What's the problem? Too many to list. What's the solution? Pharmacists.

Earlier this year the U.S. Surgeon General was quoted as saying, "We have the evidence health leaders and policy makers need to support evidence-based models of cost-effective patient care that utilize the expertise and contribution of our nation's pharmacists as an essential part of the health care team."

The Surgeon General specifically identified three demands within the health care system that pharmacist-delivered patient care can help meet:
  1.  providing care for chronic disease patients;
  2.  increasing access to care, addressing insufficient time for focused medication management;
  3.  and supplementing the primary care provider workforce.

Health reform through pharmacists delivering expanded patient care services?  Absolutely.  Through testing in the federal sector, several practices have been implemented and embraced, including a health care delivery model through physician-pharmacist collaboration.  This model has demonstrated that patient care services delivered by pharmacists can improve patient outcomes, promote patient involvement, increase cost efficiency, and reduce demands affecting the health care system.

Another opportunity for pharmacists: Studies conducted by the Association of American Medical Colleges show that America is producing a consistently stagnant number of doctors each year relative to our continually growing population.  Since 1980, the U.S. population has grown by 70 million while the number of M.D. graduates has remained flat at about 16,000 per year.

Experts have warned that there won't be enough doctors to treat the millions of newly insured under health care reform laws.  It is predicted that the U.S. could face a shortage of as many as 150,000 doctors in the next 15 years; 45,000 physicians short by 2020.  This data clearly predicts an even more limited access to health care providers.  What profession will step up and fill this need?

Over the past 10 years, we have seen signs of pharmacy going from a product-focused - or medication-focused - profession into a patient-focused profession.  The medication is no longer our product - the patient and their outcome is.  Every element of pharmacy is broadening.  A few more steps and pharmacists will no longer be, in large part, "dispensers" or "verifiers".  Visualize pharmacists as conduits of health; providers of education; builders of relationships and trust; and the rising professionals who will affect change in the health care industry.

Through EMR and EHR, the technology is in place for collaborative practice agreements where pharmacists can:
  1.  perform patient assessments;
  2.  have prescriptive authority - to initiate, adjust, or discontinue treatment; to manage disease   through medication use; and deliver collaborative drug therapy or medication management;
  3.  order, interpret, and monitor laboratory tests;
  4.  provide care coordination and other health services for wellness and prevention;
  5.  and develop partnerships with patients for ongoing care.

More and more of the pharmacy profession is impacted by external events, but the pharmacist's core continues to remain the same - to treat those who are ill, relieve suffering, and act in the service of our community.  The degree to which we can 'treat' is an exciting evolution that we are lucky enough to be experiencing during our careers.  The progression may be coming in stops and starts, but we are moving forward like never before.

77% of pharmacy patients say their pharmacist is a valuable resource; 28% of patients interact with them.

The pharmacy health and wellness market is a lucrative one, expected to reach $170 billion by the end of 2012.  This industry continues to experience rapid loyalty growth, in part due to the numbers - customer spending and repeat shopping is on the rise.

Pharmacy companies are investing in and revitalizing customer loyalty programs to booster sales and grow loyalty.  Tracking customer sales allows companies to understand where and how often customers are spending, enabling personalized offers and rewards.  It's a win-win - customers are saving money and feeling valued, and pharmacies and health and wellness businesses are gaining better customer insight, increasing sales and retaining customers.

According to research released in October by AccentHealth and Boeringer Ingelheim, 90% of pharmacy patients have a preferred pharmacy - and for 98% of that group, it isn't mail-order.  The key to success is being the most "preferred."  But it also means that converting customers to your pharmacy will probably take some effort.  Thus far in 2012, only one in ten patients has changed their pharmacy.

Factors Affecting Patient Preference:

• 75% of surveyed patients rated convenience/location as their first priority.
• 57% of patients rated customer service as their second priority.
• 34% of patients said the pharmacist is a "very important factor" in choosing their preferred pharmacy.

It's Always about the Money
When all things are equal - specifically cost - there is no doubt that satisfied pharmacy patients are fiercely loyal to their preferred store.  But if cost is a considered factor, then:

• 32% of patients said they would change pharmacies for a savings of $5 or less.
• 8% of patients said they would change for a savings of $1 or less.

