Letter to the Editor of USA Today

As a practicing community pharmacist I read with interest the story on the fine agreed to by Walgreen’s Pharmacies. Since they agreed to the fine I assume that Walgreen’s agrees that they had a lack of control and has now taken steps to correct this oversight.

My concern is how the DEA spokesperson is so quick to point the finger at pharmacist’s oversight, wholesaler’s oversight but never seem to accept responsibility for the ultimate source of this problem. After all, which government agency licenses practitioners and enables them to prescribe these drugs in egregious quantities? Exactly the DEA! Who licenses the clinics that open? Exactly, the DEA! Who solicits from ALL of the major Pharmacy Benefits Managers dispensing data that shows who is writing these prescriptions? Exactly, the DEA!

My point is, why don’t they act on the entity that INITIATES the prescriptions? Because they are infringing on a physician’s decision making and that scares them to death! They are not physicians! By the time they get around to the obvious, thousands if not millions of prescriptions have been written.

Instead they pick the easy target, the community pharmacist. They question OUR judgment and give us ZERO opportunity to respond or explain why our decisions are made. They limit our ability to purchase medications. They threaten our suppliers if they don’t collect our patient’s private health data and turn it over to them.

We are being used as scapegoats for the meth craze and now the oxycodone explosion. The DEA is a typical bureaucratic entity that rather than solves the actual problem, would rather collect fines and pat themselves on the back publicly than listen to community pharmacists who MIGHT actually have some good ideas on how to address this problem.

Pharmacists KNOW who writes these prescriptions. In fact, a pharmacist friend of mine in Bean Station, TN lost his life at the hands of a drug head 2 weeks ago trying to do what the DEA expected him to do. We can point the DEA to rogue physicians. What we are not allowed to do, is play physician. How can we be SURE that a patient is a dealer and not a patient in real pain? One might say that you can tell by looking or that you can tell by the amount of the prescription but that is only true to a certain degree.

In the pharmacy in which I work we have strict protocols to determine whether or not to dispense. If it were up to our decision making process we would have removed hundreds of thousands of illicit medications from dealer’s hands. Instead when we turn them down they continue to go from pharmacy to pharmacy until they find one that is either too busy or slips up and gives them their medication. The root cause is the WRITING of the prescription. So instead of rewarding us for taking care of our patients they place arbitrary purchasing rules and squeeze wholesalers to limit the amounts that we can buy…whether or not we are following the rules. In turn this causes us to treat legitimate patients like drug addicts because we can’t get enough medication to fill their prescriptions.

It is like most issues facing community pharmacists today. The better we do our job the less we are allowed to do our job.

The bottom line is this…community pharmacists are the true gatekeepers of our emerging healthcare system BUT the “system” refuses to utilize us and pay us for the benefits we provide to our nation. We are not even recognized as a healthcare provider by Medicare so that we can be paid for providing services to our nation’s seniors. It is time to quit compromising our ability to do the job for which we have been trained. It is time for the DEA to quit squeezing those who want to be part of the solution and go after the obvious problem…the people that they license to write the prescriptions and begin the process.

I realize that by even commenting on this I place myself open to retribution but it is time to focus this debate on the real issue and not on the healthcare professional that places his/her life on the line everyday to make the right decisions.

Another Show of Disdain to Independent Pharmacists

I continue to be amazed at the lack of outrage from our profession at the announcement that Pfizer is now going to bypass pharmacists and sell Viagra directly to the public.

I’m sure that there will be some reaction eventually, but the response from EVERY organization that supports community pharmacy should have been immediate and harsh. We live in an instant information society so the response needs to be instant!

This is NOT about patient care or concern that patients are not getting “real” Viagra. It is about Pfizer profits and nothing more. If they were really concerned they would offer these discounts through established channels of distribution and not just through their website. Hey, Pfizer, try selling the drug at a reasonable price instead of $25 per tablet, ever think about that?

The response from State and National Associations, Buying Groups and Wholesalers that depend upon independent community pharmacy for survival should be the IMMEDIATE banning of Pfizer from gaining exposure through trade shows and conferences by exhibiting. Will any of these organizations step forward in support?

This is a dangerous trend and one that if successful will only accelerate the demise of our profession. Instead of making drugs affordable through community pharmacies lets just cut out the pittance we pay them and sell direct. As usual, one of the biggest whores, CVS is right in the middle of this and will do the fulfilling of these orders.
I for one, will be discussing with my patients the benefit of Cialis…until they follow suit and bypass us.

So, let’s just continue to do business as usual and allow ourselves to be walked over. Dispensing is the future right? Well, it seems as if we are not the only ones who believe that. The only problem is, everyone seems to think that the ones who do it best don’t need to be involved at all.

ePrescribing Safer? Seriously?

Is anyone else tired of hearing how great ePrescribing is? I mean, I’m all for progress and certainly I am for anything that reduces medication errors, BUT is ePrescribing living up to that promise?

Personally, I find errors in almost every prescription I receive through this method. Maybe the errors are not life threatening, but none the less, they are errors I have to correct. Time consuming? You betcha! I actually dread seeing those prescriptions show up in my computer. Is this really an improvement?

