Drug Topics Voices 01-10-2015

Alive and kicking

Re: “Is fee for service dead?” [Mike Schuh, Dispensed as Written, December 2014]: Kudos, Michael, for identifying the fact that, for the most part, the profession has jumped on the MTM bandwagon way too soon and has done so in an environment without a lot of extra discretionary funds to make the experience financially worthwhile.

Mark Burger’s posted response [see below] probably applies in just a few locations in this country. He’s fortunate to have a pharmacy located in a community whose per capita household income is 50% higher than the national average, where there are extra dollars available to cover a novel pharmacy product. (Try cash-only compounding or MTM in inner Detroit and see how long you last.) In most large cities, locations where one or two individuals might succeed with an MTM practice are few and far between. The real shame is that the chains are now including MTM activities as part of their “productivity monitoring.” This will only reduce the quality of these interventions by setting a target number/day vs. intervening when it really matters.

Anonymous
Posted at www.drugtopics.com

All consults, all the time

“As pharmacists, we have no ability to bring money in.” Really? I can make my annual salary and more without dispensing at all.

I charge cash for my consults (if you want to call them MTM, go right ahead). I don’t care what some third party is willing to pay me. My patients are willing to pay cash.

Why? Because I get results, not “Band-Aids-over-bullet-holes,” which is how most pharmacists practice MTM.

People want to be healed/cured - they don’t want their medication changed, substituted, or given at another time of day, in another dose, or in a different form (e.g., omeprazole instead of lanzoprazole). They don’t want to take medicine. They want to be told/taught how to heal the core issues.

When you:

• Get them off their medications (or reduce the quantity of what they take);

• See and correct the hypomagnesemia, for example, caused by the diuretic given for a one-time hypertensive measurement in the doctor’s office;

• See that they are depressed because they have low 1,25-dihydroxyvitamin D levels and their doctor thinks 50,000 IU Q week of D2 is the answer when daily D3 dosing is appropriate;

• Notice that they are anemic because they can’t absorb iron, B12, B6, or folate due to the PPI they are on;

• Explain all this to them and fix all the problems brought on by a system that treats them like a number (N=? in a study quoted as evidence), you will get results and you will get paid for it.

Try it. They’ll like it.

Quit teaching pharmacists that no one will pay them for what they know. Just tell pharmacists to quit “knowing” what the doctors, epidemiologists, FDA, CDC, BC/BS, UHS, Caremark, Charter, and Express Scripts “know.”

Shake off the shackles. Bill patients for helping them live better, with a better quality of life. 

Mark Burger
posted at www.drugtopics.com

Community pharmacy forever

Re: “Is community pharmacy a dying profession?” [Truman Lastinger, DT Blog, Dec. 10, 2014]:

It is true that the pharmacy profession must change with the times and that the pharmacy model followed by Truman Lastinger and my father for decades is probably unreasonable now, but as long as people need/demand help and advice, pharmacists will be there for them. People still want someone there to provide advice on self-help OTCs or the new heart medication that the physician was too busy to tell them about, not to mention “How the heck do you use this newfangled lancet device, anyway?”

With more and more healthcare being pushed to the outpatient level because of cost-containment, there will be a demand for midlevel healthcare providers such as PAs, NPs, RPhs, etc. I find myself doing cholesterol tests on patients, providing vaccinations to keep them healthy, “furnishing” prescriptions to patients traveling overseas, and writing lab orders to monitor patients’ white cell levels, all in the interests of making sure they stay as healthy as possible.

Is it a long way from the old-fashioned corner-store pharmacy with the soda fountain? Yes and no. The soda fountain is no longer there, but the “care” in pharmaceutical care is still there. As long people are in the community, there will be a community pharmacist to help them.

Jeffrey A. Wong, PharmD
San francisco, calif.

Big Brother, Big Pharma, Big ... Watson?

In addition to all the points Truman has made in his article, consider the possibility that Big Pharma may one day surpass PBMs and deploy its own automated mail-order directly to the consumer, possibly from offshore fulfillment centers, if they can effect buy-in from the FDA.

Then there are the advances in computer science. What if IBM’s Watson [cognitive information-processing technology] were applied to designing drug therapy? Suppose that for a small fee, Watson will evaluate all of a patient’s data, design a drug regimen for optimum outcome, and forward the prescriptions (with the physician’s electronic signature, of course) to the appropriate fulfillment center for next-day home delivery?

What’s more, for a small fee, Watson could also review changes in a patient’s health from the patient’s smart wristband and contact the physician with an offer of appropriate alternatives to current therapy.

Naturally, somewhere in a cubicle, there will be a pharmacist to answer patients’ questions - in between remotely verifying the accuracy of a robot that never makes mistakes - at a fulfillment center in India or China.

After seeing all the changes in my practice over the last 30 years, I don’t believe that these scenarios are that far-fetched.

And Truman might be wrong about those coopers. Perhaps, in the next 30 years, being a cooper who makes oak barrels for premium American bourbon will become a far more lucrative trade than pharmacy.

Anonymous
Posted at www.drugtopics.com

Clinical pharmacists in the ED? You betcha

Re: “Hospital puts pharmacists in ED to reduce med errors” [Dec. 1, 2014; www.drugtopics.com]:

Dr. Svenson’s statement, that smaller hospitals could not afford to have a pharmacist sitting around, would apply to all hospitals. Clinical pharmacists should be engaged in patient care, not taking up space in the ED.

I piloted a clinical pharmacist-based ED service in a small 100-bed hospital with a 22-bed ED and proved that it is cost-effective to have the pharmacist in the ED. It is true that the volume is an issue to justify the cost of the pharmacist, but different models can be used to optimize the pharmacist’s time and ED coverage provided.

My pilot program included staffing assignments for the pharmacist to assist with inpatient care, with a focus on critical care. For the safety of the patients, ED-trained pharmacists should be available to all EDs across the nation. According to the size of the facility and the volume, the model should be scaled and adapted to be as cost-effective as possible for each facility.

Todd White
posted at www.drugtopics.com

Clarification: The online article “The pharmacists’ role in preventing acetaminophen overdoses” [Drug Topics, Dec. 19, 2014], was updated Dec. 29 to clarify the timing of the proposed rule on adult acetaminophen; the labels referred to in the last paragraph, which are prescription labels; and Dr. Oswald’s quote in the fifth paragraph.