As 40% of patients would change pharmacies to save $5 or less (if cost is important), the pharmacy staff needs to work to develop that customer loyalty.  Research shows that engagement with pharmacists varies by pharmacy type: in 2012, independent and food store customers interacted the most; chain pharmacy customers interacted the least.  Customer engagement with the pharmacist has little correlation with the time they wait to speak with their pharmacist, and filling wait times have no direct correlation with increased spending in the store.  But let's not mince words - wait times directly affect overall customer satisfaction.

Perception v. Reality
77% of patients believe that the pharmacist at their preferred pharmacy is always available to answer questions and discuss medications, but only 28% say they interact often with their pharmacist.  One can conclude that the pharmacist plays an important role in patients choosing a pharmacy; and yes, they are a trained, valuable, accessible resource.  But very few people are reporting that they utilize the pharmacist as a regular source of information.

Chain pharmacists have a distinct advantage - chain customers are shopping at their primary pharmacy 4.4 times per month on average, which leads all other pharmacy types.  The advantage?  This frequency gives the pharmacy staff ample opportunity to provide the service and care the patient requires, certainly increasing loyalty.

A parting thought - a clear majority of surveyed patients believe that chain drug stores have the most professional and trained pharmacists.

Theory is now reality. Welcome to the future.

We all know that politicians are still fighting about health reform, but health providers (including Texas Health Resources) have made their decision: The big overhaul is coming regardless of what happens in the November elections.  There has been an acknowledgement of the inevitable - and the unsustainable.  Health spending has reached a high of 18% of GNP, up from 12% in 1990.  Accountable Care is not just a theory anymore... it's reality.

Providers are feeling the pressure of offering more consistent care at a lower price.  Accountable Care Organizations are a big part of health law - get the right treatment at the right time at the right price; and keep patients healthy by bringing together primary care doctors, specialists, hospitals, pharmacy, and more.  This is the beginning of the end of our crippling fee-for-service system.

Texas Health Resources facilities treat one in four patients in this region.  The group has already spent $200 million on electronic medical records systems and a data analysis company, Healthways.  The tracked health data will identify congruent health issues among patients and the most effective protocols; smartphone tools will record follow-up treatments, medications and several other measurable effects.

Cost control efforts are being seen across the spectrum.  Next month Medicare will enforce new policy for hospitals with high re-admission numbers to be paid less than hospitals with fewer preventable re-admissions.  A New England Journal of Medicine study shows that 20% of Medicare patients return to the hospital within 30 days of discharge - their conditions still serious and costing the U.S. about $17 billion each year.  34% of patients are re-hospitalized within 90 days of discharge.

Admittedly, many of the returning patients are high-risk; they may be frail, have chronic conditions, or are unable to get to their follow-up medical appointments.  To add another layer, hospitals tend to transfer patients to less costly settings once their conditions are stable.  Follow-up care at home or through a skilled nursing facility is an option many patients prefer, but their condition needs to be carefully managed for the best outcome.

The Affordable Care Act is expected to allow countless seniors to live longer, healthier lives.  The ACA brings lower drug costs, more free preventative health screenings and an annual consultation with a physician to create a personal health plan.  And, it should also mean an end to obscene increases in medical costs.  Senior advocate organizations have strongly supported the health care bill, and virtually all the major health care and health insurance associations have given it their full support.

New rules allowing for administrative simplification are gradually being rolled out and accepted as part of new health care law.  These changes are expected to save providers and health systems about $4.6 billion over the next 10 years.  How?  By eliminating the red tape.  Directed by Health and Human Services Secretary Kathleen Sebelius, a universally used administrative process is essential in providing cost-effective, patient-care focused treatment plans that lead to more time with the patient, less time filling out forms, and more positive patient outcomes.

And Missouri Stands Alone…

49 states have now passed legislation to electronically monitor controlled substance and

narcotic prescriptions, with the exception of Missouri.  Senator Rob Schaaf of St. Joseph, Missouri, is a first time senator and family practitioner.  Schaaf is adamant that Missouri will not adopt a prescription database, as he believes – along with other critics – that the database represents an infringement on personal liberty.  Protecting a patient’s confidentiality should be a priority, Schaaf has said, adding that citizens “shouldn’t have to give up their right to privacy just to stop people from doing bad things.”

