america’s SEPTEMBER 2010

Published by the National Community Pharmacists Association PHARMACISTTHE VOICE OF THE COMMUNITY PHARMACIST from to

PHARMACOGENOMICS • Hard Target • CASE FOR ADHERENCE •

www.americaspharmacist.net america’s

PHARMACISTTHE VOICE OF THE COMMUNITY PHARMACIST CONTENTS

Features From the Cover 16 From Good to Great by Jennifer Jelinek, CPhT Taking your pharmacy to the next level through continuous workflow improvement.

20 Pharmacogenomics Opportunities by Tina Schlecht, PharmD, MBA Practical and potentially profitable applications for ‘personalized medicine.’ 24 Hard Target by Richard Logan, PharmD Developing a pharmacy crime prevention strategy requires a preemptive approach.

30 The Business Case for Adherence by Devin Stone Helping patients and the bottom line.

34 In the Long Term, It’s About Care by Chris Linville Attention to detail helps drive success for Grants Pass Pharmacy. Departments 4 Up Front by Doug Hoey, RPh, MBA Meet, learn, succeed in Philadelphia.

2220 6 Newswire Community pharmacies aid patients when mail order can’t deliver. America’s Pharmacist Volume 132, No. 9 (ISSN 1093-5401, USPS 535- 410) is published monthly by the National Community Pharmacists As- 8 The Audit Advisor sociation; 100 Daingerfield Road, Alexandria, VA 22314. © 2010 NCPA®. Inventory audits. All rights reserved.

Postmaster—Send address changes to: America’s Pharmacist, Circulation 10 Inside Third Party Dept., 100 Daingerfield Road, Alexandria, VA 22314; 703-683-8200; info@ Eye on PBMs ncpanet.org. Periodical postage paid at Alexandria, VA, and other mailing offices. Printed in the USA. 12 Foundation Report For membership information, go to [email protected]. For other by Avon Pagon information go to www.ncpanet.org. The reliable neighbor in your community.

2 america’s Pharmacist | September 2010 www.americaspharmacist.net Cover: For pharmacist Deborah Lotspeich of J&D Pharmacy in Warsaw, Mo., an effectively designed workflow system helps her and the entire staff accomplish tasks more quickly and efficiently. Photo by Melissa Pace.

41 Continuing Education by Scott Thomas, PhD, and Michelle Matthews Medicare Part D: a primer for pharmacists.

52 Pharmacy Management by Andy Oaks Pharmacy ownership—open brand new, or purchase?

57 Reader Resources NCPA activities and our advertisers.

58 Notes From Capitol Hill Ask your member of Congress if they will help.

Letters to the Editor—If you would like to comment on an article, e-mail NCPA at info.ncpanet.org. Put AP in the sub- ject line and include your phone number. Your letter may be posted on the NCPA Web site and edited for length and clarity. 24

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 September 2010 | america’s Pharmacist 3 Up front

Meet, Learn, Succeed in Philadelphia

Next month, the NCPA Annual I would especially like to invite pharmacists Convention and Trade Exposition from the mid-Atlantic states to drive in and see will be held in Philadelphia for the for themselves. The Philadelphia Convention fifth time. The city holds a sacred Center and the convention hotels (two Marriotts place in our nation’s history, found- literally across the street) are centrally located ed as a place where people could and convenient to the city’s many attractions. practice their beliefs without fear of New formats this year integrate the popular persecution. The Declaration of In- and always topical government affairs forum dependence and the Constitution were written there, and into the Second General Session. It will feature it served as our temporary capital from 1790 to 1800. two former secretaries of Health and Human Pharmacy’s roots are deep in the city, too. The first Services: Michael Leavitt from the administra- college of pharmacy in North America was founded in tion of George W. Bush, and Donna Shalala, Philadelphia by 16 apothecaries in 1821. Today, there is nominated by Bill Clinton. Another change the Marvin Samson Center for the History of Pharmacy at adds the fun-filled NCPA Foundation Silent the college’s successor, the University of the Sciences. Auction to the opening night celebration. In The American Pharmaceutical Association, the first- addition, the trade exposition will have longer established national professional society of pharmacists, hours so you can meet with your vendors and got its start in Philadelphia in 1852. discover new ones. That fits right in with our If you attend our 112th annual convention Oct. 23–27, convention theme: you can not only see history, you can make it. We truly • MEET old friends and make new ones. believe that the continuing education, networking, and • LEARN from experts in top-notch education idea exchange opportunities can pay dividends for you sessions and from vendors at the most pro- and your pharmacy long after you leave the City of Broth- ductive trade show in the pharmacy industry. erly Love, the Liberty Bell…and Rocky. • SUCCEED with ideas and knowledge to Meet. Learn. Succeed. Those are the reasons phar- better serve your patients and improve your macists tell us why they commit to NCPA’s annual con- bottom line. vention. In turn, NCPA is committed to providing business opportunities for independent community pharmacists Hope to see you there.… through a combination of traditional product dispens- ing in conjunction with patient care that maximizes the appropriate use of the medication. NCPA is committed to developing practical, profitable business solutions. And NCPA, as always, is committed to advocacy— Doug Hoey, RPh, MBA zealously championing the interests of independent NCPA Acting Executive Vice President and CEO community pharmacy in legislative, regulatory, and legal arenas. Our convention programming reflects those values.

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

Community Pharmacies Aid Patients When Mail Order Can’t Deliver

Independent community delivery,” the association NCPA acting executive access to independent pharmacies can help meet said in a letter. “These in- vice president and CEO, community pharmacies patient needs in the face clude eliminating manda- said, “The hand-wringing that can fill the void, even of proposed reductions in tory mail order programs about what losing a day providing home delivery post office services, such that deny patients the op- of mail services means services. Patients over- as ending Saturday mail portunity to receive medi- for patients is overblown, whelmingly prefer the delivery, NCPA has told cations from their local because commonsense face-to-face interaction the U.S. Postal Regulatory community pharmacist, remedies are available with their local pharma- Commission. as well as utilizing home through independent cists, who can improve “NCPA believes that delivery programs where community pharmacies. medication adherence. other options exist to community pharmacists Evidence suggests that So, measures that allow ensure patient access to deliver medications to the Americans, whether they this to occur more often needed medications if patient’s doorstep.” live in densely or sparsely will help create better changes are made to mail douglas Hoey, RPh, populated areas, have health outcomes.”

therapy. Did you know that Adherence—It Only Takes a Minute a third of patients starting on a maintenance medica- As thousands of students cists have progressed in ships. One way to encour- tion will stop before their take the Oath of a Phar- being recognized for our age patients to open up first refill is due, and half of macist this month at white positive impact on health about their medications is patients with a chronic dis- coat ceremonies around the outcomes, as evidenced by through a concept known ease eventually discontinue country, it’s a good time to the passage of pharmacy- as “first-fill counseling.” its use altogether? Explain- reflect on the professional specific provisions in the First-fill counseling ing the dosing instructions, pledges we’ve made and the health care reform legisla- entails flagging scripts that addressing any concerns responsibilities that come tion earlier this year. But are for new medications the patient may have, with them. Upon entering the issue of medication and instructing technicians helping them simplify the profession, we dedi- nonadherence remains a or clerks to tell patients their dosing schedule, or cated ourselves to a lifetime perplexing puzzle. that a pharmacist would counseling on possible side of service to others and to What can pharmacists like to speak with them effects can put the patient fulfilling this vow: promis- do to help their patients before they check out. This at ease and on the path to ing to “apply our knowl- remain adherent? Simply pharmacist interaction adherence. In the process, edge, experience, and skills letting them know that can be a critical step in you become perceived as a to the best of our ability to you care about their health ensuring that the patient trusted patient advocate. assure optimal outcomes can facilitate dialogue and will remain adherent to As grant funding to for our patients.” Pharma- build on trusted relation- the prescribed course of expand medication ➥

6 america’s Pharmacist | September 2010 www.americaspharmacist.net THE AUDIT ADVISOR ➥ therapy management and related initiatives becomes avail- Inventory Audits able, the outcomes of nonadherence should continue to be top of mind. Q: My pharmacy been asked to send wholesaler summaries or inventory Nonadherent behavior is often the records to third parties. What do I need to know? cornerstone of medication-related A: Inventory audits are becoming more and more prevalent. You will want to issues that pharmacists are trained to ask yourself these questions when preparing for an inventory audit: identify, resolve, and prevent. How and when do they want the documents submitted? Some PBMs are requiring that the invoice summary be sent to them directly from the whole- saler. You will need to call each of your wholesalers and request two summary Independent reports: one copy mailed directly to the PBM and one copy mailed to you for Pharmacy your records. A best practice is to have your copy sent to you first so that you Today can determine whether it justifies what you billed to the third party. Pay at- tention to deadlines and request an extension if needed. New York, California, What information are they asking for? Send in only the information they Texas, Florida, and Pennsylvania have are requesting, for the dates and drugs they specify. Determine whether the au- the most independent community ditor will consider purchases 30 days before the date range to account for inven- pharmacies. They comprise about 35 tory you had on the shelf. Information they may be looking for includes NDC percent of all independents, according number, item number, package size, quantity shipped, and quantity returned. to the 2009 NCPA Digest, sponsored Why is this information needed and does my contract require me to pro- by Cardinal Health. Delaware, Rhode vide it? Third parties might request pricing information such as total net sales Island, Alaska, and New Hampshire and acquisition costs. PAAS believes that your pricing information is your have the fewest—less than 1 percent business and should not be shared with third parties. Contracts are based on of the total. New Digest figures will be average wholesale price, not actual cost, so third parties have no legitimate use released at the 112th Annual NCPA for your personal pricing information. Convention and Trade Exposition, Oct. 23–27 in Philadelphia.

By Mark Jacobs, RPh, PAAS National, the Pharmacy Audit Assistance Service. Source: 2009 NCPA Digest, sponsored For more information, call 888–870–7227 (toll free). by Cardinal Health

Rx Pain Pill Abuse with the abuse of these drugs oc- source of which lurks far too often Skyrocketing curred among nearly all segments in our home medicine cabinets.” of the population regardless of The NCPA Prescription Dis- A new government study has found age, gender, educational level, and posal Program and its Dispose My a fourfold increase in substance employment status,” a SAMSHA Meds website are aimed at helping abuse treatment admissions involv- study said. Another recent SAM- at least clean out those medicine ing nonmedical use of prescrip- HSA study found that emergency cabinets of expired or unneeded tion narcotic pain relievers in the visits to hospitals involving the prescription drugs. (Drug Enforce- past decade. The proportion of nonmedical use of prescription ment Administration policies do not all substance abuse treatment narcotic pain relievers more than permit pharmacy involvement in the admissions of those 12 and older doubled between 2004 and 2008. collection of controlled substanc- involving those drugs rose from 2.2 R. Gil Kerlikowske, director, Of- es.) So far, almost 1,000 commu- percent in 1998 to 9.8 percent in fice of National Drug Control Policy, nity pharmacies in 40 states have 2008, according to the Substance said, “These findings should serve signed on. The program was fea- Abuse and Mental Health Services as exclamation points to punctuate tured in the July 4 issue of Parade Administration (SAMHSA). what we already know—abuse of magazine, the Sunday supplement “This dramatic rise in the pro- prescription drugs is our country’s for more than 400 newspapers with portion of admissions associated fastest-growing drug problem, the 32 million readers.…

8 america’s Pharmacist | September 2010 www.americaspharmacist.net inside Third Party

ye on PBMs discourage abusive pharmacy E-mail your recent example of a problem you or a patient has had auditing practices, and require with a PBM to [email protected], or fax it to 703-683-3619. greater PBM disclosure with pa- We may edit it for length and clarity. tients and plan sponsors. Honest Explanation of Indefensible Policy The cosponsors are Reps. “I finally got an honest answer from a PBM. We filled prescriptions on John Barrow (D-Ga.), Sanford Ethree occasions for a hospice patient for Fentanyl patches where the Bishop (D-Ga.), Allen Boyd (D- doctor wrote ‘Mylan brand only.’ We dispensed the Mylan brand for the Fla.), Joe Courtney (D-Conn.), patient and were reimbursed $180 below cost on each occasion. “We tried speaking to the insurance company. They told us it was Barney Frank (D-Mass.), James the PBM’s issue. The PBM said to contact the insurance company for Himes (D-Conn.), Tim Holden (D- prior authorization. Pa.), Walter Jones (R-N.C.), Jack “The insurance company said that no ‘PA’ was available, but to Kingston (R-Ga.), Jerry Moran contact the PBM. I was told to e-mail its ‘MAC’ department to ask for a (R-Kan.), William Owens (D-N.Y.), review of reimbursement. They told us that they review the MAC prices Mike Rogers (R-Ala.), Mike Ross and it was ‘market competitive.’ “I asked to speak with a grievance department. They said there (D-Ark.), Peter Visclosky (D-Ind.), was no one who handles grievances. I finally asked, ‘What then am I and Peter Welch (D-Vt.) supposed to do?’ “Finally, I got an honest answer: ‘It’s not our problem. You signed NCPA Launches the contract.’ In the current state of PBM contracts, we need to reevalu- ate the ‘care’ in health care.” New Medicare Online Audit Tool Learn how to protect yourself Reps. Welch and Braley additional legislative solutions,” and your pharmacy from costly Seek PBM Hearings said Joseph H. Harmison, PD, recoupments and possible exclu- NCPA president. “A hearing will sion from the Medicare Part D Reps. Peter Welch (D-Vt.) and help shine a spotlight on several program by watching NCPA’s new Bruce Braley (D-Iowa) are seek- troubling questions that need online tutorial, “Medicare Audits: ing congressional hearings to answers if patients, pharmacies, Top 5 Mistakes Pharmacies Can’t explore the lack of government and plan sponsors are going to Afford to Make.” oversight of the PBM industry. be treated fairly.” With commercial support “Congress should consider provided by Universal American, regulating PBMs to require that PBM Reform Bill the 10-minute program offers they have a fiduciary responsibil- Gaining Support pharmacies an inside look at the ity to plan sponsors” and greater top five mistakes that will raise a transparency of financial relation- The PBM Audit Reform and Trans- red flag during a Medicare audit ships, they suggested. parency Act of 2010, which would and how you can avoid them. “The hearing that Braley attempt to rein in excesses by Participants also will be able to and Welch call for could create pharmacy benefit managers, now download a free audit readiness momentum for passing current has attracted 15 cosponsors. In- checklist for their pharmacy. legislative solutions to problem- troduced by Rep. Anthony Weiner Visit www.pharmacistelink. atic PBM business practices or (D-N.Y.), H.R. 5234 would limit com (click on the Medicare Au- even spark the consideration of ownership conflicts of interest, dits banner).…

