america’s OCTOBER 2010

Published by the National Community Pharmacists Association PHARMACISTTHE VOICE OF THE COMMUNITY PHARMACIST Five Fine Philly Pharmacies

PROfit Pearls • Live Oak Pharmacy • Giving Students A Shot •

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PHARMACISTTHE VOICE OF THE COMMUNITY PHARMACIST CONTENTS

Features From the Cover 14 Five Fine Philly Pharmacies by Bruce Kneeland Feeling the love in the City of Brotherly Love.

Special Section: Profit Pearls 24 Strong and Steady Wins the Race by Andrew M. Helm ‘Doing what we do best’ a wise decision for Owl Pharmacy.

30 Rooted in Community Pharmacy by Chris Linville Live Oak Pharmacy grows deep in the heart of Texas.

40 Giving Students a Shot by Tracy M. Hagemann, PharmD; Joshua R. Sheffield, PharmD; and Bethany W. Ibach By working together students and preceptors boost vaccination rates, benefitting town and gown.

46 Enhancing Your Fiscal Fitness by Steve LeFever There are seven steps to business success—learn them here. Departments 2224 4 Up Front by Joseph H. Harmison, PD Isn’t it always good news/bad news? America’s Pharmacist Volume 132, No. 10 (ISSN 1093-5401, USPS 535- 410) is published monthly by the National Community Pharmacists As- Newswire sociation; 100 Daingerfield Road, Alexandria, VA 22314. © 2010 NCPA®. 6 All rights reserved. Keystone GPO adds NCPA membership as benefit. Postmaster—Send address changes to: America’s Pharmacist, Circulation 8 The Audit Advisor Dept., 100 Daingerfield Road, Alexandria, VA 22314; 703-683-8200; info@ Is #30 with two refills the same as #90 with ncpanet.org. Periodical postage paid at Alexandria, VA, and other mailing offices. Printed in the USA. zero refills or is it an audit risk? For membership information, go to [email protected]. For other 10 Inside Third Party information go to www.ncpanet.org. eye on PBMs

2 america’s Pharmacist | October 2010 www.americaspharmacist.net Cover: Philadelphia is the site of NCPA’s 112th Annual Convention and Trade Exposition. With that in mind, Bruce Kneeland visited five Philadelphia pharmacies and in this issue he describes how they em- body the spirit of independence.

54 112th Annual Convention and Trade Exposition Sponsors, exhibitors, and corporate members.

65 Continuing Education by Stacey R. Schneider, PharmD Medication therapy management: an evolution of change.

82 Pharmacy Marketing by Dan Benamoz, RPh The five fundamental principles of success.

86 Rx Technology by Bill G. Felkey The survey says: pharmacists want MTM integration.

90 Pharmacy Management by Andy Oaks Pharmacy ownership—open brand new, or purchase? (Part II) 95 Reader Resources 30 NCPA activities and our advertisers.

96 Notes From Capitol Hill Letters to the Editor—If you would like to comment on by Michael F. Conlan an article, e-mail NCPA at info.ncpanet.org. Put AP in the sub- Doing your part in the 2010 midterm ject line and include your phone number. Your letter may be congressional elections. posted on the NCPA Web site and edited for length and clarity.

Executive Vice President and CEO Douglas Hoey (acting) Senior Director, Creative Enjua M. Claude Associate Director, Design Robert E. Lewis NCPA Officers Senior Designer Sarah S. Diab President Joseph H. Harmison President-Elect Robert Greenwood Director, Sales & Marketing Nina Dadgar, [email protected] Secretary-Treasurer DeAnn Mullins Account Manager Robert Reed, [email protected] First Vice President David Smith Director, Membership Colleen Agan, [email protected] Second Vice President Bill Osborn Third Vice President Brian Caswell Fourth Vice President Michele Belcher Fifth Vice President Hugh Chancy The National Community Pharmacists Association (NCPA®) represents America’s community phar- Executive Committee macists, including the owners of more than 22,700 Chairman Lonny Wilson independent community pharmacies, pharmacy franchises, and chains. Committee Members Donnie Calhoun, John Sherrer, Bradley Arthur, Together they represent an $88 billion health care marketplace, employ Mark Riley, Keith Hodges more than 65,000 pharmacists, and dispense some 40 percent of all Magazine Staff retail prescriptions. Visit the NCPA website at www.ncpanet.org. Editor and VP, Publications Michael F. Conlan, [email protected] Managing Editor Chris Linville America’s Pharmacist annual subscription rates: $50 domestic; $70 for- Contributing Writers Jeffrey S. Baird, Bill G. Felkey, Mark Jacobs, eign; and $15 NCPA members, deducted from annual dues. Andy Oaks, Bruce Kneeland Proofreader Lin Jorgensen Ask Your Family Pharmacist®

www.americaspharmacist.net October 2010 | america’s Pharmacist 3 Up front

Isn’t It Always Good News/Bad News?

This is my last report to to the Aetna agreement. First is the use of NCPA members as president of our sensitive, private medical information for crass wonderful organization. I was going marketing pitches. Second is the imposition of to muse about what I’d learned the the ironically named “Maintenance Choice” pro- past year and what I hoped we could gram, which can force patients into CVS retail accomplish in the future, but events or Caremark mail order. Both problems have have a way of overtaking plans. So the potential to plague additional patients as a my musings will be in my convention result of this agreement. speech and in the January issue of America’s Pharmacist. the cries of protest against compromised in the meantime, I feel I must discuss some recent care and unreasonable restrictions on patient developments that fit into the good news/bad news cat- choice are likely to only grow louder and more egory. Because of my nature, I’ll start with the good. frequent with this agreement. Regrettably, Our prescription drug takeback program, “Dispose Aetna customers and patients can anticipate My Meds,” has been a great success. Congratulations to a barrage of misleading sales pitches and the more than 1,000 pharmacies in 47 states, and also complex schemes intended to camouflage CVS congratulations to our partner, Sharps Compliance, Inc., Caremark’s history of overpromising and under of Houston. Those pharmacies are voluntarily providing delivering on pharmacy savings. a valuable community service to help keep prescription the Federal Trade Commission and at least drugs out of our water and to limit the potential for abuse 24 states and municipalities are investigating of these medications. CVS Caremark regarding the many anticompeti- since we launched the first phase of our program tive, anticonsumer complaints raised by pa- during the 40th anniversary of Earth Week, April 17–24, tients, members of Congress, and independent participating pharmacies have collected and safely dis- community pharmacists. NCPA will continue to posed of four tons of unused prescription drugs. That’s work to support these and other investigations phenomenal. Stay tuned for Phase II. in the hopes that regulators will see the need to now I must turn to the bad news or, perhaps more implement meaningful changes to protect the accurately, unsettling and uncertain developments. In patient’s choice of pharmacy, and to restore late July, CVS Caremark announced that it had signed a meaningful pharmacy competition.… 12-year “strategic agreement” with Aetna and would be providing pharmacy benefits to the insurance giant’s 9.7 million covered lives. aetna said there would be no changes for pharma- cies through the end of the year and “in most instances” Joseph H. Harmison, PD no rate changes before then. No financial details were NCPA President 2009–10 disclosed. two criticisms lodged against CVS Caremark since the 2007 merger would appear to be particularly relevant

4 america’s Pharmacist | October 2010 www.americaspharmacist.net Newswire

Keystone GPO Adds NCPA Membership as Benefit

The Keystone Pharmacy efforts that affect them pharmacies and their stores to NCPA member- Purchasing Alliance is daily,” said Keystone CEO patients makes it a perfect ship. We look forward including NCPA mem- Mel Brodsky, RPh. “We fit for NCPA membership,” to an active partnership bership as a benefit to must remain diligent in our said NCPA Acting Ex- going forward.” its members. “We feel a efforts to ensure that our ecutive Vice President and the Keystone Phar- well-informed pharmacist patients receive the best CEO Douglas Hoey, RPh. macy Purchasing Alliance, owner can better adapt to pharmaceutical care that “As Keystone is a long- Inc. is a group purchasing the almost daily changes in they all deserve at their local time supporter of NCPA organization formed in our profession and also be independent pharmacy.” programs and advocacy 1996 in Philadelphia. For better informed to take part “Keystone’s dedi- efforts, we are excited to additional information, visit in legislative advocacy cation to independent now formally welcome its www.kpparx.com.

tell you the medication Adherence—It Only Takes a Minute is for? • How often are you tak- In the September issue of sophisticated technolo- having a dialogue with ing this medication? America’s Pharmacist, we gies for refill reminders, your patients at the counter • How were you told to examined the importance including automated phone about their health can make take this medication of first-fill counseling. calls. Could you imagine all the difference. Let them (and what do you do if Here’s a startling statistic receiving a prerecorded call know you’re not there sim- you miss a dose)? to back that up: Most from a nameless, faceless ply as an extension of the • What were you told patients forget up to 80 electronic voice telling you prescriber to tell them what to expect from the percent of what their phy- a prescription you never or- to do. Instead, you’re avail- medication (side ef- sician tells them as soon dered is ready for pick-up? able as a trusted resource fects, improvement of as they leave the office, This is where com- with genuine interest in symptoms, etc.)? and nearly 50 percent of munity pharmacists thrive, their well-being. By engag- • What have you experi- what they do remember is by taking care of patients ing your patients in such enced so far? recalled incorrectly. with high-touch service. To conversations, you will em- While often it takes borrow a mantra from Fritz power them to take charge Tell your patients, “I’m hearing the same message McGinnis (whom you’ll of their own health. The on your team. If I have several times for something read about later on in this following are some simple to sound like a broken to sink in, the source can issue, starting on page 24), questions you can ask your record for you to stay on make all the difference. “Do what we do best, and patients to gauge how much your medications, I will.” In an attempt to demon- do it better than anybody (and well) they understand Something tells us they’d strate their commitment else.” It doesn’t have to be their therapy, whether it’s prefer the sound of your to adherence, several chain in the form of an in-depth the first or fifteenth fill: voice to an automated pharmacies have rolled out counseling session; simply • What did your doctor message any day.

6 america’s Pharmacist | October 2010 www.americaspharmacist.net THE AUDIT ADVISOR NCPA Seeks to Block New Paperwork Rule Is #30 With Two Refills the Same as #90 With Zero NCPA has signed on to a letter to Sen. Refills or is it an audit risk? Mike Johanns (R-Neb.) supporting his S. 3578, a companion bill to H.R. Q: Many pharmacies want to know whether a prescription written for a 30- day supply with two refills is interchangeable with a 90-day supply with zero 5141, sponsored by Rep. Dan Lun- refills, and whether filling it that way puts them at risk for an audit. gren (R-Calif.), which would repeal paperwork-creating Section 9006 of A: These two are not interchangeable, and making a change like this to a pre- the new health care law. This section scription without any documentation is an audit risk. Any time a prescription mandates that beginning in 2012 all is changed, the change must be verified with the prescriber and documented. companies will have to issue 1099 IRS Your state law may not require a phone call in this instance, but a third-party payer may. When adding a clinical note to the original prescription with any tax forms not just to contract work- changes, you need to clearly document whom you called, why you called them ers, but to any individual or corpora- (patient request?), what you were told, the pharmacist’s initials, and the date. tion from which they buy more than PAAS suggests obtaining a new telephone order for authorized changes $600 in goods or services in a tax year. and processing it as a new prescription with its own prescription number. Currently, 1099s are just used Without any documentation or a new prescription order, an auditor will to document income for individual recoup the extra 60-day supply you dispensed that was not authorized. The potential pharmacy savings is $100–$500 or greater. workers for services other than wages and salaries, and are not used for corporations or for the purchasing of By Mark Jacobs, RPh, PAAS National, the Pharmacy Audit Assistance Service. goods. NCPA objects to this new red For more information, call 888-870-7227. tape for small businesses. CMS to Crack Down on 2007, even though CMS did not Invalid Prescriber IDs strongly put into effect an National Independent Provider Identifier requirement until Pharmacy Invalid prescriber identifiers on a quarter of the way through 2007. Today Medicare claims are a continu- NCPA relayed our members’ con- • A $93.1 billion market- ing concern at the Department of cerns to staff of the Senate Home- place Health and Human Services. land Security and Governmental • $86.8 billion in prescription sales a recent report by the HHS Affairs Committee, including the • Average independent pharmacy Office of Inspector General found fact that one of the largest Part D dispensing: 64,635 prescriptions • Average independent’s total sales: that in 2007, $1.2 billion in Medicare plans did not start requesting pro- $4.026 million Part D prescription drug claims, or vider NPI’s until July 18, 2008, and • Average independent’s prescrip- 18 million claims, contained 527,749 currently, one of the largest Part D tion sales: $3.756 million invalid prescription identifiers. The plans’ provider services manual Source: 2010 NCPA Digest, sponsored OIG recommended and the Centers still allows for Drug Enforcement by Cardinal Health (preliminary fig- for Medicare & Medicaid Services Administration and/or state license ures). Final figures will be announced agreed to conduct periodic reviews numbers as a substitute when the at the NCPA annual convention. to ensure the validity of prescriber NPI is not available. identifiers used on prescription drug nevertheless, it remains vital event (PDE) records. that NCPA members make every ncPA has concerns that the effort to include valid NPI numbers OIG focused on invalid prescriber or physician identifier numbers on identifiers for PDE records from all Part D claims.… inside Third Party

ye on PBMs we fill, if all this information is not written on the face of Editor’s note: Norman W. Davis of Medical Park the hard-copy prescription, it is subject to a full recoup- Pharmacy in Phenix City, Ala., recently wrote U.S. ment by Prime with no allowance to remedy or appeal. Sen. Jeff Sessions (R-Ala.) about a problem not There is no information on whether this affects all new unique to their state: frustrating and unreasonable prescriptions after the implementation date [July 1, PBM audits. Following are excerpts, printed with his 2010] or if refill prescriptions are included, which would Epermission. The entire letter is on NCPA’s blog, The Dose be a real problem. (ncpanet.wordpress.com). “This is absolutely harassment and recoups [rev- enue stream] at whim. If, after a couple of years, with Dinged by PBMs All the Time the volume of these prescriptions that we do, an audit “Just recently, Blue Cross/Blue Shield of Alabama sold is done with a recoupment, stores could be forced out its prescription drug benefit plans to a company called of business—not for improperly filling a prescription Prime Therapeutics, a pharmacy benefit manager but for filling, in good faith, a prescription for a particu- (PBM) with which we have had very little experience. lar need, for a particular person, for a product which Most of the claims for prescriptions are still transmitted we have paid for with our own money, just to have in the same manner as before, with very little change. someone come in and, for lack of a written number “We recently received notice of the audit policy of [which has already been furnished], steal all proceeds Prime. Even though the doctor’s DEA number, National that, in reality, have very little profit. Provider Identifier [NPI] number, the origin of the “This is in addition to the well-documented prescription [written, electronic, faxed, phoned-in], and breach of the firewall that was supposed to be all other pertinent data are readily retrievable from our erected with the idiotic approval of the CVS Caremark computers, and are transmitted with each prescription merger. Our patients are continually contacted by CVS concerning the data that we have had to transmit to Caremark. They also have incentivized sponsors into forcing their employees/retirees into using mail order or only a CVS in our community, even though we have contracts in place. “Additionally, Express Scripts has enticed their sponsors to preenroll their employees into mail order, employing passive acceptance whereby, in order to continue the trust relationship with the pharmacist of their own choosing, they have to physically take action themselves to disenroll from something that they never enrolled in. This is insanity. “We get dinged by all of the PBMs for all kinds of fees: fees to transmit claims over toll-free phone lines, formulary fees, nonformulary fees, maintenance (?) fees, and administrative (?) fees. These nickels and dimes cost me over $8,000 last year, and for NOTHING. “Senator Sessions, we need help and we need it soon. We independent pharmacists need an antitrust exemption so we can pool our numbers and collec- tively negotiate contracts similar to our competitors. We have the numbers; we just need the ability. We can already join together in order to negotiate purchases…. “We need to be able to negotiate fair, transparent contracts. We need to be viable in our communities. We need your help. Thanks for your time.”…

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Five Fine Philly Pharmacies

Feeling the love In anticipation of NCPA’s in the City of 112th Annual Conference and Trade Exposition being Brotherly Love held in Philadelphia this year, America’s Pharmacist asked me to visit a few successful pharmacies in Philadelphia. The goal was to document some of the things they are By Bruce Kneeland doing to thrive in a rapidly changing industry. With the help of several local wholesaler representatives who Photography by Bruce Kneeland pointed me to some great stores, I set out one bright and sunny day in June to visit five pharmacy owners who are

www.americaspharmacist.net October 2010 | america’s Pharmacist 15 In case you missed out on our other articles featuring 30 pharmacies, ! log on to www.americaspharmacist.net, and catch up!

D C

e a

b

A Philadelphia Pharmacy

b Elwyn Pharmacy

c Rapoport Pharmacy

d Willits Road Pharmacy

e Falls Pharmacy “makin’ it happen” in the City of Brotherly Love. I hope their stories help you in tackling some of the challenges you might face in your own business. three things happen: Prescriptions get filled accurately, prescriptions get filled fast, and—this is central to Fast, Friendly, and Festive Ost’s philosophy—every customer gets individualized Philadelphia Pharmacy is an institution in the attention. That means calling people by name, treating northernmost section of central city Philadelphia. Owner them with respect, explaining the purpose of each Richard Ost, RPh, has found a number of ways to tie medication, and making sure the patient’s entire regimen into the community. The most visible thing he has done is reviewed. If lapses are occurring on any medication, the is sponsor a large mural that covers the entire exterior patient (or caregiver) gets counseled on the benefits of of his store. Building art is a fairly common part of the taking all medications properly. Philadelphia culture, and this colorful mural speaks to the One of the most amazing things Ost has done ethnic roots of the area and is a major landmark. is organize a process that allows his technicians to But the real magic in Philadelphia Pharmacy takes make hundreds of outbound refill reminder calls place on the inside, where attention to detail and a well- each week. To ensure that patients are served quickly, structured workflow allow this pharmacy to fill several Ost employs a few more pharmacy technicians than hundred prescriptions quickly and accurately each day— would be customary in other pharmacies. This means without the aid of robot. Ost is a stickler for detail and that there are times when all that talented labor is not has organized his pharmacy staff into layers, each with filling prescriptions. So, being the creative entrepreneur specific duties and responsibilities. that he is, Ost has formalized a process for having his The core purpose of this structure is to make sure technicians, who know each patient well, make calls and

16 america’s Pharmacist | October 2010 www.americaspharmacist.net miles from his retail pharmacy. In the specialty business Karalis and his team provide a wide variety of injectable medications to patients nationwide. And it is in the area of specialty pharmacy that Karalis is making his mark. Karalis says, “I am building my practice on three legs: traditional retail pharmacy, specialty pharmacy, and my growing LTC and assisted living area.” But to call his retail pharmacy traditional would be an understatement. The location features customary dispensing, compounding, and a large durable medical equipment/home medical equipment section. To top it all off, he is refurbishing the outside with a special new “wrap” that has turned inquire as to why medications have not been picked up this once staid retail location into a truly amazing topic or requested to be refilled. During the call, technicians of conversation in the community. Using technology work with patients to understand the problem —and developed for advertising on buses, Karalis has found an help overcome any obstacles—by contacting doctors, effective and affordable way to update and modernize the calling insurance companies, and providing any other look and feel of his business, and turn his storefront into a services they can to make sure their patients come in powerful ad vehicle. and get the medications they need. On a final note, Ost has completely plugged into the social fabric of the large Latino population in the community. Many of his staff members speak Spanish fluently, and others do so with at least the ability to communicate pleasantries with their customers. And his front end has been carefully merchandized with a variety of household chemical and kitchen supplies, and other convenience items popular in the community.

