Changes

I took a major step this morning for my career and accepted the position as a district pharmacy manager for my company.  I'm excited and sad at the same time.  I have loved my work as a pharmacy manager and the people I have been fortunate to work with.  I felt like a real pharmacist for once.  Now an opportunity has opened up and I feel like it is time for me to take a chance.

This means I may have to take a break from blogging as I train and tackle this new position.  I am also going to remove my name and identifying information from my blog.  I have always attached my name to my articles because I believe transparency is important and we should stand beside our opinions and actions.  Unfortunately, my student loans won't pay themselves, so I need to protect myself and make sure my opinions don't put me in the unemployment line.

A reminder that I needed

I have worked hard over the past few months to get information out to the public about issues facing health care, primarily the practices of Pharmacy Benefits Managers that are having a negative impact on patient care.  After finishing one of the 20 or so transfers that I received from Walgreen's today, a patient did something that reminded me of the importance of our work.

We had just transferred this older gentleman's prescription due to Walgreen's not accepting his Express Scripts insurance any longer.  While he was picking up the prescription, he was very confused and not sure of why he had to come to this new pharmacy when he was happy with Walgreen's.  In addition to the confusion over his health insurance, the old man had a look on his face like his mind was somewhere else.  After my technician rang up the gentleman's order, he said he wasn't having a very good day.  My technician asked why and was just showing empathy as she does with every patient (one of the things I love about our pharmacy are the caring techs and pharmacists we employ).  The old man said he just dropped his wife of more than 60 years at the nursing home for the first time and he began to cry...

I watched the whole thing unfold and my heart just died.  My technician immediately began to tear up, as did the patient behind the old man in line.  I stopped what I was doing and joined my technician in the conversation.  There was nothing we could do to help but listen to this sweet person.  We told him that if he ever needed anything he could always call us.  He wiped his eyes and thanked us for listening (my technician had to go back in the break room to regain her composure).

This incident didn't have anything to do with a PBM or anything else that I've been so torn up about over the past few months.  This older man faced a problem that many people have faced and he reacted as many loved ones do when they feel helpless.  Pharmacy practice is changing in front of our eyes and I will continue to fight for the things I feel strongly about.  This sweet old man reminded me that I am taking care of PEOPLE, not prescriptions.

Who will be next?

As 2011 comes to an end it doesn't look like Walgreen's and Express Scripts will kiss and make up, forcing millions of patients to find a new pharmacy.  Walgreen's refused to accept a contract that offered below the industry average cost to dispense a medication and seems prepared to give up the 90 million prescriptions it filled for ESRX in the previous year.  With Walgreen's out of the network, I'm starting to wonder which pharmacy will be next?

As long as Express Scripts, and other PBM's, are allowed to own and operate a private mail order pharmacy their will always be an incentive to push patients in that direction.  By owning both parts of the process (payer and provider), PBM's are able to realize incredible profits through an obvious conflict of interest.  If you own an insurance company and a pharmacy, it makes sense to push out other competitors.  Of the 90 million prescriptions that Walgreen's may have filled in 2012 under Express Scripts, a large portion may now be filled by the Express Scripts mail order pharmacy.  Now what will happen if the contract for 2013 is even worse for pharmacies?  Will other chains like Wal Mart, CVS, or Rite Aid refuse to sign the deal?  Will this leave millions of patients with no choice other than mail order?

Discussion at the Dinner Table
Many friends have asked my opinion of this ordeal.  I really knew it was big news when this was brought up for discussion at my family's Thanksgiving dinner by my two aunts who are school teachers in the state of Kentucky.  They were upset that they could no longer get their prescriptions at Walgreen's and couldn't understand why this was happening.

I explained that Pharmacy Benefits Managers, such as Express Scripts, have been playing this game for years with community pharmacy and for once a major corporation has had enough.  The independent pharmacy owners have complained about PBM contracts for several years but they have been ignored because a chain pharmacy was always willing to accept the terrible PBM offer to gain market share.

Dear Pharmacy Benefits Managers,

We have gotten off on the wrong foot and I would like an opportunity to rebuild our relationship.  First I want to apologize for attacking you and your business practices in a negative way.  I disagree with the current direction that you continue to push pharmacy practice, but that doesn't mean we can't find common ground and work together.

As we work on rebuilding our relationship, we have to address some major issues.  First, I am not a robot and will never be a robot (except for about an hour after my Venti Iced Coffee).  In order for our relationship to work you have to accept me as I am and work with my strengths as a human.  