Why are doctors held to some kind of standard? Why can they just sling any font, grammatically incorrect set of directions in there and leave us to clean up their mess? How many prescriptions do you get that are supposed to go to another pharmacy? How about those that never show up, then you are reamed out when you let them know? Of course it HAS to be our system, right?

Finally, why are doctors not REQUIRED to accept refill request by eScript? There is not a single doctor in Cleveland or Chattanooga, TN that I am aware of that accepts refills by eScript. Why? Doctors have their systems given to them and we had to pay several thousands of dollars to be able to accept them. Couldn’t they AT LEAST be required to do something to make the system easier for everyone?

I am not intimidated by computers and in fact, get accused by my staff of being a “techie.” (As a Georgia Bulldog fan, that particularly stings!) I am certainly not afraid of change and in fact, I embrace change that actually betters things. However, I’m beginning to believe that, as usual, pharmacists have been on the receiving end of another rape initiated by insurers. I have ascertained that it takes us approximately 3 times longer to fill an eScript than it does to fill a new written one. I am NOT finding a reduction in errors but an INCREASE in them. If it is a totally new prescription, I find myself having to question the patient to be sure the physician didn’t just click on a wrong drug.

To add insult to injury, we actually have to PAY MORE per prescription for this “privilege.” How do physicians pay to ePrescribe? Exactly.

How about you? Do you find this easier or safer than what we have been doing? If not, why is this not being reported?

Where Are The Leaders?

 

“Pharmacists won’t change!” These words are being bounced around in board meetings of the very organizations that you and I are members of and endorse. Quite frankly, if recent history is any indicator they are right. It is because of this very attitude that independent pharmacy is in extreme jeopardy and in danger of extinction.

How many independent pharmacies that you personally know of, have closed or sold out to chains in the last two years? Because my business is talking to our fellow independent pharmacists around the country on a daily basis I can honestly say that the number for me is approaching 100. What happened to these businesses that were once the backbones of the local economies in which they thrived?

I think it is time for independent pharmacy as a segment of our great profession to accept responsibility for our own demise by admitting that we have dug in our heels and we refuse to change! Sorry, but I’m really tired of hearing that it is the PBMs fault. I’m tired of hearing that it is the insurers fault. I’m tired of hearing that it is politicians fault. It is a cop out of the greatest nature.

Call it Obama Care, Romney Care, Affordable Care Act or any other name you want to attach to it, but the FACT is that healthcare is changing…with or without us. Any of you reading this that stubbornly hangs onto the past way of doing business and refuse to accept the facts as they stare you in the face WILL face the same end…or worse.

In fact, the same thing can be guaranteed for our buying groups, wholesalers and professional associations. Quit dangling another basis point, another penny on reimbursements and another day on Capitol Hill in front of us as the solution! We don’t want another carrot on a stick! We want to thrive again! Paralysis is no longer an option and you know it. Your members look to you to lead…so lead!

As I look at the CE programs being offered this summer at the conventions and trade shows that we attend, I am embarrassed! Same old, same old. Why? Why do you continue to perpetuate the same good old boy network that has led us to our current situation? You ALL know that independent pharmacy’s days are numbered and that we cannot survive under the same model that we have practiced under for the last 50 years. It is time for anyone that depends on independent pharmacies for survival to LEAD THE WAY into the future and quit living for today.

Even Walgreens, with all of their clout and power recognizes the fact that change is inevitable. They know they can’t survive under the current model. They actually said NO! Imagine that. How did you, our buying groups, associations and wholesalers respond? Did you seize upon this opportunity to point out that it doesn’t make sense for independents to accept a contract that is so bad that a behemoth like Walgreens can’t even accept it? No. You hid behind the nebulous fear of “anti-trust” and let this opportunity to send a message to Express Scripts pass us right by. We need to serve our customers you said. Well, no we don’t. We need to create a market where we can actually meet a real need of our customers and actually make enough money to survive.

By contrast how did Walgreens proceed? They began the process of change in their culture by remodeling all of their stores in Indianapolis, IN (with Chicago not far behind) to show how they envision community pharmacy in the not so distant future. They began a national advertising campaign (although pretty lame) to show that their pharmacists are changing the way they look at their patients. Their leadership, in describing the new stores said that they are “the first manifestation of bringing our strategy to life: transforming from a traditional drug store to a health and daily living solutions store…it’s centered around how we help customers and patients live well, get well, stay well and eat well.”

Why would they do that? Wouldn’t it be easier to just sign the darn contract and keep doing business the same way they always have? Absolutely! However, unlike independents, they obviously plan on being around in the future. They are not maintaining and looking for someone to bail them out. They are CHANGING! They are changing not because it is easy; they are changing because they know baby boomers, generation Xers and any other acronyms for future consumers you want to use are demanding it.