Entrepreneur Extraordinaire Nick Karalis, RPh, purchased Elwyn Pharmacy in 2003. Located in Glen Mills, a close-in suburb of Philadelphia, the pharmacy is well-established in the community. The previous owner had long ago branched out and serviced a number of nursing homes and assisted living facilities. Since purchasing the retail pharmacy, Karalis moved the long-term care and assisted living operations to a closed door facility, and then set out to grow the business in truly amazing ways. Today Karalis is the proud owner of not only Elwyn Pharmacy but Elwyn Specialty Pharmacy, a closed door facility that occupies the entire second floor of a commercial building in an industrial complex about five

www.americaspharmacist.net October 2010 | america’s Pharmacist 17 My visit in June was to the specialty pharmacy site, and it is truly a remarkable facility. Occupying about 8,000 square feet of second floor space, it includes a number of offices, supports a call center, has administrative and clinical office space, and even includes a nicely furnished conference room. But the real action is on the pharmacy floor, which includes conveyer belts for moving product from one work station to another, an AutoMed unit dose system, and bar code scanning and document imaging technology, all connected to the outside world by a T1 line. And to make sure this all works together to support his customers, he and his team have developed an electronic medical administration record (eMAR) software package that they have named Accuflow, which they intend to market to other like- minded pharmacies in the near future. Karalis has become an expert in networking and The store displays a collection of canes, wheel chairs, relationship building. He currently sits on the board of and walkers, along with ostomy, surgical hose, and other the Community Specialty Pharmacy Network, which products. And he even provides oxygen. serves about 150 member pharmacies, and also serves on Moskowitz is an outgoing guy. One way he builds the Cardinal Health National Retail Advisory Board. Both his DME business is to call on doctors and discharge of these groups provide Karalis with access to important planners. He says one of the most successful things he people and information that helps him acquire the does is visit chain pharmacies and explain the products products he needs to build his specialty pharmacy. and services he provides. He says they seem more than happy to suggest Rapoport Pharmacy to their patients for Mr. Moskowitz’s Neighborhood a product they are seeking. The Rapoport store manager Jeff Moskowitz, RPh, grew up in the 1960s in North Philly, is also a handyman and is often able to install bathroom just a block or so from the corner drugstore. When he was safety equipment. Of course, he says, he carries extra 14, he took his first job working in Rapoport Pharmacy, liability insurance to cover this service. and he has worked in this 1,300 square-foot location ever Moskowitz has arranged to service a number of since, buying it from the original owner in 1989. assisted living homes with compliance packaging. He says Today, Rapoport Pharmacy is a neighborhood even a few adult family caregivers find his compliance institution. It services the community with a number of packaging useful. traditional drugstore services, such as personal charge He is quick to point out that surviving in this day accounts and free delivery—a service so in demand that and age is not easy. Many of his long-time patients are the pharmacy keeps two delivery cars busy making 30–50 also career union members and, as they retire, he finds deliveries daily. many of them being forced, or at least assuming they are Moskowitz has moved aggressively into the durable being forced, to use mail order. He says he sees mail order medical equipment/home medical equipment market. and its uncompetitive practices as one of the biggest He has completed the durable medical equipment, threats to his business; he continually struggles to help prosthetics, orthotics, and supplies (DMEPOS) customers understand the value of the extra care and accreditation process and accepts Medicare assignment. service he provides.

18 america’s Pharmacist | October 2010 www.americaspharmacist.net To combat this negative trend, Moskowitz says that the best thing going for him is his relationship with the physicians in his neighborhood. He calls on them routinely, explains his unique services, provides them with flu and other vaccines, and even fills and delivers prescriptions for personnel who work in their offices. The thing that keeps him excited about pharmacy, he says, is the ability it gives him to work face-to-face with patients and get to know them and their families and help them feel better. And indeed, doing this has made Rapoport Pharmacy an integral part of this north Philly neighborhood. robot makes his pharmacy a much more pleasant place to work and allows his staff to provide an extra measure Nice, New, and Nifty of personal attention to their patrons. Another key to Without question, one of the most effective success the pharmacy’s success is the networking it does in the formulas I have noticed over the past few years is the community, which has resulted in winning the rights to power of carefully organized pharmacy partnerships. By serve a number of assisted living facilities. Cavanaugh pulling a few like-minded owners together into formal rounds out the professional side of his practice with partnerships, there is no question that synergy can be a fully equipped compounding lab (still located on created. Such is the case with Jim Reginelli, RPh, and the second floor of his former retail location); he Mike Cavanaugh, RPh, owners of the brand-spanking- aggressively promotes his custom prescription services new Willits Road Pharmacy. To be clear, the actual to patients and prescribers. business itself is many years old and a community To help pull traffic into the store (which competes institution. But the pharmacy I saw had just moved a few with several independents as well as Rite Aid, Walgreens, doors down to a newly refurbished and larger facility in CVS, a supermarket, and big box stores), Willits the same strip center. distributes several Promotions Unlimited circulars each Cavanaugh is the day-to-day manager of this location year. Cavanaugh says that, while this takes a fair amount but, in concert with Reginelli and a handful of others, of work, the circulars bring people to the store, where shares ownership in six Philadelphia pharmacies. They the staff can convince them to become customers by combine their purchasing power to negotiate for better talking with them and giving them useful information. prices, terms, and services from their suppliers. But more Cavanaugh says that one point they try to make with all importantly, they share ideas and inspire one another. their patients is this: Whether they are on some sort of The first thing I noticed when walking into the store financial aid or have a company-sponsored prescription was how clean it was. Granted, they had only been in plan, the co-pay for prescriptions is the same at Willits this new location a few weeks, but the floors were still Road Pharmacy as at one of the chains. immaculate, the lighting was bright, and the shelves were “Once we get people to understand that, they turn clean, well-stocked, and featured a variety of point-of- into prescription customers,” Cavanaugh says. purchase signage. All are common elements of the super- successful pharmacies I visit. Never Look Back As part of the move to the new location, the Beth Dewan, RPh, and Genevieve Levans, RPh/MBA, pharmacy had just installed a Parata Max, replacing opened Falls Pharmacy on the extreme western edge of an earlier-version robot. According to Cavanaugh, the Philadelphia about 10 years ago. Dewan, who grew up

20 america’s Pharmacist | October 2010 www.americaspharmacist.net Along with the traditional circular, Dewan and Levans use The HealthConnections flyer and say the product selection and health tips it features seems to be well received by their patients. They also have subscribed to the Drug-On-Card, a device that supports a prescription loyalty card program. It provides a wallet card with all patient prescriptions listed, allowing patients to show their physicians all of the medications they are taking. As with Philadelphia Pharmacy, Falls Pharmacy makes personal outbound compliance calls. Dewan says they call about 50 patients each week and that “our customers say they appreciate the reminders, and the vast majority of them come in and pick up their in this part of town, says she just “sort of knew” the area medication in the next day or two.” would support an independent pharmacy. Based on her The two owners have an outgoing and friendly gut feel, they started their pharmacy from scratch and style, and it shows up in their staff. They take great have never looked back. pride in wearing their Falls Pharmacy golf shirts and in After eight years in their original location, they providing personalized service. They are “plugged into” sensed the need to expand into a larger facility and offer the community and have become a genuine resource for a few more traditional items. So, in December 2009, people living in the neighborhood. they moved a few blocks south and set up shop in a new building with a great storefront and enhanced visibility on Where to Start? Ridge Ave., one of the city’s major thoroughfares. Two of these five fine pharmacies recently moved In the new location, the entire front of the store into a new location, close to their previous one, that features a large sign announcing the presence of Falls expanded and improved the curb appeal of their Pharmacy. To help bring people in, they run a number pharmacy. The other three of these super stores made of Promotions Unlimited sales each year. They also significant improvements to the exterior of their existing have an attractive selection of boxed and regular location, making it much more appealing. For all of candy bars, cold sodas, and other convenience foods. them, sprucing up the premises was a starting point Additional items include greeting cards and a variety of for greater community presence and growth. Perhaps household chemicals. there’s an idea here for your pharmacy’s to-do list of On a professional level, both Dewan and Levans improvements. provide a number of immunizations, including Zostavax. They get out and meet the doctors and health care professionals in the area; they are not shy about calling Bruce Kneeland is a contributing writer for America’s doctors with recommendations for medication changes Pharmacist and a veteran pharmacy industry con- or asking them to recommend their pharmacy for sultant specializing in helping small chain and inde- patients with special needs. They are active in working pendent pharmacies success. He lives in Royersford, Pa., and can with the University of the Sciences 6th year PharmD be reached at [email protected] students and use students to provide hands-on blood pressure monitoring and to write health-related articles for the neighborhood newspaper.

22 america’s Pharmacist | October 2010 www.americaspharmacist.net Bruno Budrovic Strong and Steady Wins the Race

24 america’s Pharmacist | October 2010 www.americaspharmacist.net profit pearls

“Profit Editor’s note: Pearls” is an occasional series of articles by pharmacy experts in various specialties, offering tips and advice for improving patient care and creating a healthier bottom line. This month focuses ‘Doing what we do on doing what you do best best’ a wise decision better than the competition. for Owl Pharmacy

By Andrew M. Helm

e’ve been hearing more about the impor- A primary tenet of his philosophy is to invest in his tanceW of adapting with the times—using new technolo- employees. McGinnis is surrounded by people who are gies, billing for new services, and finding niche markets both excellent at what they do and dedicated to being that can’t be filled by the big box chains. Not to down- his partner in making his business successful. Deliber- play those important messages, but sometimes we forget ately trusting his employees with enough responsibility to pay as much attention to the basics of who we are as and knowledge to keep them invested in the success of independents: the best in the business. A great example the business, along with taking the time to make them of this is Owl Pharmacy in Spokane, Wash. Owl Phar- feel appreciated for their contributions, keeps his entire macy customers can be characterized as long-time, loyal staff working as a team toward common goals. In other patrons who value the service, the meaningful rela- words, Owl Pharmacy is careful to make sure that the tionship with their pharmacist, and access to the most right people are on the bus. reliable and expert advice available without making an Next in the profitability philosophy is offering appointment regarding over-the-counter and prescrip- top-quality service. The close relationship that custom- tion medications. ers have with Owl Pharmacy is no accident. Pharmacy employees take pride in making every interaction a good A Philosophy to Stay in the Black experience. Employees invest the time to get to know Fritz McGinnis, owner of Owl Pharmacy, reminds their customers, know what is important to them, and us that expensive new technologies and new niche listen to what is happening in their lives. Patients will markets aren’t the only answers for staying viable in tell you that the pharmacist takes time to come speak a competitive market. In each of his four pharma- with them when they pick up a prescription—every cies he employs a basic philosophy. “Do what we do time. As we all know, that’s much easier said than done, best, and do it better than anybody else,” he says. It’s a but their dedication has been rewarded. Owl is known great philosophy, especially when it rises above being a for unmatched patient care, happy customers who are catchy motto and becomes a deliberate way of running fiercely loyal to their pharmacy, and a bottom line that a business every day. remains unwaveringly black.

www.americaspharmacist.net October 2010 | america’s Pharmacist 25 Kai Eis e l in

▲ Spokane River and the old flour mill as viewed from Canada Island in Spokane, Wash.

McGinnis can’t talk about his philosophy for stay- coming complacent as an owner and letting the business ing in the black without mentioning his main driver: run on autopilot, or sitting on laurels while the business cash flow. All of the other good business habits—solid becomes stagnant. So far, doing what the business does inventory selection, inventory turnover, increasing units best, and doing it better than anybody else, has turned per transaction, increasing amount of foot traffic and out to make cash flow king. time spent in the store—can be seen in the cash flow, which helps him know where and when to tweak his What About Innovation? operations. Knowing the mechanics and implications of Owl pharmacy is not opposed to innovation. McGin- business indicators is a must in this department, and the nis and his team are always on the lookout for new attention to detail will pay off in an understanding of services and ways to add to the value they have in the what really makes the pharmacy work. community. They offer basic immunizations, dia- Owl also stays competitive through its membership betes counseling, deliveries to assisted living homes, in a good buying group—a must for any independent and “brown bag” sessions, to name several services. these days. McGinnis warns about the dangers of be- Each has been deliberately added as an extension of

26 america’s Pharmacist | October 2010 www.americaspharmacist.net Background: George Diebold shannon helm 28 associations.local He pointsoutcan thattheseentities suchorganizations as NCPA, aswellinstate and McGinnis keeps uphismemberships inprofessional nis says. Beyond hismembership inabuyinggroup, I cangive to backgood andbe pharmacy,” McGin - to good hasbeen me,“Pharmacy for soIlook ways ‘Tend toOurProfession’ model, but for ithasbeen. Owl pharmacy decision inevery mayThis theright notbe quisition andmaintenance for asystem you don’t use. call. they time phone every And- there ac isnocost of his decision to have the aperson on theother end of such asaphone tree, McGinnis’s customers appreciate therewhen are benefits known to using technologies move. out tomentation hasturned asmart be Even itsresistance imple- tosome of technology knee-jerk maketerm. course updates will Owl asneeded, Of but analyzed for benefit, thenet andlong both theshort in choices.a menu of iscarefully Each new technology each receipt, patients through andnoIVRguidingOwl weather thelocal forecastthat prints on theback of able. No new robots for them, nopoint-of-sale system becomes anew technology systems time avail every - What have they notdone to isrush update technology online refills and quick-reference business information. way.its own It maintainsawebsite, which features thebusiness. to therest of that improves thebottom line, aslong asitconforms do. they everything It’s idea agood to any add service McGinnis’s philosophy at thebest being of primary america’s Owl Pharmacy hasalsoembraced technology, Pharmacy Owl in

Pharmacist

| October 2010 success. secrets toOwlPharmacy’s There arenodeepdark State UniversityCollegeofPharmacy. isa2011PharmDcandidateattheWashingtonAndrew M.Helm,BS, bottom line. profession asanindependent, ahealthy anddo itwith as welldowewe what do might best: inthe thebest be like look wait to they what pharmacy, see inour own are models and new practice on the way but, we while bypharmacy best. only offering thevery Innovation committed to upto living itsstatus asanindependent overvigilance thebusiness andtheprofession. It is deliberate andconsistenttion to thefundamentals with success. It’s anindependent paying atten pharmacy - There are secrets nodeep dark to Pharmacy’s Owl Strong andSteadyWinstheRace toneed tend to ourprofession.” come. McGinnis sums hesays, itupwellwhen “We apathfor successup themantleandchart inyears to models, there isanurgent forto need pharmacists take models,ing practice andrestructured reimbursement behalf. healthcare reform, In of thesetimes chang- committees action political (PACs) on his thatact habits, good his mouth iswith such asdonations to hisbusiness.health of And where heputs hismoney to thecontinued vital cannot, be will andtheseefforts advocate forinaway pharmacy thattheindividual the fundamentals paying attentionto independent pharmacy and theprofession. vigilance overthebusiness deliberate andconsistent It’s an www.americaspharmacist.net

with Rooted in Community Pharmacy

30 america’s Pharmacist | October 2010 www.americaspharmacist.net Rooted in As we move into Live Oak Pharmacy the second decade

grows deep in the of the 21st century,

Community heart of Texas a distinctly new wave of independent pharmacy own- ers seems to be emerging, putting their own spin on the traditional concept of the neighborhood drug By Chris Linville store. Of course, they aren’t abandoning bedrock Photography by Justin Wallace values such as friendly service, efficiency, commitment Pharmacy to patient care, and a strong community presence. But instead of having a soda fountain, they might have

www.americaspharmacist.net October 2010 | america’s Pharmacist 31 an herbal tea bar. And along with marketing through And as for the pharmacy name? Maitland says that conventional methods such as newspapers, radio, and came fairly easily. television, they are also engaged in social media such “There’s a lot of live oak [trees] in Austin, and Austin as Facebook and Twitter. is really big on supporting independent local business,” In Austin, Texas, Scot Maitland and Nathan D. he says. “It just kind of felt natural. We’re rooted in the Pope, PharmD, saw an opportunity to take the best of community. We’ve gotten a great response from our old-school pharmacy and give it a modern twist. Austin name and our logo. A lot of people think we’ve been here is the Texas capital city and the home of the University a lot longer than we have. So it’s nice to hear that we feel of Texas. Its 786,000 residents are an eclectic mix of familiar already.” university professors, students, politicians, musicians, Live Oak’s standing in the community was affirmed state employees, and high-tech, blue-collar, and white- in early September when it was named one of the city’s collar workers. The city also bills itself as the “The Live best new local businesses in an Austin Chronicle reader Music Capital of the World.” It seemed to be the ideal poll. The newspaper has been publishing “Austin’s Best environment for Live Oak Pharmacy, which opened in Of” for the past 21 years. April 2010. “Our tying for the win of ‘Best New Local Business’ “Nathan and I had been talking about opening up is really a reflection of the wonderful customers and a pharmacy for awhile now,” says Maitland, co-owner patients that we have at Live Oak Pharmacy” says Pope. and director of communications and education. “He’s “By receiving this honor we’re able to introduce more worked in the industry all through college and into his Austinites to our integrative approach to health and well- professional career. My background is in wellness and ness and offer them a choice.” nonprofit fundraising, so we kind of wanted to combine our two passions—helping people and providing service Sealing the Deal to people—and create our own pharmacy. Maitland and Pope put the ownership wheels in motion “We realized in downtown Austin there was definite- when they attended an NCPA ownership workshop in ly a lack of independent pharmacies, and our downtown Seattle, in August 2009. After listening to the business area was booming, and there was no one to provide and financial experts at the conference, and hearing [downtown businesses] with these services.” stories from others who had recently opened their own And for Live Oak to be successful, it had to first fol- pharmacies, they decided it was time. low one of the cardinal rules for business, Maitland says. “That kind of sealed the deal for us,” Maitland says. “It’s all about relationships, and cultivating those “We realized we were going to move forward and make relationships,” he says. “We want our pharmacy to be the this a reality. So we began the process of hiring architects, kind of place that you associate with a small town phar- consultants, and contractors, and looking into vendors, macy. We wanted a place to be comfortable to come visit, and choosing wholesalers, and all of that. The space that to say hello, to ask a couple of questions, and to catch up we rent is a mixed use space, so the whole first floor is with what’s going on in the neighborhood.” retail, and above us are apartments. So all that was up were the walls, but the walls weren’t even finished. They were just beams—there was no sheet rock. So we started completely from scratch.” Live Oak Pharmacy occupies a 2,200-square-foot space, with traditional and compounded prescriptions. It has two rooms for in-house consultations and about 500 square feet of retail. Maitland says Live Oak's goal is to grow to 90 compounded prescriptions and 350 standard prescriptions per week by the end of its first year in business. It hopes to reach $100,000 in monthly sales by the end of its first year. Similar to some other

32 america’s Pharmacist | October 2010 www.americaspharmacist.net them ready every month,” Maitland says. “They can either be delivered to their home or office via the mail, or we can have the vitamins ready in a bag so customers can just come by and pick them up and head out the door.” Live Oak also does veterinary compounding. “We’re really focusing right now on building up the veterinary business. We’re actually a pet-friendly pharmacy, so you can bring your dog to the store if you like.” The products in the retail section are carefully se- lected, Maitland says. “We wanted to have convenience items, but we didn’t want to be a convenience store,” he says. “We have 180 apartment units above us, and we try to think about what they might need on a day-to-day basis. We have a Pictured are (front): Marilyn Maitland (left) and Charmaine Pope. majority of the stuff that you would see in a traditional Back row (from left) are Scot Maitland, Nathan D. Pope, pharmacy but, for example, where there might be four and David Pope. brands of antacid [somewhere else], we have two. So we’ve kind of pared it down, not having a lot of options, newer pharmacies, Maitland says most of the OTC because we felt like we picked the best product out there, merchandise is on gondolas that sit in the middle of as we really vetted it. the retail area, but they’re mounted on wheels so they “From a vitamin and supplement standpoint, we can be rolled out of the way to create extra space. This only carry two lines of vitamins, and they are profession- arrangement allows the pharmacy to seat 20–25 people al- grade products. We have a huge selection of homeo- comfortably for presentations. pathic remedies, as well as herbs. You aren’t going to see “You want to take full advantage of that,” Maitland these things in a Walgreens or CVS, either.” says. “We try to think about how we can repurpose Maitland says that Live Oak seeks customer input on just about every single room in the store so we can get its product mix. maximum usage out of the square footage, so it isn’t just “We are real big into asking for feedback, and find- sitting there.” ing out what kinds of products they like to see on the The staff consists of three people—Maitland, Pope, shelves, because it’s their store,” he says. “We’re also and Christine Sumer, a certified pharmacy technician. working with other health care providers to see what Along with marketing and communications, Maitland is kinds of products they recommend to their patients that also a registered pharmacist technician trainee. they don’t carry, but we can have for them. We’re looking Aesthetically, the pharmacy has what Maitland de- to do a partnership with a nutritionist, so we can offer scribes as a “very modern look. It’s definitely very urban nutrition consultations in the store.” when you walk into it. We have polished concrete floors, As with any business located in a busy downtown and all of our shelving is all wood and custom built, so it area, Maitland says that he and Pope designed Live Oak has a really organic feel.” Pharmacy to make it as accessible as possible. Consultations are a prime focus for Live Oak. Top- “The store was customized and designed for a very ics range from hormone restoration therapy, adrenal fa- urban population,” Maitland says. “We have access to tigue, and vitamin wellness. On Fridays and Saturdays, more than 100 parking spots behind our store that are chair massages are available. (Maitland is a licensed all covered. We have two doors, so you can enter from massage therapist.) the street or from behind the garage. We did it that way “As part of the vitamin wellness consultations, our so that it’s easy to come in and come out. We lost some customers can also participate in a type of auto-shipment process for their vitamin supplements so that we can have Continued on page 38 ➥

34 america’s Pharmacist | October 2010 www.americaspharmacist.net “Emdeon Edit’s Market U&C reports have increased our gross margin by more than 2%.” Add to your bottom line with easier business analysis Dennis Holley opened Fireside Pharmacy more than 25 years ago with little more than a cash register and the help of one technician. Since then, the industry has changed quite a bit, sending independent pharmacies like his in search of innovative ways to increase efficiency and bottom lines. As a result, the Pensacola, Florida, pharmacy, aided by the latest technology and Emdeon’s pre/post editing service, has been able to reduce third-party claim submission errors and increase its gross margin percentage.