10 america’s Pharmacist | September 2010 www.americaspharmacist.net Foundation report

The Reliable Neighbor In Your Community By Avon Pagon Foundation News Bone Marrow Donor Drive: Please e-mail t one time, pharmacies were a gathering [email protected] by Oct. 1 to request information about conducting a donor drive at hotspot in communities—a place where your pharmacy. you could hang out, get a malt or soda at New Foundation Board of Trustee: Gerald the counter, or catch up on neighborhood Shapiro, PD, of Los Angeles has been ap- happenings. Though that’s not the scene pointed to serve as an NCPA Foundation at most pharmacies today, locals can still rely on their board trustee. As a second-generation phar- A macy owner of Uptown Drug and Gift Shop, community pharmacist to contribute to the wellness of he has been a patient advocate since 1969. their neighborhoods and to educate them about national Shapiro is a former NCPA Foundation John W. health causes. An example of this is the community phar- Dargavel Award winner and has served on the macy Bone Marrow Donor Drive. NCPA National Legislation and Governmental Affairs Committee for many years. In addition, Bone Marrow Donor Drive Continues he is past chair of the Academy of Pharmacy In the fall of 2009, the NCPA Foundation and DKMS Owners of California. He has been married to his wife Jo Ann for 46 years and has three Americas organized the first Bone Marrow Donor Drive. daughters and seven grandchildren. Independent pharmacists helped recruit 625 new bone Annual Fundraising Auction: Be sure to attend marrow donors to add to the national registry and, as a this popular fundraising event at the NCPA result of a match, a transplant procedure was scheduled Annual Convention in Philadelphia on Oct. 23. in May 2010. The donor drive highlighted the fight against It starts at 6:30 p.m. during the Opening Party, leukemia and saved one life. but you can get a head start by visiting the auction page of www.ncpafoundation.org to Last year, nearly 140,000 people in the United browse the silent auction catalog. States were diagnosed with leukemia, lymphoma, or Recovering After a Disaster: The Disaster myeloma that required treatment with bone marrow Relief Fund offers financial assistance to transplants. More than 70 percent of these patients community pharmacy owners for recovery in must rely on an unrelated donor to find a bone marrow the event of disasters, accidents, or adverse match. Donors of all races are needed, but the need for circumstances. Assistance is available to in- dependent pharmacies—up to $1,000 per site minority donors is critical. for NCPA members and up to $500 per site In November, the NCPA Foundation and DKMS, the for nonmembers. For more information or to world’s largest bone marrow donor center, will again download a disaster preparedness checklist, coordinate a donor drive in recognition of National Bone visit www.ncpafoundation.org. Marrow Awareness month. Joining the national registry is a simple process for donors and requires a small test, donors on the bone marrow registry and pos- which involves a cheek swab using a cotton tip. sibly saving lives.… Pharmacists are needed to promote the donor drive and to screen potential donors at community pharma- cies. Donors recruited won’t leave with a milkshake, Avon Pagan serves as administrative manager for the but they will feel good about increasing the number of NCPA Foundation.

12 america’s Pharmacist | September 2010 www.americaspharmacist.net From to

J&D Pharmacy staff pharmacist Deborah Lotspeich benefits from an efficient workflow system. Taking your pharmacy to the next level through continuous workflow improvement

By Jennifer Jelinek

hat’s the difference between a good pharmacy and a great pharmacy? Take a look at workflow. How much consideration is put into it, and how Wmuch effort is spent in continuously improving it? Workflow can refer to robotic technology or the steps you take to complete a process. At our business (J&D Pharmacy in Warsaw, Mo.), it is about actively seeking processes or actions that can be made better, faster, and stronger. Fine-tuning your workflow, with the ever-changing aspects of pharmacy, improves employee efficiency, accuracy, patient wait times, third-party payments, and patient outcomes. It also solidifies employee loyalty. Sometimes it is about adding more “wow” factors for your patients without adding inefficiencies. As important as workflow is, it can easily be overseen by a conscientious technician, allowing the pharmacists to

Meli ss a pace remain in their vital clinical and production roles.

September 2010 | america’s Pharmacist 17 Filling Roles purchase from another pharmacy in lieu of an expensive We have jokingly said that daily life here would make special order, finding out why we are underpaid on a a comical reality show, but we are very much like a claim before it goes out the door, or ensuring that the group of actors filling specific roles. In our approach, patient allergic to dyes has only white tablets—without each technician owns a specific position based on us losing any money. personality, likes, and talents. Each technician has We have a fantastic problem solver and detective. several understudies and other duties. However, there People or prescriptions that have more difficult issues, is a definite owner for each role, and that owner knows such as workers compensation or multiple insurers, get where the priority lies before moving to other tasks. filtered to her. She is also good at solving those mysteries These owners take pride in ensuring that their position that normally slow down the whole process, such as is the best it can be. It is an amazing staff. I firmly believe “Where is the 60 oxycodone that our inventory says we that placing them in positions where they thrive in is a are supposed to have?” big contributor to the results they accomplish. Our delivery technician is the voice of our delivery patients. She continues to ensure that their individual needs are communicated and follows through to make sure they are met. Our drive-through technician knows how to keep people (and their dogs) moving quickly and happily. Listening to her talk to them, you would swear each vehicle includes a personal friend. Patients may drive up in a bad mood, but they drive off feeling good about the pharmacy they chose. One technician owns the process for all patients who require special packaging. This includes skilled facilities, assisted living, and independent living. She takes pride in ensuring that these people are not faceless to us and that they receive the attention they deserve just as much as those present in the store. Another technician is responsible for all compounded prescriptions. This role requires a conscientious person who Technician Lisa Plybon keeps customers happy. takes seriously the responsibility that every prescription is absolutely perfect, to ensure that the patient is satisfied and Our entering technician is the “director.” She receives will be a repeat customer. all retail prescriptions and answers initial questions Aside from these conventional positions, we have about items such as cost and insurance coverage. She two others that may not be traditional technicians places them in an electronic queue with a label note that but are very much a part of our workflow process. directs prescriptions to the next step, recording urgency We have a patient services coordinator who takes and special instructions. the time to sit down face-to-face with patients. She Our main “counting/assembler” technician ensures enrolls them in pharmacy programs, takes their blood that all prescriptions in the electronic queue are being pressure, arranges medication therapy management handled in the proper order and verifies that no one is for them, synchronizes their medications, and offers slowing them down. She makes sure that anyone waiting various other patient services. This is also an ideal can make it back to the register as quickly as possible. time for her to discover other needs the patient might One technician specializes in inventory control and have that we can help provide. One technician receives ace efficiencies. All day long, she comes up with alternatives and resolves all insurance rejections, personally helps

to save us money—whether finding 10 tablets to patients understand and fix coverage issues, educates Meli ss a P

18 america’s Pharmacist | September 2010 www.americaspharmacist.net them on assistance possibilities, and answers the bulk fills in any of the productive roles, even if it is for a of our phone calls. 15-minute break. Our front end staff is key to the final presentation to the patient, but that is a topic that Focusing on Vision deserves its own story. The overall vision we hope to convey to our patients is that everyone’s individual circumstances are being met and addressed quickly. The bulk of the prescriptions It is my goal that all are being moved very swiftly from beginning to end. Some take a quick exit from the main stage directly to patients who interact someone who can competently and personally address the patient’s need. Once that need is met, it is back to the with J&D by walking fast track. It is my goal that all patients who interact with J&D Pharmacy by walking in, driving through, or calling in, driving through, or from home will know that they are important to us. On a large scale of workflow, our owner (Don Grove) calling from home will is the idea man. Don has a grand vision in mind. I am the detail oriented micromanager. He tells me what he know that they are wants, and I make it work. One example is the pharmacist important to us. workstation designed for the “production” pharmacist. Don requested that this station be private from the rest of the pharmacy for concentration, while at the same The Customer Point of View time providing quick access to the sacking area for We have all been told many times that we should walk checked prescriptions and patient counseling. To do this, I into our store through the front door as a customer positioned this station on the other side of the drug bays, does. See what they see. We should also wait in our separating it from the hustle and bustle of the technicians. store or go through the drive-through as customers The station is unconventionally round. This allows do. It is a great way to gain insight on workflow from the pharmacist to slide around the table easily without their perspective. You might learn that your seating knocking into corners. A step to the left allows access to is uncomfortable, product placement could be better the printer for all monographs and medication guides. for the waiting eye, or that maybe a little bit too much A step to the right and the pharmacist places completed conversation can be heard. orders on a shelf for sacking. By turning around, the Constant improvements and updates keep our pharmacist has access to two private counseling areas. On workflow a real differentiator in how our pharmacy an extraordinarily busy day, the clinical pharmacist can operates. Technicians own their positions and have use a second station to check the overflow. the autonomy to keep making processes better. The While Don can focus on “producing” as many production and clinical pharmacists fill the roles they as 600 prescriptions alone from his station, Debi is enjoy most and project attentiveness to both those who there to handle patients who need “clinical” assistance. want counseling and those who just want to get home. Again, although the pharmacists wear many hats, these Our ability to make these frequent improvements, put are their priority roles. On any average day, Debi will people in the positions they enjoy, and express our own handle lengthier counseling, product instruction, and autonomy to provide excellence is one of the greatest vaccine administration; perform MTM; and satisfy benefits for all of us as independents.… physician inquiries. Everyone knows that their position is important and prioritizes it, because if one person doesn’t fulfill her Jennifer Jelinek, CPhT, is director of pharmacy operations at J&D role, the whole process tumbles like a row of dominoes. Pharmacy, Warsaw, Mo. She can be reached at 660-438-7331 When a primary steps away, a secondary immediately ext. 216, or at [email protected].

www.americaspharmacist.net September 2010 | america’s Pharmacist 19

Pharmacogenomics Opportunities

Practical and potentially surveillance and oversight of some testing devices, and has produced industry guidance documents. profitable applications for The pharmaceutical industry is promoting pharmacogenomics by investing in research and including ‘personalized medicine’ testing as part of the clinical trial process. Payers are also part of the picture. Medicare beneficiaries may be eligible By Tina Schlecht for pharmacogenomics testing if they are among a set of patients known to have a condition that will respond to treatment associated with the test. Not much is known n the August 2010 issue of America’s Pharmacist, about private payer coverage of pharmacogenomics testing authors Thomas Kupiec and Craig Shimasaki at this time. However, several pharmacy benefit managers, discussed “The Pharmacogenomics Phenomenon.” including CVS Caremark Corporation and Medco Health IThe pharmacogenomics discussion has been ongoing in Solutions, Inc., have announced pharmacogenomic testing scientific circles for several years, but there’s still much to programs in the past several years. Pharmacy practice is also learn about it. As pharmacists, more than likely you’ll be highlighting pharmacogenomics on multiple fronts. The hearing and reading more about it, and eventually answer- American Association of Colleges of Pharmacy (AACP) and ing patient inquiries about it. Now, it could provide an op- the Accreditation Council for Pharmacy Education (ACPE) portunity to expand the services you offer to your patients. have recommended that pharmacogenomics be included in pharmacy school curriculums, and many pharmacy schools Gaining Notice are responding by adding classes or integrating lectures. In general terms, pharmacogenomics is defined as The American Pharmacists Association (APhA) has the science of individualized responses to drugs and released a statement on personalized medicine indicating the melding of classical pharmacology with human that pharmacogenomics is an integral part of optimizing genetics. More specifically, it is the utilization of a health outcomes. The number of pharmacy continuing patient’s genotype to optimize drug therapy while education programs on pharmacogenomics is increasing. minimizing drug toxicity. Pharmacogenomics is often broadly referred to as “personalized medicine.” Community Pharmacist’s Role Pharmacogenomics is a term that has steadily been So where does the community pharmacist fit in? As gaining ground in the past 10 years. Scientific journals NCPA’s former Executive Vice President and CEO Bruce were the first to cover it, and then it began appearing in Roberts once said, “In a way, community pharmacists the mainstream media. Furthermore, the stakeholders have already been doing personalized medicine for some are now advancing it. The Food and Drug Administra- time. For decades, pharmacists have worked with physi- tion has raised the pharmacogenomics profile through cians to custom-make drugs to treat a patient’s condition its regulatory role. The FDA has monitored clinical [through compounding] when mass-manufactured trials, conducted safety and efficacy data reviews, medicines are either unavailable or ineffective.” and provided approval and clearance for marketing However, there’s still work to be done. In May