The Texas Department of Public Safety (DPS) officially launched their secure online prescription monitoring program, called Prescription Access in Texas (PAT), in July 2012.  This database is available to a select group of practitioners, pharmacists, and law enforcement officials.  Very recently, DPS has extended program access to additional physicians and law enforcement, mid-level practitioners, medical board and nursing board investigators.

Advocates of the program contend the database allows doctors and pharmacists to better monitor patients who frequently seek prescription medications; the program is aimed at stopping “doctor shopping,” by which people get prescriptions from multiple physicians to feed an addiction or to sell.  The number of deaths as a result of prescription drug use and abuse are greater than heroin and cocaine overdose deaths combined.  The most recent year with statistics available – 2009 – shows that nearly 21,000 deaths in the U.S. were attributed to prescription drug overdoses.

The Centers for Disease Controll says overdose dealths from prescription painkillers such as hydrocodone, methadone, and oxycodone have skyrocketed in the last 10 years.  Some estimate that deaths from prescription drug overdoses exceed those from car accidents.  In Dallas County, 14.5 percent of high school students have admitted using an illegally obtained prescription drig in the last 30 days.   

It appears that online tracking of controlled drugs will, at the very least, decrease access.  Florida was once known as the “pill mill capital.”  A few years ago, more than 90 of the nation’s top 100 prescription-dispensing physicians were in Florida.  In 2009, the state instituted a tracking program and today, the number is down to 13 physicians in the top 100.  People who fail to disclose that they are receiving pain medication, controlled substances, or narcotics from other doctors could face legal consequences. 

Pharmacists have been required to send prescription information to the Texas Department of Public Safety since 1982, now called the Texas Prescription Program.  It was once an effective and efficient tool for investigation and preventing drug diversion.  The new online PAT system does not require every prescription written to be entered in the database; pharmacists are required to report each prescription they fill for narcotics.  PAT will hold physician, patient, and controlled substance information for one year, allowing law enforcement and health care professionals’ immediate access to dispensing data.

Texas has taken measures to ensure the data is secure on PAT, and that it can only be accessed by licensed practitioners and pharmacists; however the American Civil Liberties Union has reservations about the program.  The ACLU refers to the program as “government surveillance.”  Is this another example of Big Brother tracking our every move?  Does this program violate personal liberties? 

Let’s not over-think this…  I think PAT allows providers access to data that will help them make appropriate decisions for their patients. 

A Little Less Conversation, A Little More Action

Although a slew of political controversy succeeded in distracting our attention for about five minutes, I think we’re all getting used to idea that the health care system as we know it is changing.  When we think about reform, let’s keep two things in mind: currently, the United States spends more than twice as much as any other country in the world on health care; and, despite our huge investment, our national health status is near the bottom of the developed world.

We hear political candidates sparring about a “repeal of health care reform”, but most experts think it unlikely.  Analysts and industry specialists assert health care reform will continue out of necessity, whether through the Affordable Care Act or the momentum it already has created since being passed over two years ago.  Many think it’s time to stop talking about everything that is wrong with the ACA, and just go on about it.  The odds of repeal?  Slim.  According to a Kaiser Health Tracking Poll released recently, only about 20% of U.S. voters are pushing for a full repeal.

In large part, health care reform boils down to several points:

·       If you don't have health coverage in 2014, you will have to pay a penalty.  The fee is capped at $285 per family, or 1% of income, whichever is greater; $2,085 per family, or 2.5% of income, by 2016.  Individual penalties will be $95 in 2014; $625 in 2016.

·       Employers must provide coverage for adult dependents of workers up to age 26; health plans must cover basic preventive services without charging a deductible, co-pay or coinsurance; insurers can't impose a maximum annual or lifetime dollar limit on a customer's medical care. 

·       Beginning in 2014, insurers can't drop an individual if they become sick and they cannot refuse coverage for a pre-existing condition.

·       Industry experts predict that employers who offer insurance will be even more focused on controlling their health care costs, especially since the individual mandate is expected to add more people - including more high-risk individuals - to their plans.  Expect increases in premiums and deductibles.