Secondly, you will need to end your relationship with the mail order business.  As long as you own your own mail order pharmacy you will always be tempted to make decisions that are not necessarily in the best interests of your customers or the community pharmacies in your network.  I understand that owning a vibrant mail order pharmacy gives you an opportunity to leverage big kickbacks from drug companies in exchange for formulary preference, but this practice only makes you look sneaky.  

Third of all, I would like you to revisit your contract department.  Please consider that not all pharmacies are created equal.  Pharmacists that work hard to take care of the patients in your network should be fairly compensated for their efforts.  You get what you pay for in most cases, and when you pay a little more on the front end, your patients will realize more benefit through an increase in access to patient care.  

Finally, I am not opposed to you making money.  All I am asking for is a little transparency.  Show your stakeholders (i.e.: employers, HR managers, pharmacies, patients) where you make money.  Show your stakeholders where you spend money and how much you actually spend.  True capitalism cannot exist behind a cloud of secrecy.  Show the world what you are about and compete in a fair market.  Be a leader and show that healthcare can be delivered efficiently and in an honest fashion.  You will still make money (maybe not as much at first) and you will make healthcare in our country better.

Sincerely,

Concerned Pharmacist

Medco-Pfizer Deal on Lipitor: Same old game.

It was announced that Medco Health Solutions (one of the major pharmacy benefits managers) will continue to provide brand name Lipitor (blockbuster cholesterol lowering drug) to 1.2 million patients under Coventry Health Care after the drug goes off of patent.  You may be wondering, "Why would patients continue to take the brand name drug when lower costs generics are available?"  Well the answer is pretty simple, Pfizer (the makers of Lipitor) have struck a deal to keep patients on the brand name with an insurance company that insures those patients.

This should come as no surprise because Pharmacy Benefits Managers (PBM's) have always used the leverage of their patient population to receive rebates/kickbacks/exclusive-contracts from drug manufacturers in return for including certain drugs on their formularies.  In theory, this is a good idea to lower the cost of drugs.  In practice, the patient never sees the lower cost.  The PBM will bill the patient or patient's employer for the market cost of the drug and receive the kickback from the manufacturer in another form.  This allows the PBM to realize major financial gain without passing the savings on to their customers.

Robot vs. Pharmacist: Round 3

One of the competitive advantages current pharmacists have over Medco robots, is the ability to connect with patients on a personal level.  Through caring, empathy, and a little humor, pharmacists with a good personality have the ability to work with patients in a way that a robots currently are unable to understand.  While Medco robots may count faster, Medco robots have yet to put a smile on a sick patient's face.  

Until now...

With the invention of Johnny 5, RPh, it looks like Medco has figured out a way to connect with patients and get rid of human pharmacists.  Johnny 5, RPh comes equipped with a the efficiency of a typical Medco pill counter model AND the ability to crack a joke and make face-like expressions to show empathy and concern.  See Figure 1 below.

Figure 1: Johnny 5, RPh.

FEATURES INCLUDE:

• Patient counseling 
• Vaccine administration
• Medication Therapy Management software
• Drug Utilization Review
• Programable language accent variation
• Joke database to provide witty comments to patients
• OPTIONAL: Tear duct expansion pack to allow your Johnny 5 RPh to cry with sick patients

TO SEE JOHNNY 5, RPh IN ACTION WATCH THIS VIDEO:

Audits are necessary...Bounty Hunter Audits should be illegal

Auditing is a necessary practice for any organization.  We all may be exposed to financial audits via the IRS, but auditing may expand much further for many professionals.  Pharmacists may encounter audits from regulatory boards or insurance companies.  This practice, in theory, is acceptable and necessary to ensure best practices.  All pharmacies should strive to meet and exceed practice standards to provide the best patient care possible.

In reality...

Pharmacy audits have become a source of revenue for Pharmacy Benefits Managers (PBM).  Companies, such as Express Scripts, have entire departments devoted to auditing pharmacies.  Their auditing teams look to find prescriptions that have missing elements or mistakes that could lead to recouping the paid claim from the pharmacy.  While I believe any prescription filled incorrectly should be corrected and all pharmacies should engage in CQI (Continuous Quality Improvement), I find it ridiculous to see PBM's try to recoup claims from legitimate prescriptions.