P hotographer' s C hoice and manufacturing. It has also provided post-market 2008, the Department of Health and Human Services

www.americaspharmacist.net September 2010 | america’s Pharmacist 21 Advisory Committee on Genetics, Health, and Society concluded a three-year study with a report, “Realizing The report indicated the Potential of Pharmacogenomics: Opportunities and Challenges.” The report indicated that educat- that educating phar- ing pharmacists in the use of pharmacogenomics- related products is critical for the proper use of the macists in the use of technologies. Furthermore, the report stated that patients will require education about treatment pharmacogenomics- options, and health care clinicians must be prepared and knowledgeable on the topic to speak with patients related products is about pharmacogenomics testing, possible treatment options, and potential confidentiality concerns. critical for the The August 2010 America’s Pharmacist article gave readers a primer on pharmacogenomics and outlined proper use of the several medications with cutting-edge pharmacoge- nomic applications, including Plavix (clopidogrel), technologies. warfarin, irinotecan, tamoxifen, and Ziagen (abacavir). More medications with pharmacogenomic applications patients. A survey of 1,000 American adults in June 2008 are on the way. As of June 2010, there were six medica- indicated that 91 percent would agree to a genetic test tions on the market for which FDA requires a diagnostic for one disease condition, and 65 percent would use genetic test prior to fulfilling a prescription, approxi- the results to make decisions about their health care. mately 30 drugs for which it recommends diagnostics Pharmacogenomics is a new subject for physicians, testing, and more than 200 medications that contain as well. Many pharmacies are now doing prescriber pharmacogenomic data within the drug’s labeling. detailing for their pharmacy services, and pharmacoge- nomics is an excellent topic for such a meeting. If your Business Applications pharmacy demonstrates that it’s on the leading edge Entrepreneurial pharmacists will see pharmacogenom- of pharmacogenomics, prescribers will likely contact ics as an emerging opportunity. Potential business you with questions and can be a referral source to applications include new services focused on education recommend new patients to your pharmacy. Once you and diagnostic testing, to name two. Education is needed are well-informed about pharmacogenomics, tell your for patients, physicians, and allied health care providers community so they know you are the local, reliable on this topic. Patient counseling and answering patient resource. If you are media-savvy, you can highlight your inquires should be a standard of practice. Moreover, expertise with articles, advertisements, radio or televi- it’s important to anticipate the changing needs of your sion segments, and interviews. Using social media such as Facebook or Twitter can also help spread the word. Diagnostic and genetic testing is evolving rapidly. As the science advances, pharmacies may consider contracting with a reputable laboratory and offering off-site testing to interested patients. In the future, pharmacies and physicians’ offices may be able to conduct point-of-care testing on site. The opportunity to sell OTC tests is on the horizon but is still under review by the FDA. The test costs are variable and depend on type and complexity. Some tests may be available for less than $100, while others are in the $100–$500 range,

and more extensive tests can go as high as $2,000. m on Solo Daryl

22 america’s Pharmacist | September 2010 www.americaspharmacist.net Niche Opportunities It is worth noting that pharmacogenomics is not Establishing a pharmacogenomics niche or service offer- diversifying into an unrelated business. The central tenets ing may be of interest to some pharmacists. Kerr Drug is of genetic testing include using the information to bring leading the charge on this account. In late 2009, the Kerr precision to medication therapy, uncovering drug-gene Drug store in Chapel Hill, N.C., opened a Community interactions, and helping to explain test results and what Healthcare Center. One of the center’s interests is phar- they mean to a patient’s therapeutic regimen. Pharmacists macogenomics. It is working with the University of North play an essential role in each of these tenets, and are always Carolina Eshelman School of Pharmacy to evaluate how an asset in helping patients manage their medications. patients respond to Plavix based on their genes. Offering If the subject of pharmacogenomics is new to any type of niche service in a pharmacy means evaluating you, start learning more about it today. Read articles, your patient population and your community for poten- attend continuing education lectures, or explore online tial opportunity. The service may begin as a small offering education opportunities. Prepare yourself so when the to a select subset of patients and grow as the science opportunity presents itself in your pharmacy, you’ll and practical applications evolve. One consideration, if be ready for it. And prepare your pharmacy for new providing a more extensive pharmacogenomics program business strategies as the circumstances surrounding (depending on the scope of service and the complexity of pharmacogenomics evolve into daily practice.… the testing available), is to contract with a trained genetics counselor to work with patients on an as-needed basis. The uncertainty surrounding pharmacoge- Source material for this article can be obtained by contacting nomics may concern some pharmacists. Although Chris Linville at 703-838-2680, or [email protected] all parameters around the science and its applica- tions are not defined, practitioners can use the most likely scenarios as a basis for business planning. Tina Schlecht, PharmD, MBA, is NCPA director of pharmacy affairs.

Hard TARGET

Developing a pharmacy crime prevention strategy requires a preemptive approach

By Richard Logan, PharmD

uring my years as a police officer, I have had many oppor- tunities to present programs about law enforcement, crime, and crime prevention. One of my favorite programs is wom- en’s self defense. My department has always been proactive Din training women in the use of pepper spray, self defense tactics, and even handguns. We have taught many lessons on personal safety. In every lesson we explain that having to use a self defense technique means that a criminal has gotten too close to you, and you must react swiftly and with surety to protect life or property, or to prevent injury. We tell them that the best strategy is a preventive strategy. A preventive strategy is de- veloped by thinking about the possibility of crime before it happens, and developing a plan of avoidance. Avoiding crime is the best prevention. In our programs we also explain that most criminals are looking for an easy score. They want the most return with the least effort and smallest THIS BUILDING IS PROTECTED BY chance of being caught. If you make yourself a “hard target,” a criminal A 24 HOUR SURVEILLANCE SYSTEM

A lt Varie/ is more likely to bypass you and ply his trade on another, “easy target.”

www.americaspharmacist.net September 2010 | america’s Pharmacist 25 The same can be said for criminals who perpetrate most criminals enter (and leave) by the front door. crimes against pharmacies. In most cases, given the However, like cockroaches, they can come from choice between a hard target and an easy target, they anywhere. Take a walk around your building with will choose the pharmacy that is the easiest target. your security consultant. Think like a criminal and You must make your pharmacy a hard target. look for points of entry. There are many reports of The biggest mistake easy targets make is to not think entry being gained by chopping a hole in the roof, about crime until it happens. The worst plan is no coming in from an adjoining building, coming in plan. The first step in becoming a hard target, and the back door, or entering from anywhere you can making your pharmacy more secure, is to realize (or can’t) imagine. If you use video surveillance, that there are no guarantees. Even if you practice make sure you can view entrances and exits and pharmacy in a fortress, there is a possibility that even parking lots. I like obvious video cameras. After someone will test your defenses. You must plan for upgrading our video capabilities a few years ago, we that. Talk to a security consultant. Talk to your local had a questionable “patient” look at the ceiling and ask when we got the new cameras. Criminals notice things like that. We had become a harder target. We make it a habit Of course, every pharmacy’s needs are different. Many security options are available. A reputable to mark our narcotics security consultant can sit down with you and discuss options and budgets. You don’t need to spend a lot bottles (the object of of money to have a quality security system. Whatever security or alarm system you choose, be sure that it desire for most has a battery and cellphone backup. That way you are protected in case of power failure or cut lines. pharmacy burglars) Let’s assume that you have all the security sys- tems in place. Let’s assume that you are a very hard with an identifying target but still are the victim of a pharmacy crime. What’s the next step? Let’s explore some scenarios mark on the bottom and see how hard-target planning can aid police. of the container. Burglary Burglary is defined as an unlawful, usually after- That way the bottle hours, entry with the intent to steal something of value. Most security systems (burglar alarms) have can be identified motion sensors or glass-breaking sensors. These are and traced to a designed to thwart a burglar at (or shortly after) the point of entry. If these systems are bypassed, burglar- particular burglary. ies are usually discovered the next business day when the keyholder opens up. It is usually (but not always) discovered post facto, with the burglar long gone. police department. Make a plan. Let your techni- If you have a burglary, do you have a plan? cians and clerks provide input on the plan. Discuss When implementing a burglary plan, talk to your with them “what-if” scenarios. If the situation local police. Ask them what they usually see, what arises, having thought it through beforehand may kind of evidence they look for, and how you can make them react with a cool head and save lives. help them apprehend this type of criminal. Like it Security begins outside. At some point a crimi- or not, after a burglary your pharmacy has become nal must enter the pharmacy. Statistics tell us that a crime scene. Police are interested in preserving

26 america’s Pharmacist | September 2010 www.americaspharmacist.net and collecting evidence. If you or other pharmacy apprehend a burglar. By giving some thought to personnel are cleaning up or doing inventory when the possibility of a burglary, reviewing security, the police get there, you have corrupted the crime and having a plan in place you can greatly assist scene. Notice the yellow police tape in all of the the police and increase the chances that the CSI shows? Police actually use it to keep people crime will be solved and the burglar caught. from destroying evidence. Try to remain outside, One caveat when reporting a burglary. Even or at the very least don’t disturb anything. though you’re upset, don’t call the police and say, Among the things police look for are fingerprints. “I’ve been robbed.” Tell them you need to report a If you have a routine of cleaning surfaces before clos- burglary, or a break-in. As you will see in the next ing, it makes it easier to discern a perpetrator’s fin- section, burglary does not equal robbery to the police. gerprints. They will also be interested in entrance and egress. They will look for burglar’s tools, footprints, Robbery or any other kind of evidence that might lead them A robbery usually involves a face-to-face use of force to the perpetrator. We solved a grocery store burglary or threat of force. That includes weapons or other one time by following a trail of candy wrappers to threats of bodily harm. If you call the police and the burglar. You never know what type of evidence tell them you have been robbed, the police assume will be helpful, so it’s best not to disturb anything. you have just been “held up,” probably at gunpoint, There are lots of low budget, low tech tricks and they will respond accordingly. That usually to help police bag the bad guy. We make it a habit means “running code,” in cop-speak, or driving with to mark our narcotics bottles (the object of desire lights and siren on. Know the difference between for most pharmacy burglars) with an identify- burglary and robbery. It makes the police happy. ing mark on the bottom of the container. That Making yourself a hard target for a robber involves way the bottle can be identified and traced to a many of the same security steps you just performed particular burglary. The police or your security for burglary security. Interior and exterior cameras consultant can help with other inexpensive ideas. can capture the action and lead police to the suspect. Making your pharmacy a hard target includes The physical layout of your pharmacy can help being able to give the police what they need to make you a hard target. Low counters can be easily

Inside Heist Burglaries and robberies are the most dramatic but not the only means of drug diversion. We all have auxiliary personnel, technicians, and pharmacists with the opportunity to illegally divert controlled substances. We don’t like to think of those we work with and trust as possible diverters, but we must make our pharmacies hard targets against that type of theft as well. We do that by keeping a close watch on inventories, having employees routinely double-check other employees’ work, and operating in such a manner as to discourage illegal diversion. The pharmacist in charge must maintain tight supervisory control over all facets of inventory, and remain vigilant for signs of diversion. “Trust but verify” is the philosophy. There are also times when strangers must be brought into the pharma- cy. Electricians, HVAC personnel, plumbers, computer or telephone repairmen, and others will occasionally be needed in secure areas. Most professionals are trustworthy; they want to do their job and move on to the next one. However, they represent the unknown. It is advisable to have a pharmacy employee ac- company them while in secure areas. Trust but verify. –RL R a d iu s

www.americaspharmacist.net September 2010 | america’s Pharmacist 27 jumped. High counters require more effort. Locked access doors can thwart an intended robber. Try not to Share Your ‘Scam’ Stories have direct access to the pharmacy from the front end. Everyone loves a good war story. Pharmacists know Have employees trained to maintain a high level the lengths to which a drug scammer will go to of awareness. If a person comes in acting suspiciously, procure his next “fix.” Everyone has a story of early don’t be afraid to call the police. Pay attention to the refill requests because of pills being “flushed,” or little voice that says “Something’s not right.” If your “the dog got them,” and altered prescriptions. The employees are trained, chances are they will remain state of Missouri has, in the past, produced a great calm and react as trained. That can save lives. “Scam of the Month” pamphlet detailing scamming A weapon of some sort is used in most robber- attempts on health care professionals. It’s good to ies. It may be a knife or gun. It may be a baseball bat know what types of scams are around and be on your or a bomb. It may just be the threat of a weapon. It guard. If you have had a unique scamming attempt, makes no difference. If confronted by a robber who and would like to share it with readers, please shoot says he has a weapon, believe him. We had a case of me an e-mail. I will compile some examples and in- a robber who presented a box with a bomb in it and clude them in a future article. I can be reached at said he would detonate it if he didn’t get drugs. He [email protected]. got the drugs, and the “bomb” turned out to be an old pair of sneakers in a box. The pharmacist could not tell a box of sneakers from a box with a bomb, and anything else you can remember. The police will and neither could you. It’s best to be safe. Protect ask about these details and more when they interview your employees, your patients, and yourself. witnesses. The more information that is available, There are no set plans for handling a robbery. the better the chances of apprehending the suspect. No advice given can cover all situations or scenarios. You must always make your own decisions based RxPATROL on what’s happening at the time, but most robbers If you have an incident in your pharmacy, consider want in and out as quickly as possible. Robberies reporting it to RxPATROL, a law enforcement/phar- pack a lot of fear and anxiety into a short amount macy cooperative effort to reduce pharmacy crime. of time. If confronted with a robbery situation, It gathers national statistics on pharmacy crime, your goal is to get the robber out as quickly as tracks patterns, and reports statistics designed to help possible, with no harm or injury to anyone. law enforcement stay ahead of the bad guys. It even If you have a “panic button” alarm, activate offers cash rewards for information on pharmacy it only when you can safely do so. Remember, crimes. RxPATROL works. It has been instrumental safety is the concern during a robbery, not catch- solving pharmacy related crime on a national level. ing the robber or saving the drugs. Take a look at the website, www.RxPATROL.com. When a robber leaves the pharmacy, call the police It contains great information on pharmacy crime as soon as safely possible. Lock the doors and ask all and pharmacy security. RxPATROL is one more witnesses to remain and talk to the police. Ask them not way to make your pharmacy a hard target.… to talk to each other about the robbery until after they have talked to the police. You can get a much clearer description of the robber and his actions if witnesses Richard Logan, PharmD, is a regular contributor to America’s do not compare notes before giving a statement. Pharmacist on pharmacy crime issues. Logan is owner of Do not put yourself in harm’s way to gather L & S Pharmacy in Charleston, Mo. Since 1993, he has evidence for the police during a robbery. However, if been a police officer with the Mississippi County, Missouri, possible, provide security video, descriptions of items Sheriff’s Department. Currently, he is also serving on the taken, weapon used, perpetrator, robber’s path through Scott-Mississippi County Prescription Drug Abuse Task the pharmacy, method of entrance and egress, vehicle, Force. Logan can be reached at [email protected].

