Walgreens, Express Scripts and Pharmacy Economics

Much is being made about the spat between Expess Scripts (ESI) and Walgreen's (WAG) over their latest contract. While privately many in the industry appear to be siding with Walgreen's for finally standing up for the profession for reasons listed here, pubically it appears a more even split.

Many decry the terrible burden this is for patients, as they are left to be pushed around by big business when it comes to the management of their health. Others are screaming that it is unfair for the pharmacy employees, as they are merely overworked pawns in this mess.

But with change comes sacrifice, does it not? No one will argue that the business side of pharmacy has been on a dangerous downward spiral for the last 10+ years. So why is it that when an organization is finally starting to stand firm against this spiral, that so many are speaking out against it?

Perhaps we need to simplify what this argument is all about and explain some of the numbers behind it and what they mean.

For a quick overview of the Economics of Pharmacy, check out the associated link. No, it is not college level macroeconomics, but for many who have not directly experienced it, it  does describes what the business environment is like. And, if you'll note, I have a rather accurate prediction in my closing statement.

How pharmacies are paid is quite simple, you are given an amount for the cost of a drug and a "filling" or "service" fee for actually filling the prescription.

Note that the average overhead cost of filling a prescription, before the cost of the drug, is roughly $10. That includes wages, supplies, building expenses and so on. Again, that's $10 for every prescription, irregardless of the cost of the medication.

When it comes to how pharmacies are paid for the cost of the drug is where it becomes tricky. Essentially there is a fictitious average price called the Average Wholesale Price (AWP) that is set as a standard for a drug nationwide. This fictitious price typically is not line with the actual cost, so a lot of times you'll be paid what's called AWP - 10%, which is 90% of the AWP price.

The percentages vary and there are additional systems involved, but this is generally how pharmacy economics function. Now let's run some numbers on a fictional script.

Drug A (Generic)
Drug A AWP: $13.00
Pharmacy Cost: $10.00
Overhead Cost: $10.00
Total Cost: $20.00

PBM Cost Payment: $11.70 (AWP * 0.9 = $13 * 0.9)
PBM Dispensing Fee: $1.50
Total Payment: $13.20

Now you'll notice, due to the AWP, that the pharmacy is actually paid more than the cost of the drug on this prescription. You'll then notice that the pharmacy was only paid $1.50 (15%) of the total $10.00 it costs to dispense this drug.

Believe it or not, this last fact is very common, something which pharmacies have been lashing out against for years now. And, from what I've heard, it is this sticking point which is at the heart of the ESI/WAG stalemate.

Various reports have stated that ESI wanted to decrease their dispensing fee to $0.40, that is 4% of the total cost to fill a prescription.

Now your first question is, "How do pharmacies stay in business if they lose money like this?" With some prescriptions, namely branded drugs, the prices used to calculate cost are somewhat more accurate and they have higher margins due to their higher cost.

The last article I read placed the average cost of a generic drug, for a month supply, at around $10.00 while the average price of a branded drug, for a month supply, is around $80.00. A higher cost allows more wiggle room if you will, and it is these drugs which subsidize the losses on other prescriptions.

The second question then becomes, "Well the fee is already low, you subsidize the cost with other prescriptions and it's only dropping a $1.10, what's the big deal?"

One of the ways in which pharmacy is evolving is that the percentage of generic drugs being used is increasing. The new drug pipeline has dried up considerably in recent years and blockbuster drugs like Lipitor, Prilosec and Claritin probably will not be seen again for quite sometime... if at all.

If you are dispensing fewer and fewer of the name branded products which counteract your losses on other drugs, it becomes increasingly important that you try to mitigate your losses on those other drugs. Pharmacies have been able to survive thus far on the backbone of strong, brand name drugs, but clearly this will not last forever.

Granted, this is a greatly simplified view of what the entire disagreement is all about. One could talk about the effect of the Walmart $4 generic program or government regulation or consumer indifference to the profession itself, but quite simply this is what it boils down to.

You cannot fault Walgreen's for being the first to finally stand up to one of the monster PBMs in this country. The fact of the matter is that Express Scripts needs Walgreen's more than Walgreen's needs Express Scripts.

ESI has no equity with the consumer aside from whatever experience they may have with a help line. Walgreen's has a face, a voice and a place to visit on a daily basis. It is as big of power move by Walgreen's as we may perhaps ever see.

While it's competitors enjoy the new business and take advantage of the situation, I'm sure deep in their corperate offices they are secretly cheering WAGs on as they could be next in the lines of these cuts.

This isn't about lining the pockets of the Walgreen's CEOs or it's investors. This isn't about making a pharmacy a cash cow. It is about taking a stand for what is financially right not only for pharmacy as a profession, but for patients as well. If we want optimal, efficient healthcare, we have to be paid a fair price for this service.

Remember this is not about making more money, this is about saving what little money they are making... if any.

And that, my friends, is why Walgreen's and Express Scripts are in a stand off of historic proportions. Perhaps it's not so bad after all...

Be A Proactive Pharmacist

We are all disillusioned in the profession. Considering the majority of individuals do not believe in our national professional organization, I think it is fairly safe to use the term "all."

After talking with APhA for the last month, it is clear that they are aware of the problems we all face. They do, in fact, have some reasonable ideas on how to address them. What they lack though is the solvency to actually act upon them.