·       Consumers with incomes between 139% and 400% of poverty will be eligible for tax credits to offset the cost of buying coverage through exchanges.  According to the Congressional Budget Office, the average subsidy per enrollee in the exchange will be $4,780 in 2014; $5,780 by 2018.

Medicaid is expected to include more low-income Americans – those earning up to 133% of the poverty level are eligible – with the federal government paying 100% initially and decreasing to 90% over the long term.  But individual states are given the choice of expanding their Medicaid program.  Currently, 22% of the Medicaid program is paid by the individual state.

Certainly one question looms large…  Who pays?  The answer is still murky.  The government?  Taxpayers?  Will free enterprise take over and drive costs down?  Although some analysts say the middle class will be hit the hardest, repeal at this point would add $109 billion to the deficit. 

This we do know… The federal government will shift health care cost increases to governors and states, as 160 million Americans—or one out of every two—will be receiving their health care directly from the state or through a state created and operated exchange.  This includes state employees, the 80 million individuals expected to purchase healthcare through the exchanges, and an additional 75 million on Medicaid.

Wonder what Rick Perry is thinking right now…

“I trust my drug dealer. I’ve had him for ten years.”

Customer: “Do you have real Xanax back there?”

Pharmacist: “All of the drugs in the pharmacy are real and approved by the FDA, ma’am.”

Customer: “I think I got some bad Xanax.  I don’t feel right.”

Pharmacist: “If you’re not well, I think you should go to the hospital to be checked.  There’s been a lot of synthetic Xanax in the area and it’s very dangerous.”

Customer: “No.  I trust my drug dealer.  I’ve had him for ten years.”

I heard this and didn’t know if I wanted to cry, put it on a t-shirt because it’s so ridiculous, or become a Republican.  You should probably know that this posting will most likely not be politically correct, and it is 100% the views and unqualified opinions of me – the blogger.  As far as I know, my words do not represent anyone or anything other than myself.

A friend told me another one this week…  People are getting high on “bath salts,” going crazy, and becoming cannibals.  I thought she was crazy, but I called on my most trusted resource – Google – and started reading.  She’s right.  People are injecting, snorting and smoking this new designer drug.  The main synthetic “Bath Salts” ingredients:

·         mephedrone
·         MDPV
·         methylone

These chemicals, along with others formulated by “street chemists”, were being sold in gas stations and convenience stores – displayed right on the counter near the cash register.  Now they are being sold on line and from behind the counter in smoke shops and c-stores.  Customers are currently required to ask for the product by name: Ivory Dove Ultra is $16 for a 200-mg packet.  The package clearly warns that the product is not for human consumption.

Well, humans are consuming.  Earlier this month, Miami News reported a 31-year old man high on “bath salts” attacked an older man and ate his face.  The attacker could not be subdued and was shot and killed by police officers.  Other cities are reporting incidents of users acting as “psychotic ravaging beasts,” clearly a preface to the cannibalistic activities.

                BREAKING NEWS: as of June 29^th, toxicology reports showed that marijuana

                was the only illegal drug in the Miami attacker’s system.  Scientists admit,

                however, that they don’t know what other chemicals to test for, or do not

                have tests developed to look for the known synthetic ingredients.

Cannibalism.  As a society, how have we gotten to this point?  I get that people can be addicted to things  - like video games, smart phones, fast food, alcohol, cigarettes.  Some is human nature – some people are predisposed more than others towards addictiveness.  But as healthcare professionals, are we required to show compassion to everyone?  My gut says we are, but I’m having a hard time wrapping my head around ravaging cannibals and kindness.

As adults, I believe we need to do whatever is required to protect our youth, but at what point is my obligation to my fellow man fulfilled?  There are many days where I feel like I’ve done my part, but then my conscience gets the better of me.  Perhaps I can find a balance of compassion and concern while not condoning one’s behavior?  I support the First Amendment as much as the next guy, but when we need the Second Amendment to protect ourselves from people making conscious decisions to use drugs like "bath salts”, you have to wonder… Where it will end?

Where is your end?  Where is your line in the sand?

Watch Me Say No

… is another download that teens can use to design their own anti-drug t-shirts, posters, and stickers from the National Institute on Drug Abuse website.  The NIDA website was created to educate adolescents (as well as parents and teachers) on the science behind prescription drug abuse.  It is hoped that understanding science-based facts will prompt teens to make better decisions about using drugs.  Teens were instrumental in developing the site to ensure the content addresses appropriate questions and timely concerns.

