Pharmacists on pharmacy: Drug Topics readers speak out

Drug Topics articles frequently set off rounds of thought-provoking reader comments. Here are some of the latest, on subjects ranging from nontraditional PharmD options to insurers and PBMs, healthy lifestyles, and more.

“PharmD options” (Cover story, November 10)

It's the people, not the letters
What I find upsetting in the article is the premise that the years of experience and knowledge gained are overlooked, underrated, and not given proper consideration in evaluating the quality of service the non-Pharm D job candidate can and does provide. It is the people, and how they use the knowledge obtained during years of education and practice, that make the difference, not the letters after their names.
- Leo Lawless, posted at www.drugtopics.com

An affordable degree
I was very fortunate. I started my nontraditional PharmD in 1999 and finished it in 2002 at the University of Washington. They charged the same tuition for out-of-state as in-state. My total cost, including travel, was about $10,000.
- Ron Smolen, posted at www.drugtopics.com

An unaffordable degree
Has anyone looked at the cost for pharmacists over 50? I am 51. To do non-traditional is $40,000 to $50,000! I would have to use my retirement to do this. Since I want to retire at 65, I cannot recoup this cost in 15 years. Then there would be the issue of who wants to hire a 60-year-old PharmD? It would be nice if we RPh's could be grandfathered into PharmD programs based on our experience, along with certifications. It's just sad that our profession is leaving those of us who helped build it out of the loop.
- Anonymous, posted at www.drugtopics.com

Gimme the motivated BS pharm 
I have worked in a small hospital setting and have worked with pharmacists with BS and PharmD degrees. It depends on the person, but my feeling is, give me an experienced pharmacist with a BS degree to work with. Their experience is very valuable and they are not afraid to help out with all tasks required in our small department. We have a new pharmacist with a PharmD who is a nice guy, but he is so inefficient, it's ridiculous. He will not help us and seems to think he is above checking a cart, etc. What I'm trying to say is that years of experience count for so much. Give me a motivated BS Pharm who is a team player any day to work with.
- Anonymous, posted at www.drugtopics.com

See also: Pain management and reduction of opiate use: A proven model meets resistance

 “Games insurers play” (Dispensed as Written, Nov. 10)

This could backfire
This is a good reflection on the current status of compounded medication coverage, but I don't see where this is (or should be) a huge priority for compounding pharmacies (it's a total non-issue for chain pharmacies, since they don't compound).

For one thing, compounded meds are almost always audit triggers for those plans that do cover them. Second, since only one ingredient (the most expensive "first place" ingredient) usually gets reimbursed under the current system, it's actually less profitable to bill these to insurance plans than cash sales would be.

I appreciate the altruistic reasons Salvatore Giorgianni cites, but again, pushing for mandatory third-party coverage of compounded meds is somewhat disingenuous, in light of the compounding pharmacy business model (cash only).

I truly empathize with that elderly cancer patient (or the infant needing a patient-specific dose of antibiotic with flavoring), but getting third-party payers involved in compounding will ultimately lead to the existence of fewer compounding pharmacies, when their revenues get slashed. Especially since it looks like state regulators nationwide will be introducing some very tough (and expensive to implement) standards for compounding, as a result of the well-publicized contamination events we've seen in the past couple of years.
- Anonymous, posted at www.drugtopics.com

The compound gouge
I hate to say it, but I agree with the insurance companies on this issue. I have worked in a large compounding pharmacy for about five years now, and I am shocked at what some compounding pharmacies charge for these pain creams. They take simple ingredients that only cost a few dollars (lidocaine, gabapentin, clonidine, amitriptyline, ketoprofen, diclofenac, and ketamine, etc.) and then sell them as a compounded pain cream and bill the insurance companies for several THOUSAND dollars. This is outrageous. It is price-gouging. It is immoral and unethical, and an embarrassment to the profession.

I can't blame the insurance companies that are beginning to refuse to pay. Do you think they would try to charge that to a self-pay patient? Of course not.

Don't blame the insurance companies on this issue. These pain-cream compounding pharmacies are the new equivalent of pill-mill pharmacies, and they should be put out of business.
- Anonymous, posted at www.drugtopics.com

On the subject of reimbursements

Consideration of drug costs and insurers leads us by a more or less straight line to the subject of PBM reimbursements. A correspondent of Dennis Miller’s offered the following observations in an e-mail:

No coverage for dead doc Rxs
PBMs have cut reimbursement to such a low level - and are scrutinizing every claim that is over $200 so closely - in order to eventually disqualify the claims and take back the money. For example, prescriptions from doctors who have retired or died are immediately nonreimbursable. If a faxed Rx does not contain the faxer’s phone number and the name of the doctor’s office at the very top of the fax as transmitted by the outgoing fax machine, this is now a disqualified prescription too. And we are supposed to call the doctor’s office to verify that it was they who actually faxed it and not the customer, etc. 

