Viewpoints

Every pharmacist has his own horror stories that are seared into his brain. Here are some that stand out in my mind.

Though modest at its inception, the arc of growth of hospital pharmacy as a specialty area of practice has been virtually unprecedented in its impact and scope. Since August of 1942, when 162 stalwarts formed the American Society of Hospital Pharmacists in Denver, the role and scope of pharmacy practice in American hospitals have evolved into a central and critical element of patient care. Much of this growth is a function of the increasingly important and complex nature of drug therapy in hospital care and the overall growth of acute care in our healthcare delivery system.

The levels of drug use and expenditures have changed dramatically in the past 150 years. From 1857 to 1929, information on these trends was largely anecdotal in nature. It was only in 1929 that the Department of Commerce reported its first annual census of prescription drug distribution. This was followed, in 1932, by the first annual financial analysis of independent pharmacies, supported by Eli Lilly. Then in 1939, Drug Topics conducted its first annual prescription census, using a representative sample of drugstores from every state. What follows are some observations about trends in drug pricing, using the sources cited above as well as others.

In the "B.S. vs. Pharm.D." exchanges that have been featured in these pages over recent months, one facet of the issue has been overlooked. A sine qua non of pharmacy is attention to detail, yet these exchanges have, as is so often the case, fallen into using the abbreviation "B.S." to refer incorrectly to the bachelor of science in pharmacy degree.

Addressing the Cincinnati Dental Society back in 1883, dentist F. A. Hunter said, "Your patients will bless you; you become happy in consequence. They leave your office showering down upon you the highest encomiums, and never come back again." His subject: a new medicament to treat dental caries that was made up of a paste compounded from one pint of sorghum molasses mixed with one pound of English sparrow (yes, the bird) droppings! Small wonder the good doctor's patients never returned.

Independent and chain drugstore pharmacists have had to address a significant number of new issues during 2006, such as the launching of the Medicare Part D program and new demands on their professional time to assist customers. Perhaps the single most pressing issue facing R.Ph.s, however, is reimbursement. No other issue ignites more debate than how an insurance plan, government program, or patient reimburses pharmacists for their products/services. A growing number of pharmacies across the country are falling into debt, laying off workers, and facing closure due to inadequate reimbursement levels and slow payment. This article summarizes the reimbursement plight pharmacists find themselves in and reviews three attempts under way to help resolve this issue.

I know the jury is still out on this issue, but I firmly believe mercury exposure is to blame for Alzheimer's disease (AD). It's a subject I feel strongly about because my grandmother is a victim of this horrible condition. I can see firsthand the toll it takes on patients and their families. Even though my grandmother is still alive at 89 years old, she is often so disoriented and confused, it's almost as if she's not here.

Wal-Mart offers generics for $4.00. The Deficit Reduction Act cuts billions of dollars from pharmacies' Medicaid reimbursement for generic drugs. There's no doubt about it, generic margins are under siege today.

Roll up your sleeves and work to get a piece of what is predicted to be a $2 billion-plus market.

Decades ago, when there were no pharmacy benefit managers and pharmacists were fondly called Doc and sold only medication, pharmacists were respected for the tireless care they gave patients. Over the past 20 years, PBMs working for insurance companies and government agencies have gradually disconnected the care from health, treating pharmacy like a commodity business. Because of PBMs' steady ratcheting down of reimbursements, pharmacists now barely make 1% to 2% profit margins on dispensing prescriptions for private and government plans.

Medication safety has always been an important issue, but the Institute of Medicine's (IOM) recent report showing that preventable medication errors injure at least 1.5 million Americans annually illustrates the seriousness of this predicament. The authors of the IOM report, Preventing Medication Errors: The Quality Chasm Series, even acknowledge that this is likely a conservative assessment of drug safety gaps. The report noted that each year 530,000 preventable adverse drug events-injuries due to medication-affect outpatient Medicare patients, 380,000 to 450,000 occur in hospitals, and another 800,000 in long-term care facilities.

How many times have you gone to see your doctor and, while addressing your medical concerns, he is also on the phone with an insurance carrier trying to rectify a claim or at the receptionist's desk trying to collect payment from another patient? Although you probably have not witnessed this in a doctor's office, it is a common occurrence in community pharmacy.

When my career as a pharmacist began, I thought checking prescriptions was one of the most important tasks that pharmacists performed. Was I ever wrong! It is the most important task that we perform.

How would you like to receive free e-prescribing software? Or maybe a state-of-the-art medical records software package, complete with Internet connectivity and help desk support? Well, get ready, because some gifts may be coming your way! On Aug. 8, the Department of Health & Human Services, through its CMS and Office of Inspector General, published parallel final rules allowing certain healthcare groups to donate e-prescribing and electronic health record (EHR) technology to physicians, pharmacies, and others. And, better yet, the final rules are broader and more practical than those proposed back in October 2005.

I was jolted out of a sound sleep at around 2:00 A.M. The pain across my upper chest radiated from shoulder blade to shoulder blade. It was like nothing I had ever experienced before. Then the pain in my jaw began, like a box cutter slicing me from ear to ear. I could feel my heart beating faster. I felt nauseated and little lightheaded. But most of all, I felt an overwhelming sense of doom. I woke up my wife and told her what was happening. She took one look at me and said, "Pick your ER." The expression on her face confirmed what I already knew. I was having a heart attack.