The non-medical use of controlled medications in teens has surpassed all illicit drugs except for marijuana.  Smart Moves, Smart Choices – a website sponsored by Dr. Drew Pinsky, Janssen Pharmaceuticals, Inc., and the National Association of School Nurses – is a group dedicated to educating the public on teen prescription drug abuse.  At this time, 19% of high school students have admitted to taking a prescription medication that was not prescribed to them; 33% have admitted to trying marijuana.

Research shows that prescription and over-the-counter drugs are among the most commonly abused drugs by teens, along with alcohol, marijuana, and tobacco.  Many young people access prescription drugs easily and perceive prescription medications to be less dangerous than other drugs – they believe them to be safer and have fewer side effects than street drugs.  An alarming 60% of teens who have abused prescription drugs have tried them before age 15. 

Many accuse U.S. adults of having a “casualness” about taking prescription medications – that controlled drugs are without consequence.  Some believe this attitude is helping to fuel the drug problem we now see in teens.  64% of abused prescription drugs are coming from friends or relatives; some misuse originates from a legitimate prescription.

The most abused classes of drugs are benzodiazepines, psycho stimulants, and opiates.  The most problematic class is opiates - every day, 2500 more teens use a prescription pain reliever to get high for the first time.  According to Reuters Health research released in May, one in eight U.S. teenagers has used powerful painkillers without prescriptions.  Both medical and recreational use of these drugs has increased across the United States over the last two decades, as have deaths due to painkiller overdoses.  The CDC estimates that 14,800 Americans died of an opiate overdose in 2008 – three times the number of such deaths 20 years earlier.

The health risks of drug abuse are the consequences that have plagued teens longer than our memory allows: unwanted pregnancy, intoxication, sexually transmitted diseases, violent acts, manic behavior, depression, suicide, death.  Teens who said they used prescription medication for non-medical purposes were more likely to use marijuana and binge drink, adding to the already volatile risks.

Preventing drug use before it begins is certainly the most cost-effective way to address teen drug abuse.  Successful prevention means fewer will develop substance use disorders, and the consequence of substance use – including health care, treatment costs, and criminal justice system costs – will decrease. 

What’s a fishbowl party? Teens dump random pills into a bowl and everyone takes one to see what happens.  Drug abuse is not just the problem of the individual – the cost of abuse has far reaching tentacles that touch all of us.  The adult populations can’t afford to be casual.  A potent reminder: research shows time and again that adult influencers are still the most powerful force in the lives of young people.  It is our responsibility – or even obligation - to exert that influence.

What Was, and What's Expected to Be

Earlier this month, Pembroke Consulting and Drug Channels released their official analysis of prescription data and industry trends in the report The Use of Medicines in the United States: Review of 2011. 

A quick summary:

·         the total number of retail prescriptions dispensed grew only 0.3% from 2010

      ·         chains pharmacies won again, growing six times faster than the overall industry

·         all other retail formats – independents, supermarkets, and mail order – shrank in both   absolute size and market share

·         chain drugstores filled 2,212,000,000 prescriptions in 2011, a 1.8% increase from the 2010 numbers; 2011 chain drugstore market share was 52.5%, an increase of 0.8%

·         independents filled 740,000,000 prescriptions in 2011, a decrease of 1.1%; independent market share decreased by .2% to 17.6%; independents’ market share in 1992 was 37.1%

·         supermarkets filled 483,000,000 prescriptions 2011, a decrease of 1.2%; supermarket market share decreased 0.1% to 11.5%; supermarkets filled about the same number of prescriptions since 2008, showing zero growth in four years

·         mail order pharmacy prescriptions reached 780,000,000, a decrease of 1.5%; total market share dropped to 18.5%, a decline of .3%

·         for the five-year period from 2007 to 2011, the number of prescriptions filled at chains grew twice as quickly as the overall market

 In 2011, drugstore chains and mass merchants with pharmacies continued to gain market share at the expense of all other dispensing formats.  CVS and Walgreens prevailed with new store openings, organic growth from larger and busier pharmacies, and acquisitions of regional chains.  Wal Mart, now the third-largest chain, used its $4 generic program to continue to increase traffic at its pharmacies.  2012 is expected to tell a slightly better story for non-chains, which have been picking up numbers from the 90 million Express Scripts prescriptions previously filled at Walgreens.  Stay tuned for how the ESI story develops.