To make up for all this, tech hours have to be cut deeply or the pharmacy is not profitable and must be closed. This what I have been getting from my DM in response to why hours are cut 20% for techs.
- Mike Saija

Mike added, in a subsequent e-mail to Drug Topics,

My current theory is that with the PBMs ruling reimbursement, the chains constantly need the cheapest product. At my chain we can no longer order any NDC other than the preferred one, due to reimbursement losses. This in turn has resulted in most generic drugs now being imported from India and is causing a loss of business to U.S. manufacturers and consequent loss of employment for U.S. workers.  

The PBMs charge the insurance companies one price and give the pharmacy a lower price, and that is why certain big PBMs are making record profits and everyone else is losing money or barely surviving.
- Mike Saija

Another Drug Topics correspondent had this to say about PBMs:

Reimbursement below cost
When reimbursements below cost (RBC) occur, there is very little a pharmacy can do to fix the problem. The PBMs make you fill out a form and they review it, and if they feel it does need an adjustment they will adjust it on the next fill and will not go retroactive, so you lose on that fill.

Then there is a hidden DIR fee for preferred pharmacies done on the back end of claims that doesn't appear on adjudicated claim fields. It shows up later on the remittance advices. So you can never really figure out the true reimbursements. The PBMs are going to be the end of pharmacy if they can get away with RBCs.
- Gary Einsidler, RPh

"Are pharmacists pill-happy?"

Speaking of Dennis Miller, the recent launch of the redesigned Drug Topics website appears to have knocked out the comments posted by readers of his article,“Drugs or lifestyle changes? Are pharmacists pill-happy?” [Sept. 25; www.drugtopics.com], so we end with some of the feedback he’s been receiving.

Get to the root of the problem
I'm not too sure that I agree with the particulars in the discussion. However, I do concede that a “healthy” lifestyle is much to be desired in disease prevention, and attainment of that ideal is a goal. There is a certain precariousness, and this is where the patients end up in the tertiary care centers, on dependency for medications to “control” this or that symptom.

I do not believe that allegiance to the “natural foods” industry or “vitamins and herbals” racket is the answer. There is a lot of hogwash promulgated by these high-rolling marketers without a fundamental understanding of health.

I suggest that the opposite side of the coin to “too much dependence” on the effects of prescription medication on overall health is simply exercise, rest and sleep, plenty of water, and a variety of nutritious fresh foods without all the bells and whistles.

I also suggest that examining the lives of long-lived peoples might reveal how this simplification could be managed. It would not be glamorous or require loads of money, but it might require some restructuring of societies to include ready access to nourishing basic foods; access to good childcare; dental, mental, and physical health care; transportation systems that incorporate a moderate degree of daily exercise; symbolic curfews; basic sanitary standards; and so on.
-  Anonymous, previously posted at www.drugtopics.com

Take a tip from the armed services
I was privileged to work at one time for the Air Force and then for the VA, and I respect the philosophy of those organizations. Funny thing - when the facility is assuming most of the cost of the treatment (as is the case in most federal pharmacy), suddenly prevention of disease states becomes extremely important to the system. I witnessed the processes in place to emphasize education and encouragement of the patient to exercise more control over his/her own outcomes when possible.  

Of course, meds were dispensed (lots of them), but when the focus was on behavioral management when possible, it was gratifying to see many patients take that control and make significant improvements with fewer medications.  

Also, polypharmacy was more easily addressed when the pharmacist had an overview of most of the patient’s medications.

There is no doubt in my mind that as long as the numbers (how fast and how many scripts filled) have such importance, the money will be winning out.
-  Anonymous, previously posted at www.drugtopics.com

Let's see some real facts
What is a pharmacist? Merriam-Webster: “a person whose job is to prepare and sell drugs and medicines that a doctor prescribes for patients.” I’m sure Mr. Miller has made money selling drugs.

“Many, if not most, diseases in modern societies are preventable.”

Phrases like “many, if not most” have no meaning. “Most” means a majority and is significant. “Many,” however, can mean anything - e.g., 1% - and so renders such sentences meaningless.

Mr. Miller cites a book as saying, “up to 90% of cancer is preventable.”  This is meaningless. We know not to be fooled when a store has an “up to 90% off” sale, which means that many things are 0% off.