It used to be that if pharmacists dispensed the right drug and right dose and gave the right directions to the right customer, we were free of liability. Thanks to the Omnibus Budget Reconciliation Act (OBRA), however, this is no longer the case. As a result of the OBRA counseling provisions, our profession has succeeded in tremendously increasing the risk of liability for frontline pharmacists. We now have to contend with aggressive lawyers who charge us with these three words: failure to warn.

The United States will spend more than $2 trillion on health care this year, which is more than enough to pay for comprehensive health care for everyone. That includes $200 billion (10%) on prescription drugs. Yet we will continue to see adverse health outcomes, including death, because millions are finding that health care is simply unaffordable. It is a national disgrace that people will die merely because they could not afford to purchase their prescriptions and other essential care, even though we are spending enough to provide for them.

As a missionary and pharmacist, I have spent many years providing pharmacy care in developing countries all over the world. For instance, I have served in Honduras, Mongolia, Kenya, and most recently in Tanzania. In Tanzania, I served for six years, from 1998 to 2004, as the director of pharmacy and as administrator of 85 Tanzanian employees in Kigoma Baptist Hospital, a 45-bed medical/surgical hospital with an active outpatient clinic. This article will cover the last year I spent there.

There has been extensive publicity about the possibility of an influenza pandemic, and this is a valid concern that requires high-priority attention. However, there is an existing pandemic that is apparently sufficiently acceptable that the attention to addressing it pales in comparison to the magnitude of the problem. This pandemic is, of course, smoking and the deaths of more than 440,000 Americans each year as a result of smoking-related illnesses.

There has been extensive publicity about the possibility of an influenza pandemic, and this is a valid concern that requires high-priority attention. However, there is an existing pandemic that is apparently sufficiently acceptable that the attention to addressing it pales in comparison to the magnitude of the problem. This pandemic is, of course, smoking and the deaths of more than 440,000 Americans each year as a result of smoking-related illnesses.

Local pharmacies have a special place in American society. Neighborhood pharmacists provide expert medical advice and often inexpensive prescription drugs, and they add to a greater sense of community in residential areas. But, in recent years, the neighborhood drugstore has come under increasing attack by national pharmacy chains, which have gobbled up market share in many areas across the country.

Treating HIV patients has always been a passion of mine. At ourpharmacy in the Bronx, N.Y., we've been able to achieve 85% to 90%monthly refill rates on the HIV patients we treat. With thisexperience under our belts, I wanted to apply the techniques I havegained to HIV patients in other countries as well. This was whatbrought me to Rwanda last year.

It's one of the things I've always dreamed of doing and Iaccomplished it last October, two months before I turned 60. As anadmitted adventure travel junkie, I reached the summit of MountKilimanjaro in Africa, the world's highest freestanding mountain.

The handwriting is on the wall. With pharmacy being reimbursed at alow and slow rate under Medicare Part D and severe cutbacksexpected in the payment for generic drugs under Medicaid, communitypharmacy will need a new business paradigm in order to survive andgrow into the 21st century.

Technician-only CEs bore us, and the topics are rudimentary andrepetitive.

Since 1998, the Food & Drug Administration has had theregulatory authority to require pharmacies to distribute MedicationGuides to patients getting certain high-risk drugs. MedGuides,which provide written information to patients on their Rxs, areprepared by drug manufacturers and approved by the FDA. To date,the FDA lists more than 75 drugs on its Web site that require thedistribution of a MedGuide from a community pharmacy or uponhospital discharge. They include antidepressants, nonsteroidalanti-inflammatory drugs (NSAIDs), and others. Manufacturers ofthese high-risk drugs are responsible for ensuring that asufficient number of MedGuides are available in pharmacies.

Two married pharmacists working for one of the largest PBMs,Caremark, filed a qui tam lawsuit in 2004 against their employer.They alleged Caremark had defrauded a Florida health plan forretired state workers by switching Rxs to higher-priced drugswithout permission and failing to give the health plan credit fordrugs that were returned unopened by customers.

It's well known that many people are skeptical about the value ofhomeopathy. In fact, homeopathy is a medical science with more than200 years of documented clinical efficacy. Homeopathic remedieshave to go through rigorous regulatory review before they can makeit to market. Much of the lay public equates vitamins and herbalsupplements with homeopathy. Actually, the two categories are quitedistinct in both their legal status and therapeutic modalities.

Having worked as pharmacists at a long-term acute care hospital, we know that the concept of LTACH is widely misunderstood. Long-term acute care hospitals are not skilled-nursing facilities, acute rehab institutions, or short-term acute care hospitals. LTACHs offer different services from those of the other facilities, and clinical pharmacists who practice at LTACHs are required to have a high level of clinical and critical care skills.

It is a familiar scene in America's pharmacies—a parent carrying a sick child who is screaming his head off. To get them out of the pharmacy as quickly as possible, we zip into high gear and mix that amoxicillin up at a pace like no other. As a mother, I feel the pain of the parent and child. The reality is that many local pharmacies I have encountered are missing one crucial element, something so sought after by parents to give them peace of mind that you would think every pharmacy in the universe would be equipped with it. No, I'm not talking about a fully stocked liquor cabinet, but close! The answer is quite simple: a children's play area.