Greed

Greed — for lack of a better word — is good. Greed is right. Greed works. Greed clarifies, cuts through, and captures the essence of the evolutionary spirit. Greed, in all of its forms — greed for life, for money, for love, knowledge — has marked the upward surge of mankind.

— Gordon Gekko (played by Michael Douglas) in movie Wall Street

From time to time our pharmacy receives an order for Vitamin K tablets to treat a patient with a high INR (International Normalized Ratio). This is an urgent care drug: Vitamin K reverses the anti-clotting action of warfarin. Any delay in treatment can be very dangerous. Currently, only one oral Vitamin K product– Mephyton 5 mg tablets–is available to treat patients who have ventured into high or very high INR values while taking warfarin. This product costs about $56 per tablet. The product’s price has increased dramatically over the past several years, reportedly from about $9/tablet to the current $56/tablet.

Despite being an acute or urgent care drug, Mephyton is not kept in stock at some pharmacies. In my area, none of the independent or chain stores stock it. This means that there could be difficulty and delay in getting the medication to a patient in need.

Every pharmacy has tens of thousands of dollars of insulin in their refrigerator and hundreds of thousands of dollars on their shelf at any given time. Cost alone is not the reason the medication is not being stocked. While many medications are expensive, they don’t remain on the shelves for long—the inventory regularly is sold and replaced with fresh stock. In contrast, Mephyton is a much slower moving item. Our pharmacy, for example, has dispensed 26 Mephyton tablets in the last five years. The product is only available as a package of 100 tablets, and that means a single bottle would last 5 years or until it expires, whichever comes first.

It is not unreasonable to ask why the manufacturer only offers this medication in bottles of 100 tablets. A typical pharmacy would not use 100 tablets over the course of several years. I do not know the answer to the question, but one would have to speculate that greed, in the form of profit, is a motivation.

I won’t complain about the cost per dose of this medication: we started by stating that greed is good. The nature of this medication, which is only use for short term acute therapy in a few patients, is a reasonable justification for its current price point. Here, greed is about being able to maintain a niche drug in the marketplace. But I would add the Thriving Pharmacist’s corollary to Mr. Gekko’s statement: good greed is balanced greed.

Here, we need something to balance out the greed for profits. Something to balance the high cost of the medication with the best interest of the patient and their providers. The practice of selling the product only in bottles of 100 misses the mark.  It has the potential to jeopardize patient safety and reduce access to this life-saving medication.

Each pharmacy has their own way of dealing with this greed imbalance. One local chain pharmacy, for example, has a regional central fill location where they have product in stock. Using this strategy they only need to maintain a single bottle to support dozens of their regional pharmacies. This is an imperfect solution as there may be significant delay getting the medication to the patient. In our case, we have moved away from using the tablets as our source for Vitamin K. We ask the prescriber to write for the injectable form of the medication to be administered orally. The injectable is no less expensive, but it is available in packages of 10 units. In this way, we are able to stock the medication and simultaneously minimize the risk of expiration or dead stock.

Pharmacies work hard to care for their patients. We are greedy—we have a greed for care. That sometimes means finding ways to counter unbalanced greed. Sometimes the cure is a greed of innovation and creativity. The greed for care. Greed, yet another way pharmacists can Make Every Encounter Count!

Data Corruption

One of the more exciting collaborations happening in our pharmacy is the opportunity to coordinate with a commercial healthcare insurance company,  managing our mutual patients with the goal of improving therapy outcomes and reducing overall healthcare costs. The insurance company has provided us with new tools, giving us access to some of the detailed statistics they collect. The insurer is also very interested in several disease states. The insurer provides us specific patients they believe would benefit from additional workups. One of the targets is to identify patients that would benefit from initiation of a medium or high-intensity statin.

We have been working on this project for quite some time and have succeeded in initiating statin therapy in numerous patients were it would be beneficial. We identified these patients both using our own data as well as the information the insurance company provides us. Recently we encountered an examples of information in the health record kept by the insurance company that reminds us that we need to critically evaluate all information we receive, no matter it’s origin.

In this example of Tales from the Counter, we look at a patient the commercial insurer forwarded to us as a potential candidate for the initiation of statin therapy. Our patient is a 53 year-old female taking lisinopril / hydrochlorothiazide for essential hypertension. She reports she previously tried a statin, but was unsure when/why it was stopped. She denies a present medical history of diabetes or smoking.