Pharmacy’s next growth spurt?  Specialty drugs.
According to research conducted by IMS Health – a technology based analytics and services company – and Pembroke Consulting, a specialty drug dispensing boom is expected in the coming year.  The projected growth is encouraging market entry, drawing investment capital into the pharmacy industry, and increasing competition for specialty pharmacy services.  Dispensing of specialty pharmaceuticals will become less concentrated as regional chains and independents penetrate this market, and manufacturers will face increased pressure to broaden limited distribution networks.

Revenues in the pharmaceutical industry will shift from traditional brand-name drugs to specialty drugs over the next few years.  While a majority of specialty drugs are dispensed via a specialty pharmacy, any licensed pharmacy can dispense a specialty drug as long as the product can be purchased from a manufacturer or via an authorized wholesale distribution channel.  As a result, numerous pharmacies with specialty drug capabilities will compete vigorously to dispense these expensive therapies.

Top 10 U.S. Selling Drugs – 2010 vs. Expected Numbers in 2016:

** names in pink print are specialty drugs


2010             2016

Plavix                        Rituxan
Lipitor                       Humira
Seretide/Advair      Avastin
Seroguel                  Januvia

Epogen/Procrit      Advair

Actos                        Revlimid
Abilify                       Lantus
Enbrel                      Enbrel
Singulair                  Remicade
Remicade               Atripla

Wednesday, March 28, 2012

It's all about the dollars. And the change.

On March 23, 3010, President Obama signed the Affordable Care Act, a law allowing comprehensive health care reform to roll out over several years.  We have already seen a number of these changes influence public and private insurance, with many more policy changes to come.  Good or bad, we are experiencing a complete overall of the healthcare industry as we know it.   Perhaps the gradual changes allow us to steadily adapt instead of throwing us into the deep end of the reform pool.  All of these alterations appear to be building up to the backbone of the health reform laws – The Health Insurance Exchanges.

Mandated to be in place by January 1, 2014, these state-based health insurance marketplaces will be enrolling 32 million of the 50 million Americans who, at present, do not have health coverage.  The exchanges represent a grand plan to make health insurance accessible and affordable to those who now struggle to find and keep coverage.  Individual consumers and small business will be able to shop online for competitively priced coverage, and many will receive government subsidies to help pay premiums or be granted tax credits.

According to a recent study, 44 percent of employers believe they will provide employee health benefits through a corporate exchange in the next three to five years, although 72 percent declared they are “very or somewhat interested” in exploring corporate exchange models.  To give employers power in numbers many are trying to create a group purchasing option to negotiate lower rates from the insurers.  Corporate or private exchanges solicit group-specific insured rates while the employer determines the contribution for employees to use in purchasing coverage.  The employee then makes their final decision about coverage.  In the same study, 86 percent voted that the ability to reduce costs was the most important feature of a corporate exchange.    

States will be submitting their “Exchange Blueprint” for approval in 2013, but if a state hasn’t made much progress, the federal government can intervene and make the final decisions.  The Obama administration's request for $800 million to operate federal exchanges has gotten a frosty reception from congressional Republicans.  For things to go smoothly, state and federal officials must work together to verify private personal and financial details for millions of people, make sure that consumers are enrolled in the right health plan, and accurately calculate how much government aid, if any, each household is entitled to.

The White House is giving states some flexibility in setting standards for their marketplace, as the state gets to decide who runs the new market and which insurance companies get to participate, however Health and Human Services will certify which exchanges are – and are not – able to deliver the customer experience that the White House wants to see, including things like allowing consumers to easily compare plans and having an enrollment mechanism for both private insurance and Medicaid.

The Affordable Care Act assigns most Americans a legal responsibility to carry health insurance, either through their employer, a government program or by buying their own.  Millions will receive financial assistance for their premiums.  Whether that amounts to an unconstitutional expansion of federal power, as a group of Republican governors allege, is among the subjects of a showdown that began March 26 when the Supreme Court heard three days of arguments.  A decision is expected by June.

