When the U.S. Food and Drug Administration gave final approval in May 2019 to alpelsib, a new drug manufactured by Novartis Pharmaceutical, it was hailed by the company as “the first ever treatment specifically for HR+/HER2- advanced breast cancer that specifically addresses the needs of the patients living with this mutation.The drug was quickly brought to market under the brand name “Piqray,” at a cost of $15,500 for a 28-day supply. This example illustrates the critically important sector of the pharmaceutical market known as “specialty pharmacy” – a small but growing number of medications that are highly complex, very costly, and targeted at a small number of patients.
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Do more than fill prescriptions, be an active participant in your patients' health. Pharmacy eCare plans allow pharmacists to document the wide scope of services they provide, and the favorable impact these services have on patient outcomes. The eCare plan initiative is managed by CPESN, which oversees what has become a nationwide movement of community pharmacists interested in joining integrated networks. As of mid-2019, CPESN reports 2,100 member-pharmacies have built 45 local networks across 45 states. A guiding principle of CPESN was creation of a clinically-integrated network of pharmacies, defined as “a collection of health care providers that demonstrates value to the market by working together to facilitate the coordination of patient care across conditions, providers, settings, and time to improve patient care and decrease overall health care costs.”
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The fact is, pharmacies are being held to increasingly high standards for customer service. And as Amazon and other online companies make forays into the pharmaceutical industry – with easy, hassle-free retail experiences – local pharmacies find they must up their game to remain competitive and solidify their role as “pharmacy of choice” for their patients.This process begins with recognizing that patients do indeed have choices about where they purchase their medications, and that just as shoppers can jump from one retailer to another, the same is true about pharmacies. Pharmacies are as impacted by the need to provide a high quality “customer experience,” as any other type of retailer. Perhaps more so, given the highly personal and important nature of the pharmacy experience.
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No single word strikes fear into the hearts of pharmacy managers as the simple five-letter word A-U-D-I-T. Pharmacy managers understand that an audit can paralyze operations with extensive documentation requests, and result in clawbacks of payments from prior years, along with fines and even contract cancellations. Pharmacies face a continual risk of being selected for audits by insurance companies, pharmacy benefit managers (PBMs), third-party payers and regulators. In recent years, the number of audits has been on the increase, as payers look to streamline processes and recoup payments that may have been based on incorrect or fraudulent claims. In addition, pharmacy prescription practices have come under increased federal and state regulatory scrutiny, in the wake of the nationwide opioid crisis.
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The first thing to understand about Medicare pharmacy star ratings is that they do not apply directly to pharmacies. Instead, the Five-Star Quality Rating System is used by the Centers for Medicare & Medicaid Services (CMS) to help evaluate health plans based on several factors including quality, cost and coverage. But, several of the criteria used in determining a plan’s rating are directly linked to activities that place in the pharmacy. This means then, that pharmacies that do a good job of helping patients with medication adherence, and managing patients with diabetes, for example, reflect positively on the drug plan, which in turn would lead to a higher star rating. Conversely, pharmacies that do not monitor adherence, or proactively engage with patients about managing chronic illnesses, would be a drag on plan performance.
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At the start of 2019, the list of “most widely prescribed drugs” for patients in the United States included Atorvastatin (Lipitor), Levothyroxine (Synthroid, Levoxyl, Unithroid) and Lisinopril (Prinivil, Zestril). At an average monthly cost of $9, and with a rapid turnover rate, pharmacists can have a high level of confidence that inventories of these drugs will be sold, and can be replenished regularly to satisfy patient demand. Help has arrived in the form of “smart” technology systems that can automate the inventory management system. Pharmacists can rely on technology to gauge demand for certain drugs, to identify patients with prescriptions for specialty or high-cost drugs, and adjust orders based on that data. Technology can also help with inventory returned to stock, and with drug recalls, among a growing list of capabilities. The key though, is for a pharmacist to be “all in” with regard to maximizing the potential of an integrated technology system.
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In November 2018, the Centers for Medicare & Medicaid Services (CMS) released a much-anticipated proposal to amend certain Medicare Part D and Medicare Advantage (Part B) provisions as a way to lower prescription drug costs for beneficiaries. In announcing the proposal, Health and Human Services Secretary Alex Azar and CMS Administrator Seema Verma noted that while Part D is driven by market competition, “certain CMS regulations also constrain plans’ full negotiating power and keep them from lowering costs for their enrollees.” Since pharmacists are affected by many of the proposed changes, it’s a good idea to become familiar with the CMS plan, and to understand the impact of those changes on pharmacy operations.