One of the most oft repeated phrases is, "Why don't the disillusioned pharmacists show us that they care?" and to be honest it is a valid point. So many have taken such a long drive down the cynicism trail that it's hard to look back.

After all, why put forth a concentrated effort only to have it soundly defeated? I know I feel that way on a regular basis.

But why don't we put for some sort of effort? If not to show to APhA and others what they're missing out, but to give us some pride within our chosen profession.

What I am about to ask is simple... actually it's borderline remedial. We are all extremely busy during our work days, some more than others, but this would take just a minute out of what little free time we do have.

Ask a patient what they think of pharmacy. Ask them if they know what a pharmacist does for them on a daily basis. Ask them if they've ever heard of something called Medication Therapy Management or outline services we could, but cannot currently for financial reasons, provide.

See what they know and see what they want to know. I venture that the answers may surprise you as they certainly have surprised me when I have done this.

As much as the countless pharmacy rants have bound us together over the last few years, perhaps this could do the same. We need hope... the profession needs hope in order for us to continue to succeed.

If you choose to do this, feel free to come back, or E-mail me, and share your response. As cheesy as it sounds, maybe we can make our voices just a little louder and a little more substantial.

It cannot hurt to try now, can it?

Does APhA Really Represent Pharmacists?

Tonight I was playing with my son with the TV on in the background when a commercial splashed across the screen. Immediately I stopped what I was doing and watched, jaw slightly agape, at what was on the screen.

What was it you may ask? Take a look for yourself:


Beautiful is it not? Even more so when you go to the actual YouTube page and read the purpose of the advertisement. It truly is great to see a professional organization be assertive and stand up for their profession. Clearly the AMA will not sit idly by and wait for change to come to them.

Bravo for that.

Now wouldn't it be great if APhA did the same? Between the health professional organization trifecta of the AMA, APhA and ADA, the APhA is often the silent partner. Whereas the AMA and ADA are very active outside of their practitioners and have a very broad public awareness, few outside of our immediate profession even know what APhA is.

It's one of the topics I have pushed several times on this site in the past and will continue to do so until someone actually listens. Recently I discussed the distressing notion that a business oriented enterprise is, in effect, leading our profession to change for their own selfish reasons.

It is something which has even been brought up in publications like the Wall Street Journal. Interesting how those even within the profession see the massive amount of benefit of the idea I laid out, yet APhA does not seem interested in actually following through with it.

It is this which is the most distressing aspect of pharmacy as a whole. In school and by APhA we are repeatedly told about the "future" of pharmacy, but in reality there does not appear to be a realistic path towards this future. Progress by APhA can be measured by the speed of a sloth, and we run the risk of being bypassed by other health care profession as the system evolves.

For instance let's look over the Strategic Issues on the AMA website which describes who they are and what they are fighting for. It is rather all encompassing while being concise and plotting for the future, wouldn't you agree? It's something even the lay person could read and instantly understand what AMA, and physicians as a whole, stand for.

Now let's look over what APhA has listed as their Advocacy Issues. One of the first things you notice is a lack of an adequate summary to the overall goal of the organization. Line by line and link by link they list specific issues, but there is no connection between the issues and what they mean for pharmacy. The AMA does a spectacular job of presenting their main goals and then diving into the specifics. Here, the APhA merely presents the specifics without any cross-linking to form a cohesive idea. In the end, the problem lies not so much with the issues themselves, but more with how they are presented.

Clearly the AMA's website is focused towards both their providers and their patients whereas APhA's website is tailored to its providers. There is already a disconnect of perception between pharmacists and their patients, and this does nothing but further that divide. If anything, the APhA website continues to make it's self inaccessible to the patients they so often tout as the focus of their work.

Why is this? Why is it the organization, which is financed partially through the dues of pharmacists, seems to ignore this crucial ingredient to the long term success of the profession? Why is it that pharmacists across the country feel like they have no voice?

There was no immediate response to the disparaging remarks by the CEO of Medco from APhA. For those unfamiliar with the situation, this link provides a good summary. How is it that our so-called voice of the profession remains eerily silent while one of the most powerful individuals in health care obtusely insults our profession?

What are those dues good for then? Several times it has been reaffirmed that the APhA can only reflect the views of those members who participate, and pay, through their membership. Granted I see the logic in this, by why is membership required to represent pharmacists as a whole? Why is it that none of the 70+ pharmacists I have worked with over the last ten years are active with APhA? Why is it that rarely do you find a community pharmacist, who just happen to make up the largest constituents of the profession, that considers the APhA worthwhile?

Because they have no faith in it. APhA is viewed as a lion with no teeth and no roar. Why devote time to something which is ultimately fruitless? As pharmacists are pushed around year after year with little light at the end of the tunnel, of course they become disillusioned. Who wouldn't?

So why doesn't APhA throw up a hail mary and start to regain the trust of the pharmacists it represents? Why doesn't APhA consider educating patients on who they are to overcome the biggest obstacle the profession faces, a lack of understanding of who and what a pharmacist is. Why doesn't APhA maintain a daily, strong active voice for the profession which can readily respond to comments from individuals such as David Snow?

Why doesn't APhA model itself after the AMA and actually represent the profession?

Give me a reason to want to be a member of APhA. Give me a reason to want to be extraordinary proactive within the profession. Give me a reason to stand up for what pharmacy stands for. Give me a reason to have faith in APhA.