Labs from the primary care provider included:
BP 135/89
TC 251
TG 191
HDL 61
LDL 152
Our clinical staff calculated a ASCVD score of 2.9%
The patient denies any history of diabetes or heart disease, and their 10 year risk for a cardiovascular event is low. In other words, or staff found no reason the patient should be on a statin. Yet the insurer had flagged her as a candidate for moderate-high intensity statin therapy.
This is were things get interesting. Our staff contacted the insurer to determine the basis of their inclusion of this patient on their list. After investigating, the insurer found that the patient had an annual eye exam with an opthamalogist and the billing information submitted for that visit included a secondary coding for type two diabetes w/o complications (ICD-10 of E11.9).
There was no other supporting clinical information in the patient’s clinical records, and it was unclear if the inclusion of the diagnosis in the ophthalmologists claim submission was an error, a misunderstood question answered by the patient, or an patient-reported diagnosis that the opthamalogist simply noted. The interesting part is that the inclusion of this diagnosis in a bill submitted to the insurance resulted the patient moved into a different risk grouping.
When diagnosing a patient, it is important that the assessment is reproducible. For hypertension, multiple measured blood pressures have to be elevated before the patient is diagnosed. Diabetes is the same way, with a single high blood glucose reading not being enough to confirm a diagnosis. But once information is in the healthcare record, things are presumed to be accurate, and this is the take-home lesson. It is important for all healthcare professionals and insurance providers to look deeper than just a diagnosis on the chart. Be sure the diagnosis is accurate before treating the patient. Always question the accuracy of the information you are looking at.  Don’t assume that someone else has confirmed something. Take the time to be sure yourself. Make every Encounter Count!

 

Minor Victory in Battle with PBM in Iowa

Previously I reported that a PBM had been making headlines in Arkansas, with the Arkansas Pharmacy Association and their legislature working to correct severe cuts being made to their local pharmacists (Arkansas Leads the Way Against Anti-Competitive Actions of PBM). Similar issues have been observed in Iowa, with pharmacists in the state pushing the Iowa Pharmacy Association and state legislators. They quickly responded to the call to action and continue to fight for local pharmacies being reimbursed fairly.

Today, the Iowa Pharmacy Association announced that their work appears to be having some positive benefits.  From a news release from the IPA:

…in response to IPA outreach and concern, they’ve conducted an internal analysis and will be making an adjustment to their pharmacy reimbursement in Iowa. This adjustment will be made later this week, or early next week at the latest.

At this point in time, the PBM has not agreed to make these changes retroactive. It is my belief that this is a tactical mistake by the PBM. Additionally, the scope of the changes will take time to analyze and it will not be clear for quite some time if the adjustments are fair.

So while it is too early to celebrate, it is satisfying to know that a grass-roots movement can escalate into a wave of support. The pressure that this support put on the PBM appears to have had some impact. While not a clinical intervention, this is yet another example of Making Every Encounter Count.

Arkansas Leads the Way Against Anti-Competitive Actions of PBM

Recently, a prominent national PBM made significant and severe adjustments to their Maximum Allowable Cost (MAC) rates for generic drugs. As a result, here in Iowa we have seen a staggering increase in our Underwater (paid less than it costs us to purchase) generic prescriptions. The week that this change is obvious in the graphic below.

Change in Underwater (paid less than cost) claims from a given PBM. December into January 2018

The data shown above is for one of our pharmacies and represents the percentage of underwater generic prescription claims for each given week from December to January. All of our pharmacies show the same dramatic increase in underwater claims. However, this did not only happen in our pharmacies. It did not even just occur in our State. It has happened elsewhere around the United States as well, with the State of Arkansas taking a lead investigating this problem and taking actions. It is interesting to note that among the reported findings, the PBM in question, which also owns a chain of brick and mortar pharmacies, may actually be paying itself at a higher rate than they are paying independent pharmacies. If true, this anti-competitive behavior may prove a catalyst in the groundswell of bad press hitting the PBM industry.

Please take some time to view an interesting press conference held recently in Arkansas which outlines some of their findings. It is quite illuminating. Follow this link. The State of Iowa appears to be interested in beginning investigations in a manner similar to Arkansas. Other states are likely to follow if these findings hold up and new examples continue to be revealed.

Make no mistake, even if State and Federal legislators begin to take action now, it will be quite some time to reverse the negative actions that have and continue to jeopardize local independent pharmacies around the country. Hang on, as this might be an interesting ride.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sometimes There Isn’t a “Right” Answer

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

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

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

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

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

This medication is contraindicated in patients with glaucoma.

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

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

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

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

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

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

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

ReBlog: Abusing Drugs

Shortly after finding yesterday’s story about Express Scripts mail faux-pas, I was alerted to another news piece from prospect.org written by David Dayen covering some of CVS-Caremark’s anti-competitive behavior. This article is worth reading as it does a good job of explaining many of the more complex and dishonest tactics a PBM uses, and it also points out some of the troublesome aspects of mergers of PBMs and insurance companies. Jump here to read more.

Re-Blog: Local pharmacies losing business from accidental third-party mailer

What happens when an industry can direct entire populations? They will eventually flex their muscle and their monopoly position. An excellent example of the unchecked-power the PBM industry has over the pharmacy industry occurred in Wisconsin recently, with a PBM sending out letters to members misleading them into switching pharmacies. One of the choices, of course, was their own mail order pharmacy.

