salt of theophylline. Hypersensitivity reactions to aminophylline including maculopapular rashes, dermatitis, exfoliative dermatitis and urticaria are thought to be primarily due to the ethylenediamine component…

Pharmacists who are still confused are thinking clinically and not pharmaceutically at this point. The ADR being flagged by the software is not due to either morphine or triamcinolone (in the nasal spray). The ADR being flagged is to an excipient (inert ingredient) that both products may share: EDTA (ethylenediamine tetra-acetic acid), which is a pharmaceutical chelating agent / preservative.

The science behind this Prior ADR Warning is sound and well documented in the primary literature, though the clinical relevance may be tenuous. The prevalence of EDTA in morphine injectable formulations is lower today, with many preservative free formulations available. Checking several references, ADR references to maculopapular rash with morphine were completely absent.

The Soapbox

In the end, it was easy to identify the prior ADR to morphine for this patient: confusion. Based on this, the triamcinolone nasal spray  represented no additional risk for the patient, and the warning was documented off as a false positive. And while this computer-generated warning was not relevant for this patient, the obscure nature of the issue is not something that most pharmacists would immediately recognize and therefore it is entirely possible that a warning like this might help prevent patient discomfort in someone down the road.

Software-aided screenings can be very beneficial, but they also complicate patient care tremendously. It takes a skillful and knowledgable professional to be able to decipher and evaluate the host of information available today. Yet, pharmacy benefit managers continue to cut reimbursement for product and this is leading to pharmacies using fewer and fewer pharmacists (because labor costs are one of the largest expenditures in pharmacy). The argument is that technicians and machines can take care of more and more of the work. Without a competent pharmacist evaluating the mountain of clinical information, though, healthcare will be taking a step backwards in safety.

It is not unlike today’s aircraft: modern computer driven avionics can take a plane into the air, to the destination, and back down for a safe landing without any human intervention. But what happens when something out of the ordinary takes place,and the computer cannot make the judgement? Would you fly in a plane capable of flying itself without a professional pilot on board just in case? Modern technology can move pharmacy into a new era of efficiency in dispensing, but in the case of actual patient care, we are still a long way from not needing a professional in the trenches.

 

 

 

Dispensing Software vs Clinical Pharmacy

keBack when I was a pharmacy student, there were still some pharmacies that kept prescription histories for their patients on paper and typed prescription labels on an electric typewriter. The Bates Number Machine was still a staple of many practices. Today, with the advances in computers and electronics, modern pharmacies in the United States use computerized Pharmacy Management Systems (PMSs otherwise known as dispensing systems) almost exclusively.

Today’s modern pharmacy software has helped improve workflow, and ensures accuracy in the dispensing pharmacy. New features are being added to these systems regularly. Today, the point of sale (register) is usually integrated, as is the telephone system (by use of an Interactive Voice Response or IVR system). Some vendors have created iPad based delivery apps and even added limited integration with clinical services like Outcomes and Mirixa. Overall efficiency in pharmacies today is very high, in large part due to these software packages.

But today’s pharmacy systems are really still one-trick ponies. Despite all of the “new” features, these systems still are centered around the dispensing function. Most pharmacists and pharmacy owners becoming aware that dispensing revenue is significantly down (despite increased prescription volume and sales) in pharmacies today.

Right now, the profession of pharmacy is in a transition period; moving from product based reimbursement to service based reimbursement. Traditionally, the services provided by pharmacists and pharmacies have been (unfortunately) given away along side the paid drug product. The payment received for the drug product historically provided enough profit to cover the professional time the pharmacist spent with the patient. Current payment for product, however, is drying up at an alarming rate, and the transition from product based reimbursement to service based reimbursement is still only in its infancy.

The discussion of pharmacy management systems, and the transition of pharmacy as a profession, are intrinsically related. In order to move the transition of pharmacy forward (and ultimately achieve “provider” status with both the State and federally, with Medicare), pharmacists need to prove that what they do outside traditional dispensing is intrinsically valuable.

Almost every newly minted pharmacist since the early 2000’s received a clinically oriented degree, a doctorate in pharmacy (Pharm.D). Many older pharmacists have even gone back and added this degree. The application of the clinical skills vested in these pharmacists, however, is not encourage by many employers. Many pharmacies continue to emphasize dispensing and prescription volume. And why wouldn’t they, because that is (still) what gets them paid.

Despite the lack of clinical emphasis in their workplace, many pharmacists continue to employ their clinical skills. The next obstacle for clinically motivated pharmacists, is their dispensing oriented pharmacy management system, because it is not designed to document the care these pharmacists are implementing. This is a significant problem facing the profession. If we cannot readily document the value we provide, how can we move forward, and transition toward an actual professional fee, or obtain provider status?

This is a real problem for today’s proactive pharmacists, and the problem is going to grow exponentially as the expectation that pharmacists demonstrate their value to the health care system grows. Pharmacies need a way to seamlessly document their actions, recommendations, and overall value to patients and the system, and dispensing focused software is woefully inadequate.

In our practice, the answer was to create our own documentation system to accumulate the interventions our pharmacists effect every day. Over the course of almost a decade, we massaged and integrated the software to the point where every one of our pharmacists record important information and face to face encounters with patients, documenting what was done, what needs to be done, and any communication with other health care providers. Thru tight integration with our dispensing system, the software has become an extension of our business model. Today the product is known as PharmClin. The core concepts of PharmClin are fundamentally simple, but put taken as a whole, and in the context of a clinically oriented practice, the package is so powerful and innovative that it is patented.

Many pharmacists have seen PharmClin in use (by visiting our pharmacies) or have seen images of the product in slides at national meetings. When pharmacists see what we are doing and how we are using PharmClin, most immediately “get it” and want to be able to do the same things themselves. What needs to happen next, is to bring this concept to the rest of the profession. This type of activity and documentation will be a game-changer for our profession. It emphasizes how every pharmacist can make encounters with their patients count.