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© 2010 Emdeon Business Services LLC. All rights reserved. Live Oak Embraces NCPA Prescription Disposal Program

When Scot Maitland and Nathan Pope, PharmD, were prepar- Maitland says. “We’ll keep that tally going so we can encourage ing to open Live Oak Pharmacy in Austin, Texas, one of their people to really be involved in this. We’ve got a great response primary business objectives was to become an engaged com- from our local media. We had two interviews on the news. KUT munity citizen. When they heard about NCPA’s Prescription Dis- [the local NPR station operated by the University of Texas] came posal Program, it seemed to be a case of perfect timing, as they out to talk about it. At a block party [during Earth Day], KUT were already planning their own takeback program based on asked us to bring out the forms and tell people about it, because several successful ventures they had heard about in California. they want everyone in the neighborhood to know about it.” “It was something that we knew about and did build it into the To protect patient confidentiality, Live Oak uses black sharp- pharmacy when we started creating it, and knew that this was ies to cover the labels. Maitland says that there are only a few going to be a core part of our business,” Maitland says. “We just things they don’t take back, controlled substances being the felt like it was the right thing to do, and definitely felt like it was primary item. (They hope to eventually partner with local law another opportunity to create a relationship with our community.” enforcement to allow that at some point.) The Prescription Disposal Program that NCPA launched in “We also don’t take back personal care products [such as 2009 provided members with the tools to successfully design deodorants], but nobody’s tried to bring them in anyway,” he and market medication return programs, provided informa- says. “I’ve seen half-empty tubes of athlete’s foot cream, and tion about board of pharmacy regulations, and reinforced triple antibiotic cream.” Drug Enforcement Administration and other restrictions on the Maitland says the returns are about 75 percent prescription, return and transport of controlled substances without the direct and 75 percent OTC. With sharps items [such as needles], if involvement of law enforcement. customers buy the sharps container from Live Oak, they take it In early 2010, NCPA took another step to bolster these back for free. If they bring it in a different container from some- efforts through a partnership with Sharps Compliance Corp., where else, Live Oak charges $5 per container. “That’s the only based in Houston. NCPA members became eligible for dis- thing we charge for,” he says. counted services for the Sharps TakeAway Environmental Return With only three full-time employees (Maitland, Pope and a System. Members can receive a discount of almost 20 percent technician), the process of facilitating returns could potentially plus free shipping on the Sharps system. More information is be overwhelming. But so far, Maitland says, it hasn’t been a available in the “Prescription Disposal Program” section of the problem. NCPA website (www.ncpanet.org). “In terms of the extra labor to talk to patients, I don’t even “It was great to see that NCPA was able to work with Sharps think of it as burdensome to our bottom line,” he says. “A lot to offer a discount to jump into the program,” says Maitland, of times people just come in to get what they want, and then Live Oak’s co-owner and director of communications and they leave. But there’s an opportunity while they are filling out education. “And being a small business owner, it’s definitely the forms to engage with them in some conversation. It might nice when you can save money any way you be to thank them for coming in, or finding out can. It was fantastic for us to be able to take how they learned out about the program. That’s advantage of our NCPA membership to get a kind of been good for us also, because we discount.” didn’t pay for any advertising for the program, Live Oak’s medication takeback procedure but we did get a lot of exposure, and we put is explained on its website (www.liveoakrx.com). it on Facebook and Twitter, and we found out Customers can download a medicine disposal that KUT is where a lot of people heard about form at home and fill it in before they come in, it. Now that I know that, it’s making me rethink or they can fill out forms at the pharmacy. They radio as an opportunity for advertising, which fill out what it the medication is, where they is extremely valuable information. So that in of acquired it, how much is left (approximately) in itself was a golden nugget for us.” the container, and what size container it is. Maitland says the response in the community has been over- “After that, Nathan meets with customers and double checks whelmingly positive, and fulfilling for the staff. to be sure that there are no controlled substances in there,” “We actually had a woman come in from the next town over Maitland says. “Again, it’s about developing that relationship who had syringes that she wanted to turn in,” he says. “She had and chatting with people.” had them for about four years because she didn’t know what to The next step is to put the medications into a bag to be do with them. She was so relieved that there was a place where mailed back to Sharps. Live Oak also keeps track of how much she could take them. So it kind of justified for us that we made weight they have collected. To date it is 250 pounds. the right decision. And it would be my hope for every indepen- “That’s kind of exciting because there’s 250 pounds of medi- dent pharmacy in Austin to join us in doing this.” cation that is not ending up in our water supply or in the landfill,” — cl

36 america’s Pharmacist | October 2010 www.americaspharmacist.net Continued from page 34 ➥ our Facebook page. So it was mostly [about 90 percent] driven from us sending our press releases and following retail space because of the way the store was designed, up. Following up is the key, and explaining what it was but we wanted it to be usable for the people who visit.” all about. And of course being Earth Day, it helped gar- ner additional interest. That Thursday evening, we got Educational Focus calls from two news stations that were coming over with Education for pharmacy and technician students is a cameras to shoot Nathan talking about the program. point of emphasis at Live Oak Pharmacy. The phar- Again, we couldn’t afford that kind of advertising right macy has a connection with the nearby University of now as a startup.” Texas College of Pharmacy, as Pope is a clinical assis- To date, Maitland says that Live Oak has 626 fans on tant professor. Facebook and 419 on Twitter. “It’s very rewarding and fulfilling,” Pope says. “I “We’re kind of marrying the old and the new,” wouldn't trade it for anything in the world. The stu- he says. “The great thing is getting on other people’s dents bring a certain energy and excitement to daily websites, the different social media sites, and reposting activities at the pharmacy. I feel I have a responsibility that info again and again to hit another audience and let as a pharmacist and pharmacy owner to educate future them know. It helps.” pharmacists so they know that independent ownership As with any large endeavor—and opening a phar- is achievable and that you can push the threshold of macy certainly qualifies—there were some bumps on pharmacy services." the road. Live Oak is already planning to start a community “There were some things we didn’t expect,” Mai- pharmacy residency program in 2011. tland says. “There were items we had to pay for that “Having a resident adds a level of professionalism we hadn’t even thought of. Simple things—we hadn’t and responsibility as a pharmacist/owner,” Pope says. thought of signage for our store, and it was like, ‘Who’s “We are able to take our research to the next level and doing the signs?’ I hadn’t thought about that. ‘How increase our partnership with the University of Texas. As much is that going to cost?’ It’s another line item on long as you don't consider a resident as ‘cheap labor’ and the budget that wasn’t there before. But we weren’t have enough clinical services at your pharmacy, it can be deterred. Nathan and I are hard workers. We figured we very beneficial from a business standpoint." might as well work hard for ourselves, and be able to reap the benefits of it.” Old Media/New Media And the reality of owning a pharmacy has begun to Putting his marketing experience to good use, Maitland sink in. says that Live Oak has embraced both traditional and new “I have an opportunity to drop by the store in the media to help market the pharmacy, its services, and spe- evening, and we have this really great green neon sign, cial occasions. Not long after Live Oak opened, Maitland kind of a throwback to the old pharmacies,” he says. wanted to create awareness of the new pharmacy and “And you know you made the right decision when you its offerings, in particular its drug disposal program. He drive by the store at night and you see that green neon decided that Earth Day would be an ideal tie in to try and glowing and it’s like, ‘That’s ours, we made that. That’s secure coverage. our store, and good things happen there.’ “For Earth Day, I sent out a press release via e-mail “I think that’s what’s exciting about pharmacy in to all of the [TV] stations, and followed up with a phone the future—it has an opportunity to become what it call,” Maitland says. “And I followed up with phone calls used to be. It’s about getting involved in the community again. With radio, I sent them a press release and they and making those relationships and changing the way contacted us, which was great. That kind of motivated we do business.” me to start calling more people. I contacted the Austin American-Statesman [newspaper], and some bloggers as well, and other bloggers found out about it through Chris Linville is managing editor of America’s Pharmacist.

38 america’s Pharmacist | October 2010 www.americaspharmacist.net Giving Students

By Tracy M. Hagemann, PharmD; Joshua R. a Shot Sheffield, PharmD; and Bethany W. Ibach

40 america’s Pharmacist | October 2010 By working together students and preceptors boost vaccination rates, benefitting town and gown

Giving S imon H urst

, ( I ns e t) Fus

Students I mag e S ourc ach year, as many as one in five Americans contractsE the influenza virus. This leads to some 226,000 hospitalizations and 36,000 deaths. The Healthy People 2010 initiative has established an influenza immunization goal of 60 percent or more for adults and 90 percent for a those aged 65 and older and in nursing homes. Shot However, the number of people seeking vaccination

October 2010 | america’s Pharmacist 41 nationwide has consistently fallen below this objective. students were able to gain valuable experiential training, For the 2008–2009 flu season, the vaccination level of while creating greater access to immunizations for the adults aged 18–64, with and without high-risk conditions, community. was 38.8 percent and 42 percent, respectively. Because the seasonal influenza vaccine can reduce rates of infection History of Collaboration by 70 percent to 90 percent, increasing access to im- In the professional curriculum at the OU College of munizations through pharmacy student involvement in Pharmacy, students receive both didactic and practical vaccination clinics will not only reduce annual morbidity experience in vaccinations. The college has delivered a and mortality associated with seasonal influenza, but also 15-hour CE program to licensed pharmacists in the state prepare tomorrow’s health professionals to embrace a since 1998. vital role in the prevention of disease. Beginning with the class of 2006, this program was modified and fully incorporated into the professional Position of Influence curriculum. This allowed student interns to assist their All 50 states allow pharmacists to administer immuniza- preceptors during their advanced pharmacy practice tions, and approximately 40 percent of U.S. pharmacy experiences (APPE) and enabled them to meet the re- colleges include vaccination training as a mandatory quirements to obtain Oklahoma immunization permits part of the curriculum. Because pharmacists are the upon graduation. The current student program includes most widely accessible health care providers, they are in four hours of didactic lectures on vaccine-preventable a unique position to improve immunization rates for diseases. It also includes a four-hour laboratory where seasonal influenza. students demonstrate injection technique (intramus- In July 2003, the Oklahoma State Board of Phar- cular and subcutaneous), as well as screening skills and macy approved rules specifically allowing pharmacists in documentation. Since the class of 2006, 45 percent of Oklahoma to administer injections, including vaccines, graduates have applied for and obtained their Oklahoma to patients. Pharmacists must apply for an immuniza- immunization permits, accounting for 19 percent of tion permit, which requires a certificate of completion overall immunization permit holders. The number of from an approved training program and payment of a new graduates receiving immunization permits has also one-time fee. The approved training programs include trended upward over this time, with 40 percent from the those offered by the University of Oklahoma College classes of 2006 and 2007, and 49 percent for the classes of Pharmacy, Southwestern Oklahoma State University of 2008 and 2009. These statistics show that our phar- College of Pharmacy, American Pharmacists Association, macy students are applying the immunization education National Community Pharmacists Association, American and training in their practices, but there is much room Society of Health-System Pharmacists, and Accreditation for improvement. Council for Pharmacy Education. The college has a history of working with community For the largely rural state of Oklahoma, adult vac- pharmacists to provide early and advanced practice expe- cination coverage against riences for pharmacy students. Lassiter Drug in Del City, influenza was approxi- Okla., has had a long-term working relationship with the mately 41.8 percent in OU College of Pharmacy to provide experiential training. 2008. Beginning in 2008, This relationship has enabled collaborative partnerships a group of pharmacy stu- to develop between faculty at the college and preceptors dents from the University at Lassiter Drug, and has created opportunities to actively of Oklahoma College involve students in public health outreach, such as immu- of Pharmacy partnered nization clinics. with a local YMCA to host community influ- Project Description enza vaccination clinics. In 2008, Joshua Sheffield (a coauthor of this article) ap-

Through these clinics, the proached the Cleveland County Y (formerly known as S imon H urst

www.americaspharmacist.net This type of collaboration during the first session between community and and an additional 150 academic pharmacy gives doses during the second. pharmacists the opportunity Feedback to vaccinate larger groups Responses from all parties involved were enthusiasti- of the at-risk population, raise cally positive. The Y ap- the visibility of pharmacists preciated that the flow of the clinics did not disrupt as vaccinators, and help normal daily activities at the center, while providing S imon H urst students see the value of a valuable public health public health initiatives service that members and the community appreciated. Pa- tients enjoyed interacting with pharmacists and pharmacy as well as a model students, in addition to the convenient and efficient service collaborative practice. in a friendly atmosphere. Faculty valued this opportunity because it allowed students to participate in a real-life setting. Students highly valued the experience they gained the YMCA) to inquire about the possibility of providing from direct patient communications and interactions, and an immunization clinic during flu season to the staff, they gained confidence in their vaccination skills. members, and community. The Y had held flu clinics sponsored by non-pharmacist organizations, with mixed Conclusion results. With the approval of the Y board of directors, two Because of the successful collaboration in 2008, the dates were set. partnership between Lassiter Drug, the Cleveland In consultation with the Y, Lassiter Drug and the OU County Y, and the OU College of Pharmacy has con- College of Pharmacy selected two dates with the most tinued. In 2009, 300 flu shots were administered in two opportune clinic hours to allow maximum traffic of hours, despite the vaccine shortage. For 2010–2011 members and the community. The clinics were advertised another successful flu clinic program is anticipated. This in the local newspaper, and by the Y internally and on the type of collaboration between community and aca- outside marquee. The first date was a morning session, demic pharmacy gives pharmacists the opportunity to from 7 a.m. to 1 p.m., accommodating both early risers vaccinate larger groups of the at-risk population, raise and the lunch crowd. The second date was an afternoon the visibility of pharmacists as vaccinators, and help session, from 3 p.m. to 7 p.m., more convenient for par- students see the value of public health initiatives as well ents, children, and those visiting after work. as a model collaborative practice. In anticipation of a high-traffic flu clinic, faculty members Tracy Hagemann (a coauthor of this article), Vincent Dennis, and Sheffield requested student vol- Tracy M. Hagemann, PharmD, is associate professor at the unteers from the college to assist with patient check-in: University of Oklahoma College of Pharmacy. Joshua R. Sheffield, taking the vaccination history, screening for contraindi- PharmD, is assistant clinical professor at the University of Oklahoma cations, filling out insurance and Medicare forms, and College of Pharmacy. Bethany W. Ibach is a 2012 PharmD candi- administering vaccines. Clinic personnel comprised 12 date at the University of Oklahoma College of Pharmacy. students assisting patients with check-in, 10 senior stu- dents administering vaccinations, three residents rotating For a list of references used in this article, contact among stations, two faculty members, and one commu- Chris Linville, America’s Pharmacist managing editor, nity pharmacist. Close to 500 flu vaccines were delivered at 703-838-2680, or [email protected].

www.americaspharmacist.net October 2010 | america’s Pharmacist 45 Enhanc ing Your Fiscal Fitness

46 america’s Pharmacist | October 2010 www.americaspharmacist.net Enhanc ing Your Fiscal Fitness

n the few minutes it takes you to read this article, 40 Ibusinesses across the nation will fail—and that statistic was before the economic downturn of the last 24 months. Tragic? Yes. Remarkable? Not at all. The road to business There are seven steps success is littered with the skeletons of companies whose owners—mostly brilliant and skilled individuals—failed to business success— to “take care of business” in the financial management of their enterprise. learn them here Just a minute—am I saying that good ideas, technical skills, product knowledge, and sales ability don’t guaran- By Steve LeFever tee success? You bet I am. Anyone in a position to provide capital will tell you: The ability to develop and control an organization financially is absolutely vital.

www.americaspharmacist.net October 2010 | america’s Pharmacist 47 In the hundreds of business classifications in the Please note that I hope you’ll use this outline as a United States, each owner manages to conclude that “performance checklist.” If you don’t regularly (as in “my business is different.” So true, but in the financial twice a year) evaluate one or more of them, it does not sense they’re all different in the very same ways! It’s mean you won’t succeed. Rather, the checklist provides these common business issues and success factors I an opportunity to measure results and identify ways to want to address. improve performance. Specifically, I’d like to describe a seven-step process To ensure your own personal well being, you have for creating healthy businesses, which evolved out of my an annual physical every year from your doctor, don’t former work as a commercial banker dealing with the you? Right. Well, your business is no different. It needs hundreds of independent business owners my colleagues an annual check-up. All the businesses we work with go and I met in that capacity. In the midst of another eco- through an annual assessment. It’s a structured finan- nomic downturn some 20-plus years ago, we sat around cial review that asks these questions: Where have we one day lamenting the economic factors that had caused been? Where are we now? Where are we going? It’s good, our bank to reduce staff, thus making it more difficult metaphorically speaking, to take your business and shake to connect with our customers as often. As we did, the it—sort of get the cobwebs out. same questions and issues kept coming up again and About as exciting as watching grass grow, you say? Yes, again. In fact, when we all listed the “Top 10” issues that I agree, but it’s good for you. You don’t have time? Let me we wanted our customers to know about, we identified remind you—you have all the time there is. Why is there seven common factors that contributed to successful never enough time to do a job right, when there is always businesses—and we realized these would be critical in time to do it over? improving communication between banker and business And there’s another—and perhaps more compel- owner. You might say, “Finance is the medium, but com- ling—reason to use the annual assessment to give munication is the message.” your business a detailed performance review now. The For more than two decades, my company, Business “loan renewal time” in the banking industry is ongoing Resource Services, has worked diligently to bring the sev- throughout the year. For any of you planning to initiate, en success factors—and the financial tools and techniques maintain, or expand credit access in 2011 and beyond, that support them—to business owners and bankers, to you can expect far more rigorous underwriting standards further the goals of enhanced communication and busi- than those you faced in the past five years. In this reces- ness performance. I’d like to share these seven steps with sionary economy, the banking industry is coming under you now. far more stringent review guidelines, and you should ex- pect that to be reflected in the way your own credit needs are evaluated. An annual assessment of your business will not only uncover performance improvement opportuni- Steps to Business Success ties, it will also provide valuable insights into the loan renewal /credit access process. Businesses with the highest odds of Let’s talk about common problems and what we look survival do the following: at in an annual assessment. We’ll examine specific issues 1. Plan properly. 2. Monitor financial position. or tools and arrive at action steps. What good is analysis if 7 it doesn’t lead to action? 3. Understand the relationship between price, volume, and costs. 4. Manage cash flow. Plan Properly 5. Manage growth. Mother Nature gives expectant mothers a nine-month 6. Borrow properly. gestation period to prepare for motherhood, but she 7. Plan for transition. isn’t so kind to business owners. With regard to business organization and the Internal Revenue Service, the errors are usually of omission, not commission. Poor initial