Without vaccines, billions who are alive today would not be.

We have so much to learn about genetics, the brain, and the body. People die daily due to “illnesses of the body,” regardless of nutrition, exercise, or holistic medicine.
- Tom Simpson, PharmD, CGP
(A longer version of this comment was previously posted at www.drugtopics.com.)

Can't bill for it
I would love to spend time counseling all my patients on lifestyle changes. Preventative medicine is the best type and the most cost-effective.

Unfortunately, until pharmacists are recognized federally as healthcare providers, we cannot bill for these types of services. If we can't bill for these services, we cannot generate revenue. Our current revenue comes from pills, so to remain employed, that is what we must do.
-  Anonymous, previously posted at www.drugtopics.com

Kindred spirit
What a surprise to see a kindred spirit with the same ideas about the practice of medicine and pharmacy today.

I've been a pharmacist since 1984. I agree with Dennis Miller 100% about the overuse of medications. I have consistently advised my patients over the years to try exercise instead of popping a pill, vitamin, or herb. Most of my colleagues, including doctors, NP's, PA's, etc., just don't get it - or are in it just for the money.
- Peter Goldstein

Overmedicated and over-reliant
I agree with many, if not all of the points Dennis brings up.  I, too, have been a pharmacist for the past 25 years, and I feel our Western society is overmedicated and relies too much on prescription medicines as a solution.

Maybe there needs to be some sort of “decrease your number of pills” campaign!  Getting a pill-taking country like the United States on board will be difficult, but it could happen.

I am not saying that all patients should abandon all their pills. Certain disease states absolutely need drug therapy (such as cancer), but for many other ailments, there are nonpharmacological methods that could be tried and exhausted beforehand, or at least be used in conjunction with pharmaceuticals.

People like us have to work to get the public to understand the downside of chronic prescription medicines and let them know that alternatives are out there - and that we pharmacists are willing to help. If we had the time and resources, we could make a tremendous impact. While pharmacists are trained to discuss medication usage and are not necessarily trained to discuss nutrition and how to lead a preventative lifestyle, learning those things would be much less complex than learning all those new drugs!

Although I am still a practicing pharmacist, I am willing to dispense fewer pills and assist the public in helping themselves.  Maybe I'm in the minority, but I believe that persistence can pay off.  
- Lynn Mahbubani

Walking the talk
In my pharmacy, when someone comes in for an OTC pain reliever, we ask, “Where is your pain?” and then we steer them toward a lifestyle change. (This might mean a paid consult with the pharmacist).

Digestion. If they come in for an antacid, same thing. “How long have you had heartburn? Does it happen at night? Do you get bloated after meals? Gas? Here, let me show you how you can take care of that once and for all, and get healthier, overall, in the process.”

Osteoporosis. “Don’t like those Fosamax pills? Let us tell you how the bone maintains itself and what you can do to prevent thin bones. It starts with your diet. Here’s some vitamin D3 + K2; take one daily with food. Get your level of vitamin D up between 50 and 80 ng/mL. Here’s a 7-minute scientific exercise chart [http://bit.ly/7minchart]. If you can spare 7 minutes daily and do this, it will keep your bones strong.” (Print this out and have copies ready to hand to patients. Tell them the intensity should be 8 out of 10.)

For pharmacists who say they don’t have the time for lifestyle counseling, here are three quick questions/responses:

1.Do you have 3BMs/day? If “No,” then we need to talk about fiber and/or probiotics/diet change.

2. Do you eat protein for breakfast? Really? Tell me what that is. Oatmeal? Fruit? Peanut butter? Toast? No, I’m sorry but that is not enough protein. You need 30 g in the a.m. Try Greek yogurt, fish, eggs (2 eggs = 15 g protein), chicken breasts, bacon, sausage, etc.

3. What is you HbA1c (or fructosamine) level? Oh! HbA1c of 5.6%? That’s too high. Yes, I know, your doctor said it is okay, but it is NOT. Average blood sugars above 95 mg/dL are damaging your arteries and your brain. Alzheimer’s disease is type 3 diabetes. Start walking 30 minutes daily, with a couple of 5-10 lb dumbbells. Eventually, you should be curling the dumbells repeatedly while walking. This will cure your diabetes.

By “curing” digestive problems you will “cure” or vastly improve 60%-65% of ALL ILLNESS.

By putting on some muscle mass (at the expense of fat mass) you will “cure” metabolic syndrome and type 2 diabetes and hypertension and anxiety and insomnia and arthritis and ... and .... and ...
- Mark Burger
, previously posted at www.drugtopics.com