28 america’s Pharmacist | September 2010 www.americaspharmacist.net The Business Case for

Adherence

Helping patients and the bottom line

By Devin Stone uring NCPA’s 111th Annual Convention for these non-adherent patients to refill their medica- and Trade Exposition in New Orleans tion. For the purposes of our experiment, we will assume last fall, former NCPA Executive Vice that the patients targeted with chronic conditions on President and CEO Bruce Roberts average take five different medications each month. Dasked community pharmacists to take on the issue of The number of days that it takes a patient with a nonadherence by making a goal of enrolling two new chronic condition to refill a medication is slightly more patients each day into an adherence program. Not only difficult to determine, but it is fair to assume that it will will promoting high rates of adherence help patients, take patients between 37 and 45 days to refill a 30-day but such a goal can also help a pharmacy’s bottom prescription. To get an exact answer, claims data can line. To help community pharmacists understand the be used to compute the medication possession ratio financial impact of an adherence program, NCPA cre- (MPR), which calculates the supply of medicine that ated a simple calculator to model the possible financial a patient has, divided by the number of days between benefits to a pharmacy from raising adherence rates. refills. Typically, nonadherence is defined as having an The NCPA online calculator can be found MPR of fewer than 80 percent, which suggests that it online at www.ncpanet.org/adherencecalculator. takes the patient more than 37 days on average to refill a It is intuitive to understand why raising adher- 30-day medication. For the purposes of our example, we ence rates will make a pharmacy more profitable. will assume that nonadherent patients at the pharmacy Every prescription that a patient fails to refill is a on average refill their medications every 45 days. prescription that the pharmacist is unable to dispense. Finally, the pharmacy owner must determine the To put a price tag on this missed opportunity, this number of patients the pharmacist can enroll into an calculator can help pharmacy owners better under- stand how big the market is that adherence represents Medication Possession Ratio over 12-month, two-year, and five-year windows. (Total days supply of drugs) Average number of days (Days supply of last fill + Day of last it takes to refill medication refill – Day of first refill) Here’s the Breakdown 100% 30 days To put the idea into practice, let’s use a hypothetical 86% 35 days example that may sound familiar to many readers. 81% 37 days Assume that a pharmacy currently dispenses slightly more than 60,000 prescriptions per year and is at- 75% 40 days tempting to play a greater role in helping patients 67% 45 days with chronic conditions manage their medications. To 60% 50 days evaluate the profit from an adherence program, the first thing a pharmacy owner needs to do is calculate adherence program. It is important to keep in mind that it average gross profit per prescription, which for our will take time and resources for a pharmacy to master the example will be $13. This calculation is relatively easy implementation of an adherence program, from identify- and can be done by taking average reimbursement ing patients who will benefit to sending refill reminders per prescription drug and subtracting the average to tracking patient progress. A suitable goal will depend acquisition cost. Please note that the gross profit per on a number of factors, including the number of patients prescription does not take into account the cost of with chronic conditions who use the pharmacy and the dispensing, which will vary depending on the total resources the pharmacy has available to advertise its quantity of prescriptions dispensed by the pharmacy. adherence program to stimulate demand. Attempting to The next step is to evaluate the number of patients recruit two patients every day into an adherence program who would benefit from an adherence program. This is a noble goal, and feasible for many pharmacies. includes determining the number of chronic medica- Armed with this basic information, it is pos- tions that these non-adherent patients are prescribed on sible to use NCPA’s online calculator to evaluate the

s Jon Boye a monthly basis and the average number of days it takes impact on a pharmacy of an adherence program.

www.americaspharmacist.net September 2010 | america’s Pharmacist 31 The first thing the online calcula- Medication Adherence and Prescription Drug Revenue tor does is establish a baseline of how Calculator much money each non-adherent pa- This calculator is designed to determine the changes in gross profit for a pharmacy after encouraging a higher medication adherence rate. Please input values in the boxes below then scroll down for analysis. tient currently represents. This is done Gross profit per prescription by taking the average gross profit per In 2008 the average gross profit per prescription drug was $13.13 13 prescription, multiplying by the average number of chronic medications taken, Number of different drugs prescribed per average patient for chronic conditions. In 2008 the average patient with a chronic condition consumed 3 different chronic 5 and then multiplying by the number of medications. prescriptions the non-adherent patient Number of days it takes the average non-adherent patient to refill a 30-day medication. This number must be greater than 30. For many non-adherent patients it will take 40 to 45 is expected to fill throughout the year. 45 days to refill a 30-day medication. Using the data input from our practical Number of existing patients recruited each business day to join an adherence program.

A very good goal is to identify 2 patients each business day that are on maintenance example, the typical non-adherent 2 medications. The purpose of an adherence program is to have the pharmacist work with patient represents an average gross these identified patients to promote perfect adherence beginning on the day the patient is recruited into the program. profit of $585 throughout the year. The next step is to compare this baseline scenario with how profitable Without an Adherence Program we would expect these patients to be for Without an adherence program each patient over the next 12 months consuming 5 different medications each represent under current adherence standards: the pharmacy if they were fully compli- ant, and refilled their medications a potential gross profit of:$585 before tax every 30 days. The online calculator computes this as well, and then displays After Implementing an Adherence Program Hypothetically, if the pharmacist was able to work with existing patients to promote perfect adherence so that recruited the difference between the gross profit patients refilled all their medications on a monthly basis, then each patient measured over a 12-month time frame represents: currently experienced by the pharmacy and the amount that the pharmacy $845 in gross profit to the pharmacy before tax could make. From our example, a per- fectly adherent patient would represent Thus, each patient enrolled into an adherence program over a 12 months represents the potential for: an annual profit of $845, which is $260 $260 in additional gross profit before tax greater than the current baseline. The next step is to determine the profit from enrolling a set number of Business case patients into an adherence program A brief business case based on the input values you provided above. each day. For simplicity, the calculator Assume that there are 730 patients each on an average of 5 different chronic medications. Without an adherence program, assumes that the pharmacy is open these patients over the next 12 months will bring in:

365 days a year, so the number of $427,050 in gross profit patients enrolled in an adherence If the pharmacy has an adherence program and is able to recruit 2 of these patient(s) each business day and once recruited program will be 365 multiplied by the the patients practice maximum adherence so that each patient refills all their chronic medications every month, then starting number of patients recruited into the today, over the next 12 months these adherent patients will bring in: program each day. As all patients are $523,250 in gross profit not recruited at once, but are recruited uniformly at a constant rate, the total The increase in gross profit would be: gross profit throughout the year from $96,200 greater than what would occur under current adherence practices enrolling patients in an adherence program can be calculated by using a The long-term increase in gross profit that would result in promoting maximum adherence for 2 patients each day would be:

Riemann sum. From our example, the $384,800 over 2 years calculator shows that an adherence $2,405,000 over 5 years program that helps two new patients

32 america’s Pharmacist | September 2010 www.americaspharmacist.net Enhancing Compliance and Revenues by Mat Silverstein

In November 2009, Robert Bowles, RPh, of Big C Bowles says. “One was at 8 a.m., one was at 3:30 p.m., Pharmacy in Thomaston, Ga., had the opportunity to and the last bag was for 4 p.m. Then, we set up My provide medication therapy management to a Medicare Dose Alert to call her at each of these times. The Part D recipient. last part of my approach was to enroll her in our E-Z “During the time that I spent with this patient, Med Synchronization Program, so that I could more I quickly realized that this patient was grossly effectively monitor her compliance.” noncompliant with taking their medication,” he says. Bowles says the results were “literally amazing. “I contacted the patient’s physician and determined After 29 days of this approach, the patient was within that the patient was actually supposed to be taking 19 three days of being totally compliant [and by the next medications. She was noncompliant with 15 of these month was totally compliant]. Certainly, this becomes medications. a win-win-win-win approach for everyone. The patient Bowles realized that it would probably take is healthier, the physician is not frustrated by having multiple approaches to achieve compliance with this to deal with a noncompliant patient, the health care patient. A big question was how was the patient going system ultimately saves unnecessary medical costs to keep up with 19 bottles of medicine. He determined reflecting the value of a pharmacist, and the pharmacy that the patient had three daily administration times. realized a monthly gross revenue increase from $450 to “We set up a zip-lock bag for each of these times,” $1,200 in by taking care of this patient.”

Reprinted with permission from Pharmacy Development Services, Lantana, Fla. Contact PDS at 800-987-7386 or www.pharmacyowners.com.

for ultimate success of the program. Pharmacy owners As this basic example should carefully review the additional costs to the pharmacy of dispensing greater numbers of prescrip- demonstrates, an tions, and the costs associated with implementing an adherence program, to determine the potential overall adherence program impact on their pharmacy’s bottom line. The online calculator can help by evaluating the labor costs to the can be an excellent pharmacy of having an employee spend a portion of his or her day sending out refill reminders, as well as by way for a pharmacy calculating the additional number of prescriptions that need to be dispensed for the pharmacy to break even. to dispense more As this basic example demonstrates, an adher- medications and ence program can be an excellent way for a pharmacy to dispense more medications and realize a higher realize a higher gross profit. More importantly, such a program can help patients achieve their desired health outcomes. gross profit. Given that prescription drugs represent a tenth of all health care spending in the United States, pro- moting adherence is a great way to demonstrate realize perfect adherence will help the pharmacy bring the value that pharmacists can provide to patients, in an additional $96,200 in gross profit in its first year. while creating added value for the pharmacy.… It is important to remember that the calculator computes gross profit, not net profit. Implementing an adherence program will require additional resources Devin Stone is a former NCPA health care economist.

www.americaspharmacist.net September 2010 | america’s Pharmacist 33 Attention to detail helps the chains,” she says. “So we have products and services drive success for Grants geared toward patient needs, and it also can provide oppor- Pass Pharmacy tunities for my other pharmacists and I to do counseling.” The pharmacy is accredited for durable medi- cal equipment. “We weren’t sure how that was going By Chris Linville to go,” she says. “But because we handle so many residential care facilities, we were looking at the need within the community for patients to have somebody that would bill Medicare, because the chains that we have in our town are not billing Medicare.”