48 america’s Pharmacist | October 2010 www.americaspharmacist.net and ongoing planning is a common error. Far too many owners get into business without a sense of purpose and For years many business owners direction. It’s the “jump and hope” philosophy. Most find attempted to resolve cash flow that being in business is like being in school, except for one thing: In business, you take the test first. Although challenges with increased sales. most business owners have a plan, far too often it resides Not only did increased sales in their head and not on paper. Each of these seven steps often lead to increased to business success contributes to the planning process. borrowing to fund the assets Monitor Financial Position required to support robust sales Another common problem is the failure of owners to con- growth, but this growth often sistently and personally monitor their financial position. You leave the scorekeeping to your accountant because used cash faster than profits you don’t use the information anyway. But who’s at risk could supply it. here? Does your accountant co-sign your bank notes? I know, financial statements reflect the past, and any enter- prising owner only thinks of the future—it’s tomorrow that matters. Unfortunately, tomorrow is the sum of a series of yesterdays. If you don’t know where you’ve been, you can hardly know where you’re going. we should have known all along: Cash is king. Many business owners—with their myopic focus on sales— Know Your Costs and Price Properly often prioritize financial issues in this order: sales, net Failure to know your costs and price properly is a real profits, and cash flow. However, I recently came across a problem. The break-even analysis is the most strate- quote that is disturbingly real: “I learned the hard way: gic and powerful profit-planning tool available. For You can survive decreased profits if you have cash flow, the past 24 months, the most common message in but the converse is not true—if cash flow takes a dive, the myriad articles on business performance is, “Cut you’re in trouble.” your costs!” To improve profitability, however, I would A recession-driven priority list reveals what was true strongly suggest that before you cut your costs you all along. The priorities should read in this order: cash should know your costs. Then you’ll be able to cut with flow, net profits, and sales. A rolling 12-month cash flow a scalpel, not a hatchet. projection is not only a critical planning tool, it’s also a I say this because, sadly, many owners do not know document that banks will be scrutinizing now and in the the cost structure of their own business. Simple example: foreseeable future. The secret to successful cash flow man- Variable costs are 70 percent, fixed costs are $144,000, and agement is understanding the impact of revenue patterns target profit is $60,000. What sales are required to meet on the key cash flow drivers. the profit goal? If you can answer this question correctly, you’ve given yourself a starting point to be able to better Manage Growth—and Capital Efficiency manage your profitability. For years, many business owners attempted to resolve Central to the issue of cost management is the rec- cash flow challenges with increased sales. Not only did ognition that there are only four ways to increase profits. increased sales often lead to increased borrowing to fund Being able to identify them—and relate them to your the assets required to support robust sales growth, but this business plan—is where the break-even analysis tool growth often used cash faster than profits could supply it. becomes strategic and uniquely effective. In addition, the easy credit of the five years preceding the current recession allowed sales growth to be achieved with Manage Cash Flow increasing levels of capital inefficiency. The current economic downturn has highlighted what Probably the most valuable and effective financial

www.americaspharmacist.net October 2010 | america’s Pharmacist 51 planning resource of the last 25-plus years is the financial financial intelligence and strategic analysis to actually gap analysis, which focuses specifically on the propensity accomplish it. of a growing (or inefficiently managed) balance sheet to absorb cash faster than it can be produced. Plan for Transition The solution to this apparent growth/cash flow Finally, of course, you will come to the end of your busi- dilemma (other than a national recession to curb sales ness career. What to do with the business? Transition is growth) lies in managing the balance sheet to increase not fun to think about, but it’s very real. Too many people capital efficiency. This is most effectively accomplished take 30 years to build a nice business, and 30 minutes to by understanding and managing both the four sources of plan what will happen to it when they’re gone. Nothing capital and the primary assets that consume cash when good comes of this. Take time to do it right. managed inefficiently. When do we learn the most about running a busi- ness—in good times or bad? Most would say bad times. Borrow Properly Why? Because in bad times we are forced to focus on A good friend of mine who runs the business credit the drivers of performance and to reassess everything group for a major bank has these words of advice for we’re doing. Like the forest fire that clears underbrush would-be borrowers in 2011: “Remember that borrow- to make way for new growth, economic downturns ing is a privilege—not a right. Know your numbers— force us to reexamine our strategies and tactics. We can or stay home.” condition ourselves, and our businesses, to perform at a The previously outlined tools allow you to accurately higher level. answer the two primary questions business owners get Never waste a good recession. The annual assessment wrong all too often: “How much do you need?” and “How provides structure to a performance analysis that leads to long do you need it for?” It is remarkably common for survival, renewal, and success. business owners to underestimate both “how much” and Here’s what I can guarantee: If you apply the annual “how long.” assessment process on a consistent basis, you’ll gain in- Additionally, it’s critical to understand that short- creased control of your business—and your performance term debt is repaid from cash flow, while long-term debt will improve. is repaid from net profits. Be sure you’re on “the same sheet of music” as your banker, and be prepared to dem- onstrate your ability to service the loans you’re requesting. Steve LeFever is founder and chairman of Business Resource Clearly, there is a lot of money available in the Services (BRS) and the developer of the Profit Mastery banking industry. However, in the current economic program. LeFever has been a long-time contributor to the environment, banks are extremely risk-averse, and pharmacy industry and has worked with NCPA, NACDS, regulatory aggressiveness is only making it worse. Never buying groups, state associations, and schools of pharmacy. before has the old Boy Scout motto been more relevant: Be prepared. LeFever will return to NCPA to present two Profit Mastery ses- It’s safe to say there has not been a time in the past sions at the convention October 23–26 in Philadelphia, where he decade when “knowing your numbers” has been more will introduce the Profit Mastery program sponsored by NCPA for critical. Furthermore, using only the balance sheet continuing education for pharmacists. and the profit and loss statement, the annual assess- ment process outlined here provides powerful strategic financial intelligence that is absolutely necessary to any business owner. These tools not only help you tell the story of the business, they are also invaluable in helping you re- write the parts of the story you don’t like. This is what experts call management. And these tools provide the

52 america’s Pharmacist | October 2010 www.americaspharmacist.net PhiladelphiaAn investment in knowledge pays the best interest. — Benjamin Franklin

This section recognizes the sponsors, exhibitors, corporate members, and foundation donors whose support for the Annual Convention and through- out the year contributes to the success of NCPA and independent community pharmacy. For more information about NCPA and its products and services, visit the NCPA Pavilion, Booth #641, in the Exhibit Hall.

NCPA’s 112th Annual Convention and Trade Exposition Pennsylvania Convention Center Philadelphia, PA Convention Sponsors

Activant Solutions, Inc. Lilly USA, Inc. Pharmacy Providers of Oklahoma Passport Drawing Aisle Banner Passport Drawing NCPA Foundation Presidential Scholarship AmerisourceBergen Corporation/ Proctor & Gamble Good Neighbor Pharmacy Live Oak Bank NCPA Foundation Presidential Scholarship Bottled Water General Support Conference Portfolios PRS Pharmacy Services Convention Program Brochure and Guide Managed Health Care Associates, Inc. Pre-convention Programming Philadelphia Good Neighbor Pharmacy NCPA Pruitt-Schutte Passport Drawing NCPA Foundation Presidential Scholarship Student Business Plan Competition Leadership Dinner McKesson Corporation/Health Mart Purdue Pharma L.P. NCPA Foundation Presidential Scholarship Badge Lanyards & Pouches NCPA Foundation Catalyst Grant Awards for General Support Innovative Practice Program AstraZeneca Passport Drawing Exhibitor Theater Medicine-On-Time Prescription Drug Safety Award NCPA Foundation Presidential Scholarship Convention Banner Passport Drawing Convention Tee Shirts QS/1 NCPA Outstanding Faculty Liaison of the Year Award Boehringer Ingehleim Pharmaceuticals, Inc. MemberHealth, LLC, Passport Drawing Exhibitor Theater a Universal American Company Convention Tote Bags RelayHealth Boiron, Inc. Luncheon Symposium General Support Passport Drawing Exhibitor Theater Rexam Prescription Products Cardinal Health Merck Passport Drawing 2010 NCPA Digest Dinner Symposium General Support ScriptPro NASI General Support Centocor – Ortho Biotech, Inc. General Support Product Lab Dinner Surescripts NCPA Foundation Technology Workshop Cephalon Good Neighbor Pharmacy NCPA Pruitt-Schutte General Support Student Business Plan Competition Take Charge National Preceptor of the Year Award General Support Covidien-Mallinckrodt NCPA Foundation Presidential Scholarship Net–Rx TeleManager Technologies, Inc. Passport Drawing Passport Drawing Eisai Inc. Cyber Café Nordic Naturals TEVA Pharmaceuticals Passport Drawing NCPA Foundation Presidential Scholarship Emdeon General Support Novo Nordisk, Inc. Together Rx Access Luncheon Symposium Passport Drawing Forest Pharmaceuticals NCPA Foundation Presidential Scholarship PCCA Upsher Smith Laboratories General Support Willard B. Simmons Pharmacist of the Year Award Gallipot, Inc. NCPA Foundation Presidential Scholarship Diabetes Accreditation Standards-Practical Applications Passport Drawing Pfizer, Inc. University of Oklahoma GeriMed General Support President’s Reception Pre-convention Programming Pharmacy First/Wholesale Alliance LLC Wiley Systems, Inc. Health Business Systems, Inc. NCPA Foundation Presidential Scholarship Passport Drawing General Support Pharmacists Mutual Wolters Kluwer Health Ideation, Inc. Good Neighbor Pharmacy NCPA Pruitt-Schutte General Support Passport Drawing Student Business Plan Competition Passport Drawing Key Centrix, Inc. NCPA Foundation Presidential Scholarship (as of September 20, 2010) Passport Drawing

www.americaspharmacist.net October 2010 | america’s Pharmacist 55 Convention Exhibitors

/alert Marketing ...... 541 Enzymatic Therapy/Natures Way Mason Vitamins Inc...... 350 PRS Pharmacy Services ...... 442 Abbott ...... 612 ...... 633 Masters Pharmaceutical ...... 243 Purdue Pharma L.P...... 849 Abbott Diabetes Care...... 733 EPIC Pharmacies Inc...... 940 Matchrx.com ...... 951 Purdue Pharma LP/RxPatrol ...... 351 Activant Solutions Inc...... 406 EXP Pharmaceutical Services Corp McKesson ...... 401 Pure Encapsulations ...... 903 Aetrex Worldwide, Inc...... 503 ...... 901 Meadowbrook Insurance Group .. 635 QS/1 ...... 533 AIMSCO/Delta Hi-Tech, Inc...... 514 FDA Center for Drug Evaluation and Medisca Inc...... 943 Qualitest Pharmaceuticals, Inc. .... 236 American Association of Diabetes Research ...... 725 MemberHealth, a Universal American R.J. Hedges & Associates ...... 602 Educators ...... 247 FDS, Inc...... 301 Company ...... 748 RDC ...... 816 American Associated Pharmacies- Federation of Pharmacy Networks ... 437 Merck & Co., Inc...... 815 Reese Pharmaceuticals Co...... 1034 AAP ...... 614 Flavorx ...... 433 Micro Merchant Systems ...... 1025 RelayHealth ...... 912 Anda Inc...... 201 Foto Club, Inc...... 436 Mirixa Corp...... 732 Retail Management Solutions ...... 812 Apothecary Products Inc...... 907 Frier & Levitt, LLC ...... 451 Morris & Dickson ...... 841 Return Solutions, Inc...... 322 Arbem LLC ...... 336 G+M North America Inc...... 932 MTS Medication Technologies ..... 540 Rexam Prescription Products Inc. .. 507 Arkray USA ...... 1001 Gallipot Inc...... 715 Mylan Pharmaceuticals Inc...... 306 Roche Diagnostics ...... 914 Astellas Pharma US Inc...... 607 GeriMed/IV Med/Rx Med ...... 1003 NASPA ...... 415 RX Systems Inc...... 513 AstraZeneca ...... 921 Gladson Design Group ...... 717 National Community Pharmacists Rxinsider.com ...... 824 Auburn Pharmaceutical ...... 512 GlaxoSmithKline ...... 318 Association ...... 641 RxMedic ...... 439 Bayer HealthCare Pharmaceuticals Global Nutritional Research ...... 335 National Council for Prescription Sandoz ...... 1050 ...... 801 Gold Promotions Inc...... 450 Drug Programs ...... 342 ScriptPro PharmacyAutomation ... 621 BD Diabetes Care ...... 505 Good Neighbor Pharmacy ...... 701 National Library of Medicine ...... 547 Sharps Compliance Inc...... 850 Bellco Generics ...... 219 Greenstone LLC ...... 807 NCPA Foundation ...... 640 Sigma-Tau Pharmaceuticals, Inc. . 1021 Berry Plastics ...... 923 Guaranteed Returns ...... 448 Nordic Naturals, Inc...... 949 SmartSource ...... 225 Boehringer Ingelheim Pharmaceutical H.D. Smith Wholesale Drug Co. .. 325 Nova Libra Inc...... 616 Smith Drug Co ...... 538 Inc...... 600 Hamacher Resource Group ...... 947 Novo Nordisk Inc...... 536 Speed Script Pharmacy Systems and Boiron ...... 309 Harvard Drug Group LLC, The .... 412 O’Keefe’s Company ...... 320 Services ...... 333 Breckenridge Pharmaceutical, Inc. HCC ...... 400 OmniSYS ...... 1006 Spenco Medical ...... 909 ...... 1027 Health Business Systems Inc. (an SXC Opus-ISM Corp...... 1023 Stericycle ...... 334 Buy-Sell A Pharmacy.com ...... 933 Company) ...... 825 Origin BioMed Inc...... 934 Stone River Pharmacy Solutions ... 516 Calmoseptine Inc...... 948 Health Care Logistics ...... 532 Outcomes Pharmaceutical HealthCare Surescripts ...... 649 CAM Commerce Solutions ...... 1020 Health Engineering Systems ...... 1013 ...... 551 Take Charge Pharmacist Weight Loss Cardinal Health ...... 613 Health Mart Healthy Living Tour ...143 PAAS National ...... 936 Strategies ...... 239 CARE Pharmacies, Inc...... 1037 Humana Pharmacy Solutions .... 1046 Pacific World Corp ...... 215 Takeda Pharmaceuticals North CarePoint, Inc...... 1024 Ideation ...... 1002 Paddock Laboratories, Inc...... 438 America ...... 523 Cegedim Dendrite ...... 1016 Independent Pharmacy Buying Group Parata Systems ...... 1043 TCGRX ...... 913 Centocor Ortho Biotech Services ...... 1039 ParMed Pharmaceuticals ...... 549 TeleManager Technologies ...... 417 ...... 836 Independent Pharmacy Cooperative Partners in Pharmacy ...... 644 Together Rx Access ...... 905 Cephalon, Inc...... 227 ...... 1014 PBA Health ...... 916 Top Rx, Inc...... 1004 Cephalon, Inc...... 232 Innovation ...... 820 PCCA ...... 601 Transaction Data Systems-RX30 ... 319 Cerner Etreby ...... 735 Institute for the Certification of PDQ Communications Inc...... 446 TRI State Distribution, Inc...... 917 Chain Drug Marketing Association Pharmacy Technicians ...... 945 PDX-RX.com-PCI-Freedom Data Trxade ...... 637 ...... 315 Integra Inc...... 413 Systems ...... 312 Two Point Conversations, Inc...... 238 Colgate ...... 317 International Journal of Pharmaceutical Pennsylvania Pharmacists Association U.S. Pharmacist ...... 543 Commission for Certification in Compounding ...... 1012 ...... 337 Upsher-Smith Laboratories Inc. ... 706 Geriatric Pharmacy ...... 938 Ivy-Dry Inc...... 307 Pharmacist e-Link ...... 749 US Cosmecuticals ...... 1026 Computer-Rx ...... 425 Janssen, Div of Ortho-McNeil-Janssen Pharmacists Mutual Companies .. 646 US Nutrition Inc...... 915 Cover My Meds, LLC ...... 618 Pharmaceuticals, Inc...... 833 Pharmacists OnLine ...... 1008 US Social Security Administration Covidien - Mallinckrodt ...... 409 Jewelers Resource ...... 1033 Pharmacy Automation Supplies ... 326 ...... 1036 Creative Pharmacist.com ...... 213 KeyCentrix Inc...... 432 Pharmacy Development Services UVANTA Healthcare, formerly Health Crocus Medical Inc...... 308 Kinray Inc...... 1048 ...... 1042 One Management ...... 648 CSPN (Community Specialty Pharmacy Kirby Lester, LLC ...... 713 Pharmacy First/Wholesale Alliance Value Drug Co...... 449 Network) ...... 234 Lake Erie Medical & Surgical Supply LLC ...... 814 VaxServe ...... 727 Data Rx Management Inc...... 839 Inc...... 950 Pharmacy Providers of Oklahoma Inc. ViMax Publishing & Marketing Inc. Designer Greetings ...... 548 Letco Medical ...... 416 ...... 501 ...... 435 Diversified Imaging Supply ...... 1038 Liberty Computer Service Inc...... 343 Pharmacy Times ...... 937 Vinco Inc...... 338 Dr. Comfort ...... 604 LifeScan Inc...... 826 Pharmacy-Lite Packaging ...... 313 VoiceTech Inc...... 925 Drug Enforcement Administration Lilly USA, LLC ...... 1000 Philips Respironics ...... 1032 Wildblue ...... 650 (DEA) ...... 837 Live Oak Bank ...... 545 PPSC ...... 848 Wiley Sytems, Inc...... 303 ECRS ...... 508 Logix, Inc...... 233 Prasco Laboratories ...... 509 Wolters Kluwer Health ...... 813 EISAI ...... 721 Managed Health Care Associates Inc. PriCara, Div. of Ortho-McNeil-Janssen Zanfel Laboratories ...... 332 Emdeon Business Services ...... 207 ...... 251 Pharmaceutical Inc...... 832 Emporos Systems ...... 939 Managed Health Care Associates Inc. PriCara, Unit of Ortho-McNeil, Inc. (as of September 8, 2010) Endo Pharmaceuticals Inc...... 1005 (Net-Rx)...... 249 ...... 834 Manchac Technologies, LLC ...... 517 Prince of Peace-Tiger Balm ...... 324

56 america’s Pharmacist | October 2010 www.americaspharmacist.net NCPA 2010 Corporate Members

