Large Pizza and the 90 day Refill

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

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

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

Benefits of a 90 day “Super Size” Rx

The Patient: 

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

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

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

The Payor:

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

The PBM:

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

The Pharmacy:

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

The Real Pharmacy Benefit: Pharmacists

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

Creating the Capacity for Patient Care

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

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

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

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

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

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

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

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

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

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

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

DIR Fees–Why Are Pharmacies in the Middle?

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

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

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

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

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

Example DIR fees from a Medicare Part D PDP

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

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

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

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

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

Pharmacy Should Not be in the Middle

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

 

Residency Project: What Types of Interventions are Pharmacists Performing and Documenting with a New-Payer Model?

Background/Intro: Studies have continually shown that community pharmacists can impact and improve patient outcomes if they utilize clinical skills during the dispensing process. The question that arises is: How can we change current reimbursement models to reward pharmacies for the clinical and cognitive services we provide in the dispensing role?

Traditionally, as highlighted in previous article, pharmacy reimbursement has always been product-based. Reimbursement is based off ingredient costs (AAC, AWP, etc) and dispensing fees. Depending on the PBM contracts accepted, the type of cost used to calculate reimbursement and dispensing fees vary drastically. Due to non-transparent costs and minimal dispensing fees, pharmacies lose money on prescriptions. Community practices have therefore adapted to this by become volume-driven because no one pays for the value/costs associated with problems identified and addressed by dispensing pharmacists.

The most common way that pharmacy gets paid for clinical services are for select Medicare Part D patients through Mirixa and Outcomes MTM platforms. These interventions and medication reviews take 30-60 minutes and are usually performed by a pharmacist outside of the dispensing role. But the question still stands: How can we be reimbursed for interventions we perform on a daily basis during dispensing and performing a thorough prospective DUR?

Towncrest Pharmacy has collaborated with a local payer to initiate a pilot project that pays the pharmacy a professional fee in addition to a dispensing fee for each prescription dispensed for patient’s enrolled in this specific health plan. The objective of my project was to evaluate the different types of interventions that were performed and documented for the pilot project patients.

Methods: Data from April 1, 2014 to October 31, 2014 was extracted from PharmClin. Descriptive variables were collected for patient’s age, gender, and number of medications; Frequencies and descriptive statistics were tabulated for each intervention and drug therapy problem (DTP) documented.

Results/Discussion:

Patient Population: Interestingly, this cohort of patients compromises only 7-8% of Towncrest Pharmacy’s total patient population and only represent 3% of Towncrest’s total prescription volume. A majority (77%) of these patients were 18-64 years age category with an average age of 49 years, and only on an average number of 4 medications. Despite not being a high-risk population, 75% of the patients had a pharmacist documented intervention with the total number of interventions being n = 483. The interventions were further categorized, based on the options available in PharmClin. See Below:

Graph

Table

Discussion: Of the documented interventions, half involved prescription counseling (n = 241; 49.9%) and nearly 30% (n=144) of interventions identified various drug therapy problems. As counseling is required for any new prescription in the State of Iowa, this figure was not surprising. However, the most common DTP assessed by pharmacists was medication adherence (n = 119; 82.6%). This number has significance as 3 of the 5 current criteria for CMS Stars Ratings relates to adherence (statins, diabetes medications, and ACE-I/ARB/DRI). This makes it vital that pharmacists in the dispensing role are taking advantage of every encounter with the patient to address issues; forcing the dispensing pharmacist to change their mentality from “right person, right drug.” Instead, pharmacists are assessing the medication profile as a whole to evaluate the safety, efficacy, and appropriateness of therapy during the prospective DUR process. We have continually made improvements to PharmClin to assist in this process and flag for potential problems.

Conclusions: Pharmacists can make critical clinical interventions during the dispensing process. Better clinical documentation of interventions and reform of current reimbursement models can help shift community practice to focus on delivering quality health care.