Staff Like Partners On the staff with Belcher at Grants Pass Pharmacy is one other full-time pharmacist— Becky Eldridge, a former s the daughter of a pharmacist, it’s not pharmacy owner herself— while Belcher’s semi-retired surprising that Michele Belcher followed father works in a part-time role. The pharmacy has five in the same path as her father. And as certified technicians, one DME specialist, one general he built a business that went beyond clerk, two gift/OTC clerks, and several soda fountain clerks the standard dispensing model, it’s (typically teenagers working part-time). Belcher’s sister also no shock that she adopted a similar attitude. Melinda manages and is buyer for the gift area. She does all A “Very early on, my father had been active on the the gift/window displays and oversees the soda fountain. long-term care committee at NARD [predecessor to About 50 percent of the pharmacy's business is NCPA],” Belcher says. “So he realized, after purchas- from traditional walk-in traffic, or from patients living ing the pharmacy, that it was always important to independently at home that need delivery. Belcher’s figure out the needs of your community, and that parents started offering delivery as a free service about in turn gave you niches to be able to fill those needs a dozen years ago, and now the pharmacy has a full- and contribute to your success as a business.” time delivery driver. Belcher’s mother Bonnie worked It’s a philosophy that Belcher has continued to follow along side her husband as gift buyer, bookkeeper, at Grants Pass Pharmacy in Grants Pass, Ore., carrying delivery person, and janitor over the years. She contin- on the tradition established when her parents Michael ues to do all the bookkeeping on a full-time basis. and Bonnie Maffett purchased the business in 1973. The Belcher has utmost confidence in her staff. With 5,000 square-foot pharmacy—which Belcher joined as a Eldridge in particular, she has somebody that knows partner in 1993—has many familiar touches associated what it’s like to run a business. Eldridge grew up with independent retail stores, such as a soda fountain in Grants Pass, and owned a pharmacy in Virginia (on-site since the prior owners installed it in 1933), and before she and her family decided to move back. what she describes as a “very non-traditional gift and “I was fortunate to find someone with the former collectibles section.” The pharmacy dispenses between owner's perspective,” Belcher says. “She cares tremendously 200–250 prescriptions per day, carries general OTC about the bottom line and the service we provide, so philo- items, including cough and cold medications, and more sophically we have the same view. I could never have asked targeted products. It has a fairly extensive wound and for anyone better. I enjoy working with her on a daily basis.” dressing supply area, which Belcher created in response to Belcher credits Eldridge for keeping things loose requests from local physicians, podiatrists, and surgeons. when things get hectic. “There are plenty of challenges “The reality with OTC is that it’s very challenging for every day that makes each day a unique day,” she says.

small independents to compete with the grocery stores and “One of Becky’s favorite phrases is, ‘Every day is a great T i m MaFFett

34 america’s Pharmacist | September 2010 www.americaspharmacist.net In the Long Term, It’s About Care

www.americaspharmacist.net September 2010 | america’s Pharmacist 35 she says. “We went on all codes and traumas and managed the day in the pharmacy. You never medication aspect for the doctors and nurses. It was a very ex- know what’s going to happen.’ ” citing job, and I thought it was the area I was going to stay in.” Grants Pass, with about 25,000 At that time, Belcher’s husband, Ken, was a com- residents, is located in southwestern missioned officer in the United States Marine Corps., Oregon, roughly an hour north of and in 1987 they moved to Fredericksburg, Va., when the California state line. Belcher says he was stationed at the Quantico Marine base. Belcher the town and the surrounding area went to work at Mary Washington Hospital, which are popular for outdoor recreational was much larger than Albany (about 250 beds). It activities such as fishing, hiking, and was a bit disappointing for Belcher in that it oper- rafting. The Rogue River runs ated in more of the traditional style for the time, with through town, from its origin in nearby Crater Lake the pharmacist having a reduced care team role. on its way to the Pacific Ocean. She says the popula- In 1988, the Belchers moved to Yuma, Ariz. Belcher says tion is a mix of lifetime residents, native Oregonians, there wasn’t an opening at the hospital there, but as luck and a tremendous influx of retired Californians. would have it, the hospital’s director of pharmacy and two With its hospice, diabetes, DME, and compounding independent pharmacy owners were about to open a closed- services, the pharmacy has forged a strong reputation, but door, skilled nursing home and home infusion pharmacy. it’s in LTC where Grants Pass has left its biggest imprint. Due to her hospital experience and intravenous therapy “In 1975, my father became a nursing home provider knowledge, Belcher was hired to manage the business for and consultant pharmacist for three different local family- them. It was a position she held for the next five years. owned skilled nursing facilities,” Belcher says. “He had set “That was my first real taste of LTC in terms up a streamlined way to report the monthly chart reviews of working as a consultant in a nursing home, the and quarterly reports, along with doing nursing drug aspects of unit dosing and those kinds of things, pass teaching, getting nurses used to having a surveyor as well as running a business,” Belcher says. looking over their shoulder, as well as teaching them Soon after she was hired, Belcher visited her father for effective ways to do a medication pass [distribution of a few tips. “Consultant work was something I had not done medication to patients] consistently and without errors.” before. So I came up here and worked with him to learn the Today the pharmacy provides LTC services for expertise of doing effective chart reviews, and to do it with- a wide variety of patients, including those in foster out it taking 10 hours in each facility,” she says with a laugh. care, adult and adolescent mental health treatment Belcher admires her father’s meticulous attention to facilities, acute crisis centers, and youth prisons, along detail, and his personal touch. “It was extremely rare to with assisted-living and nursing home residents. have a deficiency in a medication pass in his facilities,”

Across the Country and Back Belcher’s parents grew up in Grants Pass, but she was born in Corvallis when her father was in school at Oregon State University. Belcher also attended OSU and received her phar- macy degree in 1986, 20 years after her father received his. “That was a very happy, shared time for both of T i m MaFFett t: us,” she says. “There were even some professors that he had that were still there at the time I was in school.” During her last year in pharmacy school, Belcher married, and after graduation she accepted a job at Albany : ROUGE W IL D ERNE SS; L e f General Hospital in Albany, Ore., near Corvallis. While T

there, she enjoyed the collaborative style of patient care. TOP LE F “It was a unique, small 100-bed hospital where the Grants Pass co-owner Michele Belcher (right) and Becky Eldridge pharmacist was an integral part of the interdisciplinary team,” are the pharmacy's two full-time pharmacists.

36 america’s Pharmacist | September 2010 www.americaspharmacist.net she says. “I think it was because of his whole approach different independence and developmental levels,” she says. to being the provider pharmacist, literally being at the “We wrote the training standards for the staff, and trained nursing home every single morning when the nurses were the staff so they could have effective medication passes.” picking up the medication sheets, letting them know who Belcher says Grants Pass looked at MOT he was, and interacting and asking questions. Then, for in other areas that it thought would be benefi- many years [after working with my father], we would cial, and decided to expand into foster care. deliver the medications after closing, so that we were able “Again, it’s a situation of having non-skilled staff pass- to touch base with the evening shift nursing staff. We ing medications, so how can we best help to educate them?” felt that was important and made us different—those she says. “So it’s really about educating foster care providers are the things that we as independents can do differ- about doing their medication pass ef- ently compared to the big long-term care providers.” fectively: how to do their checks and bal- ances, and if they get interrupted, how to Coming Home come back and know that they are giving A few years after Operation Desert Storm in 1991, the correct medication. If you are a nurse Belcher’s husband left the Marine Corps. Her parents or a non-nurse foster care provider, many asked if they would be interested in coming back to times you are dealing with fairly com- Grants Pass, with Michele becoming a partner. Belcher plex drug regimens, so the key is to keep and her husband (also a Grants Pass native) both missed them safe and effective for the patients. the Pacific Northwest and relatives, so in June 1993 they Medicine-on-Time packaging helps to moved back and started a family. (The Belcher's now keep the medications organized.” have a 16-year-old son and a 15-year-old daughter.) Belcher says that Grants Pass uses MOT for its other “It was just a wonderful fit right off in terms of know- patient populations (from those in full lockdown to ing this was what was really meant to be,” Belcher says. semi-secure situations). These consist of four adult mental "My knowledge with IV therapy helped us expand into health treatment facilities, two adolescent mental health infusion therapy in the nursing home setting, as patients facilities, one acute crisis center (housing short-term were being released from the hospital much earlier, yet still patients that may or may not stay or be moved into a more needed IVs. We were able to provide all of those services.” extended or LTC setting), and approximately 40 foster care By 1993, Belcher’s father had been servicing homes. The Oregon Youth Authority (youth prison) has traditional skilled nursing facilities with standard five facilities in Oregon and the Rogue Valley Facility is the bingo-card packaging. After she came on board, they only one in the state that uses MOT, according to Belcher. began looking to branch out into other areas and a “Even though you have nursing staff there, the staff one-size-fits-all approach wouldn’t be adequate. that’s passing the medications are correctional officers “It’s a wide-ranging operation; the needs are that are non-skilled in terms of nursing capabilities,” she so different,” she says. “For example, the needs says. “So the decision of the youth authority was that it’s of a foster care provider are very different from a great idea for the staff to learn how to pass medications those of a mental health treatment facility. effectively. It allows non-trained personnel to pass meds.” "So, being flexible and looking at each situa- This creates several benefits, Belchers says. “It tion on a case-by-case basis was important. We have changes the focus of their time in a different direc- homes that have between 3 to 125 patients in each. As tion, because the medications are packaged together. an example, Belcher says that at one home, patients So instead of handling eight bottles, or eight different had limited reading comprehension, but enough cards, it is what’s been termed ‘salad’ packaging—I’m that they could still compare dates on a calendar. not crazy about that term, by the way. But it’s packag- “So we invested in the Medicine-on-Time® (MOT) ing multiple medications within the same medication specialty packaging system, and helped to write the policy pass, and it’s labeled for the individual, date, and time, and procedures for a group of homes that have patients with and labeled with each medications that’s in it. varying degrees of developmental delays. So based on the “So I try to stress to the staff that the time that they

www.americaspharmacist.net September 2010 | america’s Pharmacist 37 are spending in passing medications is redirected. Instead initely something to expand on, but I’m allowing it to grow of manipulating bottles or cards, you are concentrating on its own so it doesn’t overwhelm us. And we can continue on administration records, the patient, and your medica- to provide the service that patients have come to expect. tion passes. It’s more of a big-picture situation and helps “The benefit right now for compounders is because in managing time and resources more effectively.” it’s so greatly patient driven, we don’t have to spend At one point, Belcher was spending many, many time marketing, and if you are providing a good service hours onsite at the various facilities, setting up policies and education and product, it will continue to grow and procedures. Now that everything has been in place because of interest from the patient population.” for awhile, most of her visits are for monthly or quarterly Another priority is medication therapy manage- reviews to satisfy various regulatory requirements. ment, “Because I think that’s a necessity,” she says. With medication procedures, “We try to have a very “It’s vital that independent pharmacies take the time thorough check system in place, where basically it ends up to invest, because we are going to lose it to the chains with a three-check process, between the technician and [otherwise]. When I talk to colleagues, it’s not that they pharmacist,” she says. “We have an extremely low-error rate. don’t want to provide that service, but it’s that they don’t Having two every six months might be our max, which know how to find the time. But we have to find a way makes us pretty proud. With five certified technicians, their and find time to offer that service in the manner that role has become very specialized within the certain focuses we all pride ourselves on providing to our patients.” of the pharmacy, so they are specialized in different areas.” It’s no secret that there are challenges to owning an independent pharmacy. For those with a heavy LTC Multiple Services investment such as Grants Pass Pharmacy, issues such as Even with the LTC focus, Belcher says she is excited audits and short-cycle medication initiatives are a con- about some of Grants Pass’s other services, in particular cern. Like her father more than 30 hospice care and compounding. The pharmacy has years ago, Belcher is responding to offered compounding since 1993. It is the only PCCA these challenges as chair of NCPA’s pharmacy in Grants Pass, and Belcher has been a Long-Term Care Committee. She hospice consultant pharmacist since 1993. She espe- also serves as a vice president on the cially enjoys consulting on pain and symptom manage- NCPA Board of Directors. “My father ment and solving a complex patient’s problem. felt passionate about these issues, “We talked to physicians and providers in the area, Michael Maffett and I feel the same way,” she says. and tried to educate them on hormone replacement, and bought Grants Pass Despite these challenges, alternative administration of certain medications for pain Pharmacy in 1973 practicing as an indepen- and symptom management,” she says. Of course, due to the dent is greatly rewarding. time and resources she needed to devote to the LTC efforts, “There’s a personal satisfaction of having a patient expe- Belcher was not able to devote as much time as she would rience a good outcome, to stay out of the hospital, to manage have liked to compounding, but she’s hoping to enhance their disease state better,” she says. “We have an opportunity its profile. Currently Grants Pass does only non-sterile to educate patients so they understand things better. For compounding, with about 75– 80 percent hormone replace- example, what is the difference between LDL and HDL? ment (male and female), and the rest being either pain and Nobody’s really taken the time to sit down and explain and symptom management through hospice. Anywhere from provide them with literature on really understanding those 40– 60 compounded prescriptions are done each day. things. Sometimes there’s an assumption that the patient Belcher is more concerned with quality versus understands those things, so we have an opportunity to help quantity when it comes to compounding. them understand. That patient interaction is what we can do “We are really at a good place with it,” she says. differently as independent community pharmacists.”… “[Recently] we had 20 new compounds come in that we had to do that day, so getting those all entered and trying to bill

T i m MaFFett insurance takes a certain amount of time and effort. It’s def- Chris Linville is managing editor of America's Pharmacist.