Is that too much to ask?

Health Literacy and Increasing Patient's Decision Making

Health literacy has been a buzz word in health care for several years now. It is an obvious idea when one thinks about it, but may not be overly apparent. Often we take our intrinsic knowledge for granted, and do not consider that a patient may not have basic reading skills yet alone basic science knowledge.

Because of this in class we talk about open ended questions, talk-back guidelines and reading level of materials. All very valid points, but they all underline a common theme. There is way too much unfiltered information out there for patients now.

Think about it, with the internet and sites like Google, the average patient has ready access to nearly the same medical material that health professionals have. This post does not even consider the large amount of misinformation present. I'm more concerned with the sheer amount of correct and pertinent information related to a patient's health.

Think about it, what if you had immediate access to, say, the building plans of your workplace.  The next day you come in and talk to the owner telling them you think this wall should be moved back another five feet or so to give us more room. In looking at the plans, you say it doesn't appear to be doing anything other than partitioning the floor space.

You know what would happen? The owner would laugh his ass off and walk away as you unknowingly want to move a load bearing structure.

Yet this is what we are forced to deal with in health care each day. Patients log on to WebMD or watch Dr. Phil, are presented with information that they do not have the neccessary background to fully understand. They then take this information, come to us and decide to make decisions about their health care without considering our own expertise.

At best it is ludicrous. At worst it is deadly.

I know, I know, you are all screaming. "But a patient has a right to know this information and participate in the management of their health!" And this is true... to a point.

Consider when the negative press about Avandia came to light. One particular patient of ours immediately stopped taking to the medication due to fear of "heart problems." Never mind the fact that the liklihood of this problem was not all that great, we cry wolf far too much in protocols now but that's another discussion, she did not want to die from a heart attack.

The pharmacist looked her straight in the eye and said, "Well you can possibly die from a heart attack or for sure die from diabetes. Your call."

Good for him.

As much as we do not wish to think of our profession in this way, pharmacy is really the management of poisons for positive health purposes. There are side effect whether we like them or not almost solely for this reason.

Many people simply do not understand this part. Life is full of risks, you speed on the freeway to make an appointment or start smoking to look cool with your friends. But when a drug can benefit a patient, but they don't want to take it due to a minor chance of a severe reaction that's okay?


Solutions to this problem can be insanely simple. For instance, when we hand out drug monographs, or when they are posted online, side effects are often listed under categories like 'common' or 'severe'. Dizziness is often listed in the same breath as heart palpitations... but does that mean that the probablity of both are equal? Actually, how often do these side effects occur?

As pharmacists, we know these answers. Patients do not.

So why not add odds of occurrences to all side effect listing? Or perhaps list them in the order of occurrence? I'm sure a few more patients will panic by seeing the exact numbers, but I'm sure many more will have their minds put at ease when they see how rare these 'common' side effects are.

A simple change like that mitigates one of the problems with health literacy and compliance. We have made information a little more digestible and give them a stronger base to make a decision about their health.

We talk about white space and reading level, but not how to relate the information to patients. Honestly, that should be the primary goal of health literacy. It doesn't matter if the material is at a fifth grade level if there is no way for the patient to relate the information in order to make a decision.

And that's ultimately what this is all about, making sure the patient is properly informed so they can make decisions about them selves. We cannot rid the world of WebMD or Oprah, as much as we may want to try, but we can certainly organize the information we give out in a better manner.

Seems simple enough, right?

The Battle of the PPIs

The remains of the fallen solders from the Prevacid tribe

In the annals of historic battles there are Gettysburg and D-Day, but never before has there been a battle as epic, or as dramatic, as the Battle of the Proton Pump Inhibitors this past evening.

On one side sat the old guard, the Tribe of Prilosec led by General Astra Zenica. As one of the oldest tribes in the PPI realm, Prilosec had felt the increasing pressure of the Prevacid Tribe as they first encroached on the Prescription Peninsula and then eventually OTC Island. Using shimmery, metallic purple colors they attempted to outshine Prevacid Tribe, but in recent months had continued to be besieged by the upstart tribe. Now they felt their livelyhood was immediately threatened by its racemic counterpart.

Prevacid Tribe, led by the venerable General Takeda, had surpassed all expectations and supplanted themselves as a force on PPI isle. A more multi-racial tribe composed of equally mixed pinks and aquas, Prevacidians found themselves ambitious and eager as they attempted to topple the mighty Tribe of Prilosec.

At 7:04 PM on Tuesday the 31st of May, the General Zenica gave the order which would alter the history of the PPI isle. A surprise attack on the capital of Prevacid Tribe, Novartis, sought to finally rid the world of the too-similar Prevacidians.

Using intimate pharmacologic knowledge, Prilosec leaders used optical attacks from the left and right to decimate the Tribe of Prilosec. Capsule and capsule parts lie strewn across the land, with the innards of Prevacidians coating the counter-side.

By the end of the battle, the Tribe of Prilosec stood victorious over their nemesis, and found themselves the reaffirmed King of PPIs... for now.

I Have A Question… A Lesson for the Profession

It is not very often that my mind is blown while working a pharmacy. After doing this for as long as I have, even the unexpected, to a certain degree, has become expected.

So yesterday when a patient turned to me and said as they were leaving, “I have a question before I go…” I thought little of it. The cynic me expect some inane question devoid of common sense, as typically that is the question you receive in this stage of a pharmacy visit.