For example, if a pharmacist fills a prescription for a patient's antibiotic written on November 7, 2011 and puts that the prescription was written on November 1, 2011 (possibly due to legibility between a "1" and a "7"), the PBM could say this prescription was filled incorrectly and try and dispute the claim.  Is this claim an example of a pharmacy trying to "fraud" or "abuse" the insurance company?   No.  This is a clerical error and mistake that could be quickly corrected.  However, PCMA and the insurance company lobbyists are launching campaigns claiming their teams are fighting fraud, waste and abuse by pharmacists, when in reality...they are trying to pull back more money.

This issue is better illustrated when you consider their strategy.  Insurance companies spend little time disputing these errors when it involves a generic like amoxicillin.  They spend their time seeking out claims for expensive medications.  This makes sense from a business standpoint, like the IRS auditing millionaires instead of auditing a teenager working a part time job.  If they were truly concerned about accuracy for their patients, they would conduct a fair audit of a random sample of medications.  Since the generic utilization rate at many pharmacies exceeds 70%, then at least 70% of the claims they audit should be for generic low cost medications.  I find it too much of coincidence that they purposefully dispute all of the big dollar claims.  I understand the business model, so let us call it what it is.  Do not audit in the name of "accuracy" when all you are really concerned about is recouping as much money as possible.

PBM Wishlist

My Political Wishlist for PBM's for 2012:

1. Ban on spread pricing.

2. Separation between PBM and provider (ie: make it illegal for a PBM to own its own pharmacy or mail order pharmacy).

3. Banning Drug Manufacturer rebates, aka "kickbacks" to PBMs for formulary decisions.

4. Mandatory Firewall on proprietary pharmacy info.

5. Fair Audit Practices - audit for fraud, waste and abuse, NOT to reclaim good/legal prescriptions.

6. Faster Prior Authorization turnaround.

7. Higher dispensing fees.

8. Lower healthcare costs - keeping patients from important maintenance medication puts them in the hospital, just because you save on the pharmacy costs doesn't mean you save on the whole system.

9. Pass on some savings to your customers - for too long you have raised your premiums and have not lowered costs...and you pay the pharmacies less and you get kickbacks from PhRMA...stop.

10. Better patient care - patients aren't just numbers and statistics. They are people. Treat them that way.

That is all for now...


- Posted using BlogPress from my iPhone

Robot vs. Pharmacist: Round 2

When Medco CEO, David Snow, promoted the use of robots over pharmacists I really had to give this idea some thought.  In Round 1 of Robot vs. Pharmacist, I decided to give the edge to R2D2, PharmD thanks to his WebMD like reflexes and beep humor.  In Round 2, I realized that pharmacist may face a pretty big uphill battle thanks to Terminator, PharmD, BCPS, MBA, MPH (yes, its amazing the number of documents and degrees this cyborg has accumulated over his career).

Figure 1: Terminator, PharmD, BCPS, MBA, MPH


Round 2 doesn't look good for the pharmacist.  This new model of Terminator robots will serve the health care industry in many ways that regular pharmacists bound by their "morals and a conscience" can not.

Example 1:  A patient walks into the pharmacy on a Friday night to pick up their prescription of Gengraf they have taken for 12 years since their kidney transplant.  Thanks to a switch in their company's pharmacy benefits their prescription now requires a Prior Authorization that the patient wasn't informed about until they reach the pharmacy counter.  


So how do we handle this patient?

Pharmacist: The human pharmacist realizes that the Prior Authorization (while important to controlling healthcare costs) in this case will more than likely be approved.  Since the patient is out of medication, rather than making the patient pay out of pocket for the full cost, the pharmacist allows the patient to have a 3-5 day supply at no charge until the pharmacy can work out the PA with the physician and insurance company.  Knowing that this medicine could keep this patient's body from rejecting his transplanted kidney and thus out of the hospital, the pharmacist is happy to help and save the healthcare system a large sum of money.

Robot: Upon rejection of the insurance claim, Terminator, PharmD, BCPS, MBA, MPH informs the patient that he needs a Prior Authorization for his insurance company to pay for his expensive medication.  The 1's and 0's programmed in his CPU quickly determine that the rules of a Prior Authorization are simple to understand and then wonders why this human is so ignorant to his health benefits plan that he clearly signed up for.  When the patient pleads his case and need of his medication so his body doesn't reject his kidney, the Terminator replies with a programmed response: "If you would like to get your medication today, we also accept cash."

Well, it looks like in Round 2 of Robot vs. Pharmacist, the robot wins again as the pharmacist is just a sucker who helps patients at their own expense...