The mailing was reportedly an error, but the impact was and is very real. The misleading letter negatively is hurting many independent pharmacies in Wisconsin.. For more, follow this link.

Monopoly and the DIR fee

Recently we rolled the dice and moved our giant capsule token in the game of Pharmopoly. We landed on Community Chest and drew the infamous:

You have won second price in a beauty contest, collect $10
Community Chest

The actual prize was several thousand dollars paid back to our pharmacy from a True-Up done to correct DIR fees withheld from our remittance back in 2015. While this is good news for our pharmacy, not everyone was as fortunate. Some pharmacies landed on Luxury Tax, others drew hospital bills. In other words, the True-Up cut both ways, with some pharmacies hit very hard. Let us take a closer look at how this DIR fee was set up and why such a contract should not be allowed by Medicare.

There are two overlapping parts to the contract: a DIR and the GER (Generic Effective Rate). The DIR fee in question dictated that the pharmacy would repay the benefit manager 50% of the ingredient cost of the drug. The GER defines the average allowable ingredient cost the pharmacy will receive over the term of the contract.

The challenge arises because the PBM does not simply adjudicate each claim using the GER as the basis for ingredient cost. Instead, ingredient cost is determined by a Maximum Allowable Cost (MAC) for the drug. The MAC for a given drug can be very different from the contracted GER.  Periodically, the PBM then calculates and collects their DIR fee. This is based on the originally adjudicated ingredient cost.

Much later, the PBM will look at all claims the pharmacy has adjudicated over the course of the contract. It will then calculate the average discounted ingredient cost paid to the pharmacy and compare it to the contracted GER. From there, the PBM will either refund the difference to the pharmacy (winning 2nd place in the Beauty Contest) or collect (land on Pay Luxury Tax) the difference from the pharmacy. To better illustrate, I have adapted the following example:

Reimbursements and subsequent true-up details for two different generic drugs. These numbers are for illustrative purposes only. The contracted GER is the same for both pharmacies. The two different drugs being adjudicated have very different MAC price discounts.

Drug A:

Drug AWP = $100

Contracted GER
AWP – 90%

Drug B:

Drug AWP = $100

Contracted GER
AWP – 90%
Adjudicated MAC Price (ingredient cost) (A) (effectively
AWP-40%)		 $ 60.00 (effectively AWP – 99%) $ 1.00
Amt of DIR collected (specified as 5% of ingredient cost) (B) DIR $ 3.00 DIR $ 0.05
Amount pharmacy has been paid after DIR (Amt paid to pharmacy less DIR collected from pharmacy) (C) Net Drug
Profit		 $ 57.00 Net Drug
Profit		 $ 0.95
Contracted GER (the ingredient cost pharmacy should have been paid) (D) AWP-90%
GER ingredient cost		 $ 10.00 AWP-90% GER ingredient cost $ 10.00
Actual DIR Fee (5% of corrected ingredient cost) (E) Correct DIR $ 0.50 Correct DIR $ 0.50
Amount owed to or due from the pharmacy (True-Up) Phy owes PBM $  47.50  Phy refund from PBM $  (8.55)

 

So in the case of Drug A: The PBM overpaid the pharmacy at the point of sale by $50.00 (Row A – Row D). The DIR paid by the pharmacy was therefore overpaid by $2.50 (Row B – Row E) resulting in the pharmacy owing $47.50 back to the PBM.

In the case of Drug B: The PBM underpaid the pharmacy at the point of sale by $9.00. The DIR paid by the pharmacy was therefore underpaid by $0.45 resulting in the PBM owing the pharmacy $8.55.

The key point is that the MAC price during the course of the year does not have to mirror the contracted GER.

To this I would like to add two questions:

  1. Why not just adjust all MAC prices to the GER up front to eliminate the need for a True-Up?
  2. who gains from the added complexity and obscurity?

The answer to the first question is that there is no reason that the plan and PBM could not tie their adjudicated prices to the GER instead of using nonaligned MAC prices. By adding complexity where it is not required, the PBM must gain some financial advantage. The cost of the true-up is certainly measurable and the cost would have to be offset by some other revenue. This is yet another example of the deliberate non-transparency in this industry. This is supported by an audit on about 1,000,000 claims performed by our contracting organization that resulted in them contesting the true-up.

Medicare, the very organization that allowed the creation of the DIR fee, also explicitly states that DIR fees should, whenever possible, be calculated at the point of sale. This is not a technically challenging requirement. Despite this, many PBMs have continued to maintain that the complex calculations they use for DIR fees cannot be evaluated at the point of sale, propagating the non-transparent nature of their industry.

Congress, Medicare and the leaders of the pharmacy industry need to unite to demand more transparency in the PBM industry.

 

Does a Pharmacist Represent the Insurance or the Patient?

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

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

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

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

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

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

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

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