SuperSync: the Super Hero of Adherence

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

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

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

Med Planners

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

SuperSync: Synchronization plus Packaging

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

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

Cost Analysis

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

Traditional Prescriptions

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

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

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

Strip Packaging (commingled)

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

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

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

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

Kryptonite for SuperSync

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

Workflow and Equipment

The two biggest challenges with using a SuperSync process are:

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

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

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

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

Tie-Ins and Prescripton Drugs

Pharmacies are being paid less and less for prescription drugs, and adequate reimbursement for clinical services is still not a reality. At the same time, pharmacies are being evaluated on performance, and this requires investments in the practice. Keeping the bottom line balanced means that today’s pharmacy owner needs to maximize efficiency in their pharmacy department and find new revenue streams to help fill the widening gap between overhead and drug product reimbursement until reimbursement for services can add significantly to the bottom line.

Chain drug stores rely on extensive front ends to buoy pharmacy department sales. Independent pharmacies often cannot leverage an extensive front end in the same manner. This does not mean, however, that the independent pharmacy cannot use their front end to support their overhead during this paradigm changes in pharmacy.

Don’t try to beat the Big W

Over the years, I have emphasized that the chain pharmacies around me are not my competition. They do things in ways we would never consider. Conversely, they do not generally have the flexibility and latitude to attempt things an independent pharmacy could try. So, when selecting products for the the front end (over the counter) section of the pharmacy, it is always a good idea to strive to find products that the chain pharmacies not or cannot stock. Quality merchandise is also something that will set an independent apart from a retail chain pharmacy. The trick, however, is to jump-start the sales of these products.

While an independent pharmacy might shy away from mass market merchandise, there is no reason that the independent cannot look at some of the common retail strategies used by the chain drug stores. Of specific interest today is the use of tie-ins at the point of sale. Tie-ins are those items hanging next to the thing you were looking for. In a grocery store, grated Parmesan cheese might be hanging on the shelf right next to the spaghetti sauce. If you are looking for one, you are more likely to impulse purchase the other.

The Prescription Tie-In

An independent pharmacy can take this strategy and really make it shine by integrating the pharmacists clinical knowledge during the final verification phase of each prescription checked in the pharmacy. Many drugs either are dependent upon, or deplete specific vitamins / minerals or other nutrients from the body. These nutrients can become tie-in marketing opportunities for the pharmacy. While this is not a new strategy, this strategy can be optimized and made successful with a little advance planning. The result can be a significant boost to revenue to help offset the decreases seen with prescription drugs.

Examples of possible tie-ins might include:

  • Recommending a Coenzyme Q10 supplement for patients taking HMG Co-A inhibitor (e.g. atorvastatin, lovastatin, pravastatin etc).
  • Recommending a pro-biotic to patients taking a broad spectrum antibiotic
  • Recommending a vitamin and mineral supplement to patients taking diuretics

Strategies

  • Be selective: choose a product line that is unlikely to be stocked by , or unavailable at chain stores. This might be a premium brand with a high quality standard.
  • Start Simple: There are dozens of classes of medications that have potential tie-ins for supplement sales. Rather than overwhelm the pharmacy staff and the patients, start with a few select classes and grow the program from there
  • Think Clinically: While there are dozens of class of medications with potential tie-ins for supplement sales, some of these are better documented than others.
  • Research before you sell: Be sure you understand the mechanisms and pathways. Having this knowledge helps earn the patient trust and understand that you are providing more than just product, but knowledge.
  • Train your staff: Be sure that all of your staff understand what the program is and how it is going to be executed. Be sure that the pharmacists are familiar with the research done above.
  • Document: If a patient is flagged for consultation about their medication and, after considering the pharmacist’s rational for the recommendation to purchase a supplement, the patient declines, document the outcome.
  • Plan follow-up: Do not flag the same patient for consultation and recommendation of a supplement every time they come into the store. Remember that this is a professional consultation. Instead, document the outcome in a manner that all pharmacy staff will know when the consultation was made, the patient’s response, and when to follow-up (e.g. approach patient in 6 months to re-visit the topic)

Our pharmacy is beginning the implementation of this type of program. We have chosen Ortho Molecular Products as our “premium” brand of supplement. One advantage for choosing Ortho Molecular is their “Pharmace Replete” program designed to help tie-in sales. This includes materials that my be helpful to a pharmacy wanting to implement this type of program.