38 america’s Pharmacist | September 2010 www.americaspharmacist.net continuing education

Medicare Part D: A Primer for Pharmacists By Scott Thomas, PhD, and Michelle Matthews

pon successful completion of this are often referred to as beneficiaries. It is important to continuing education activity, the note that Medicare is different from Medicaid. Medicaid pharmacist should be able to: is a state and federal program that has few age restric- 1.…List (in order) the four stages of tions and offers health insurance to people with very low beneficiaries’ Part D coverage. incomes who fall into certain categories. U2. determine whether a vaccine is covered by Medicare is broken into three “parts.” Part A is inpa- Medicare Part B or Part D. tient insurance which covers hospital stays, skilled nursing 3. Explain what the drug utilization tool “step facility stays, and other inpatient services. This is the part therapy” is. that most people get for free if they have worked at least 4. describe the first step a patient should take 10 years in the United States. when a drug plan denies coverage of a Part B is generally known as outpatient insurance, medication. which includes doctors’ services, ambulatory services, 5. Refer patients to where they can apply to mental health services, and more. This part has a monthly the program known as Extra Help that as- premium. People can choose not to receive Part B. sists with prescription drug costs. However, before deciding to decline Part B, it is important that beneficiaries get careful counseling. If they decide to Introduction decline Part B just because they do not want it but then Pharmacists are a valuable source of informa- decide at a later time to enroll, they may incur large pre- tion for their patients who have Medicare pre- mium penalties. They will also be able to enroll only at cer- scription drug coverage. They can help explain tain times of the year. In some cases, people must wait as why some medications are covered and others long as 15 months to get Part B. In contrast, if they decide are not, why the amount patients pay for their to decline Part B because they have sufficient coverage, medications can change during the year, and they will have a time-limited right to enroll at a later time how patients can make an appeal if a medica- without penalty and without regard to the time of the year. tion they have requested is denied by their drug Sufficient coverage is a complicated issue and usually plan. The following article will discuss the basic requires careful assessment and counseling to determine. structure of Medicare and the details of Medi- One common mistake is to believe that your retirement care prescription drug coverage. insurance or COBRA is considered sufficient coverage. This is just one of the many issues that must be clarified Medicare before a person makes a choice about Part B enrollment. Medicare is a federal government program that The most recent addition to Medicare is Part D, provides health insurance to people who are which covers outpatient prescription drugs. Part D is also 65 or older and people who are under 65 and not required, but again, beneficiaries should consider a have a disability or have endstage renal dis- number of factors before choosing not to enroll in a Part D ease (ESRD). People of every income level can plan. These factors should include their drug costs, if they receive Medicare. Those receiving Medicare would be eligible for programs that might be able to help

www.americaspharmacist.net September 2010 | america’s Pharmacist 41 them with their costs, and if they have creditable cover- care, every formulary is required to cover all age. Creditable coverage is coverage that is as good or or substantially all of the drugs within certain better than Medicare drug coverage. When a beneficiary classes. These six classes of drugs include loses creditable coverage, they have a time-limited right to antiretrovirals, antidepressants, antipsychotics, enroll in Part D without penalty and at any time of the year. anticonvulsants, antineoplastics, and immuno- There are two ways that people can receive Medicare suppressants. There are some important limits benefits. The first is directly from the federal government. to this protection. For example, plans do not This is known as Original Medicare. Everyone who has have to cover every formulation of these drugs. Medicare receives a “red-white-and-blue” Medicare card. Also, plans cannot apply utilization restric- This is the card that patients usually show when they re- tions to drugs in these classes if beneficiaries ceive health care services if they have Original Medicare. are refilling old prescriptions. However, except The second way a patient can receive Medicare for antiretroviral drugs, plans can apply these benefits is through a private health plan. This is often restrictions to new prescriptions in these pro- referred to as Medicare Advantage. Medicare Advantage tected classes. Finally, when new drugs come (MA) plans combine Medicare Parts A (hospital insurance) to market in these classes, plans have up to 90 and B (outpatient insurance). Many Medicare Advantage days to add them to their formularies. plans include Part D (prescription drug) benefits as well and may be referred to as MA-PD plans. There are several Drug Coverage Exemptions different types of Medicare Advantage plans, including There are some drugs that Medicare Part D plans Health Maintenance Organizations (HMO), Preferred cannot cover because Medicare law excludes Provider Organizations (PPO), Private Fee-For-Service them from coverage. The plans may elect to (PFFS), Special Needs Plans (SNP), and Medical Savings cover these drugs, but these are usually offered Accounts (MSA). Private plans may have premiums in at a much higher cost because the plans may addition to the Part B premium, and they may also cover not use any Medicare-subsidized funds toward additional benefits that Original Medicare does not cover the drug. Some drugs are excluded only when such as routine dental and vision care. used for certain purposes. For example, weight gain drugs are listed as excluded, but weight Part D gain drugs used to treat AIDS-related wasting or Medicare’s outpatient prescription drug benefit is cachexia are not excluded by law. Refer to the list referred to as Part D. It was created as part of the of excluded drug classes in the provided chart. Medicare Prescription Drug, Improvement, and Mod- ernization Act, which was signed into law in 2003 and Drug Classes Excluded by Medicare Law began offering coverage to Medicare beneficiaries in Barbiturates 2006. Unlike Parts A and B, there is no Part D plan that is Benzodiazepines offered directly by the federal government. Beneficiaries Drugs to treat anorexia who want a Part D plan must purchase a plan through Weight loss drugs private insurance companies. Weight gain drugs There are two ways to obtain Part D coverage from a private company. A beneficiary who has Original Medicare drug plans also may not cover drugs that can purchase a stand-alone Part D plan (PDP) from one of have not been approved by the Food and Drug many private companies that offer PDPs. If a beneficiary is Administration (FDA). This includes older drugs in a Medicare private health plan, the Part D plan is usually that never underwent FDA approval. Addition- provided as part of the same plan (MA-PD). ally, any drugs prescribed for use other than Plans are required to cover drugs in each therapeutic that approved by the FDA are excluded. This class or category but have flexibility to establish preferred is called “off-label use.” The only exception to drug lists, or formularies. However, to be part of Medi- this is when off-label use of a drug is listed in

42 america’s Pharmacist | September 2010 www.americaspharmacist.net one of three Medicare-approved drug compen- medication. A patient who has had a drug initially denied dia, or medical encyclopedias of drug uses. is likely to be upset and unable to understand the rea- Medicare also accepts indications of drug use son for the denial. This is especially true if the patient is for anticancer chemotherapeutic regimens from told only to call the drug plan to see what the problem additional compendia and other peer-reviewed is without further explanation or support. Taking time to medical literature. If the off-label use cannot explain what prior authorization or step therapy is will help be found in the compendia or other approved the patient understand what to do or say when calling the literature, the plan is unlikely to grant an excep- drug plan. Many pharmacies will offer to contact the doc- tion for coverage. tor and start the prior authorization process for patients to Finally, Medicare will not allow coverage of help expedite it. drugs that don’t meet the FDA’s Drug Efficacy Explaining the process can also give patients the con- Study Implementation (DESI) standards. DESI eval- fidence they need to obtain the requested documentation uates the effectiveness of drugs that have been from their doctor. Many patients are hesitant to question or approved as safe, and those that are considered feel burdensome to their doctor. This can be especially true “less than effective” are categorized as “DESI-LTE” for older adults who receive Medicare. They may be hesi- and are excluded from Part D coverage. tant to go back to their doctor and ask for a letter they can give their drug plan that states why a specific medication is Drug Plan Restrictions required. However, patients may be more likely to take ac- Prescription drugs that are not on a plan’s tion if a pharmacist reassures them that it is not uncommon formulary are not covered and the beneficiary for a plan to require something like prior authorization and must pay out of pocket for those prescriptions. that most doctors know what to do in these cases. Additionally, plans may put restrictions on all their drugs, both those that are required to be Formulary Changes covered and the ones they choose to offer. Plans can generally change their formularies at any time These restrictions include prior authorization, after the first 60 days of the plan year. Remember that in step therapy, and quantity limits. Pharmacists most cases beneficiaries can change their plan only at cer- can play an important role in educating and tain times of the year. Plans also may remove drugs sub- assisting their patients when these restrictions ject to approval from the Centers for Medicare & Medicaid affect the medication they were prescribed. Services (CMS), although the agency discourages them Prior authorization is when a plan must give from doing this too frequently in the middle of the year. permission in advance before it will cover a par- If the change does not involve generic substitution ticular prescription. Step therapy is when a plan or safety concerns, the plan must automatically con- requires a beneficiary to first try other drugs to tinue to cover refills of the drugs for plan beneficiaries treat their condition before allowing them to use (at the same cost-sharing level) for the remainder of the the drug that was originally prescribed. The drug calendar year. Beneficiaries may receive a notice indicat- that the plan wants them to start with is usually ing that change in formulary, but it should indicate that less expensive than the prescribed drug. Quan- their coverage will stay the same. If the change involves tity limits are when a plan limits the quantity of a substitution of a generic drug for a brand-name drug, the certain drug on its formulary that a beneficiary plan must either give affected individuals 60 days notice may receive. (by mail) before the change affects them or give them A pharmacist can be of great help to a a 60-day refill and notice at the pharmacy. The notice patient when it comes to these restrictions. must include the reason for the change, the names of This help can take the form of both explanation similar drugs that are covered and their cost-sharing, and and support. It may not be immediately clear information about filing an appeal. Beneficiaries will need to a patient that even though a drug has been to file an exception, as more fully explained as follows, if denied, they can still take steps to receive that they want to maintain coverage as before. If the change

www.americaspharmacist.net September 2010 | america’s Pharmacist 43 is based on safety concerns, the change will be effective In addition to inpatient services and some pre- immediately and no prior notice or refills are required. scription drugs, Part B also covers durable medi- Plans must provide notice as soon as possible after the cal equipment (DME). DME includes items that change takes place, however. are medically necessary, can withstand repeated If plans intend to remove drugs from their formulary use, and are appropriate for use in the home. This or add utilization management tools for the next calendar includes items such as walkers, wheelchairs, and year, the plans either must help beneficiaries change to a portable oxygen equipment. Some nondurable therapeutic equivalent or complete an exception request items are billed as DME under Part B under the before Jan. 1, or must provide beneficiaries a 30-day home health care benefit when they are needed, transition fill of the medication and notice of appeal rights such as intravenous supplies, gauze, and cath- during the first 90 days of the new plan year. Plans can eters. Finally, for those with diabetes, Part B will deny quantities or doses based on safety issues, but they cover some medical supplies, like lancets and test must provide a transition fill up to the minimum dose or strips, as a preventive care benefit. quantity and help beneficiaries file an exception if they have not already done so. Appealing Denial of Drug Coverage Medicare Part B Versus Part D It is important for pharmacists to know about a Some drugs are covered through Medicare Part B, the patient’s right to appeal a denial of drug cover- outpatient insurance benefit, and are not available as Part age by a Part D plan. Patients with Medicare D drugs. These are physician-administered drugs that are have the right to appeal whenever they disagree typically not self-administered, such as immunosuppres- with a plan’s decision to deny a drug for cov- sant drugs, anticancer drugs, antiematic drugs, and some erage. Some of the reasons patients appeal dialysis drugs. include the drug not being on the plan’s formu- Which part of Medicare that vaccines and immuni- lary, not being “preferred” by the plan, requir- zations are covered under depends on the reason for ing step therapy, needing a higher quantity or administration. In general, when a beneficiary is at an dosage than the plan allows, and the drug being immediate and high risk for a disease or illness, or if the at a high copayment tier (“tiering exception”). vaccine or immunization is required to treat an illness or If beneficiaries have their doctors’ support and disease, then it would be billed under Part B. Part B al- sufficient evidence, then they may have a strong ways covers the flu shot, including both the seasonal flu case to win the appeal. shot and the H1N1 flu shot, the pneumonia vaccine, and However, for drugs excluded by Medicare the hepatitis B vaccine if a patient is at medium to high law, it is very difficult to win an appeal. This risk. When a beneficiary steps on a nail and receives a includes the seven excluded categories, drugs tetanus shot, for example, it is billed under Part B be- classified as DESI-LTE (or drugs labeled as cause the vaccine is necessary to prevent an imminent “less than effective” by the FDA), and off-label infection. If the beneficiary is getting his decennial teta- prescriptions that lack support in the Medicare- nus booster, then Part D covers both the immunization approved compendia. While beneficiaries have and the administration of the shot because it is simply the right to appeal these decisions, they are very a routine shot. In other words, Part D covers vaccines difficult cases to win. and immunizations that are routine in nature, such as the The process for appealing is the same shingles vaccine. All Part D plans must cover any com- whether the beneficiary is in a Medicare Advan- mercially available vaccine that is not covered by Part B. tage Part D plan (MA-PD) or a stand-alone Part D Part D plans must pay for the vaccination itself and for plan (PDP). First, the beneficiary and their doctor its administration. Plans must cover these vaccinations must submit a formulary exception (or tiering whether they are received at a network pharmacy or at a exception) request to the plan. The plan has 72 physician’s office. hours to make a decision. If the plan denies the