Instead what followed damn near caused my jaw to hit the pharmacy floor.

“I was reading up on health care legislation and kept coming across something called therapy services by pharmacists and how helpful it was for the patient. Wouldn’t it make sense for you guys to help out with my drug management instead of just my doctor?”

After pinching myself and realizing that the patient, indeed, had said what she had just said, I quickly began to formulate a concise way to explain what she was talking about.

First, I mentioned that the majority of what she was talking about would be covered under the term MTM. I went over how it works and how it is integrated into current health care. We then glanced over some general cost savings associated with it that could be had, to which she replied,

“So, what you’re saying is that everyone could save money from doing this simply by catching problems before they get worse and making things more efficient? And patient's health could be better? Why aren’t we doing this already?”

I then mentioned some of the studies that had attempt to do this sort of thing, and she wrote down information about The Asheville Project to do a little more research on her own. Lastly, I explained the difficulties we are facing in wide spread implementation of MTM services from the patient, provider and insurer prospective.

It was a conversation which lasted a mere 15 minutes or so, but nonetheless provided a wealth of information for her.

By the end of the conversation, I realized that she was just a typical patient who had stumbled upon what we are all striving for. Inquiring with the normal pharmacy staff, to find out if she was someone with extensive education and/or health care experience, they confirmed that she was none of the above.

And it was the closing statement she made that offered the most telling benefit of our conversation.

“Well pharmacists need to start getting more involved with this. I’m going to talk to someone at my insurer to see why they don’t insist on something like this for everyone because it seems stupid we’re not doing it already.”

The patient gets it. A simple conversation explaining MTMs and the future role of pharmacy, and the patient gets it. And all it took was a little conversation during a slow afternoon in the pharmacy.

Are you listening APhA? This is exactly what I have been saying for the last year. If you want to proliferate the next generation of pharmacy services, don’t go after providers or insurers. Go straight to the source and start educating patients to the benefits of them.

It's a simple supply and demand problem. You can't create something without showing the demand for it. Recently I discussed with the Director of Pharmacy for a, somewhat, rural hospital on how they were implementing MTMs into their patient care for employees. Her, and the hospitals CFO's, idea was to force employees to use MTMs services combined with their own PBM. The plan then was to show the benefits of said program to local employers and attempt to show them the benefits that could be had.

Naturally this will work in their area, due to the small population size. On a larger scale, we need more grand ideas to challenge the status quo.

This little story could prove to be the catalyst that finally gets the proverbial ball moving. If this patient is as interested in MTMs as we are, why aren't we more vocal about it? Why aren't we casually mentioning it to patients who are waiting on slow days? Why aren't we pushing fliers and educational materials to show them what we can accomplish?

Why aren't we standing up for the profession on a daily basis to ensure that we reach our full potential?

APhA, are you listening?

Roads... Where We're Going We Won't Need Roads... But We Will Need a Prior Auth

Is there any other rejection phrase I dread more than:

DRUG NOT COVERED; STEP-THERAPY/PA REQUIRED. CALL 1-800-JACKOFF

Seriously, that simple string of words is enough for this normally calm little pharmacy student to erupt in a fury of rage reminiscent of taking a cake away from a fat kid.

What makes it worse is that it happens when you least expect it, eerily similar to a herpes outbreak. Kind of like when someone brought in a new prescription today for loratadine.

"But Phathead," you're saying, "The smidgen of glue that holds the label on the bottle costs more than the number of tablets in the bottle. Never in a million years would a PBM require a PA on it."

Well that would be true... if PBMs were run by human beings with a lick of logic.

This particular plan, cough Medco cough, decided that cetirizine needed to be first line and that, for some god forsaken reason, loratadine would only be paid for after a PA and step-therapy.

Way to go Medco, you just saved yourself a whopping two cents by denying the initial fill. Glory be to you for such a wise financial decision which will ultimately bring troves of riches to your CEO. And by troves, I mean one or two extra Tootise Rolls after lunch.

Long time readers may remember that I have a particular hatred for the sadists that call themselves Medco. If anyone deserves to have bamboo shoots shoved up their urethrae and then forced to watch Glee for 24 hours straight, these guys are the unanimous winners.

After the pharmacist stopped laughing at the ridiculousness of the rejection, we kindly pointed her to the allergy aisle and told her it would only be a few dollars more to bypass this lunacy and receive the same treatment. She agreed, the gray skies parted and for a brief while peace and tranquility returned to the pharmacy.

Until the next PA rejection. About two minutes later.

Damnit.

Rite Aid: Cheapening the Profession $5 at a Time

The majority of us are aware of Rite Aid's guarantee to patients that their prescription will be ready in 15 minutes. For the most part, I don't have a problem with that. I give our guarantee to our patients that if you fill your Norco on time, a Spanish speaking Monkey will fly out of my ass and make you a denver omelet.

See, I can promise things too.

Apparently, this wasn't enough. Oh no, in an age where a Dateline special lurks around the corner for a worn down, exhausted pharmacist to make a mistake, Rite Aid decided to kick it up a notch. They decided to offer a $5 gift card if that 15 minute guarantee is not met.

Bravo Rite Aid, bravo. Way to aim yet another shotgun blast to the image of pharmacy.