It’s a Managed World, After All.

With much fanfare, anticipation, anxiety and expectancy, March 1^st hales the beginning of Medicaid Managed Care in Texas.  We’re certainly not the first state experiencing this transition; many have come before us and lit the path.  But because it’s happening to US, this change is much BIGGER and MORE IMPORTANT than any state has experienced prior to NOW.

Texas’ expanded Medicaid Managed Care Organizations will provide incentive payments for health care improvements, monthly stipends to physicians for coordinating patients’ care (including preventative care, acute care, and hospitalization), and direct more funding to hospitals that serve large numbers of uninsured patients.  Communities and hospitals will form regional health partnerships that support more localized health care solutions, and the partnerships will qualify for incentives by identifying ways to improve health services in their region.

Under MCOs, Texas pays a set fee each month to a health plan to provide care for the Medicaid client, who selects a primary doctor from the plan’s network to coordinate his or her care.  MCOs boast more coordinated and efficient patient treatment and by their calculation Texas is expected to save about $100 million over the next two years.  Patients are being assured “benefits will not be cut to those in need” and MCO’s are looking for even more populations to enroll in an effort to save everyone more money.  Wink, wink.

Prescription drug benefits for Texas’ 3,313,960 Medicaid patients will be delivered through Pharmacy Benefits Managers with a state-approved formulary.  A recent study showed that Texas’ dispensing fee under the Medicaid/Vendor Drug Program-administered prescription plan was among the highest in the country, although pharmacies were paid less of the product cost.  According to a coalition of Texas pharmacists, the dispensing fee per prescription is predicted to fall from about $6.50 with VDP system to as little as $1.35 with the new PBM system.

Many things are confusing but this nugget jumps to front of mind: adding multiple for-profit MCO and PBM middlemen will probably increase total healthcare costs.  Why would Texas want to surrender day-to-day management of prescription drug plans to the most highly litigated and highest profit-margin vendors in health care - PBMs?

A quick Google search showed PBM Express Scripts 2010 net income of $1.2 billion, an increase of 82%; 2011 net income reached $1.3 billion, an increase of 8%.  PBM SXC Health Solutions 2011 revenue was $5 billion, a 42% increase from 2010.  PBM Medco’s 2011 net revenue was $19 billion, an increase of 12.2% from 2010.

A final thought:  Americans have been fighting the good fight, but many are still feeling the residual effects of the recession that began in late 2008.  It’s impossible to calculate the number of people who left prescriptions go unfilled because money was needed for other things.  Millions are trying to make their way in this new economy, and we see proof of that every day in our stores.  Meanwhile PBMs are posting record profits and MCOs are promising to save everyone more money.  But at what cost to the patient? 

Baby, We've Come a Long Way.

As long as there have been societies and physicians to treat them, there have been specialists whose sole purpose was to prepare and administer medicinal treatments.  Pick any ancient civilization, and there will be evidence of organized and skillful application of pharmaceuticals.  The modern drugstore varied significantly from its ancient counterparts, in that the proprietors were often making medical decisions by diagnosing and treating patients without the consultation of physicians.

And the pendulum swings again...  Pharmacists in today's drugstores are tasked with the responsibility of evaluating the appropriateness and managing the dispensation of pharmaceuticals prescribed to patients under a doctor's care, assuring - most importantly - that the patient is safe from interactions or adverse reactions.  Although dispensing responsibilities remain the same, we're beginning to see more clinical, preventative, patient care focused services available in the most convenient setting - the store on the corner.

I think everyone will acknowledge that this is possible because pharmacists, every day, are becoming a much bigger part of total health care - of total patient care - than ever before.  It's exciting to realize that the pharmacist role today and going forward has an opportunity to affect real, valued change in patient outcomes and the health care industry in the U.S. as we know it.  The glass half-empty side?  We're still chained to the verification computer.  But we're working on that.

Alas, The Wellness Experience has arrived.  The pharmacist is in front of the pharmacy, available to answer questions, provide valuable counseling, Medication Therapy Management, adherence solutions, immunizations, and preventative health care screenings.  A "Health Guide" is on duty to help patients navigate the store and their health care options, and enroll patients in upcoming health and wellness programs in the new "Health Corner".  In our mind's eye, we see better patient outcomes, the prevention of hospitalizations, and savings for patients, employers, insurers and - as a whole - the health care industry.  We also see the pharmacist practicing at their most valuable level.