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Imagine a scenario in which a patient walked into a drug store, and asked the on-duty pharmacist some questions about a health concern only to be told: “Sorry, I can’t help you.” Of course, that would almost certainly never happen, since the nation’s pharmacists value their patient relationships, and take seriously their role as patient advocates. Which is why it’s so puzzling, that pharmacists are not universally considered “medical providers.” Without this categorization, pharmacists are effectively prevented from being reimbursed by federal and state payers for services they are well-qualified to offer patients. The American Pharmacists Association considers achieving full provider status for all pharmacists a top priority, and is seeking federal legislative relief.
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With a growing number of Americans entering their golden years – 10,000 baby boomers celebrate their 65th birthday every day – the nation’s pharmacies will continue to be an essential source of products and services including prescription drugs, medical devices, testing and immunizations, and counseling and education. More than ever pharmacies provide a lifeline to their senior patients, and are a vital link in the health care network. That said, it’s increasingly important for pharmacy managers to ensure they provide an optimal in-store experience for their senior citizen customers, and achieve maximum efficiency from technology-based pharmacy systems. As pharmacists prioritize the need to provide “whole patient care,” it can be helpful to evaluate current processes, and determine if changes are in order to improve efficiency or levels of care.
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When a trio of reporters from The Chicago Tribune set out in 2016 to investigate the rate at which local pharmacies warned patients about potentially dangerous drug combinations, they could hardly have predicted that their findings would result in legislation to change pharmacy protocols, and serve as a catalyst for reform among pharmacies nationwide. The reporters armed themselves with prescriptions for various drug combinations which, taken together, could have serious health implications. One combination, for example, included a prescription for the common antibiotic clarithromycin, along with one for anti-cholesterol drug simvastatin. Used alone, each drug is relatively safe but, as the Tribune noted, “together they can cause a severe breakdown in muscle tissue and lead to kidney failure and death.”
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According to the Centers for Disease Control and Prevention (CDC), every day more than 115 Americans die from opioid overdoses and in 2016, more than 2 million Americans were addicted to opioids. As many as 29 percent of patients prescribed opioids for chronic pain will misuse them, and between 8 and 12 percent will develop an opioid use disorder. Despite the widespread media attention the opioid crisis is now receiving, the crisis seems to be worsening, with CDC analysis finding “that America’s overdose epidemic is spreading geographically and increasing among demographic groups.” In the Midwest alone, for example, opioid overdoses increased by 70 percent from July 2016 through September 2017. And overdoses in large cities increased by 54 percent across 16 states during that same period.
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Developed as part of the national initiative to implement electronic patient records across the healthcare industry, the Pharmacist eCare Plan initiative – which recently concluded a successful pilot phase -- will allow pharmacists to maintain detailed patient health and medication histories, and to share that information across a patient’s health care team. At the same time, the system will help facilitate changing payment requirements, which require documentation of services delivered to patients. As pharmacies embrace the benefits of being able to provide electronic, accessible records for their patients, it’s essential for managers to take the time to consider their technology options, and ensure they select the best solution for their pharmacy.
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While prescription drug prices have long been a source of friction between patients, manufacturers and insurers, PBMs are increasingly being cast as the villain for this and many other pharmacy-related issues. Research by the National Community Pharmacists Association (NCPA), for example, found overwhelming dissatisfaction with PBMs among its pharmacist members. Developed as part of the national initiative to implement electronic patient records across the healthcare industry, the Pharmacist eCare Plan initiative – which recently concluded a successful pilot phase -- will allow pharmacists to maintain detailed patient health and medication histories, and to share that information across a patient’s health care team. At the same time, the system will help facilitate changing payment requirements, which require documentation of services delivered to patients. As pharmacies embrace the benefits of being able to provide electronic, accessible records for their patients, it’s essential for managers to take the time to consider their technology options, and ensure they select the best solution for their pharmacy.
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Former Surgeon General C. Everett Koop once famously said that “Drugs don’t work in people who don’t take them.” Dr. Koo¬p was referring to the high incidence of medication non-adherence among U.S. patients, a problem The New York Times referred to as “an out-of-control epidemic.” Non-adherence is clearly a serious problem and a top concern for the healthcare industry. Pharmacists, who interact directly with patients, can be a leading force in encouraging prescription compliance. And now, thanks to innovative technology solutions, pharmacists have an additional tool to use in helping to guide patient behavior.
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