NCPA Honors Eli Lilly and Co. Retail Management Solutions Association of Northwest Pharmacies Corporate Members Emdeon Business Services LLC Return Solutions, Inc. Broadway Pharmacy Inc. On behalf of the nation’s indepen- Endo Pharmaceuticals, Inc. Rexam PLC California Pharmacists Academy of dent community pharmacies, NCPA Finpago, Inc. Roche Diagnostics Operations, Inc. Pharmacy Owners recognizes the companies that have Forest Pharmaceuticals, Inc. Rx Systems, Inc. Compliant Pharmacy Alliance shown their support for independent Galderma Laboratories, L.P. Sandoz, Inc. Cooperative pharmacy by joining our Corporate Genentech Sanofi-Aventis Pharmaceuticals, Inc. EPIC Pharmacies Member program. Gladson Store Design Group ScriptPro LLC Federation of Pharmacy Networks NCPA encourages independent GlaxoSmithKline Sharps Compliance, Inc. Garden State Pharmacy Owners, Inc. pharmacy owners and managers to Global Nutritional Research LLC Spectrum Pharmacy Products Georgia Academy of Independent show their support for NCPA Corpo- Global Pharmaceuticals, a Division of Speed Script (Digital Simplistics, Inc.) Pharmacy rate Member companies by carefully Impax Laboratories, Inc. Spenco Medical Corp. Independent Pharmacy Alliance considering them when purchasing Greenstone LLC StoneRiver Pharmacy Solutions Independent Pharmacy Buying goods and services. NCPA members Guaranteed Returns SureScripts, LLC Group, Inc. can contact any of these companies Hamacher Resource Group, Inc. Take Charge Pharmacist Weight Independent Pharmacy Cooperative directly by visiting www.ncpanet.org. Health Business Systems, Inc. (HBS) Management Kansas Independent Pharmacy Healthcare Computer Corp. (HCC) Takeda Pharmaceuticals North Service Corp. Ideation, Inc. America, Inc. Keystone Pharmacy Purchasing Key Centrix, Inc. TCG Rx Alliance King Pharmaceuticals, Inc. TeleManager Technologies, Inc. Louisiana Independent Pharm. Assoc. Kirby Lester, LLC TEVA Pharmaceuticals USA Northeast Pharmacy Service Corp. Kowa Pharmaceuticals America, Inc. Trxade Pace Alliance, Inc. Lake Erie Wholesale Medical Supply Universal American Corp. Partners in Pharmacy Cooperative LearnSomething.com, Inc. Upsher-Smith Laboratories, Inc. PBA Health/TrueCare Pharmacies Corporate Members Liberty Computer Service US Compounding Pharmacy Franchise Owners Abbott Diabetes Care Live Oak Bank Vimax Publishing & Marketing, Inc. Association Abbott Laboratories, Inc. Managed Health Care Associates, Inc. VoiceTech Pharmacy Provider Services Corp. Activant Solutions Inc. Manchac Technologies, LLC Watson Pharmaceuticals Inc., U.S. Pharmacy Providers of Oklahoma, Inc. Aetrex Worldwide, Inc. Mason Vitamins, Inc. Generics Div. Pharmacy Services Inc. Allergan, Inc. MatchRx.com Wockhardt USA LLC Quality Care Pharmacies Amgen, Inc. Meadowbrook Insurance Group, Inc. Wolters Kluwer Health Rx Plus Pharmacies, Inc. Amneal Pharmaceuticals Medicine Shoppe International, Inc. World Wide Audio Media Smartfill Apotex Corp. Medicine-On-Time Southern Pharmacy Cooperative Apothecary Products, Inc. Medisca Inc. Wholesaler Corporate Members Texas Academy of Independent Arkray USA Merck & Co., Inc. AmerisourceBergen Corp. Pharmacists Astellas Pharma USA Mirixa Corp. Anda, Inc. AstraZeneca Multiview, Inc. Bellco Generics NCPA Membership Partners Auburn Pharmaceutical Mylan Pharmaceuticals, Inc. Burlington Drug Co., Inc. Honor Roll Bain & Co. Nova Libra Inc. Cardinal Health, Inc. CARE Pharmacies, Inc. Bayer HealthCare Diabetes Care Novartis Pharmaceuticals Corp. Dakota Drug, Inc. Independent Pharmacy Alliance Bayer HealthCare Pharmaceuticals Inc. Novo Nordisk Inc. Dik Drug Co. Independent Pharmacy Buying BD Diabetes Care Ortho-McNeil, Div. of Ortho-McNeil H. D. Smith Group, Inc. Boehringer Ingelheim Janssen Pharmaceuticals, Inc. KeySource Medical, Inc. Kansas Independent Pharmacy Pharmaceuticals, Inc. Parata Systems Kinray, Inc. Service Corp. Boiron, Inc. ParMed Pharmaceuticals, Inc. Letco Medical, Inc. Keystone Pharmacy Purchasing Bristol-Myers Squibb PCCA Louisiana Wholesale Drug Co., Inc. Alliance Buy-SellaPharmacy.com PDX-RX.com-PCI-FDS Masters Pharmaceutical, Inc. Louisiana Independent Pharmacies CAM Commerce Solutions Pfizer, Inc. McKesson Corp. Association CARE Pharmacies, Inc. PharmFreshMedia Morris & Dickson Partners in Pharmacy Cooperative CarePoint, Inc. Pharmacists Mutual N.C. Mutual Wholesale Drug Co. Pharmacy Providers of Oklahoma, Inc. CECity.com, Inc. Pharmacy Development Services Rochester Drug Cooperative, Inc. Rx Plus Pharmacies, Inc. Centocor Ortho Biotech Services, LLC Pharmacy First/Wholesale Alliance LLC Smith Drug Co. Texas Academy of Independent Cephalon, Inc. Prasco Labs The Harvard Drug Group LLC Pharmacists Cerner Etreby Prince of Peace Enterprises, Inc. Top Rx, Inc. Computer-RX Procter & Gamble Health Care Valley Wholesale Drug Co., Inc. (as of September 9, 2010) CoverMyMeds PRS Pharmacy Services Value Drug Co. Covidien Prudential Consulting Broker Services Data Rx Management, Inc. Purdue Pharma L.P. NCPA 2009 IPO Members Designer Greetings, Inc. QS/1 American Associated Pharmacies Dr. Comfort R. J. Hedges & Associates American Pharmacies ECR Software Corp. Ranbaxy Pharmaceuticals, Inc. American Pharmacy Cooperative, Inc. Eisai Inc. RelayHealth American Pharmacy Services Corp.

58 america’s Pharmacist | October 2010 www.americaspharmacist.net NCPA Foundation Providing Philanthropic Support

Thank you to the following individuals Joseph P. Burghardt PRS Pharmacy Services Alisa Peters and organizations for making cash and/ Donnie and Cindy Calhoun Nancy Pruitt Pharmacy First/Wholesale or auction donations to the National Brian Caswell QS/1 Alliance LLC Community Pharmacists Association Covidien Tom Schnorr Procter & Gamble Health Care Foundation. Donations support the Eli Lilly & Co. David A. Shipman Freddy J. Rabon NCPA Foundation’s mission of preserv- David Elm Todd Sondrup Mark Riley ing the legacy of independent pharmacy. Stephen L. Giroux Scott Stanley Gerald W. Roberts Visit www.ncpafoundation.org to learn Robert Greenwood Sharon Steen Ivan Saiff more, or contact [email protected]. Holly and Mike Henry Rick Stradtner Dale Schmidt David B. Holman Charles C. Stuart Shailesh Shah Is your name missing? Larry D. Irwin Larry Wamble Dale Smith If your name is not included and you Karen Iseminger Tony Welder Edward M Sturgeon think it should be, or is not at the gift Eric Ludwig David A. Wilcox Gregory L Sutton level you believe appropriate, please McKesson Corp. TEVA Pharmaceuticals USA contact the foundation. The period Michael T. Rupp Fellow (individuals $250–$499/ Adrian A. Thomas for gifts covered is from July 1, 2009 Phil Schneider corporations $2,500–$4,999) Phil Tygart through June 30, 2010. John Schutte Zaheer Ahmed Gary Warren Gerald and JoAnn Shapiro Gary Avnet Lonnie D. Wilson Legacy Society Steven T. Simenson Osam Awad Bruce D. Wood The Legacy Society recognizes David M. Smith Sam Bakar individuals who remember the NCPA Andrew C. Stout Thomas Ray Barnett Patron (individuals $100–$249/ Foundation through a major gift of Jay T. Thompson Michele M. Belcher corporations $1,000–$2,499) $10,000 or more, or in their will, estate William D. Weaver Brian Bevins David M. Adams planning, or other planned charitable R. Wayne West Brian Bolinske Juan Carlos Aragon gift. Major gifts may be pledged in Dirk and Trish White Ann Bromstedt Kenny E. Archer installments allocated over a number Allan Wong Sharon Carpenter Ahmed S. Atallah of years. Legacy Society members: Joyce Caviness Patti S. Ayesh Ed Berg Strategist (individuals Susan L. Chin James Baker David Elm $500–$999/corporations Charles D. Cottrell Timothy E. Baker Holly W. and Mike Henry $5,000–$9,999) Courtney A. Cunningham Bruce Balog Forrest “Woody” Pack Bradley J. Arthur Timothy J. Davis Charles P. Barone Nancy Pruitt AstraZeneca DKMS Americas Carrie Baumgardner Betty Schutte Shelley Bailey Gary Dugger Robert W. Beauchamp Andrew Stout Daniel Blakeley Mark B. Evanstad David G. Benoit Boehringer Ingelheim Pharmaceuticals Omololu Fatukasi Ed Berg Visionary (individuals Frederick J. Bonchosky Forest Pharmaceuticals Inc. Stephen P. Bernardi $5,000 and above/corporations John R. Carson Rebecca S. Gramling Joseph S. Bettman $50,000 & above) James Clayworth Travis Scott Hall Nathan Bhakta AmerisourceBergen Corp./Good Community Pharmacy Foundation Leland R. Hansen Sam Birdsong Neighbor Pharmacy Ronald G. Davis Steve E. Hartwig Timothy N. Bishop Sharlea and Gary Leatherwood David DeVido Bentley F. Hawley Gregory Blank Pharmacists Mutual Ricky T. Guidry Elizabeth B. Henshaw Ralph A. Blansett Purdue Pharma L.P. Joseph H. Harmison Edmund R. Horton Bonnie Lee Bobbs James and Darrell Rankin H. Edward Heckman Ian Johnson Michael G. Branstetter Betty Schutte Holly W. Henry Patty Johnston Grant H. Brown Keith Hodges Steve P. Karagiannis William Brown Futurist (individuals Forrest M. James Nabil Khalife Kathy L. Browne $2,500–$4,999/corporations Kris Kaniski Janet Kusler John E. Bull $25,000–$49,999) Richard I. Katz Laurelyn J. Larson Leonard R. Buntz Apotex Corp. Deborah Keaveny Thomas J. Liautaud Thomas H. Burris Lonnie and Nancy Hollingsworth Pamela Keil-Ehlers Arlene J. Mark-Ng Mark Edwin Byrd Joseph and Anna Margaret Mosso Joseph P. Lech James L. Martin Steve Chastain John and Karen Tilley William R. Letendre Charles H. McWilliams Victor Chikasawa Charles and Becky West Garry Levitsky Annie Melendez Ellen M. Church Paul B. Lewis Valerie Mongold Troy Clarambeau Catalyst (individuals J. P. Marco National Community Rodney C. Clay $1,000–$2,499/corporations Dorinda Martin Pharmacists Association Larry J. Coats $10,000–$24,999) Pat Mattingly Scott Pace Jacob Cohen Calvin J. Anthony Larry McLellan Elliot Pacheco Dale Coker Allan D. Bell Dilip Mistry Earl Wayne Padgett Frank Conwell C. Robert and Eilene Blake Donald and Naomi Moore Arnold Palmer Robert E. Cull J. Chris Bradberry Thomas F. Ohliger Diven Patel Susan Detamore Anthony T. Budde Michael T. Ohnemus PCCA Sylvia Dingus

60 america’s Pharmacist | October 2010 www.americaspharmacist.net Larry Doud Richard B. Moon Maurice J. Warner Melanie V. Kue Kenneth Dove William O. Moore Jeffrey Warnken Lake Erie Clg of Osteopathic Medicine Larry Durrant David C. Morgan Earnest J. Watts Charles F. Lange John M. Elam Allan I. Morris Leland E. Wehde Laurel Valley Golf Club/Arnold Arthur Boyd Ennis John Moss Gregory Wendling Palmer Patricia A. Epple DeAnn Mullins Thomas H. Whitworth Katrina E. Loncar Seamus Feely Jill C. Mutz Jonathan J. Wolfe Philip M. Lubaroff Rogelio Fernandez Peter Nazarian Paul C. Woods Hugh P. Mack Charles J. Fievet Kathleen M. Nelson Ed P. Wright Robert S. McClelland Ben B. Finch Robert Newhard Lynn Zickefoose Marsha A. McDonald Tim Alan Fleeman Joanne Nguyen Medical Plastic Devices Ruben P. Fonseca Phu Nguyen Associate (individuals: up to Rocking & Will Meyer Robert B. Frankil Steven A. Nilson $99/corporations: up to $999) Mister Rogers Foundation Dennis K. Gailey Heather K. Novak Jerry A. Ackerman W. Whitaker Moose Emily Kathleen Galvan John F. Ochs Beverly Z. Adato Morrison House/Kimpton Hotels Cheryl L. Garvin Olukayode Ogundipe Titilayo Akinyoyenu Martha Mosher Mary Giamartino David Olig Alabama Pharmacy Association Museum of Science and Industry Eddie Glover Alejandra Ortiz Stephen J. Amato Herbert T. Myerson David Goldberg Bill Osborn Appalachian COP Shawn Nairn Cheryl L. Greenwood Dushyant Patel Armfield, Harrison, & Thomas Dean Ng Jamie H. Grepiotis Matt Paulson Insurance Trissie D. Nguyen John C. Griffin Max J. Peoples Martene Barker Dmitriy Notkin Kimberley A. Griffith Douglas Pinnow David Bateshansky M. C. Oestreicher Jeffrey A. Hempstead Patrick T. Potter Timothy Bredehoft PAAS National Steve Hiemenz Thomas M. Quinlan George W. Brookins Vishal Ishverlal Patel S. Mark Hobbs Thomas B. Rankin Robert A. Brown Rodney Pawich Brian Douglas Hoey Eugenia W. Raper Frank K. Cable Pennsylvania Pharmacists Association Ronald T. Hofmeister Guy M. Reeser Nolton W. Causey Dong N. Pham Karen L. Hogue Terry A. Richardson Robert M. Cisneros Ramesh Rakholia Nedra Holder Brenda Riley Patrick Thomas Comerford Thomas C. Reed Homestead Anne Roberts Glenn Cox Dana L. Reed-Kane Tom M. Houchens Ronald Louis Rumsey Billy P. Crabtree Robert P. Rehal Truman Hudson Richard S. Sabatelli Steven J. Crosby Samford University Walter M. Hughes Charles Harvey Satterfield David Cross Doreen M. Sayler Ed L. Hunter Beverly J. Schaefer Pedro L. Cuellar William James Scott Nathan Ikner Paul W. Schaffer DC United Syed Shah Veera Indana William L. Scharringhausen Vicki DeAtley Eric R. Shields Lowell M. Irby James R. Schiffer Mercedes I. Delgado Jay R. Sibulkin Andreas Iskos Frederick E. Schmid Nelson Der Donald R. Smith I. J. Jacobson William R. Seitzinger Steven Diaz Morganne Taylor Smyth Carl T. Jakopec Bharat Shah Yvonne M. Dietrich Larry O. Spears Cary D. Johnson Ronald Shell Lloyd J. Duplantis Jr. Stabler Leadbeater Apothecary Joel Marsden Jolley Jae K. Shin Roy H. Eberhart Museum Glen I. Jorde Dewey Shoup Anthony L. Esker Robert A. Stoxen Michael J. Kaplan Nelson L. Showalter Elizabeth M. Forster Randy Tammara Mark King Joel D. Shpigel Jeremy C. Forster James R. Taylor Mark E. Kinney Jeffrey D. Sigler Ira N. Freeman Cathy Jo Thrasher Sherwood Klein Joe Smith Mark P Freitas Touro University Bruce Kneeland Nick Smock Roger Glaser Doris A. Twardosky Pamela Kohrman Richard A Soileau Mark Glassman University of Montana Brian Komoto Michael Somma Global Pharmaceuticals University of the Pacific Rose Lee Dan L. Somsen (Div. of Impax Labs) Upsher-Smith Laboratories Brian Loomis Philip John Spitznagle Richard B. Greene Evan James Vickers Nasir Mahmood David R. Stevenson James Hamilton Robert J. Vickers Mark Malzer Nestor Stewart Vincent A. Hartzell Charles H. Villarreal John C. Marion Stacey M. Swartz Jon C. Haugan Virginia Commonwealth University Jimmy D. Martin Patricia Taylor Hillerich & Brasby Co. Washington Capitals Kevin McClimon Joseph Testa John A. Hogden Washington Nationals William S. McFarland Chuon A. Thi John H. Hood Washington Redskins Warren G. Meador Roger Thibodeau Independent Pharmacy Cooperative Mitchell Weiner Edgardo A. Mercadante Laurie Ann Thompson Deborah S. Johnson John F. Zban Marc Merrill Gordon E. Tweit Frederick Allen Johnston Jerry Meyers Jose J. Valadez Dean Jolley Sherry D. Middleton Dennis G. Vermillion Rebecca H. Jones Charles M. Miller Rasiklal Vikani Kimpton Hotels Byron J. Millet Rajan Vohora Roscoe H. Kinkead

62 america’s Pharmacist | October 2010 www.americaspharmacist.net continuing education

Medication Therapy Management: An Evolution of Change By Stacey R. Schneider, PharmD

pon successful completion of this Useful Websites continuing education activity, the pharmacist should be able to: ■ www.pharmacist.com 1. Discuss the development of This is the American Pharmacist Association website. It provides useful informa- medication therapy management tion about MTM services across the health care spectrum, called “MTM Central.” U(MTM) services, including government initiatives ■ www.amcp.org as well as specific criteria set forth by pharmacy This site provides a link to the Academy of Managed Care Pharmacy continuing organizations defining MTM services. education activity entitled “Sound Medication Therapy Management Programs,” 2. Examine MTM services that are currently Version 2.0 with Validation Study. being delivered in the community pharmacy ■ www.cms.gov/PrescriptionDrugCovContra setting. This site is a link to the Centers for Medicare & Medicaid Services. A section 3. Describe the perceptions of patients, pay- under Medication Therapy Management contains information related to Part D ers, physicians, and pharmacists about MTM MTM program requirements and links to a fact sheet that provides a summary of the 2010 Part D Medicare-approved MTM programs. services. ■ www.ncbi.nlm.nih.gov/pmc/articles/PMC1698122. 4. List barriers to providing MTM services as This is a link to an AACP Report, Roadmap to 2015: Preparing Competent Phar- experienced in the community pharmacy. macists and Pharmacy Faculty for the Future. Combined Report of the 2005–06 5. Discuss elements of a Medical Home Model Argus Commission and the Academic Affairs, Professional Affairs, and Research and the role of a pharmacist within that struc- and Graduate Affairs Committees. ture. 6. Describe the challenges to pharmacy educa- tors in preparing competent pharmacists for Prescription Drug, Improvement, and Modernization the future. Act of 2003. MTM services began to be offered in the 7. Understand how MTM services will be af- community, but there was little consistency and a lack of fected by the introduction of the Patient reimbursement for the pharmacist. However, things have Protection and Affordable Health Care Act. changed. Pharmacist education has evolved to incorpo- rate a highly clinical skill set, and pharmacist competen- INTRODUCTION cy to deliver such services has dramatically increased Pharmacists have historically been seen as a result. The view of pharmacists as medication as medication dispensers. As the need for therapy experts has long been recognized by patients improved clinical and economic outcomes in and providers. With the provisions established in the relation to the U.S. health care system became new health care reform act, MTM services have been apparent, pharmacists began to take on an more clearly defined, and pharmacists have obtained integral role as part of a health care team con- the support necessary to establish MTM services. All tributing to patient-centered care. Medication these elements are factors in establishing that pharma- therapy management (MTM) services were offi- cists are key contributors to improving patient care in cially recognized by Congress in the Medicare the health care system.