For more than several years, pharmacists have been proving they are capable of much more than safely dispensing.  Health care reform is imminent.  Today it's hard to imagine a picture that includes mandatory insurance, wellness benefits to employees and employers, tax credits and cost-sharing, Medicare bundle payments to better coordinate patient care, annual fees for drug manufacturers based on market share, and incentives to participate in health and lifestyle programs to reduce the risk of chronic disease.  But I'm sure society will learn the new ways and adapt.

Reform will push the pharmacy profession to adapt as well.  It is predicted that pharmacists will provide patient-centered and population-based care that optimizes medication therapy, where the patients health outcome is the product, not the medication.  Some foresee pharmacists having the authority and autonomy to manage medication therapy and be accountable for patients' therapeutic outcomes, while working cooperatively with practitioners of other disciplines to care for patients.

When the pendulum swings again, we'll see.  I've only met one person in my life who likes change - Kelly Demitt.  The rest of us will be anxious, then able to tolerate, then understand, and then adapt.  We've kicked up a whole lot of dust behind us, but there's a whole lot of trail left in front of us.  Hold steady the course.  We'll make it.

A National Problem with Local Solutions

Patient medication adherence is a problem of national importance to all involved: patients, their caregivers, health plans, employers, physicians, pharmacists and health systems.  Any complacency about adherence directly leads to the failure of medical treatment plans.  Research has shown that, on the whole, we can assume 50% of patients do not comply with treatment recommendations, allowing for devastating consequences:

• 11 to 23% of all hospital and nursing home admissions, resulting in 340 deaths per day;
• three times as many physician visits and $2000 per year per non-adherent patient in additional costs compared to patients who are adherent;
• 20% of all unintentional pregnancies in the United States at a cost of $2.6 billion annually;
• 33 to 69% of all medication-related hospital admissions in the U.S. at a cost of $100 billion annually;
• costs of $50 billion annually from the loss in productivity.

The annual estimated cost of people being non-adherent approaches $290 billion and leads to the death of 125,000 Americans per year.  Clearly, prescription drugs work only if they are taken, and taking a medication as prescribed is a behavioral choice.

Research has proven that pharmacists - the medication experts - must be a part of the solution.  As strategies to lessen non-adherence are developed, it is pharmacists who have shown the ability to educate, problem-solve, and provide support directly to and with patients.  Our new Helping our Patients Stay Well adherence program starts on January 12th, and we now have the tools needed to help our patients address the practical and behavioral reasons why they may not take their medications.

Educating and working to change the patients' behavior requires different strategies for different people.  Trust, hope, fear, knowledge, motivation, literacy, confidence, and competency are key concepts in the drive to medication adherence.

"The rates of non-adherence to prescription medication therapy have remained stagnant for the past three decades; although these topics have been discussed and debated, these problems have generally been overlooked as a serious public health issue and, as a result, have received little direct, systematic, or sustained intervention.  As a consequence, Americans have inadequate knowledge about the significance of medication adherence as a critical element of their improved health."         Enhancing Prescription Medication Adherence: A National Action Plan

Surely, good patient adherence is following the agreed recommendations from their health care providers.  Non-adherence is as dangerous and costly as many illnesses.  It has become an
international epidemic; in the words of The New York Times, it is the "world's other drug problem."

The issue of why people don't take their medication, even when they need it to prolong or save their lives, belies simple explanation or demographics.  Some of it is human nature, and inner rebellious voice that resists the doctor's orders.  Many patients mean to take their pills, but don't write down what the doctor said and end up not following the directions correctly.  Others forget, particularly when they have do it more than twice a day.  But research has shown two significant reasons for non-adherence.  1.  The patient feels the medication is not necessary; and 2.  a fear of side effects. 

Behavioral changes, such as adhering to a medication, typically occur when patients are sufficiently motivated to make that change.  Being motivated to change is a natural result of the patient understanding that the benefits of the change outweigh the risks.  Pharmacists are in a unique position to help patients by better understanding the factors influencing the patients choices, and identify ways to alter those influences to improve patient motivation.