We live in a world where pharmacy is viewed as a product based business rather than the service it truly is. That's how PBMs reimburse us, that's how the public views us and that's how we are treated on a daily basis. If we are to truly reach the goals laid out by APhA and other organizations, we must truly remedy this fallacy.

But then there is Rite Aid, making sure that for every step forward that we are shoved back another five.

A few weeks ago I questioned why national organization such as APhA did not denounce WAG's creation of Wal-beer. Again, I ask, how can APhA allow such a cheap attempt to attain customers without disparage?

It doesn't so much matter that the 15 minute guarantee is a game of Russian Roulette as it is. Rite Aid just made sure that the barrel is loaded with five bullets instead of just one.

Rarely are we complemented for the work we do in fixing errors by doctors, solving various insurance issues, keep track of interactions or offering simple advice. We are chastised when their doctor takes one day too long to fax back a refill authorization or when the four different C-IIs they drop off take a bit too long to fill.

The public already treats us like we're the bitch of the health care system, there's no need to give them another whip to play with.

People need to start realizing that in pharmacy the customer is not always right. In fact, they are not a customer at all, they are a patient and we are a health care provider. This is not a Jiffy Lube where we'll top off the washer fluid just for the hell of it.

And with ridiculous programs like the one Rite Aid is employing, we'll have a damn hard time trying to convince anyone otherwise.

It's just too bad they can't use their $5 to buy a six pack of Wal-Beer. Oh wait, I think I just gave someone an idea...

The Problem With MTMs

Judging from what we're told at school, MTMs are the second coming of Jesus. It is "an example of the future of the profession" or "identifies the new role of the pharmacist in the health care community."

That is entirely true... to an extent. The problem though is that everyone, and by everyone I mean those in power, realize what MTMs can do for the profession... yet choose to ignore the relevant problems of adopting it to our current business model.

We all know the benefits of a service such as MTMs. Physicians are even conceding to the benefits of MTMs, a fact which is more groundbreaking than most realize.

The problem is the consumer does not know the benefits of MTMs. Hell, they don't even know what MTMs are for the most part.

I covered this fact earlier last year and it is something I have been pushing APhA to look into for the last few months.

Essentially we are telling the various insurance providers that we can offer this service which will, ultimately, save them money but will do so in a novel approach. Herein lies the bigger problem... there's no demand for these services.

Really, there's not. Name one time a patient came up to you asking for something similar to what MTMs do? I bet you cannot name one specific instance can you?

That all comes back to the fact that the public is blissfully unaware of what a pharmacist can do. We have to create the demand if we want to take this next step. Some pharmacists, namely Eric, RPh, are already taking the brave first step into this new world.

If we're so intent on moving in this direction, we have to tackle the business aspects that we have so far been ignoring. Pharmacists, in general, have been the passive members of the health care community and in many ways this has become an ingrained trait. It is time to step out side of this self-induced funk and reassert ourselves.

And if not for ourselves, for the future of our profession.

Would it really be so difficult to devise a system for billing for time spent monitoring a patient? We already have ICD-9 codes and DURs to classify what it is we're doing, would it be so difficult to add one more field classifying some time scale? This wouldn't require a complete rewrite of how we do our every day business, merely a small adjustment.

Honestly, I think that is the biggest hurdle places like WAGs, CVS and the likes have with pushing for these services, successful implementation of billing. Sure there would be some trust involved, but it's there are ways to self, and externally, audit times.

And for the business minded folks, the sheer dollar amount that is available out there is astounding. It's almost as if we're sitting on top a giant field of oil, yet we're too scared to drill some test wells.

Ironically enough, the exact same could be said in terms of benefits for patients.

Really, what on Earth are we waiting for?

Useless Term of the Day: Generic Utilization

Last week at work one of our newer tech's asked me what the phrase "Generic Utilization" meant. He had seen it on a memo from our DM and couldn't quite grasp what it meant.

The more I thought about it and tried to explain it to him, the more I realized how utterly ridiculous the term was.

The memo itself was telling us that we needed to increase our generic utilization. How though? 95% of what receive is filled as a generic (if one exists) right off the bat. The remaining 5% are either on a brand for a specific reason or are anal retentive and refuse to switch.

So how precisely are we to effect that? Why waste time and energy focusing on something of which we have very little control.

Can someone out there with a bigger and more developed brain explain it in any better fashion?

Taking On Walmart: Lawsuit Style

Over the top post title? Perhaps, but hear me out.

Every one within the pharmacy world agrees that Walmart pharmacies are the cancer of the profession. They are mostly detrimental to the profession, to the point that something needs to be done about it.

In the Walmart I recently worked at, my store manager told me the pharmacy is responsible for 4% of the yearly revenue of the store. Think about that, just 4% of the entire store. In the great scheme of things, the total profit brought in by the pharmacy does not have a high priority. What a pharmacy does accomplish, though, is to drive more people into the store. And that's where the problems arise.

It's not difficult to imagine that twenty years from now we will see the final death blow for true small town, rural, independent pharmacies as the four dollar generic program that Walmart began a few years ago. The effects from this program will begin to become more evident as the years wear on (I personally believe it will, or maybe already has, trickle over to the reimbursement side of things). It's a program which is great for consumers, but utterly terrible for pharmacies and pharmacists.

Previously I have covered how we are routinely underpaid by insurers for the services we provide. Here is how Walmart, in its revenue based mindset, gouges the profession using poor, and unethical, business practices.