www.americaspharmacist.net October 2010 | america’s Pharmacist 65 HISTORY OF MTM SERVICES elements to be delivered within each program. The Medicare Prescription Drug, Improvement, and A list of these elements can be found in Table 1. Modernization Act of 2003 required that Medicare Part D This provided a framework that gave community insurers provide MTM services to selected beneficiaries. pharmacists a basis for establishing their ser- This legislation called for a number of specific elements vices. The Academy of Managed Care Pharmacy to be contained within the services. These included edu- (AMCP) also developed a set of MTM guidelines cation of beneficiaries to improve knowledge about their based on the consensus of a panel consisting of medication, improving medication adherence, detecting physicians, pharmacists, and government orga- adverse drug reactions, and preventing misuse of medi- nizations. Compared with the first set of guide- cations. This bill did not clearly define how these services lines, these recommendations were focused on were to be delivered to the patient. This document also the perspective of the insurer. AMCP guidelines stated that the providers should be paid for their services suggested MTM services should focus on but did not establish a fee schedule, and left the details of coordination of care, outcomes assessment, the service to be determined by the plan administrators. establishing eligibility of patients, and using an The Centers for Medicare & Medicaid Services (CMS) interdisciplinary team approach to patient care. was tasked with serving as the governmental agency to the AMCP document has since been approve MTM services. CMS required each Medicare Part amended to include new recommendations D plan to establish an MTM program for targeted ben- pertaining to MTM services. The second ver- eficiaries. Each plan could specify its own requirements sion of this document stated that the term MTM but had to offer MTM services to beneficiaries who have should apply to all programs that improve multiple disease states, are taking multiple drugs, and are medication management, not just programs likely to incur extensive annual costs for all Part D covered meeting Medicare Part D criteria. This group drugs. Even though this bill did not establish a clear set felt that more specific criteria should be used of guidelines for providing MTM, it did acknowledge the to identify eligible patients for MTM services. value of these services and the value of the providers’ They also recommended that MTM programs time in delivering them. measure results on a population basis as well in July 2004, 11 national pharmacy organizations as for individual patients. This consensus stated achieved consensus on a definition of MTM services. They that MTM services do not always necessitate a defined MTM as “a distinct service or group of services face-to-face encounter. It was recognized that that optimize therapeutic outcomes for individual patients this type of interaction is not always feasible [that] are independent of, but can occur in conjunc- and that, in some circumstances, other means tion with, the provision of a drug product.” Based on the of contact are considered acceptable. How- 11-group consensus definition, the American Pharmacists ever, it remains the consensus of APhA and the Association (APhA) and the National Association of Chain NACDS Foundation that, in order to perform Drug Stores (NACDS) Foundation determined the core the most comprehensive assessment of the patient, a face-to-face interaction is required. Table 1. Core Elements of MTM Service Model in Phar- It is the belief of these groups that this type of macy Practice encounter optimizes the pharmacist’s ability to Core Elements assess nonverbal cues as well as to enhance Medication Therapy Review (MTR) the pharmacist-patient relationship. Personal Medication Record (PMR) Medication Action Plan (MAP) CURRENT MTM SERVICES IN THE COMMUNITY PHARMACY SETTING Intervention and/or Referral What distinguishes MTM services from other ser- Documentation vices the pharmacist is already performing, includ- Follow-up ing patient counseling and disease state manage-

66 america’s Pharmacist | October 2010 www.americaspharmacist.net ment? Patient counseling is a tool for delivering plans hired an MTM administrative service company to information to the patient to ensure safe and effec- serve as a business partner in the administration of MTM tive use of prescription medication. Disease state services. The administrative company created a database management is a mechanism that gives patients that consisted of MTM services collected from pharmacy- the knowledge and resources necessary to man- submitted claims for pharmacist-provided interventions. age a particular disease. MTM is patient-specific This study analyzed claims that had been submitted over and encompasses the patient’s comprehensive a seven-year time period (Jan. 1, 2000–Dec. 31, 2006) drug therapy needs. MTM can encompass a by participating pharmacies. The network of pharmacies broad list of services, including (but not limited to) for this MTM administrative services company included a medication reviews, complex medication consults, mix of independent, franchise, chain, health system, and health and wellness services, immunization, dis- consultant providers located in 47 states during the time ease education, and health coaching. of the study. Data analysis from this study indicated that a number of these types of programs have the most common reason for MTM intervention was new been established by pharmacists within the or changed therapy. The most common action taken by community. The Asheville Project began in 1996 the pharmacist was patient education/monitoring, and the as an effort by the city of Asheville, N.C., to most common result was therapeutic success, which was provide education to its employees with chronic determined by the pharmacist. health problems, such as diabetes, asthma, hy- Other analysis of the database provided some interest- pertension, and high cholesterol. Patients were ing information. The average age of the patients increased also teamed with community pharmacists, who from 30.4 years to 57.6 years. There was a decrease in made sure they were using their medications interventions for acute medications and an increase in correctly. One positive aspect for the profes- interventions for chronic medications. Changes were also sion was that the pharmacists were reimbursed observed in drug categories over time, with decreases in for this project’s cognitive services. This type antimicrobials and increases in cardiovascular and central of reimbursement for pharmacists was a new nervous system agents. The most common agents associ- and developing concept at this time. Another ated with MTM services in 2000 were penicillins, versus similar innovative approach to delivering MTM statins and other lipid-lowering medication in 2006. Other services was demonstrated through the Ten City notable changes included the reason for the intervention Challenge. This was a program sponsored by shifting from new or changed drug therapy to cost efficacy the APhA Foundation, with support from Glaxo- management. MTM interventions provided from 2000 to SmithKline. Participating employers provided a 2006 included a shift from patient education/monitoring voluntary health benefit and waived co-pays for to prescriber consultation. Patient refusal of MTM services diabetes medications and supplies for employ- also declined steadily over this same time period. Finally, ees, dependents, and retirees with diabetes. examination of MTM reimbursement showed a greater than Challenge participants were assigned to a spe- 60 percent increase in the mean pharmacy payment. cially trained pharmacist to help them manage another study analyzed data obtained from Fairview their diabetes on a day-to-day basis. Both of Health Services of Minneapolis/St. Paul, which implement- these programs have documented improvement ed the Collaborative Practice of Pharmaceutical Care at six in clinical as well as economical outcomes, and of 15 primary care clinics beginning in 1999. The interven- have been landmarks in the delivery of MTM tion consisted of MTM services provided by pharmacists to services in the community pharmacy. Blue Cross BlueShield health plan beneficiaries in col- several studies have been conducted to laboration with primary care providers. This study exam- look at different aspects of MTM programs in ined the effectiveness of these services as offered by the the community pharmacy. One study examined pharmacist over a one-year period. Results indicated about claims in a database that was developed as 40 percent of the drug therapy problems were related to an early innovation for MTM services. Benefit indication, 30 percent to effectiveness, 20 percent to safety

www.americaspharmacist.net October 2010 | america’s Pharmacist 67 concerns, and 10 percent to adherence. Twenty percent of defined chronic diseases. Table 2 lists these iden- the drug therapy problems involved a dosage that was too tified disease states. Of these, diabetes, hyper- low to be effective for the indication being treated, and 10 lipidemia, and hypertension are the top targeted percent were a result of ineffective therapy. Chart audits for diseases. The second criterion establishing MTM patients with hypertension management indicated that 71 eligibility requires a plan member to be taking percent of patients in the intervention group had reached multiple covered Part D drugs. This data revealed their goals of therapy, while only 59 percent in the noninter- that approximately two-thirds of MTM programs vention group met the therapeutic goals. For patients with targeted beneficiaries who are taking at least hyperlipidemia, 52 percent of intervention patients met their eight covered Part D drugs. CMS also required therapeutic goals, while only 30 percent of the noninterven- beneficiaries to incur an annual cost of at least tion group met their goals. Of the drug therapy problems, $3,000 for all covered Part D drugs, lowered from 78 percent were resolved without the direct involvement $4,000 in 2009. Sponsors were required to offer a of a physician, while 22 percent were resolved through minimum level of MTM services for each eligible collaboration with a physician or another primary provider. beneficiary, which included a comprehensive This study was able to demonstrate that total health expen- medication review (CMR) annually and quarterly ditures were reduced by 31.5 percent. Results from this medication reviews, with follow-up interventions study continue to support the growing body of evidence when necessary. that indicates improvements in both clinical and economic the end result of the CMR, after reviewing outcomes are attributable to MTM services. the beneficiary’s medications—including pre- cms gives plans flexibility in determining who will de- scription and over-the-counter medications, as liver MTM services. However, there are certain requirements well as herbal and dietary supplements—is that that each plan must meet. In 2010, expanded require- providers produce a personal medication record ments were enacted to increase the number of beneficia- (PMR), a medication action plan (MAP), and ries eligible for MTM services. CMS released a fact sheet recommendations for monitoring, education, or in June 2010 that analyzed the data obtained from these self-management. Notice that the CMR closely enhanced programs and addressed some of the changing resembles the MTM core elements previously eligibility criteria. For 2010, CMS allowed a plan sponsor to discussed. The 2010 data showed that recom- determine whether to target beneficiaries with at least two mendations to current drug therapy, followed chronic diseases or at least three chronic diseases. Data by a personal medication record, were the most indicated that approximately 72 percent of the programs common type of written summary supplied to the required a minimum of three chronic disease states. At a beneficiary at the time of the CMR. These new minimum, sponsors had to target at least four of the seven requirements allowed for more valuable services to be included in an MTM consultation, such as Table 2. CMS-Defined Chronic Diseases general education about medication regimens, Disease State refill reminders to increase compliance, and refer- rals to improve overall patient care. Hypertension as evident in the previously mentioned stud- Heart Failure ies, MTM services have evolved from delivering Dyslipidemia patient education involving acute medication Diabetes to providing more consultation services related Respiratory Disease (such as asthma, chronic obstructive to chronic medications. These shifts in MTM pulmonary disease [COPD], or chronic lung disorders) services have allowed for greater estimated cost Bone Disease–Arthritis (such as osteoporosis, osteoarthritis, savings and have increased the reimbursement or rheumatoid arthritis) amounts to pharmacists. These shifts suggest Mental Health Disease (such as depression, schizophrenia, that MTM services will become increasingly bipolar disorder, or other chronic and disabling disorders) important as we see the aging of the popula-

68 america’s Pharmacist | October 2010 www.americaspharmacist.net tion. The increase in demands for MTM services ing the definitions of the MTM components, the respon- will also be evident due to the greater number dents agreed that these services were valuable, but they of beneficiaries eligible to receive MTM services showed concerns regarding pharmacist time and privacy under Medicare Part D. issues. These findings confirm the importance of pro- viding MTM services on a more consistent basis, as it THE PERCEPTION OF MTM SERVICES appears patients would be receptive to these services. In For pharmacists to successfully deliver MTM most cases, patients believed that these services would services in a community pharmacy setting, many help improve their relationship with a pharmacist as well factors must come into play. These include the as improve their overall health and medication use. acceptance of pharmacist-delivered services by several studies have attempted to look at the value the patient, physician, payer, and pharmacists of MTM services from the perspective of the payer. One themselves. Several studies have attempted to 2007 study was performed to elicit payer perspectives determine the acceptance of MTM services in this and provider views on MTM contracts. Part 1 of the study setting. The Lewin Group provided a review of attempted to obtain the provider perspectives in rela- MTM services by examining peer-reviewed litera- tion to contracting with certain health plans. This study ture; studying existing MTM practices; interviewing concluded that providers varied widely on what types pharmacists, pharmacy benefit providers, health of services they provided, and had not established any plans, and policy makers; and holding discus- means by which to assess the costs and benefits of sions with industry experts. From patient inter- MTM services. Instead, they associated the value of views, it was evident that patients are generally such services with their professional role in the health highly supportive of MTM services. Many patients care system. Part 2 focused on the perspective of the find that their pharmacist is easier to approach payer alone. The results of this analysis further demon- and can spend more time answering questions strated that, similar to providers, payers varied widely than their physician. Interviewees relayed that on how they implemented and monitored MTM services. physicians tend to be skeptical of MTM services at The associated value of these programs was reported to first. However, many physicians who are open- be cost avoidance, improved member satisfaction, and minded and accept pharmacist-initiated efforts improved medication adherence. to coordinate patient drug therapy now realize from a separate perspective, other studies have the value of pharmacist-provided services. In attempted to determine the attitudes affecting MTM fact, often the pharmacist can provide answers to services by community pharmacists. A survey attempted patient questions in a timely manner. Physicians to determine the barriers of performing MTM services noted that pharmacists have in numerous cases perceived by pharmacists. The survey assessed phar- improved patient wellness by improving health macist comfort level with providing cognitive services, outcomes. This included reducing the need for pharmacist perceived value of providing these services additional medications and ensuring appropriate to patients, perceived facilitators and barriers to providing medication use. It is evident by the formation of these services to a patient, potential utilization of develop- collaborative practice agreements between physi- ment resources, and current involvement in MTM services. cians and pharmacists that the physician is willing Respondents indicated that the greatest facilitators of to acknowledge the pharmacist as a partner in the these services were patient willingness to participate and overall health care of the patient. the educational background of the pharmacist. Lack of One study surveyed customers at four time was the greatest barrier, and physician acceptance community chain pharmacies to determine the was also noted as a barrier to implementation of these patients’ perceptions and expectations regard- services. This study demonstrated the importance of the ing MTM services. This study demonstrated pharmacists’ confidence and educational background that patients had little knowledge about the in driving the likelihood of the pharmacist to become in- core elements of MTM services. After review- volved in delivering MTM services. For example, a survey

www.americaspharmacist.net October 2010 | america’s Pharmacist 69 of fourth year pharmacy students regarding knowledge as well as having clinical expertise in the special- and attitudes toward MTM services found that almost all ized area. Those surveyed believed that most respondents believed that participation in such programs pharmacists are willing to and should implement was important to pharmacy advancement. The students such services. Most believed their pharmacy is generally believed that these services would foster an currently able to deliver a higher level of services improved patient-pharmacist relationship by allowing the and that they had access to adequate informa- pharmacist to achieve higher levels of care. Most respon- tion enabling them to deliver such services. dents agreed that they were equipped with the knowledge Three specific challenges were commonly cited base and skills to be successful in a practice setting en- that affected the delivery of these services: dif- gaged in delivering these services, with 60 percent agree- ferent requirements by each health plan, lack of ing or strongly agreeing that they intended to provide staffing, and uncertainty in reimbursement pro- MTM. However, willingness to seek employment where cedures. Also noted was lack of uniform systems they could provide these services dropped slightly to 54 for documentation purposes. To date, many percent, and only 37 percent agreed or strongly agreed new software systems are available to support when asked if they would take initiative to get approval the pharmacist in documenting their outcomes. to offer the Medicare Medication Therapy Management In comparison with pharmacists in the current Program if their employer did not plan to offer MTMS. workforce, the respondents in this survey had a another study displayed similar findings: The confi- higher percentage of advanced training. Despite dence level of the pharmacist was the greatest facilitator this limitation, the authors concluded that their to involvement in delivering this higher level of care. This findings have been similar to other recently pub- emphasizes the importance of role-playing in the dispens- lished data. ing lab, supervised internship experience(s) with construc- several factors come into play when deter- tive feedback on patient counseling technique, the need mining the success of an established MTM service for community pharmacy residency programs, certificate in the community pharmacy practice setting. The programs, and advanced practice sites that allow the chronic care model suggests that the likelihood pharmacy extern to develop the necessary competencies for the success of MTM programs depends on to deliver MTM services to community patients. This study preparedness and willingness of the pharma- was also able to demonstrate that students who were cist to provide such services to the patient. Also exposed to settings in which these services were being de- important is Medicare Part D enrollees’ knowledge livered were more likely to choose a future practice site that about available programs and their perceived enabled them to perform such activities. The majority of need for such a program. Acceptance of phar- respondents indicated that they were more likely to choose macists as providers of MTM and support from to practice in a setting that provided these services over health plans for these programs also are key to a practice setting that did not offer MTM services. Other the success of these services. Most data to date studies have similarly shown a trend toward less interest in shows a willingness of pharmacists to provide dispensing medications and more interest in providing clini- MTM services, but they are in need of assistance cal services to patients. in the process, possibly including standardized a research brief published in Science Direct surveyed protocols, documentation, and billing. the willingness of community pharmacists to provide MTM services. The survey was linked to the electronic weekly MOVING FORWARD WITH MTM SERVICES newsletter of the National Community Pharmacists As- There is no doubt that the majority of individuals sociation (NCPA). The majority of the respondents re- who seek or need medical care will eventually ported having some form of advanced training, ranging require medication. Medications have become from specialized certification programs to a residency or the main intervention in the health care arena. fellowship. Most respondents reported being adequately As prescription drug use continues to grow and prepared to deliver MTM services from a knowledge base, medication regimens become more complex,

