What happened to community pharmacy?

Truman LastingerIn the drugstore, each customer who walks up to the counter presents a different and unique situation to which the pharmacist must react. Consequently, there is no way a pharmacist can plan the next hour or even 30 minutes of the day. Quite often, I had salespeople or business associates or customers call and ask whether they could come see me at a certain time. I had to tell them just to come on in, and when they did, we would snatch moments to talk or visit between customers. In order to sit down and spend some time conversing with them, I had to do it after hours. The way things are now, the pharmacist can hardly do that.

Ours is one of the small number of reactive jobs in the United States. There is no planning, just reacting.

See also: Is community pharmacy a dying profession?

Paid by the piece

We had to spend many years earning a degree in order to get a license to do this kind of work. Yet since the adoption of the professional fee, the pharmacist is not compensated for the quality of his work or for its good results.

He is paid on the basis of how many prescriptions he can turn out and how quickly he can do it - and the prices on those prescriptions are determined by someone besides the pharmacy involved.

See also: Been there, done that, got the message

"Prescription cards"

The insurance companies sell their plans to people or organizations or companies that then issue a card telling customers they are insured.

A large number of companies issue free "prescription cards" that are not insurance. These cards do not reimburse the pharmacy; they only suggest a total price that the pharmacy can charge for the drug involved. (In this instance, someone is controlling pharmacy business who is not remotely involved in pharmacy but has found a way that helps them sell something to the public.)

Each of these so-call prescription cards has a bank identification number (BIN). Usually the name of the insurance company is on the card, and most of the time the name of the PBM paying the bill is not.

The claim process

When you enter the BIN number and the name of the insurance company, and then submit the claim, it is quite often denied as not covered. You don’t know whether the patient is not covered or the drug involved is not covered, which requires a phone call. In the meantime, you have to contend with a “patient” who cannot understand why it is taking so long just to fill a prescription.

Calling the doctor

When a customer is denied a drug, it requires a phone call to the physician. Having made the call, you have to listen to “If this is an emergency, hang up and dial 911.”

Then you get a menu, which has been changed, so listen carefully to find the person you want to talk to.

After listening to all choices, when you can’t decide, you are told to dial 0 in order to talk to a person.

When the person comes on the phone and you tell them what you want, they will dial the extension of the person you need to talk to. Then you hear a message saying that the person who can help you is busy and cannot answer the phone right now, so please leave a message and they will call you back.

Then you have to explain to the “patient” why it is taking so long.

Billing

Another problem is that the particular switching company using that BIN number has many different companies using their system, and nowhere can you find the one that should be billed. This now involves a call to the company for more information as to how to bill the claim.

A call to the 800 number gets you to a menu system that you have to listen to, and quite often it is hard to decide which menu number you need to select. Even then, a computer tries to talk to you; you are required to answer its questions and then the computer does not understand what you are saying.

Then you have to wait to talk to a person, because all the representatives are busy, “but your call is important to us, so please be patient.”

Most of the time, if you are not by yourself, your tech handles this situation, thank goodness, but he or she may be on the phone for many minutes just trying to get the claim to go through - a claim that only pays you $2 or so.

Costs

By the time the claim goes through, the drugstore has paid the pharmacist or the tech more than it will receive in compensation for the prescription. At the same time, customers have backed up, because only one pharmacist and one tech are available to do the job.

In addition to this loss of revenue, the switching system has charged the drugstore a fee for every time the computer sends it a claim, despite the fact that the claim didn’t go through. This fee is assessed by the company that reimburses the drugstore, and it cuts down even more on the markup of $2 or so.

The fact that the cost of the drug dispensed is $300 or so, less the switching charges, means that there is hidden loss of revenue.

Under the system being used by the PBMs, there is no way the pharmacist can check to see whether he is actually receiving the proper amount for each prescription he dispenses.

Audits

Then the insurance representatives or PBMs can come in and demand to audit certain charges submitted to them. The pharmacist or tech has to go back and pull each prescription being questioned and then spend time with the agent going over the circumstances.

Often there is a clerical error of some sort that the insurance company seizes on, and if there is a certain percentage of these errors, they then charge the drugstore retroactively for claims billed by this same percentage, for all claims submitted.

Retroactive prescriber costs

The state of Georgia, where I live, has a law requiring that if a prescription was written by a nurse practitioner (NP) or physician assistant (PA), the filled prescription must include the name of the physician under whom the PA or NP works.

Since the issuance of NPI (National Provider Identifier) numbers, the PBMs now require that all prescriptions be submitted using the NPI of whoever writes the prescription. This in turn allows NPs and PAs unfettered prescribing authority; they have to answer to no one except the insurance company. (NPs and PAs stepped up to the plate and accepted responsibility. They make decisions, charge for their decisions, and get paid for them. Pharmacists should have the same power. NPs and PAs are prescribing based on whatever the sales representatives tell them about the drugs involved. Pharmacists are a great deal more knowledgeable, to say the least.)

Some of these PAs were grandfathered in a few years back. The auditors can demand and take back all the charges for prescriptions that have been submitted using the supervising doctor’s name instead of the name of the NP or PA.

This can amount to many hundreds of dollars, even if they do not use the percentage criterion. They will deny the claims that include the error, and they will deduct the same from future payments to the store. If a claim for the drug in question has cost the drugstore hundreds of dollars, there is no way the pharmacy can go back and bill or charge the “patients” involved. It just has to absorb the loss.

Under these circumstances, there is no way that pharmacists can function as they did even in 1993.

These customers are now referred to as patients. Referring to them as patients implies that we are indeed professionals. All the professionals that I know of can make decisions about what, when, where, and how much they will charge. And then there are pharmacists.

Critical mass

The sale of my store and my subsequent employment by the chains has convinced me that the business of retail pharmacy has changed for the worse. I feel that the downward spiral is reaching a critical point for the retail drug business.

I now strongly recommend to pharmacy students that they go into research, sales, or specialty pharmacy or hospital pharmacy. However, the hospitals are now using graduate PharmDs doing their residencies and there is little room for new pharmacy employment there.

In the chains I worked for, there was very little time for the kind of interaction with individual customers that I had been accustomed to. And owing to the reduction of personnel in the pharmacy department, the techs are now doing a lot of what the pharmacist used to do. Most of the interaction with individuals is being done by techs.

In my opinion, the public has lost a very valuable source of health information. The pity is that people will never recognize the loss - probably because they never had to pay for that information. When you pay for something, you value it more than something that is free.

Truman Lastinger lives in Suwannee, Georgia. “Farming to Pharmacy,” his memoir of a lifetime in rural pharmacy,was published in December; it is available from Amazon and booklogix.com. Contact him at truros@att.net.