In the state I am in at the moment, the average cost of a prescription, prior to the addition of the cost of drug, was $10.28 as of 2006. This is the most recent data we have and does not take into effect the legal changes since then which have significantly increased overhead labor costs. If you consider that the most of the drugs listed under the $4 generic program actually cost roughly $1 per 30-day refill, we're looking at a total cost (in this state) of $11.28 per 30-day supply.

Using a bit of simple math, we can see that Walmart is selling these $4 generics at 64.6% below true cost. Sure they're making a "300%" return on the cost of the drug, but we're a service based profession and you cannot quantify cost in that manner.

Here is where the lawsuit would come into effect; there are laws in place to prevent businesses from undercutting competition by ensuring that they cannot price their products and/or services below a price floor, namely the cost of the product/service. It a byproduct of the monopolistic tendencies of big business at the turn of the 20th century and the anti-trust laws that followed.

This is called predatory pricing, and it is usually intended to drive competition out of business. In Walmart's case, they are doing so to drive more consumers into their store and not so much to rid them of competition.

However, one of the key components of predatory pricing is a high market entry barrier. By pricing their prescriptions so low, and under cost, they are in effect presenting a high market entry barrier. It is one thing for a new, or small, pharmacy to be unable to offer all of the insurance plans offered. It is a completely different problem when they cannot come close matching the cash-pricing policy of Walmart.

Under the Sherman Antitrust Act, this is considered monopolistic business practices and is unhealthy for both the market and the consumer. And, at least legally, you could file a class action lawsuit claiming as such.

The thing is, you would lose the lawsuit. Walmart is far too big, far too powerful and with far too many attorneys. Also, it has proven difficult to adequately argue for monopolistic business practices, although I concede we could develop at least a moderately successful argument.

But here's the best part... we wouldn't have to win the lawsuit.

Really what we need is consumer awareness of what is happening within our profession. It's been shown time and time again, especially when it comes to Walmart, that when the public is presented with an injustice they will move on their own to attempt to right it. People like a good deal, but only to a point.

We have the data, we have the facts, we have the manpower, so why not? What's stopping a group of us from standing up and actually doing this? It isn't about increasing pharmacy profits, about maintaining the integrity of one of the most important health care professions in existence. We an argue convincingly that we have been put on a dangerous path and, if it is not righted, in a few years we will be presented with a very serious problem.

Cost/revenue cannot be the sole driving force for the profession, yet Walmart, and to a lesser extent the other large corporations, have decided to take that route. It will continue to harm us, the market and, ultimately, the patients. The last part of that statement is what we have to proclaim most loudly.

Let's rile up the consumers, let them see how big business is harming one of the essential health care services in this country. It can only go up from here, right?

The Quandary of Clinical Pharmacy

Quick, in one brief sentence describe the role of a clinical pharmacist.

Tick Tock. Tick Tock. Tick Tock. Tick Tock.

And your answer... is probably correct even though it differs from the twenty other responses given. Actually it may not even be remotely similar to half of the other responses given.

This is precisely the reason I dislike the term 'clinical pharmacist' because it truly does not mean anything. It is a blanket description to cover the roles of a pharmacist that currently lack an accurate description. In fact, I'd say roughly a third of the 'clinical pharmacists' I meet are really ambulatory pharmacists.

Yet even they are unaware of this fact.

No one person is to blame for this facade. It's simply a byproduct of an ever evolving profession, but it is something that we must address at some point. The 'roles' of a clinical pharmacist are incredibly varied that any lay person would question if they really fell under the same umbrella.

Honestly, it may sound petty to begin to discuss what to call ourselves, but in reality is it so petty? We already have a problem with the public and our patients over a misconceived notion of what a pharmacist is. Do we really need to compound the problem by the repeated use of such a vague description of a role?

Naturally this is not something which will change over the night. In fact, in fifteen years I would not be surprised if pharmacy schools were producing pharmacists with specific specialty titles, akin to the current medical school practice, so it may eventually correct itself.

Where do we start? Well if you consider yourself a 'clinical pharmacist' start thinking about what it is you truly do.

Do you call yourself one because you're not sure what the actual title of the role is? Do you call yourself one because you like the sound of it? Do you call yourself one because no one has ever told you otherwise?

I'm sure some use the phrase clinical pharmacy as a bridge between the past hierarchical gap between pharmacists and medical doctors. That is completely understandable, but that bridge cannot stand unless we reenforce the legs upon which it stands.

Let clinical pharmacy remain the general term for the professions specialists. But remember that this is, indeed, merely a general term. An oncologist does not introduce himself as a medical specialist, but simply as an oncologist.

Seems logical enough, wouldn't you agree?

Pharmacy School: Supporting SSRIs!

In one corner sits a person ashen faced, staring into nothingness. Perhaps a slight streak of drool traces their chin, but they are dead to the world.

In another someone sits face in hand, sobbing uncontrollably. Their body shudders with each stifled wail as on-lookers stare.

Yet another person is merely wondering aimlessly about the room. Mumbling incoherently, a kind passerby offers a consolation of candy and is greeted by an indifferent stare.

What is the connection between these three individuals? They're all pharmacy students!

If you want to discuss an up and down roller coaster of emotions, talk to your nearest pharmacy students. For every high you there is a stunning low which is soon to follow.