70 america’s Pharmacist | October 2010 www.americaspharmacist.net our health care system has become more prone Table 3. CDC Facts on Therapeutic Drug Use to medication errors and adverse drug events. Medication-related problems are a major public Category Percentage health problem in the United States. The 2006 Percent of visits to MD office 71% Institute of Medicine report on preventing medi- involving drug therapy Hospital outpatient department cation errors noted that an estimated 1.5 million 75% preventable adverse drug errors occur in the visits involving drug therapy Hospital emergency department United States each year. It is estimated that these 77% adverse events result in $177 billion in injury and visits involving drug therapy death. Table 3 lists some statistics available on the Centers for Disease Control and Prevention care would be a regional or national health information (CDC) website in relation to therapeutic drug use. exchange that facilitates access by prescriber, lab, and according to this data, there is an obvious pharmacy (and other parties certified to participate) need for interventions relating to medication to current and historical health records. One model to therapy, and pharmacists have the most compre- improve management of chronic diseases and foster hensive knowledge regarding medications. Phar- this concept for centralized patient care is the primary macists have become an essential resource in care medical home. This concept for centralized patient this growing complexity of medication regimens, care has evolved since it was first described in 1967. and their expertise makes them the obvious A primary care practitioner is responsible for facilitat- choice as the key player in delivering MTM ser- ing continuous care for the patient. Although a relatively vices. These services have been documented to new concept in the health care arena, the primary care improve clinical as well as economical outcomes medical home has been implemented in various set- in the health care system. It is necessary to strive tings, mostly showing improvements in health outcomes. to make MTM an essential part of the health care Research has provided some data, but they are limited, experience, not simply an option. The public im- and the optimal model for the primary care medical home age of the pharmacist as a product-driven health has yet to emerge. With a patient’s comprehensive medi- care provider is rapidly changing. The pharmacist cal history accessible electronically, providers would be is quickly being seen as the professional who is better equipped to handle patient care issues, including optimally placed within the health care arena to preventive and chronic care. With a long-term relationship ensure appropriate and safe use of medication, developing between patient and facilitator, the patient by providing enhanced clinical services. Unfor- would receive better coordinated care and better access tunately, pharmacists have historically provided to other providers. their consultation services free of charge, con- the idea of a pharmacist being the facilitator of the pri- tributing to the lack of value attributed to clinical mary care medical home is currently being explored. There services. It is important for those who want to see is strong evidence to support this role, as the pharmacist is change to continue—or start—lobbying health key to promoting increased awareness and to improving out- care policymakers, to ensure that pharmacists comes related to medication management. The infrastruc- are seen as indispensible members of the health ture of pharmacy networks already exists within the commu- care team, and thus deserving of reimbursement nity and is easily accessible in most communities. Year after for their cognitive services. year, pharmacists are consistently rated among the most Once pharmacists are recognized as a trusted professions and are recognized as competent health critical member of the health care team by pay- care professionals. Taking into account the central role ers, their role as a provider may be increased. medication plays in a patient’s overall approach to achiev- Pharmacists can help to eliminate the poor ing good health outcomes, a pharmacist seems the logical management of disease states that results from choice to be the key player in developing a primary care fragmented care. The solution to uncoordinated medical home. The patient would schedule drug therapy

www.americaspharmacist.net October 2010 | america’s Pharmacist 71 monitoring with the clinical pharmacist at the pharmacy service to constantly and consistently document between physician visits or, in some models, at the clinic in all interventions and perform outcomes assess- conjunction with the clinic visit. The pharmacist would be re- ments, as listed in the core elements. sponsible for a variety of functions, including blood pressure monitoring, blood glucose screening, lipid test administra- HOW DO WE PREPARE? tion, and overall assessment of the medication regimen as The Joint Commission of Pharmacy Practitioners, related to disease states. These are functions that phar- a group of chief executive and chief elected macists are currently performing as part of providing MTM officers of 11 national pharmacy organizations, services. The pharmacist would then document relevant developed the Future Vision of Pharmacy Practice information from the encounter, ideally using an EHR-capa- 2015. This document states that “Pharmacists ble system allowing the primary care provider instant access will be the health care professionals responsible to the new lab data and pharmacist notes. This system could for providing patient care that ensures optimal be an extension of an existing MTM platform being used medication therapy outcomes.” It is commonly by the pharmacy. It seems apparent that pharmacists are recognized that the population is aging as a ideally situated within the community setting to play a central result of longer life expectancy, and an increased role in the primacy care medical home. As well as having the number of elderly will be living longer. It has been necessary clinical skills and knowledge, pharmacists are at a estimated that the number of people older than key position to reduce overall health care costs by managing 65 will double from the year 2000 to 2030. This complex medication regimens. will increase the need for greater care in settings the challenge to implementing these services in the such as patient homes, assisted living facilities, community pharmacy setting is building a business model skilled nursing facilities, and group homes. Thus, that ensures successful MTM services delivery. Developing the community-based practice model for phar- a business plan is the first step toward implementing MTM macy will become increasingly important as this services, and several considerations are required before aging of America continues. More point-of-care finalizing it. First, it is imperative to remember that quality testing may be required in this type of practice, patient care is always the main goal. Know your patient with pharmacists measuring the outcomes of population and their individual needs. The MTM service more chronic disease states such as diabetes, may include any of a number of services, such as vac- hypertension, and hyperlipidemia. cinations, risk assessments, diabetes education, compre- it will be essential for future pharmacists hensive medication review, case management, chronic to be knowledgeable in the field of geriatrics care management, and wellness and self-care measures. and proficient at implementing evidence-based Consider workflow and where the services can be imple- medicine. Often a gap exists between evidence- mented. Will appointments need to be scheduled, or could based medicine and what actually happens in patients request your services on a walk-in basis? Identify the community. Pharmacists are ideally situated payer sources, which may include a list of Medicare Part to make a major impact in this area by improving D plans, other health plans, medical practices, and grant standards of care, based on current literature. funding. Identify key associations or other health care pro- As discussed previously, health care is often fessionals to partner with to help build your services. This fragmented, with a resultant increase in medica- will also aid in resource utilization. Be aware of all costs as- tion errors and inadequately treated patients. The sociated with every aspect of the service, including salary, urban population has been noted to suffer from training, and other overhead expenses. Finally, an effective an increased prevalence of chronic conditions as marketing plan is important in making the service a suc- a result of poor access to health care. It has been cess. This may include physician detailing, community postulated that 75 percent of the population will education programs, or in-store advertisement. The key to live in urban areas by the year 2030. Consumers being successful is to document to the payers your return are beginning to take a considerable amount of on their investment. This makes it essential for any MTM ownership for their health care and have become

72 america’s Pharmacist | October 2010 www.americaspharmacist.net increasingly intolerant of mistakes. With the cy of the different health care disciplines. As noted earlier, continued aging of the population, there will be the full value of a pharmacist beyond the role of dispensing a greater need to focus on the quality of life and medications has not yet been realized. Many practitioners the cost of chronic diseases. Pharmacists need are unaware of the depth of the contributions a pharma- to be prepared to work within systems to improve cist can make to improve patient outcomes. Pharmacy health care quality and patient safety. There education is empowered to take a lead role in strengthen- will be a need to critically evaluate the scientific ing a pharmacist’s image. The pharmacist will need to be literature and use evidence-based approaches to seen as a fully valued member of the health care team optimally treat patients. Pharmacists need to pro- to establish MTM services, along with being effectively mote self-care and encourage healthy lifestyles compensated for these services. Inter-professional educa- to prevent complications from chronic diseases. tion experiences will be crucial to enabling the pharmacy Patients need to empower themselves to take student to see the value and appreciate each discipline’s the initiative to optimize their own care in order to unique contributions to the overall care of the patient. promote positive outcomes. along with a focus on inter-professional course work, Pharmacy educators should provide suf- an emphasis on competence in meeting the demands of ficient educational and clinical experiences to the aging population will need to be incorporated into the prepare pharmacists for the upcoming chal- pharmacy curriculum. This includes competence in the lenges. Educators should serve as a resource field of geriatrics, palliative care, public/population health for conducting research in community pharmacy domains, urban health needs, alternative medicines, ethics, and prepare students to incorporate a facet of and using scientific technology effectively. There will be an this research into their own future practice sites. increased need to develop more community-based educa- Population health issues represent an ideal col- tion and training sites, and unique areas that encourage laboration for interdisciplinary education oppor- community-based research. Pharmacists should be trained tunities, not only in the pharmacy curriculum but to be effective facilitators of MTM services, including also in research. Innovative methods will need to implementing, evaluating, and obtaining reimbursement for be developed to successfully integrate new tech- them. All of these items will continue to be a challenge with nological advances into the pharmacy curricu- the ever-growing need of pharmacists to become health lum. The continued growth of informatics, leading educators at a college of pharmacy. to health information exchanges, will profoundly the education and professional growth of a phar- affect many practice environments. Pharmacists macist does not end upon graduation from pharmacy must be equipped to handle these technologi- school. As the demands on pharmacists to become a more cal advances to be a successful member of the integrated and valued member of the health care team diverse health care team. The world functions increase, the profession must strive to maintain continual today by having the patient physically seek out professional development (CPD). CPD is defined by the medical services. As the population ages, there International Pharmaceutical Federation as “the responsi- will be an increasing need to move theses ser- bility of individual pharmacists for systematic maintenance, vices to the patient. Pharmacists must prepare development and broadening of knowledge, skills and for these innovations and commit to self-directed attitudes, to ensure continuing competence as a profes- learning, if they are to be successful. sion, throughout their careers.” Pharmacists who engage With the implementation of MTM services, in CPD commit to the development and broadening of their there is an increasing need for pharmacists who knowledge and skill base to ensure their competency as practice in a patient-center care environment. The pharmacists throughout their careers. The elements of a need for this specialized competency will further successful CPD program include self-directed learning and impact the state of pharmacy education. As a outcomes-focused development of knowledge, skills, and result of these higher-level clinical services, there attitudes to ensure professional competence. Pharmacists will be an increasing need for the interdependen- are presented with an enormous challenge: not only to

www.americaspharmacist.net October 2010 | america’s Pharmacist 73 establish their position as an essential and valued member greatly improve outcomes and decrease costs. of the health care team but also to challenge themselves to Interventions at the community level to reduce maintain professional competency, in order to function with behaviors that promote chronic diseases have this higher level of clinical skill set. shown high levels of return on investment. The current structure of the health care system IMPACT OF HEALTH CARE REFORM has incentives in place to treat illness once it ON MTM SERVICES develops, as opposed to preventing or delaying Compared with other developed countries, the United its occurrence. Only a few health care policies States has been criticized for the inefficiency, poor out- encourage wellness and prevention. To create a comes, and costs associated with the delivery of U.S. more efficient system, the United States needed health care. This is partly due to low accessibility to medi- a health care system overhaul that would ad- cal care for a substantial portion of the population. The dress patient safety and efficacy, provide cover- fragmented delivery system also leads to excessive costs age for uninsured and underinsured Americans and administrative waste. There is agreement among that cannot afford better health coverage, and patients and providers that the U.S. health care system meet the needs of an aging American popu- should be more efficient and more accessible, although lation. On March 21, 2010, the U.S. House the means to provide universal coverage for all U.S. of Representatives passed H.R. 3590—The citizens—regardless of employment, disability status, or Patient Protection and Affordable Care Act— age—is the subject of debate. Ideally, a reformed health designed to do just that. care system should integrate preventive health, acute changes relating to the Medicare Part D care, and chronic medical care, along with public health “donut hole” will reduce the amount that Medi- and population health initiatives. Currently, only a small care Part D enrollees are required to pay for percentage of health care dollars is invested in preven- their prescriptions when they reach the cover- tive health, despite evidence that such investments can age gap, gradually phasing in different levels

Table 4. Section 3503: Medication Management Services in Treatment of Chronic Diseases Provisions Reform Measures Establishes a New Medication Therapy Management • Provides grants to eligible entities to implement Grant Program MTM services provided by licensed pharmacists, as a collaborative, multidisciplinary, inter-professional approach to the treatment of chronic diseases. Defines Targeted Individuals (meeting one of the four • Takes 4 or more prescribed medications criteria) • Takes any “high risk” medication • Has two or more chronic diseases • Has undergone transition of care or other factors likely to create a high risk of medication related problems

Secretary Will Submit a Report on Quality Measures • Assess clinical effectiveness of pharmacist-provided services • Assess change in overall health care resources • Assess patient and prescriber satisfaction with MTM services • Assess impact of patient-cost sharing requirements on medication adherence • Identify other factors that may affect clinical and economic outcomes

74 america’s Pharmacist | October 2010 www.americaspharmacist.net Table 5. Section 10328. Improvement in Part D Medication Therapy Management Programs Provisions Reform Measures Plan Sponsors Must Offer MTM Services to Targeted • Annual Comprehensive Medication Review (CMR) Beneficiaries • Follow-up interventions warranted based on findings of CMR

Sponsors Must Assess the Beneficiaries Not Enrolled • Sponsors must assess on a quarterly basis the in the MTM Program medication use of at-risk individuals, including those who have undergone a transition of care (if plan has access to that information) • Automatically enroll those not previously in program if considered high risk • Allow such beneficiaries to refuse service of subsidies for brand and generic drugs. Be- sides defining targeted individuals, this section specified ginning in 2011, patients in the donut hole will certain criteria for an MTM service. This provision stated receive an automatic 50 percent discount on that MTM services should include formulation of a medi- the price of their brand name medications. By cation treatment plan consistent with the therapeutic 2020, 75 percent of the cost of generic drugs goals agreed on by the patient and prescriber. The phar- in the gap will be subsidized by manufacturers, macist is permitted to select, initiate, and monitor any and Medicare and beneficiaries will pay the medication therapy as allowed by state law, including remaining 25 percent. applicable collaborative pharmacy practice agreements. in addition to these reform initiatives, the Performing an initial comprehensive medication review specific issue of MTM services was also ad- is required to identify and resolve any preventable medi- dressed by the Patient Protection and Afford- cation related problems. This also included quarterly able Care Act. In particular, it was important targeted medication reviews for ongoing monitoring or to the pharmacy community to establish as deemed necessary by the provider. Documentation is pharmacists as vital players in any collabora- required of all communication, including a summary of tive care model, and to include pharmacists in the medication review and the recommendations of the a payment structure for any transition of care pharmacist to other appropriate health care providers in activities. Another goal was to ensure that a timely fashion. pharmacists were provided with the resources as part of the MTM services, a pharmacist is required necessary to establish and support MTM to provide appropriate educational materials designed to services in any health plan and request grant enhance the patient’s knowledge of the medication regi- funding to aid in the development of these ser- men. The pharmacist is also responsible for coordinating vices. Section 3503 addressed MTM services and integrating MTM services within the broader health care in treatment of chronic diseases, and Section management team. This grant program is not yet funded 10328 addressed improvement in Part D MTM and the focus of the grants remains to be determined. programs. Tables 4 and 5 illustrate the key pro- section 10328 (Table 5) addressed improving MTM visions associated with these sections. Section programs in relation to Medicare Part D. The section 3503 addressed the issue of MTM services addressed those who were currently receiving MTM by providing grants or contracts to implement services, adding new required interventions, as well as MTM provided by pharmacists, to improve the those who did not currently receive services. For those clinical and economic outcomes of chronic beneficiaries who are not receiving any MTM services, diseases. Requirements for targeted individu- the plan is now required to assess these patients on a als were defined as illustrated in Table 4. Be- quarterly basis to see if they become eligible for MTM

www.americaspharmacist.net October 2010 | america’s Pharmacist 75 to opt out of enrollment in the MTM program. Case Study At a minimum, the MTM services offered by a Mary Moe is an active 67-year-old female with a history of hy- pertension, diabetes, and dyslipidemia. She also suffers from plan sponsor to beneficiaries must include a mild heartburn and has an occasional backache for which comprehensive medication review (CMR) by a she uses ibuprofen. Until recently, she has not had any com- licensed pharmacist or other qualified provider. plaints. Over the past two weeks, she has noticed that her This intervention must be person-to-person, blood glucose readings have been 140–150 mg/dl when she or by using telehealth technologies, and the takes them in the morning before breakfast. As you begin beneficiary must be provided a written summary talking with Mary, you realize she knows very little about her medications except that she takes them to stay healthy. You of the interaction. learn that she just enrolled in a Medicare Part D Program. She seems to have a lot of questions about her medication, CONCLUSION but she is not sure whom to talk to about them. There is no doubt that the role of a pharmacist is so much more than dispensing a product, Her current medications: and many pharmacists in the community are Metformin 500 mg BID Lisinopril 10 mg daily key players in patient-centered care. With the HCTZ 25 mg QAM aging of the U.S. population, it is crucial to Ibuprofen 200mg 1–2 Q4-6H PRN implement systems that improve clinical and Simvastatin 20 mg QHS economical outcomes. There is a critical need Centrum Multivitamin QD to increase access to health care and decrease the fragmented delivery of health care. Case Questions: 1. Does this person meet the criteria to be eligible for a Medication regimens have become a key com- CMR? ponent of medical care. These regimens have 2. What aspects of the CMR are you required to perform? increased in complexity, and a need for moni- 3. Would you be compensated for your follow-up visits? toring this therapy to improve outcomes and decrease costs has become apparent. Phar- Answers: macists have the most comprehensive knowl- 1. Yes, she does meet the criteria to be eligible for a CMR. According to Section 3503, which defined targeted indi- edge regarding medication therapy, and this viduals, she meets two of the four criteria. She takes four expertise makes them an indispensible agent or more prescribed medications (including over-the-coun- to provide MTM services. With the higher level ter products). Participants are also eligible if they have two of pharmacy education and increased clinical or more chronic diseases. This patient has three chronic skill level of pharmacists, they are in a position disease states: hypertension, diabetes, and dyslipidemia. to provide these services to patients. The role 2. An annual CMR should be furnished person-to-person, if possible, so it would be a good idea to schedule a meet- of the pharmacist as one of medication man- ing time with Mary. The CMR must include a review of the ager has become more accepted in the eyes of individual’s medications with the creation of a medication the patient and provider, along with the payer. action plan. The beneficiary is then provided with a written With the health care reform act supporting the or printed summary of the results. implementation and delivery of MTM services 3. Yes, if after consulting with Mary you felt it would be by pharmacists, the profession is likely to see necessary to consult her primary care physician about her uncontrolled blood sugars or any other issue you think is a vast array of opportunities to truly practice pertinent, you would be compensated for any follow-up. to the best of their ability to improve quality of patient care in the health care system.… services. This includes those who have experienced a transition in care, if the sponsor has access to such infor- Stacey R. Schneider, PharmD, is an assistant professor of mation. Plan sponsors are required to automatically enroll pharmacy practice at Northeastern Ohio University’s Col- targeted beneficiaries, who are subsequently permitted leges of Medicine and Pharmacy in Rootstown, Ohio.

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Continuing Education Quiz 5. Which professional organization developed a set Select the correct answer. of MTM guidelines focused on coordination of care, outcomes assessment, establishing patient eligibility, 1. Which of the following was the first piece of and an interdisciplinary approach to patient care? legislation that required Medicare Part D insur- a. APhA ers to provide medication therapy management b. NACDS (MTM) services to selected beneficiaries? c. AMCP a. The Medicare Prescription Drug, Improve- d. NCPA ment, and Modernization Act of 2003 b. The Patient Protection and Affordable Care Act 6. According to the studies that looked at current MTM c. The Health Care and Education Reconcilia- services in the community pharmacy setting, which of tion Act the following was NOT a finding of these studies? d. Omnibus Budget Reconciliation Act of 1990 a. The average age of the patients receiving MTM services has continued to increase. 2. Which government agency is required to ap- b. Patient refusal of MTM services has continued to prove MTM programs? increase. a. Agency for Healthcare Research and Quality c. There was a decrease in interventions for acute b. Agency for Healthcare Administration medications and an increase in interventions for c. Centers for Medicare & Medicaid Services chronic medications. d. Advisory Council on Medicare Part D Program d. MTM interventions have shifted from patient educa- tion to more prescriber consultation. 3. Which of the following is NOT considered a core element of an MTM program? 7. In 2010, CMS revised the requirements for a Medi- a. Medication Therapy Review care Part D program. At a minimum, sponsors had b. Personal Medication Record to target at least four of the seven defined chronic c. Medication Action Plan disease states. Which of the following was NOT listed d. Coordination of Care Documentation as a chronic disease state? a. Bipolar disorder 4. What statement best describes Medication b. Asthma Therapy Management? c. Osteoporosis a. It’s a tool used to describe the delivery of d. Hypothyroidism information to the patient to ensure safe and effective use of prescription medication. 8. All of the following have been cited as a barrier or b. It’s a program used to describe a broad challenge to providing MTM services, except: list of services that is patient-specific and a. Uncertainty in reimbursement focuses on the patient’s broad drug therapy b. Varying requirements by health plans needs. c. Lack of clinical expertise, or inadequate training c. It’s a program that delivers complex medica- d. Understaffing tion consults but does not focus on health and wellness services. d. It’s a mechanism to deliver patient knowl- edge and resources necessary for the patient to manage a particular disease.