These future senior citizens are not going to accept life as their parents. They don’t want to just live longer, they want it all! They want to be able to do the same things they have done their whole lives and they know that in order to accomplish that goal they have to…wait for it…CHANGE! They know they have to get healthy and begin paying attention to the things that are causing their health to deteriorate. The FACT is that they will patronize those in healthcare that provide them with the knowledge, services and products that facilitate that change. Will it be independent pharmacy or Walgreens? It is time for us to decide.

So I ask our buying groups, wholesalers and professional organizations, what is your Plan B? Plan A is not an option. We don’t need another 0.001% reduction in our COGs. We don’t need another 0.10 per claim increase in reimbursement. We don’t need to stake our future on expecting healthcare to regress to the way it was. It ain’t gonna happen! By focusing on these short term Band-Aids you continue to dangle the carrot in front of us and lead us down a path that will lead to our…and your demise. It is time to make the tough decisions just as Walgreens has. If Walgreens cannot make it under the current system, what makes you think that we can?

So what do I expect these groups to do? LEAD! Take a chance on something new! Use the influence that you have to facilitate change. Quit dangling carrots that you know will not lead us to survival much less prosperity, in front of us. We are all in the same boat, and we are all headed for the deadly waterfall.

I read a great statement from one of the LEADERS of a major religious denomination just a few days ago that I feel applies directly to independent pharmacists so I am going to put it into that context. “Pharmacists will not change until the pain of change is exceeded by the pain of staying the same.” My friends and colleagues, I tell you the way it is…that time is now.

Express Scripts / Medco Merger

I realize up front that there are going to be many offended by my post here and for that I am sorry, but it is time to say it.

Seriously, is anyone surprised by the Express Scripts/Medco merger? Big business always wins in today’s environment. I’m sure NCPA will get this decision delayed but in the end a merger like this will always go through because of the shell games played by the participants and $$$$$.

You have all been hearing this for years. Profits from filling prescriptions are gone and are NEVER coming back. If you want to continue to bank your future on profits from  prescriptions it is only a matter of time. You see the results every time you fill a prescription! It is now a commodity. What is the old saying that people erroneously claim is a definition for insanity? Continuously doing the same things and expecting different results. It really is a definition of failure.

There are those in our profession who still believe that the answer is squeezing wholesalers for lower cost of goods. You are not going to see lower COG because they are not there! Their profits are gone too. They are as efficient as they can be. Why do you think they are shifting emphasis to “specialty drugs?” National wholesalers try to be our friend and I believe that they really want to be our friend, but they don’t know how. So they cover their own rears by courting the very enemies of our profession that they claim to fight against. Don’t believe me? Then answer me this; why do they even provide pricing to the PBMs? Did it ever occur to you that the only way PBMs know what we pay is because the wholesalers tell them? Why do they do that? The reason is because all of them either owned PBMs or were incentivized by PBMs to provide this information. For what purpose? I’ll let you decide.

Others believe that belonging to groups is the answer. The fact is it doesn’t matter which PSAO or GPO you belong to, the prices are virtually the same. There is no give left. However, GPOs are necessary.They provide an island of sanity in this sea of insanity. Find one that fits your needs and JOIN! Go to conventions! Network with your colleagues! We are not each other’s enemies so let’s try being each other’s friends!

Ken and Jim Fields who own ApproRx, a pharmacist oriented PBM, and are innovative pharmacists in their own rights, will tell you, we are not playing the same game anymore. Our ONLY option is to CHANGE. Yes, that is right CHANGE. I know that it kills us to think about it but the way we have existed since the 50?s is not going to get it done. Joining together to demand lower and lower prices from wholesalers is fruitless. There are only pennies to be gained. You think Walgreens is buying significantly lower on brand names? Wrong! Why do you think they chose to stand down Express Scripts and lose that business? Because there is no money there!

Until we learn to let go of the past we will continue to wallow in self-pity and eventually drown. We MUST begin now to offer something that the PBMs need. That is a way to lower cost to their clients without milking dispensing costs. Even ES knows that there is a limit to those savings. They are at the bottom. ES is just trying to gain market share with this merger to buy time. They know their old way of doing business is ending. Transparency is here. Group by group, employers and government are going to demand accountability and ES cannot provide it and still make money.

Preventative care is the answer everyone is seeking. Active health coaching is a pharmacist’s dream. Instead we dream that one day all independents will work together. It is just not going to happen. There are dreamers and there are doers. ApproRx and RxAlly are actively providing answers TODAY. However, even they cannot do it without us.

What is the number one thing that is costing the health care system? You know the answer and it is inarguable. Obesity. The amount of money to be made by providing the answer to this problem is immeasurable. Provide a solution for the majority of the players in this scenario beginning with the patient, and the HMOs, PBMs, employers, government, ACOs and any other initials that you want to throw out there, will beat our door down for our services.

Argue this point all you want. Lampoon me all you want. The only thing holding pharmacists back from the future is us…and our need to find the easy way out. I’ve got news for you; there is no easy way out. However, I will make this one GUARANTEE. Continue to spend all of your energy trying to find a solution within this current system in which we all operate and the only thing you will find is the end of your business.

Change is inevitable and the time is here. Those who embrace it will be around to fight another day. Those who don’t….