At no point do you catch your breath and often you find new depths to your own personal despair. It's like being punched repeatedly in the balls, helped back up, and then be hit in the same balls with a jackhammer.

And then be pissed on by a bunch of angry elderly women.

Truly, it's amazing. If I were in any other situation, I would think there is something mentally wrong with myself. Eventually, such as days like today, you reach this insanity driven breaking point when you incessantly giggle. As if nothing in the world matters and everything is hilarious.

And here's the best part... this isn't the worst of it. Not by a long shot. That threshold is still a year or so away.

No time to wallow in the depression tonight, yet another exam awaits a mere 38 hours away. And let me tell ya, I truly am excited... and by excited I mean three seconds away from bashing my head repeatedly into a wall.

Good times.

Health Care Reform

We all struggle to relate complex items, such as the current health care reform, to friends, family and even patients. We were shown this video in class from Kaiser Permanente and found it to be humorous while educational.

I though it best to share it to help defuse the confusion that is so often found when discussing current reform.

Thank God for Advil Congestion Relief

With the winter season quickly approaching, all are in the opening stages of prepping for the onslaught of the winter cold season. With the exception of the occasional sadist, no one in enjoys the sneezing, hacking and congestion the arrives with our yearly cooling.

But wait.... What's this? Could it be a savior for all of our cold symptom woes?!?


Contains Ibuprofen AND Phenylephrine? Genius!

1 Pill Dosing? Spectacular!

And at just $8.98 for 20 tablets it's a steal!

Hooray, the upcoming cold season is already defeated! Let that pesky rhinovirus burn in hell!

Wait a minute... 200 mg of ibuprofen... 10 mg of phenylephrine? How can this be? You could by the separate components for a mere fraction of a cost... but then again why would you to begin with?

With that sort of dosing you might as well just eat the box. Maybe drizzle some Nyquil on it for added effect and flavor.

Oh Pfizer, you never cease to amaze me in how you can squeeze money of the unknowing consumer. Bravo to you and your creative marketing product. Hope you can sleep well at night in your giant mansions.

Congestion free of course.

The Disconnect in Pharmacy Management

One of the disconnects in pharmacy, and truly in many jobs, are the orders which come down from the corporate side of the business. As most are aware, this time of year in pharmacy everyone is pushing for immunizations. Often the manner in which they are pushed, and promised to patients, shows a clear disconnect between what corporate wants and what is actually possible.

And truly there is a simple solution to this problem.

During my travels across the pharmacy world, I once worked for a successful, and fairly sizable, independent chain. The owner made it a point to regularly work a shift in one of his pharmacies in order to have an accurate gauge of what it was he was truly running.

It wasn't always a full day, but there was still a consistent amount of time spent in a store on a regular basis.

Wouldn't you know it, last I checked his business was thriving.

Why is it so hard to do this? Yes, we're all busy and needn't be bothered by additional work, but isn't it a good idea to have first hand knowledge of what things are like at ground level? Wouldn't many of the problems we face be mitigated if the person making decisions was actually forced to deal with them?

Would the regional manager who keeps cutting hours for technicians still do so if they were forced to work in a busy pharmacy with minimal help? Sure, it would not change the thought process of some, but I'm sure it would change it for some.

One of the things that is preached in business courses is efficiency. It is this which can bring in the most revenue over a long period of time. In order to run a business efficiently, one has to not rely merely on second-hand knowledge of processes. Obviously this is a stark change in how many upper managers conduct their business, but it seems so logical that it would be foolhardy to ignore it.

Then again, whoever said upper management was logical...

Hooked on Phonics for Prescribing

Little verbiage from me today other than a collection of some prescriptions I have seen come my way over the past two weeks.

I thought being in a much bigger city would provide at least slightly better prescription writing skills.

I was wrong.

Avelox 40mg/0.4mL
#5
Inject Daily For Five Days

Vytorin 10/40mg
#6
Take 1 tablets as needed prior to sexual intercourse

Lisinopril 20mg
#30
Take 1 tablet. Inject in right eye four times daily for diarrhea

Oxycontin 80mg
#120
Take 1 tablet by mouth four times daily
Refills: PRN

Somewhere, some place, Grumpy is rolling around in his office...

What Type of Industry is Pharmacy?

Is pharmacy a product based industry or a service based industry?

Surprisingly there are many pharmacists that I have talked to that state we are a product based industry. Even more perplexing, they state that we need to become MORE product based and that programs like MTMs are worthless and will never do anything for the profession.

To me, that seems like a massively ill-conceived idea.

Part of the problem that what a pharmacist does is not accurately portrayed to the non-pharmacy public. I cannot even say the non-medical public because there are many medical professionals who do not know what a pharmacist can do. I covered this fact alone in a few months back.

If anything, we need to do more to be seen as a service based industry.

Sure we dispense a product that is sold and the surrounding areas of the store do the same. But that is not what a pharmacy is.

The classical definition of pharmacy is 'the art of preparing and dispensing medication'. I think a more accurate definition would be, 'the study and understanding of how medications react and treat disorders in the body.'

Or something of that nature.

The PBMs can justify the fact they pay us as a product based industry because that's how everyone else views us. No one cries wolf because no one sees anything wrong.

What would happen if doctors were reimbursed solely for the materials they use in an office visit? What would happen if a dentist was paid only for the cost of the filling used during a procedure?

There would be a nationwide outrage, would there not be?