44 america’s Pharmacist | September 2010 www.americaspharmacist.net request, the plan will send a Notice of Denial, If the IRE, ALJ, MAC, or federal court decides the plan which details how to continue the appeals pro- must cover the drug in question, the plan must process cess and lists the reason for denial. At this point, the coverage within 72 hours (24 hours for an expedited the appeals process begins, and beneficiaries appeal) from the date the plan receives the decision. have 60 days to submit their appeal. Redetermi- nation is the first step, and the beneficiary should Cost of Part D Drug Plans address the reason for denial by sending in The cost of drug plans under Medicare varies greatly and documentation to the plan’s appeals department changes annually. Some Part D plans have low premiums listed on the Notice of Denial. The plan has seven with high deductibles, while some plans have high premi- days to respond. In the case of an emergency, ums with low copayments and no deductibles. a doctor may request an expedited appeal, in which case the plan has 72 hours to respond. The standard charges for a Part D drug plan are: If a plan gives a favorable response to the • Premium: The amount that an individual must pay the appeal, the plan must authorize coverage no Part D plan for coverage. Premiums are generally paid later than seven calendar days from the date monthly. it receives the appeal request (72 hours for an • Deductible: The amount that the beneficiary must pay expedited appeal). If the plan gives an unfa- for prescriptions before the Part D plan begins to pay. vorable decision, then the beneficiary has the • Copayment (or copay): A flat amount that a benefi- right to escalate the appeal to an Independent ciary is required to pay for each prescription after Review Entity (IRE). Maximus Federal Services reaching the deductible (such as $3 for generics and is currently the private contractor that handles $5 for brand name drugs). Medicare prescription drug appeals when a • Coinsurance: Similar to a copayment, but it is per- plan has denied a request for coverage. Maxi- centage-based. For example, some plans pay 95 per- mus is independent and is not affiliated with any cent for generic drugs and 80 percent for brand-name Medicare private drug plan. This is the last level drugs, so the beneficiary would be responsible for a of the appeals process that has a short deci- coinsurance of 5 percent for generics and 20 percent sion timeline. The beneficiary can continue to for brand-name drugs. appeal to higher levels such as: • Administrative law judge (ALJ) hearing: If Part D Coverage Stages and Patient the beneficiary disagrees with Maximus’ de- Out-of-Pocket Costs cision, he or she can request an ALJ hear- The amount of money your patients pay for prescription ing within 60 days of Maximus’ decision if drugs will change throughout the year, depending on what the amount in question meets the minimum stage of coverage they are in. There are four stages of amount that Medicare sets each year ($130 coverage in the Part D program. in 2010). • Deductible. If the patient’s plan has a deductible, • Medicare Appeals Council (MAC) review: If he or she will have to pay the full cost of their drugs the beneficiary disagrees with the ALJ’s de- (100 percent) until the patient meets that amount. cision, he or she can appeal within 60 days While deductibles can vary from plan to plan, no of the date on the ALJ decision to the MAC. plan’s deductible can be higher than $310 (in 2010). • Judicial review (federal district court): If the Some plans have no deductible. beneficiary disagrees with the MAC’s deci- • Initial Coverage Period. This phase begins after the sion or if the MAC denied the request for patient meets the plan’s deductible (if the plan has appeal, and the amount in question meets one). During this period, the patient will pay a portion the minimum amount that is adjusted annu- of the cost of his or her drugs (coinsurance or copay- ally ($1,260 in 2010), he or she can request ment), which varies by drug and by plan, and the plan review by a federal court. will pay the rest. How long the patient remains in this

www.americaspharmacist.net September 2010 | america’s Pharmacist 45 initial coverage period depends on the patient’s total strophic coverage. (The cost of the patient’s drug costs (how much the patient pays plus how much monthly premium is not included in the the plan pays) and the plan’s benefit structure. Most $4,550.) Then the patient will pay either a 5 plans’ initial coverage period ends after the patient has percent coinsurance on the cost of cov- accumulated $2,830 in total drug costs in 2010. ered drugs or a copay of $2.50 for covered • Coverage Gap. After the patient’s total drug costs generic drugs and $6.30 for covered brand- (what the patient pays and what the plan pays) reach name drugs, whichever is greater. a certain amount ($2,830 in most plans in 2010), the patient may have to pay the full cost of her drugs until Actuarial Equivalence he or she reaches the catastrophic coverage stage. Part D plans generally fit into one of three cat- Some plans do not have a coverage gap. egories: the standard benefit, alternative cover- • Catastrophic Coverage. In all Medicare private drug age that is actuarially equivalent to the standard plans, after a patient has paid $4,550 in 2010 in out- benefit, or alternative enhanced benefits. All Part of-pocket costs (regardless of the patient’s total drug D sponsors must offer at least one drug plan costs) for covered drugs, the patient will reach cata- that provides either the standard benefit or the

Case Examples

Case Study 1 Case Study 2 Problem: Mr. H. recently changed from individual insur- Problem: Ms. B. has Original Medicare Parts A and B ance coverage to Medicare. His Medicare coverage and prescription drug coverage through a stand-alone included a Part D drug plan. When he went to his phar- Part D plan. She takes medication to control her blood macy, he was told he could not get his usual medication pressure. She has tried many different medications, but because his Part D plan would not cover that particular only one particular drug has been able to stabilize her medication. He was also told that he would have to pay blood pressure without any serious side effects. Two the full cost. months ago, she received a letter from her plan stat- ing that next year her medication would be moved to a What to do: Every Part D plan is required to have a higher tier of her plan’s formulary and would cost twice “transition policy” to ensure that new members can ac- as much. The letter also mentioned another medication cess medications they have been taking regularly. The that she could take at a lower tier cost. However, it was a transition fill must be used within the first 90 days of the drug she had already tried and it was ineffective. Neither plan to get at least a 30-day supply of the medication. of the plan’s options would work for Ms. B. This is true even if the medication is not covered by the plan or has a restriction like Step Therapy. What to do: Ms. B. spoke to her pharmacist to see if she Mr. H. went back to his pharmacy and asked the had any ideas about how she could get her medication pharmacist to fill the prescription using the “transition fill at a price she could afford. The pharmacist suggested policy.” The pharmacist called the Part D plan and asked that she ask her plan for something called a “tiering for the override code so he was able to bill it correctly. exception.” This is when the patient and doctor ask the The pharmacist told Mr. H. that the transition fill plan to provide the medication at the lower cost tier level. was only temporary and he would need to ask his Ms. B. had her doctor write a letter in support of doctor to write a letter formally asking the plan for an her request and explained why she needed to take that exception to the formulary in order to obtain future specific medication and not another medication. refills of this medication. Ms. B. heard back from the plan a few days later and Mr. H. asked his doctor to write a letter and, within they denied her request. She then decided to continue to 72 hours of receiving the letter, the plan informed Mr. appeal the plan’s decision by asking for redetermination. H. and his doctor that they would cover the medication The plan denied her again at the redetermination level, for the rest of the year. If Mr. H. decides to stay in the and she continued her appeal to Maximus, the Indepen- same plan next year, he will need to have his doctor write dent Review Entity. Maximus decided to grant Ms. B. a another letter asking the plan to continue covering the tiering exception. Ms. B. will be able to continue to get medication next year. her drug at the lower cost price for next year.

46 america’s Pharmacist | September 2010 www.americaspharmacist.net actuarially equivalent benefit. Each year, CMS Coverage Gap creates guidelines that set cost-sharing for the Currently, one of the most challenging aspects of Part standard benefit in Part D plans. This includes D for consumers is the coverage gap, also known as the annual deductible (which is $310 in 2010), the “doughnut hole.” This is the point at which a drug a 25 percent cost-sharing structure during the plan stops sharing any costs and the beneficiary is initial coverage period, and then a zero percent responsible for paying 100 percent of all prescription cost-sharing structure during the coverage gap. drug costs. The gap typically begins when a patient’s The coverage gap is when the beneficiary pays total drug spend reaches $2,830 (in 2010). This figure 100 percent of the cost of their prescription includes both what the beneficiary has paid and what drugs. The coverage gap is followed by a period the plan has paid. To get out of the coverage gap, the called catastrophic coverage, where beneficia- beneficiary must spend a total of $4,550 on prescription ries’ drug costs drop significantly. drugs. This does not include any payments to the plan Part D sponsors can also offer “alterna- such as premiums. tive” Part D plans that provide coverage equal However, most beneficiaries who enter the coverage (“actuarially equivalent”) to the value of the gap never make it out, and the costs can be overwhelm- standard benefit. Alternative plans cannot ing to many seniors. Recent health care reform took this impose a higher deductible or higher cata- issue into account. The Patient Protection and Affordable strophic limit than the standard benefit, but Care Act, which was signed into law in March 2010, will they can vary cost-sharing amounts in most gradually reduce the burden the coverage gap puts on other ways. Finally, plans can offer alternative beneficiaries. Below is a timeline showing how the cover- enhanced coverage that is greater than the age gap will be phased out over the next decade: standard benefit. Plans can increase the value 1. In 2010, any Medicare beneficiary who enters the of the standard benefit in several ways, includ- doughnut hole and does not have will receive a one- ing providing coverage of excluded Part D time $250 rebate check from the government. drugs, coverage during the coverage gap, and 2. In 2011, those who enter the doughnut hole will pay 50 a reduction in cost-sharing during the initial percent coinsurance for brand-name drugs from phar- coverage period. maceutical manufacturers and a 93 percent coinsur- Most plans decide to use alternative cover- ance for generic drugs through a government subsidy. age that is actuarially equivalent to the standard 3. Starting in 2013, the coinsurance for brand-name and benefit. They do so by setting up a tiered copay- generic drugs will steadily decrease until 2020, when ment system. For example, they might charge the beneficiary will be paying only 25 percent coinsur- $5 for generic drugs, $40 for a higher-tiered ance. That 25 percent is equivalent to what beneficia- drug, and then 60 percent of the negotiated ries had been paying before they reached the cover- price for specialty drugs. As long as this tiered age gap. structure is actuarially equivalent to the standard Part D plan, this is in accordance with Medicare Help Paying Drug Costs requirements. The calculations can be quite If beneficiaries find themselves struggling to meet complex, but it all must equal out in order to Part D costs, there are several government programs pass Medicare’s test of actuarial equivalence. that can offer assistance. These programs are avail- For patients, this method of using actuarial able to those who qualify based on income and asset equivalence is why one plan may be much eligibility guidelines. Extra Help is a federal program more cost-effective than another. A patient may that helps beneficiaries pay for some or most of primarily use drugs that have been placed in the costs of Medicare prescription drug coverage. a lower cost tier by one plan and not another. Beneficiaries can apply for the Extra Help program Pharmacists can help their patients understand through the Social Security Administration or their lo- what their actual out-of-pocket costs will be. cal Medicaid office.

www.americaspharmacist.net September 2010 | america’s Pharmacist 47 As mentioned earlier in this article, Medicaid is a that a patient may suddenly find that a drug federal and state program that covers medical care for they use is no longer going to be available to certain populations with low income. Medicare beneficia- them or is going to cost more. In this case, ries who also qualify for Medicaid are known as “dual- there is always the danger that patients may go eligibles” because they are receiving benefits from both through a period of not having their medication Medicare and Medicaid. Medicaid offers additional drug available, or stop using it altogether, because coverage, including the coverage of certain excluded they don’t know how to respond to this change. drugs in some states and other drugs not included on the There are many ways a pharmacist can help beneficiary’s Part D formulary. Medicaid enrollees are au- patients with Medicare drug plans get the most tomatically enrolled in Extra Help and assigned to a Part out of their benefits. Five important ways that a D plan if they have not already chosen one themselves. pharmacist can help are: State pharmaceutical assistance programs (SPAPs) 1. Informing patients about the Medicare are offered in some states to help pay for prescriptions Plan Finder on the Medicare.gov website for those with limited incomes. Most SPAPs have income (www.medicare.gov/find-a-plan/questions/ guidelines but do not consider assets. SPAPs have differ- home.aspx). This plan finder is a valuable ent benefit designs but many pay the Medicare drug cov- resource to patients who are just starting erage premiums. Some SPAPs may also cover Medicare to look for a plan or considering changing cost-sharing in the coverage gap, and drugs that are ex- plans. It can help patients find the plan that cluded from Medicare drug coverage or are not included fits best with the specific drugs they use in in a beneficiary’s Medicare drug plan’s formulary. terms of availability and overall costs. Patient assistance programs (PAPs) offer free or 2. Printing out a list of the drugs that the pa- low-cost drugs directly from the company that manufac- tient currently uses. This list is very impor- tures them. Many companies have their own programs. tant for patients to have before they use the In most cases, a patient’s doctor must apply on the pa- Medicare Plan Finder website. tient’s behalf. While many patient assistance programs 3. Clearly explaining to patients why they might do not allow beneficiaries to apply if they are eligible for not be able to immediately get the drug the Medicare drug benefit (Part D), some do. their doctor prescribed and what steps they There are additional programs for beneficiaries with need to take to receive it. This explanation limited incomes, including Medicare savings programs would address prior authorization and step that help pay Medicare’s costs. People can apply for these therapy, as well as the right to file an excep- programs through their state Medicaid programs. Charity tion as described in the article. A pharma- programs such as NeedyMeds (www.needymeds.org) and cist can be especially helpful if a drug plan medical low-cost clinics often offer drugs on a sliding scale requires a prior authorization, by offering to to those who qualify. Some states also have prescription contact the patient’s doctor and help start drug discount card programs. that authorization process. 4. Emphasizing to patients that they always How to Help Your Medicare Patients have the right to appeal any denial by their As can be seen from this article, there are many reasons drug plan. It is also important for them that patients could have difficulty fully understanding their to understand that there are a number of Medicare drug benefits. Not only are there many drug different levels of appeal. This means that plans a patient can choose from, those plans can vary in while an appeal may be denied at one lev- regard to which exact drugs they cover and how much el, it may succeed at another. Free packets they charge for them. This variation is true even though of information that describe and help with they all adhere to a standard coverage requirement. the appeals process can be obtained by Plans can also make midyear and annual changes calling the Medicare Rights Center helpline to the drugs that are on their formulary. This can mean at 800-333-4114.