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9. Which of the following is true regarding the perception 12. Due to the aging of the population, the Joint of MTM services in the community setting? Commission of Pharmacy Practitioners sug- a. Patients were generally favorable of participating in an gests that pharmacists will need to increase MTM program, stating that pharmacists were easy to their knowledge and skill levels to be comfort- approach and had more time to answer their health able to practice in which of the following loca- care questions. tions? b. Physicians remain skeptical of the services and are not a. Skilled nursing facilities or group homes in favor of pharmacists delivering such services. b. Emergency rooms c. The patients were not supportive of MTM services c. Rural communities because they felt the relationship they had with the d. Surgery centers pharmacist was not applicable to foster these types of programs. 13. Challenges pharmacy educators may face d. Payers were supportive of these services despite the in preparing pharmacists for future practice fact that there has been no documentation relating to include all of the following except which? cost avoidance and improved medication adherence. a. Increasing assessment of acute diseases in the curriculum 10. Which of the following is true regarding the concept b. Successfully integrating new technological of the primary care medical home? advances into the curriculum a. Numerous practitioners would be responsible for facili- c. Preparing students to incorporate research tating continuous care for the patient and maintaining into community practice sites the centralized database system. d. Population health issues as an opportunity b. The medical home model has never been shown to for inter-professional education improve outcomes. c. A potential advantage of this model is use of electronic 14. Which of the following is NOT an element of health records (EHRs), allowing patients to be seen a successful continuous professional develop- by various health care providers at connected practice ment (CPD) program? sites. a. Self-directed learning d. Practicing health care in this way would lead to frag- b. Commitment to maintain professional com- mentation of patient care. petency c. Maintaining a broad base of knowledge and 11. Which of the following is true when building a busi- skills ness model to ensure the success of an MTM service? d. Online testing to avoid live CE programs a. The only measure of success is increased revenue. b. Look at the population as a whole to determine broad 15. Which of the following would be considered patient needs. a goal of health care reform? c. It is not necessary to measure wellness and patient a. Limit coverage self-care outcomes. b. Improve quality of health care d. Examining the current workflow is important. c. Increase costs d. Increase revenue

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Medication Therapy Management: 16. How much has the change in the Medicaid An Evolution of Change generic drug reimbursement plan been projected Oct. 1, 2010 (expires Oct. 1, 2013) • Activity Type: Knowledge-based to increase revenues in the community pharmacy? FREE ONLINE C.E. Pharmacists now have online access to NCPA’s a. $5 billion C.E. programs through Powered by CECity. By taking this test online— b. $10 million go to the Continuing Education section of the NCPA Web site (www. ncpanet.org) by clicking on “Professional Development” under the c. $3 billion Education heading you will receive immediate online test results and d. $10,000 certificates of completion at no charge.

To earn continuing education credit: ACPE Program 207-000-10-010-H04-P 17. Beginning in 2011, patients in the “donut A score of 70 percent is required to successfully complete the C.E. quiz. hole” will receive what percentage discount on If a passing score is not achieved, one free reexamination is permitted. the price of their brand name medications? Statements of credit for mail-in exams will be available online for you a. 50 percent to print out approximately three weeks after the date of the program (transcript Web site: www.cecerts.ORG). If you do not have access to a b. 25 percent computer, check this box and we will make other arrangements to send c. 65 percent you a statement of credit: q d. 75 percent Record your quiz answers and the following information on this form. q NCPA Member License 18. Which section of the Patient Protection and NCPA Member No. ______State ______No. ______q Nonmember State ______No. ______Affordable Care Act addressed improvements in All fields below are required. Mail this form and $7 for manual processing to: MTM programs in relation to Medicare Part D? NCPA C.E. Processing Ctr.; 405 Glenn Drive, Suite 4; Sterling, VA. 20164 a. Section 3502 ______b. Section 3503 Last 4 digits of SSN MM-DD of birth ______c. Section 10320 Name ______d. Section 10328 Pharmacy name ______Address ______19. Which section of the Patient Protection and City State ZIP Affordable Care Act established a grant pro- ______Phone number (store or home) gram to support MTM programs? ______Store e-mail (if avail.) Date quiz taken a. Section 3502 Quiz: Shade in your choice b. Section 3503 a b c d e a b c d e c. Section 10320 1. q q q q q 11. q q q q q d. Section 103258 2. q q q q q 12. q q q q q 3. q q q q q 13. q q q q q 4. q q q q q 14. q q q q q 20. According to the new health care reform 5. q q q q q 15. q q q q q act, which patient would be targeted to receive 6. q q q q q 16. q q q q q MTM services? 7. q q q q q 17. q q q q q a. A patient with diabetes only 8. q q q q q 18. q q q q q b. A patient with diabetes who recently experi- 9. q q q q q 19. q q q q q 10. q q q q q 20. q q q q q enced a diabetic foot ulcer c. A patient who is taking lisinopril and hydro- Quiz: Circle your choice chlorothiazide only 21. Is this program used to meet your mandatory C.E. requirements? a. yes b. no d. A patient who has recently moved from an 22. Type of pharmacist: a. owner b. manager c. employee assisted living facility to a skilled nursing 23. Age group: a. 21–30 b. 31–40 c. 41–50 d. 51–60 e. Over 60 facility 24. Did this article achieve its stated objectives? a. yes b. no 25. How much of this program can you apply in practice? a. all b. some c. very little d. none

How long did it take you to complete both the reading and the quiz? ______minutes

NCPA® is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. NCPA has assigned 1.5 contact hours (0.15 CEU) www.americaspharmacist.net of continuing education credit to this article. Eligibility to receive continuing education credit for this article expires three years from the month published. pharmacy Marketing

The Five Fundamental Principles of Success By Dan Benamoz, RPh

This is the second in a series of The more you help others—the articles designed to shift your current greater your own success perspective on marketing by provid- This principle focuses on putting the best ing vital information to enhance your interest of your patients and customers ahead knowledge.You can apply this infor- of your own, without focusing on the financial mation to grow and build a successful outcome of the transaction. When people trust and prosperous pharmacy in today’s that you have their back—that you are there for rapidly changing environment. them—they learn to depend on you. If people if you don’t have the most convenient location, hours, rely on you, and you meet or exceed their ex- or product selection, why would a customer or prospect pectations, they will have no reason to change decide to do business with you? The answer lies with the their shopping habits. This personal touch far five common business principles used effectively by the outweighs the occasional item that may be most successful pharmacies in the country. priced lower in a local chain store.

People don’t care how much you know little things separate ordinary —until they know how much you care from extraordinary While customers value knowledge, their connection with While everyone is looking for home-run ideas those that genuinely care about their well-being is as to catapult their business to success, we often valuable as—and, in many cases, more valuable than forget basic, tried-and-true retailing fundamen- —knowledge alone. The mass merchandising business tals. Merchandise selection, presentation, and model doesn’t focus on developing genuine relation- signage, along with store staff appearance and ships with customers. And it is this gap where you have demeanor, are simple to manage and leave the the unique opportunity to differentiate yourself from your customer with a positive experience overall. Even competition in the marketplace. choreographing the customer’s experience in there are a number of effective ways to show custom- advance— from how you answer the phone to ers that you care. Do you step from behind the counter how they are greeted and treated while in your and touch their shoulder, for example? Sometimes a hug, store— affords you small ways to streamline the taking a moment to listen to them, or even holding their process, ensuring the customer is satisfied with hand will express to them how much you care. A personal their shopping experience with you. phone call or note by mail now and then makes a lasting impression. Don’t discount the idea because you think Consistent execution is a you don’t have time. Even the best and busiest in our competitive advantage industry have found effective ways to implement these Touching your customer in a caring way occa- ideas because, in applying this principle, they have seen sionally during their visits to your store will not a jump in business growth and prosperity. move you toward the lasting relationship you desire. They don’t know what they can count on or expect with you. A great example of this is Mc-

82 america’s Pharmacist | October 2010 www.americaspharmacist.net Donald’s. We each know exactly what we are getting each and every time we order. Consider the idea that it is the con- sistency of service, not the product, that made McDonald’s the most successful restaurant in the history of that industry. measure it, manage it, improve it The common denominator of the best in the business is find- ing ways to quantify everything. If it’s measured, performance can be tracked. Then corrections can be made quickly, and the effectiveness of those corrections can also be measured. for more information on execution, feel free to request additional information at our website, www.pharmacy-own- ers.com. To read the full version of this article and to leave comments, please visit our blog: www.pharmacyowners. com/blog.…

Dan Benamoz, RPh, is a multi-store owner and founder and president of Pharmacy Development Services (PDS), which provides business coaching and marketing ideas and strategies to independent pharmacy owners nationwide. rx tECHNOLOGY

The Survey Says: Pharmacists Want MTM Integration By Bill G. Felkey

As reported previously, would be possible between pharmacies and the NCPA Technology and In- MTM plans. Pharmacists would also be prompt- novation Committee members are ed to seek patient consent and participation working hard to provide help to with the MTM process. This could take place pharmacists and the technology during a scheduled appointment, or while they vendor community to prioritize their are waiting for other prescription dispensing ac- development efforts on behalf of tivities to take place in the pharmacy. The new the profession. At the time of this standard is undergoing testing, and it is hoped writing, one survey has been deployed and another that the positive response from pharmacists in has been launched to collect responses from pharma- this and subsequent surveys will help encour- cists regarding the integration of medication therapy age rapid implementation of the MTM standard management into their practice management systems by the vendor community. and workflow. The first survey began by asking, “Would the first survey also asked a series of open- you like to have an integrated feature in your pharmacy ended questions to ascertain what other fea- management system to identify patients qualifying for tures pharmacists desired from the technology an MTM [medication therapy management] encounter?” they employ to make them more efficient and Of the 272 pharmacists who responded, 94 percent effective. Some were critical that their practice indicated that they would desire this feature. Pharma- management vendors had not yet provided any cists who are currently providing MTM to patients must support for the delivery of MTM services. Other access external websites, e-mails, or respond to a fax pharmacists who had MTM support in their that represents the existing communication channels systems also expressed a need for increased available to the profession. integration of billing tools associated with reim- On the first survey, a second question helped to bursement for these services. This is the focus determine if the addition of this integrated feature would of the second survey, which NCPA members will make it more likely that pharmacists would participate be able to use to voice their opinions related to in offering MTM programs. This question received a 95 this matter of MTM reimbursement. percent positive response from those pharmacists who indicated a desire for the new feature. The great news is Technology Track Returns that a standard for achieving this additional functionality for Convention has already been published by the American Society for Other input from the survey was used by the Automation and Pharmacy (ASAP). Once this standard- Technology and Innovation Committee to form a ized communication channel has been implemented by special technology track at NCPA’s Annual Con- pharmacy practice management vendors, then a bidi- vention, Oct. 23–27, 2010 in Philadelphia. Ken rectional flow of data such as a current drug profile to be Whittemore of SureScripts will provide updates reconciled and MTM services required to be performed to attendees on electronic prescribing of con-

86 america’s Pharmacist | October 2010 www.americaspharmacist.net trolled substances. This session will be followed a special pharmacist panel will help determine the by a panel of mobilized pharmacists who will appropriate time to adopt technology such as workflow discuss how they use portable information ap- technologies according to prescription volume, and the pliances and other peripheral technologies that focus of an individual practice. This should help phar- they have integrated into their workflow. macists realize the full potential for their investment in health care reform has introduced new technology systems. We are also planning a special requirements for pharmacists to protect the joint session with the NCPA Communications Commit- HIPAA security rights of patients. There will be tee to demonstrate how social networking tools can be several practical suggestions offered on how incorporated appropriately into a practice. I will begin the to avoid severe penalties that come from a session by giving an overview of what’s available. It will classification of action called willful neglect. I be followed by a demonstration from Tim Davis about the will be presenting a session on how to meet the features and benefits benefiting his progressive phar- demands for pharmacy connectivity that are macy practice. Also, Scott Halverson, a 2011 PharmD emerging from health systems and positions as candidate at the University of Missouri-Kansas City they prepare for health care reform. I will also School of Pharmacy, will offer step-by-step instructions on present a newly created a set of tools avail- building some of these steps by taking a pharmacist from able in an online Technology Resource Center the audience and helping that person build a promotional created by NCPA that will include substantial pharmacy Facebook page in only 30 minutes.… technological assistance for the understanding, selection, evaluation, and adoption of support- ive technologies available to the community Bill G. Felkey is professor emeritus at Auburn University’s Harrison pharmacy practice. School of Pharmacy. pharmacy management

Pharmacy Ownership— Open Brand New, or Purchase (Part II)? By Andy Oaks

Do I open from scratch or the upper hand and is more likely to charge an purchase an existing pharmacy? inflated price. It’s a critical question that aspiring after both parties have agreed to the sales owners need to answer. In Part I price, the next step is to get the deal funded. In last month, it’s a question I began all likelihood, the buyer will look to seek funding exploring by giving conditions from a lending source for a large portion of the and considerations if you were to amount of the purchase. The lending source choose the “start from scratch” or financial institution will require that you have route. If you aspire to purchase an already existing prac- cash or collateral or both, along with a formal tice, it presents a different set of challenges and advan- business plan explaining in detail how the debt tages. Part II will explore the pros and cons of that option. will be serviced over the term of the loan. Again, there are several key factors to consider when look- there are a number of different and creative ing to buy an existing pharmacy: financing options/products in the marketplace • Identify the opportunity. to consider. When deciding to purchase an • Determine if the deal is right. existing business in lieu of opening a new one, • Obtain funding. the most significant difference is that it usually • Plan and manage for success. takes a much larger sum of capital or access to capital to do the latter. Purchasing an existing pharmacy has its unique Once funding has been secured and the challenges. To begin with, you must identify or locate an deal has been finalized, it’s time to manage the operation for sale. This task is not too difficult given the plan to the numbers for long-term success. In- collective number of resources in the marketplace that terestingly enough, this same aspect holds true can help identify/locate operations for sale. Once this has for either scenario. Having a formal business been done, the more complicated task is to determine plan and managing it to the numbers is the the market-right price or value of the operation you wish key to success for both an upstart and existing to purchase. business. However, in purchasing an existing there are a number of formulas used in the market business, the debt or financial responsibilities to determine the value of a retail pharmacy practice. are usually much higher; thus it’s more costly if From the buyer’s perspective, the objective is to reach mistakes are made. an agreement with the seller so that the deal gets done. Purchasing an existing pharmacy operation Once again, there are a number of resources in the mar- usually involves greater risk than opening a new ketplace to assist in these negotiations, in determining a one. But done correctly, the risk is manageable fair price. If you are a buyer, you must be sure to be well and an existing business has its advantages informed and know that the agreed-on selling price is in over an upstart. The most significant are: line with documented and validated financial and other Immediate Cash Flow—An established busi- business performance reports. Otherwise, the seller holds ness has already endured the growing pains

90 america’s Pharmacist | October 2010 www.americaspharmacist.net of an upstart operation. Sales volume and profit margins portunities, timing, knowledge, desire, financ- should be at levels sufficient to cover cost of goods sold, es, geography, and other factors all play vital payroll, and operating expenses while servicing the debt roles. Putting them all together in the manner incurred in purchasing the business. that best fits with personal and professional Immediate Earnings—If the business was purchased at goals is the key to success. It is easier said the right price and with the right terms, the operation should than done, but nevertheless a reality today for produce bottom-line profits. The key is to know the his- thousands of independent pharmacy owners tory of all line items that make up the formal business plan who share that entrepreneurial spirit and an (operating budget) and to make any necessary adjustments overwhelming desire to serve.… once transitioned into new ownership and operation. Systems/Staff Already in Place—Requiring much less time implementing, training, and developing systems and Andy Oaks is the president of Retail Pharmacy Manage- staff than a start-up operation, an existing business has ment Services, Inc. RPMS provides solutions and support computer systems, communication/telephone systems, and to independent pharmacists throughout the United States. personnel needed to run the business. For additional information, visit www.rpms.biz. For inqui- Wealth building—Good deals properly acquired and ries about this article, please contact Oaks at 800–662– managed can be a faster track to prosperity than going the 9035 or [email protected]. upstart route. Once these skills have been mastered, rep- lication of efforts has proven effective in meeting financial goals of many multi-store independent pharmacy owners. many factors are involved in determining the best route to take in becoming an independent pharmacy owner. Op- Reader Resources NCPA activities and our advertisers

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Statement of Ownership, Management, and Circulation 1. Title of Publication: America’s Pharmacist Issue date for Circulation Data, herein: Average No.Copies Actual No. Copies of 2. Publication No.: 535-410 August 2010 of Each Issue During Single Issue Published 3. Date of Filing: August 27, 2008 Preceeding 12 Months Nearest to Filing Date 4. Frequency of Issue: Monthly 5. No. of Issues Published Annually: 12 A. Total No. copies 24,115 24,200 6. Annual Subscription Price: $50 7. Complete Mailing Address of Known Office of B. Paid and/or Requested Circulation Publication: 100 Daingerfield Road, Alexandria, Virginia 1. Paid/Requested Outside-County Mail 17,112 16,627 22314-2885 Subscriptions 8. Complete Mailing Address of the Headquarters of 2. Paid In-County Subscriptions None None General Business Offices of the Publisher: National Community Pharmacists Association, 100 Daingerfield Road, 3. Sales Through Dealers None None Alexandria, Virginia 22314-2885 4. Other Classes Mailed through USPS None None 9. Full Name and Complete Mailing Address of the Publisher, Editor, and Managing Editor: C. Total Paid and/or Requested Circulation 17,397 17,927 Publisher—National Community Pharmacists Association, D. Free Distribution by Mail 100 Daingerfield Road, Alexandria, Virginia 22314-2885 1. Outside-County 6,159 5,673 Editor—Michael F. Conlan, (703) 838-2688 Managing Editor—Chris Linville 2. In-County None None 10. Owner: National Community Pharmacists Association, 100 3. Other Classes through USPS None None Daingerfield Road, Alexandria, Virginia 22314-2885 4. Free Distribution Outside the Mail 559 600 11. Known Bondholders: None 12. The Purpose, Function, and Nonprofit Status for E. Total Free Distribution 6718 6273 Federal Income Tax Purposes: Has not changed during the F. Total Distribution 24115 24200 preceding 12 months G. Copies Not Distributed None None H. Total 24115 24200 I. Percent Paid and/or Request Circulation 72% 74%

www.americaspharmacist.net October 2010 | america’s Pharmacist 95 Notes from capitol hill

Doing Your Part in the Midterm Congressional Elections By Michael F. Conlan

ids are back in school, fall has begun, and Democratic seats reached 60—the number Election Day, Nov. 2, will be here before we needed to defeat a filibuster. know it. Election days have been important But now as we approach Nov. 2, the political to independent pharmacy owners ever since landscape has shifted dramatically. Although several hundred of them met in the banquet swinging 39 seats is a mighty task for Republi- Khall of the St. Nicholas Hotel in St. Louis in 1898. They cans to regain rule in the House, most political were spurred to form an organization to represent the analysts now consider it very possible. A party professional and proprietary interests of independent change in the Senate is considered less likely pharmacy owners by congressional action. Congress (though not impossible), but a 60-vote super- had levied a stamp tax on proprietary medicines and majority is out of either party’s grasp. cosmetics to help finance the Spanish-American War. “Both the manufacturers and wholesalers had found a way Our lobbying and to pass the tax on to pharmacists,” wrote C. Fred Williams in A Century of Service and Beyond. “Although the fee was contributions are about minimal, it nevertheless reduced the small margin of profit building relationships— that independent druggists earned. Decades of battling getting to know the right people so department stores, large mail order houses, proprietary we can make our case. medicine companies, physicians who dispensed prescriptions, and aggressive price cutters had left most What all this means is that this midterm community pharmacists with little margin of profit. The election is a pivot point—certainly a scene- stamp tax was the last straw….” setter for the 2012 presidential contest. Your sound familiar? To influence Congress, NCPA main- contributions to the PAC are important and tains an aggressive lobbying presence on Capitol Hill, appreciated. Our lobbying and contributions are supported by a robust political action committee funded about building relationships—getting to know entirely from personal—not corporate—contributions the right people so we can make our case. We from NCPA members. So far this election cycle, the PAC have a good story to tell, and now is the right has raised $1 million. That follows $1.25 millon raised in time to tell it to your congressional candidates. 2007–08. Check the NCPA website for details on is- november 2008 certainly was historic…the election of sues that affect your business, your patients, the first African-American president and the first Roman and your community. Let the candidates know Catholic vice president; the first time the Republican Party where you stand, and ask them to stand with nominated a woman vice presidential candidate; and the you. And, don’t forget to vote. first time in 56 years when neither an incumbent president nor a vice president ran. in the House, Democrats expanded their ranks further Michael F. Conlan is editor of America’s Pharmacist. after regaining a majority in 2006. In the Senate, the

96 america’s Pharmacist | October 2010 www.americaspharmacist.net