Yet this is precisely what happens on a daily basis in a pharmacy and we are supposed to take it in stride.

What's more, it's not even PBMs that are shooting us in the foot. The four dollar generic program instituted by Walmart a few years ago was the biggest punch in the crotch the profession has endured. As if that wasn't bad enough, other organizations are resorting to giving away meds for free to 'compete'.


Low prices. Always.

Right.

So not only are we already viewed by the public just as someone who puts pills in a bottle, we also do so for free.

How can we function like this?

In truth, we can't. Simple economics state that we cannot continue to devalue our product without devaluing ourselves. We're already dangerously close to a point where the public views us on the same level as the cashier at McDonald's.

And then where we be? Everyone is trying to take the next step in the evolution of the profession, but no one is acknowledging the problems we currently have. Instead, most put on a happy face, throw around terms like 'MTMs' and 'Revolutionary Clinics' and assume all is well.

All is not well, and all will not be well until we start to resolve these problems.

The first step could be as simple as reaffirming to our patients that we provide a service to them. Obviously you can't say that point blank, but you can certainly start presenting yourself in ways that will lend credence to that idea.

Of course the first step is a baby one, as it's the next step that'll be the big one.

Until the majority of pharmacists in this country began to stand up for themselves and take a stand, we won't see this happen. No longer can we afford to sit idly by and be the quiet profession in the medical community.

We have been the whipping boy for far too long, and it's time to assert who we are and what we do.

What type of industry is pharmacy? An irreplaceable service that is being squandered by people ignorant of what the profession actually is.

And that is damned sad.

When You Don't Know an Answer, Just Make Up Something

Believe it or not, at one point in my life I was a rather shy and introverted individual. Actually, not just at one point, for the most of my life.

Through various means I have climbed out of that shell, so trust me when I say that when someone asks you a question that you don't know, one can have a tendency to panic or not want to take the steps needed to answer it.

Never once though did I make up a false answer just to pacify a customer.

A few nights ago I was kickin' ass at the register at Big Evil, like I usually do, when I overheard the conversation of the elderly couple I was checking out. They were both upset as she now needed a walker to get around, but they didn't have the money to spend on one.

I inquired what precisely they were looking for, and the husband informed me that they had just been to the pharmacy and asked if Medicare would cover it. Apparently two of the people behind the counter told them Medicare only covers drugs and in no way covers something like a walker.

Sigh.

They were both very upset for obvious reasons, even more so because they had already looked at the prices for various walkers.

Immediately I stopped scanning their items and whipped out a piece of paper. I told them the steps that they would need to take; getting a Rx from a doctor, what part they would have to pay for, how to get their supplemental to cover the rest of need be. I told them about the differences in basic walkers and the four-wheeled variety and how Medicare will pay much less of the four wheeled variety if they choose to go that route.

I also told them their best bet is probably to find one of the local medical supply companies in town as they are often more specially trained in that area and would be able to help them with any other problems they may have.

To say they both looked flabbergasted was an understatement. He asked how I knew all of this, and I explained my current situation.

To which he replied, "Well why the hell aren't you working back there with those numbskulls?"

As they were leaving I explained that if they had any more questions, I am found here most nights and would be more than happy to assist them further.

It was my first taste of pharmacy in two months and I relished it. Although I was left wondering just why in the hell they would tell them that sort of thing to believe with.

My guess is that either those people were vastly misinformed, they simply did not know the answer or they did not want to answer. That time of night there is only a tech and pharmacist on duty, so I know a RPh was involved at some point.

And that bothers me. Makes me wonder who else they shoo away when they don't want to answer something.

Now, I'm real excited to start working over there...

Introducing Lipitor HD

It seems almost as if you can get anything in 'HD' today. Oh no, HD is not just for televisions anymore. There are HD Sunglasses, HD paint and I even saw a sticker on a mirror claiming it was HD quality.

Naturally, it would make sense for the Big Pharma to jump in on this. And why not? They pray on the lack of knowledge the public has on drugs, they might as well kick it up a notch.

I'm sure it would go something like this:

NEW YORK CITY, NY - Today Pfizer CEO Jeff Kindler announced their newest product to be offered to consumers, Lipitor HD.

"Everyone knows that Liptior will soon be going off patten. As a company that has been unable to produce an innovative drug in many years, it is imperative that we find some way to continue making money while doing as little work as possible," Kindler began.

"One of the most popular terms signifying quality and wealth is the phrase 'High-Definition' or simply 'HD'. We decided that we needed to be the first company to produce a HD drug, and thus Lipitor HD was born."

Pfizer explains that it will explain to consumers that Lipitor HD is Lipitor but at a much higher resolution. This makes it more effective because a higher resolution automatically means it works better.

"Then we decided to market it in a 10,000 µg, 20,000 µg, 40,000 µg and 80,000 µg because bigger numbers mean that Lipitor HD is more powerful than non-HD Lipitor."

It is expected that Pfizer will price Lipitor HD at a 50% markup from the current price of Lipitor.

"The increase in price is representitive of the fact that we will continue to make sure the public believes our product is vastly superior to any generic counterpart. Our motto at Pfizer is 'Money First, Brain Washing Second and Skirting Government Regulations Third."

Lipitor HD is expected to hit pharmacies nationwide in Q3 2011.

Note: Lipitor HD is a fictional product, but don't put it past Pfizer to actually attempt something like this.