48 america’s Pharmacist | August 2010 www.americaspharmacist.net

5. Providing a copy of the resources box Continuing Education Quiz (below) to Medicare patients. This box Select the correct answer. includes the Web addresses for Medi- care, Medicare Plan Finder, and Medicare 1. Which types of drugs are excluded from Medicare Interactive. Medicare Interactive is a public drug coverage? website that provides a wealth of informa- a. Antidepressants tion on every aspect of Medicare. b. Over-the-counter drugs c. HIV/AIDs drugs Medicare Resources d. Anticonvulsants

■ www.needymeds.org 2. Which of the following classes of drugs does Medi- NeedyMeds care exclude by law? ■ www.medicare.gov/find-a-plan/ a. Antidepressants questions/home.aspx b. Anticonvulsants Medicare Plan Finder c. Barbiturates ■ www.medicare.gov d. Antipsychotics The official U.S, Government site for Medicare ■ www.medicareinteractive.org 3. COBRA is considered sufficient coverage that would Medicare Interactive allow a beneficiary to decline Part B. a. True Finally, pharmacists should use the Medi- b. False care Rights professional hotline if they have any questions about Part D drug benefits or 4. When does Medicare cover drugs not approved by anything related to Medicare. This is a free the FDA? service and is unaffiliated with Medicare or a. Never any health plans. The professional hotline b. Older drugs that never underwent FDA approval number is 877-794-3570.… c. Drugs listed in one of the three Medicare-approved compendia d. Drugs approved outside of the United States Scott Thomas, PhD, is director of education at the Medicare Rights Center. Thomas directs the staff in the education de- 5. Which of the following is not a drug utilization man- partment in the writing, editing, and vetting of Medicare- agement tool that can be used by drug plans? related materials prepared for both internal and public use. a. Step therapy He has worked in public health for more than 20 years with b. Prior authorization a primary focus on the implementation and sustainability of c. Redetermination health improvement programs in social service and health d. Quantity limits care settings 6. If a plan substitutes a generic for a brand-name drug Michelle Matthews served as an AmeriCorps VISTA volun- on their formulary, what notice do they have to give teer in the Education Department at the Medicare Rights beneficiaries? Center. During her year at Medicare Rights, she spearhead- a. 60-day notice by mail, or 60-day refill and notice at ed efforts to rework educational materials to improve health the pharmacy literacy and readability and was integral in redesigning b. 30-day notice by mail and 30-day refill Medicare Interactive, the largest online source of Medicare c. No notice and no refills information on the Web. d. 90-day notice by mail

www.americaspharmacist.net September 2010 | america’s Pharmacist 49

7. What is the first step a patient should take when re- 14. Which drug-cost assistance program is of- questing a drug that is not on the plan’s formulary? fered from drug companies? a. Reconsideration a. Extra Help b. Exception b. State pharmaceutical assistance programs c. Redetermination (SPAPs) d. Administrative law judge c. Pharmacy discount generic programs d. Patient assistance programs (PAPs) 8. Which vaccine does Part B always cover? a. Tetanus shot 15. Most people can change their Part D drug b. Shingles vaccine coverage at any time. c. Pneumonia vaccine a. True d. Meningitis vaccine b. False

9. Mr. W. stepped on a nail and needs a tetanus shot. 16. What is prior authorization? Which part of Medicare will cover his shot? a. Asking a patient to try less expensive a. Part A drugs before the plan will cover more b. Part B expensive drugs c. Part C b. Getting plan permission in advance before it d. Part D will cover a specific prescription c. Allowing only a certain dosage of the 10. Part D covers all drugs and durable medical equip- prescription ment (DME) received at a pharmacy. d. Allowing only a certain quantity of the a. True prescription b. False 17. Which is the last level of appeal that the drug 11. The appeals process is the same whether a beneficiary plan itself can make a decision? is in a stand-alone Part D plan (PDP) or a Medicare Advan- a. Exception tage Plan with drug coverage (MA-PD). b. Redetermination a. True c. Administrative law judge b. False d. Medicare Appeals Council

12. How long does a Part D plan (PDP) have to respond to 18. What is the correct order of Medicare Part D a patient’s standard exception request? coverage stages? a. One week a. Deductible period, initial coverage period, b. 72 hours coverage gap, catastrophic coverage c. 48 hours b. Initial coverage period, coverage gap, cata- d. 24 hours strophic coverage, deductible period c. Catastrophic coverage, initial coverage period, 13. Where can beneficiaries apply for the Extra Help pro- deductible period, coverage gap gram to get assistance paying prescription drug costs? d. Initial coverage period, deductible period, a. Social Security Administration or their local coverage gap, catastrophic coverage Medicaid office b. The pharmacy or 800-Medicare c. Their doctor’s office d. Their local hospital

50 america’s Pharmacist | September 2010 www.americaspharmacist.net

Medicare Part D: A Primer for Pharmacists 19. The Patient Protection and Affordable Care Sept. 1, 2010 (expires Sept. 1, 2013) • Activity Type: Knowledge-based Act, which was signed into law in March 2010, will gradually reduce the burden the coverage gap FREE ONLINE C.E. Pharmacists now have online access to NCPA’s C.E. programs through Powered by CECity. By taking this test online— puts on beneficiaries. Below is a correct statement go to the Continuing Education section of the NCPA Web site (www. ncpanet.org) by clicking on “Professional Development” under the excerpt from the timeline showing how the cover- Education heading you will receive immediate online test results and age gap will be phased out over the next decade: certificates of completion at no charge. a. In 2010, any Medicare beneficiary who enters To earn continuing education credit: ACPE Program 207-000-10-009-H04-P the doughnut hole and does not have Extra A score of 70 percent is required to successfully complete the C.E. quiz. Help will pay 50 percent coinsurance for If a passing score is not achieved, one free reexamination is permitted. brand-name drugs from pharmaceutical man- Statements of credit for mail-in exams will be available online for you ufacturers and a 93 percent coinsurance for to print out approximately three weeks after the date of the program generic drugs through a government subsidy. (transcript Web site: www.cecerts.ORG). If you do not have access to a computer, check this box and we will make other arrangements to send b. In 2010, any Medicare beneficiary who enters you a statement of credit: q the doughnut hole and does not have Ex- Record your quiz answers and the following information on this form. tra Help will receive a one-time $250 rebate q NCPA Member License check from the government. NCPA Member No. ______State ______No. ______q Nonmember State ______No. ______c. In 2011, those who enter the doughnut hole will receive a one-time $250 rebate check from All fields below are required. Mail this form and $7 for manual processing to: NCPA C.E. Processing Ctr.; 405 Glenn Drive, Suite 4; Sterling, VA. 20164 the government. ______d. Starting in 2013, the coinsurance for brand- Last 4 digits of SSN MM-DD of birth ______name and generic drugs will steadily decrease Name ______until 2020, when the beneficiary pay 50 percent Pharmacy name ______coinsurance for brand-name drugs from phar- Address maceutical manufacturers and a 93 percent ______City State ZIP coinsurance for generic drugs through a gov- ______Phone number (store or home) ernment subsidy. That 25 percent is equivalent ______to what beneficiaries had usually been paying Store e-mail (if avail.) Date quiz taken Quiz: Shade in your choice before they had reached the coverage gap. a b c d e a b c d e 1. q q q q q 11. q q q q q 20. Once out of the coverage gap, the benefi- 2. q q q q q 12. q q q q q q q q q q q q q q q ciary will move into what is called “catastrophic 3. 13. 4. q q q q q 14. q q q q q coverage,” and their drug costs drop signifi- 5. q q q q q 15. q q q q q cantly. Beneficiaries should expect to pay: 6. q q q q q 16. q q q q q a. Only 5 percent of the cost of each covered drug, 7. q q q q q 17. q q q q q or a copay of $2.50 for generics and $6.30 for 8. q q q q q 18. q q q q q brand-name drugs, whichever is greater 9. q q q q q 19. q q q q q 10. q q q q q 20. q q q q q b. Only 5 percent of the cost of each covered drug, or a copay of $5 for generics and $12.60 Quiz: Circle your choice for brand-name drugs, whichever is greater 21. Is this program used to meet your mandatory C.E. requirements? a. yes b. no c. Only 10 percent of the cost of each covered 22. Type of pharmacist: a. owner b. manager c. employee drug, or a copay of $2.50 for generics and 23. Age group: a. 21–30 b. 31–40 c. 41–50 d. 51–60 e. Over 60 $6.30 for brand-name drugs, whichever 24. Did this article achieve its stated objectives? a. yes b. no is greater 25. How much of this program can you apply in practice? a. all b. some c. very little d. none d. All of each covered drug, up to $150 for ge- nerics and $250 for brand-name drugs. 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 management

Pharmacy Ownership— Open Brand New, or Purchase? By Andy Oaks

I recently received a call from a Prescription Sales—This is the most important pharmacy intern (and NCPA member) line item for an independent pharmacy, as more who looking for answers as he pon- than 90 percent of revenues for the typical opera- dered this question: Should he open tion come from prescription sales. Forecasting this his own independent pharmacy opera- line item requires knowledge of demographic fac- tion, or purchase an existing one? tors and experience in determining sales volume, Needless to say, I was excited average selling price, and expected profit margins. with the call and thrilled to learn of Other Sales—The challenge here is to determine his strong desire to become an independent pharmacist. which product categories to offer and appropriate Furthermore, I was proud of the fact that he was turning inventory amounts to put on the shelves without to a resource he had learned of while reading America’s tying up too much capital. Pharmacist. I also figured that many other aspiring indepen- Cost of Goods Sold—Primary wholesaler and dent pharmacists with that entrepreneurial spirit would have other vendors and suppliers must be determined. similar inquiries and interest, thus the purpose of this article. With many options in the marketplace, negotiating Opening a pharmacy from scratch or purchasing an the best value that will best serve your needs at existing operation both have distinct advantages and chal- the best possible prices is the task at hand. Third- lenges to consider. Since purchasing an existing operation party networks are often tied to primary wholesaler requires successfully negotiating terms of the deal with the proposals and should be considered when mak- seller and is not totally within an individual’s control, I’ll start ing this decision. with opening a pharmacy from scratch. Payroll—This is the largest and most controllable line item expense. It covers interviewing, hiring, Starting From Scratch and training qualified staff members and deter- The first thing that comes to mind when I think of someone mining a fair compensation/benefits package to wanting to open their own pharmacy is all the aspects of get- ensure loyal and productive performance. ting started correctly that must be addressed from the outset. Advertising—This is a critically important ex- And it must begin with the creation of a formal business pense with a multitude of options. Getting the plan, also known as an operating budget. The fact is that 33 biggest bang for your buck while getting the mes- percent of all new businesses fail within the first six months of sage out effectively that brings in the customers is opening. And according to studies by Dun and Bradstreet, the the challenge. number one reason businesses fail is that they lack business Computer Services—This entails much more plans. Failing to plan is planning to fail, as the saying goes. than filling prescriptions. Your dispensing system The creation of a formal business plan is quite complex must also be adept in pricing functions and billing and requires knowledge of and experience with factors that capabilities, must interface with wholesalers and affect every line item found in an operating budget. Listed other vendors, and must produce robust reports below are crucial line items and tidbits of information to con- with all pertinent data needed to effectively mea- sider for an upstart pharmacy as each item is addressed: sure and manage performance.

52 america’s Pharmacist | September 2010 www.americaspharmacist.net Rent—Do you buy, build, or rent real estate? It’s enough capital resources and funding necessary to sustain important to determine the best available location the business until the business can sustain itself. Determin- for the business and coupling this with the most ing a business’s staying power is a critical function from optimal facility at a price the business can afford. the outset so that appropriate measures can be taken to assure capital funds when needed. There are also a number of other important line Having a business plan in place from the beginning is item considerations for an owner to deal with when critical to survival. Having the ability to measure the success opening a store. Some of these are auto/delivery or lack thereof of the plan is equally important. Make sure service, banking products and needs, insurance— these measures and tools are in place to greatly increase the both property and practice needs—professional likelihood for success. services (accountant and legal), security service, Purchasing an existing pharmacy may be the better supplies, taxes/licenses/permits, telephone and route to take in becoming an independent pharmacy own- communications systems, and utilities. er. Be sure to check out next month’s edition of America’s Then the challenge is to build volume to the Pharmacist, where I’ll be writing about aspects to consider point where the business begins to have cash in Part II of this article. flow and is able to meet all payroll and operating obligations in a timely manner. While there are too many factors to consider before you can deter- Andy Oaks is the president of Retail Pharmacy Management Services, mine at what point the business will have cash Inc. RPMS provides solutions and support to independent pharmacists flow, most upstarts take at least one year to reach throughout the United States. For additional information, visit www.rpms. the position of operating in the black. biz. For inquiries about this article, please contact Oaks at 800–662–9035 Therefore, an upstart owner must have or [email protected]. Reader Resources NCPA activities and our advertisers

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Community Pharmacy’s Platform For Our Patients and Our Pharmacies

Ask your member of Congress if they will help…

H Address any anti-competitive and anti-consumer with chronic disease: We support H.R. 3108 and activities of CVS Caremark: We urge members of S. 3543, which would give Medicare patients with Congress to ask the Federal Trade Commission (FTC) chronic conditions, such as high blood pressure and for a speedy resolution to its year-long investigation diabetes, greater access to the patient care services of a of the CVS Caremark merger. We call on the FTC to community pharmacist, so they can make the best use take strong and decisive action that would protect pa- of their prescription medications. tients’ ability to choose a pharmacy and not be forced to give up their own community pharmacist, while H Enact prompt pay for pharmacy’s long-term care continuing to curtail fraud, waste, and abuse. prescriptions: We support legislation that would require Medicare Part D plans to pay pharmacies H Support PBM reform to preserve patient choice: within 14 days for prescriptions provided to patients We support H.R. 5234, which would protect pa- in nursing home and assisted-living facilities— just as tients and pharmacists from the seemingly abusive they must do for retail prescriptions. Prompt pay will practices of unregulated pharmacy benefit manag- help assure that community pharmacies can continue ers (PBMs) such as CVS Caremark. This bill would to provide pharmacy services to these senior citizens. prevent PBMs from mandating or creating unfair incentives for patients to use the out-of-state, mail order pharmacies owned by the PBMs, forcing them away from their local community pharmacy.

H Allow Medicare patients with diabetes to obtain Vote... supplies from community pharmacies: We sup- November 2, 2010 port H.R. 5235, which would protect the ability of Medicare patients with diabetes to continue to ...for candidates that support obtain their critical testing supplies, such as glucose community pharmacy strips and lancets, from their community pharmacy.

H Support pharmacy services for Medicare patients

56 america’s Pharmacist | September 2010 www.americaspharmacist.net