The MTM Debate

I'm usually not one to use my blog to blast anyone or anything, but this has really ruffled my feathers. My company uses a company called Outcomes to file MTM claims. Some of you may be familiar with this company. I recently got "locked out" of my store's account because, and I quote, I was "filing too many of the wrong kind of claims". What, you may ask, are the "wrong" kind of claims? Well according to Outcomes my claims have been "educational in nature and do not significantly effect the patients' outcomes". Again, that is a direct quote from the Outcomes rep that I spoke with. Now, I don't know about anyone else, but I can quote several well-known, multi-national studies that have proven beyond a doubt that the pharmacist's role in educating the patient DOES significantly affect the patient's outcome. So, upon informing the rep  of these studies I received the following reply. "Well, your claims have to justify our existence to the insurance companies for us to continue to offer this service". Wow!  How many of you didn't know that this was the reason for MTM services? Foolish me, I thought the reason for the service was to better the patient's disease outcome through pharmacist intervention. After 30 minutes of debate with this rep, the conclusion was that the only claims they want to see are ones that save them money. They have absolutely NO interest in bettering the patients' outcomes. The only claims they really want to see are things like drugs being discontinued or changed to something less expensive. They hide this fact behind a facade of caring for the patient's financial expenditure, but when I pointed out that most of my patients who qualify for this MTM service are receiving their Medicare Part D plan through state funding and their copays are the same regardless of what they get then the issue of financial expenditure only applies to the insurance company themselves. Now, my main concern for my patients is that they get the best care possible. I am also a strong advocate for giving them the best care at the lowest cost. However, there are situations where lower cost medications have been tried, have failed, and the patient is placed on a higher cost medication that works for them. Outcomes does not want to hear this. They are run by business professionals and not healthcare professionals so they do not understand this concept. All they see is dollar signs. They don't believe that educating patients on proper dosing, proper technique, possible side-effects, monitoring parameters, etc. is of any use. Why they allow for these kinds of claims to begin with is just part of the facade that is erected. File too many of these and you are banned from filing any more. I was informed that I could still file the "right" kind of claim and that if I file enough of those claims then I will be allowed back into the fold. You know what, I don't need Outcomes. I have been caring for my patients for 23 years without them. It would be great to get paid for the interventions that I have been performing for all these years but I will not be part of this farce. Their threat is that if pharmacists don't perform for them then they will start using nurses to do MTMs. Who cares! I will go on doing my job. I will not allow Outcomes, or anyone else, dictate how I care for my patients. What do they expect us to do with those patients who may cost a little more to care for? I will continue to educate my patients because I know it makes a difference. I have seen it with my own eyes. I ran a diabetes education clinic for several years and I saw patients whose blood glucose went from in the 500's down to normal after just a few sessions of pure education. Now that is truly an outcome!

What Keeps Me Young

One of the things I love most about my job is working with young people. Invariably, the technicians I hire are young, very young. Most of the time they are working as a technician while in school or while trying to decide what to do with their lives. ( I know, and work with some technicians who are "seasoned" and I love working with them as well, but I'm not addressing them right now.) These young people usually have zero experience which alot of pharmacist might consider a negative but I like molding them to my own liking. Call it hubris if you will but I think I do a good job of teaching them. Anyway, working with the youth of  today gives me insights into their culture that I would not normally be aware of. I don't have children and even if I did they would be old enough to be pharmacists themselves. I sometimes end up feeling like a mom to these young people. I know I am their boss and they know that I will "take care of business" if I need to, but I tend to be a little more layed-back in my approach to the title "boss".  In the words of one of my current 20 year old techs "You don't act like a boss but I still know you are." Many times these young people come to me with things they wouldn't go to their parents about. Some of it is funny, some sad and some concerning but I am honored that they feel comfortable enough to talk to me. It can be anything from how to obtain birth control to writing letters of recommendation for college.  Over the years I have seen many of these young people mature into wonderful adults. I see them go to college, get married and have families and I can't help feeling a parental pride. I hope that in some way I have influence them to be the adults they are. I hope they can look back on their lives sometime and remember me with fondness and respect. I know that when I was a 17 year old technician I worked with a pharmacist that influenced me to become one myself. She loved her job and it showed. She also helped me to understand how to get financial aid for college. No one in my family had ever gone to college so we didn't even know such aid existed. This pharmacist was my role model and mentor. She was fresh out of school herself and I thought she was the smartest person I had ever met. I have over the years lost touch with her. She would be in her late fifties by now so she would still be going strong if she is still working. Her husband was an archaeologist, which is unusual so if she's out there she knows who I am talking about. Anyway, back to my own young people. I want them all to know that not only do I want to influence their lives in a positive manner, but that they also influence mine. Working with them keeps me young! It's like having children but only for 8 hours a day. Sometimes some of the things they say makes me feel old, but for the most part I don't. They, of course love to point out how old I am when a song from the 80's plays on the in-store radio and I know all the words. They weren't even born yet. (I don't care what they say, the 80's had the best music!) I love seeing my "kids" get excited over things they are doing or new boyfriends. It also breaks my heart to see them disappointed or devastated by stuff that I know will seem trivial to them later in life. Anyway, this is what keeps me feeling young. Youth itself is the true Fountain of Youth. Youth is contagious so I keep it around.
  As a disclaimer: I love all my "older" techs too. "Older" is a relative term so deal with it! Experience techs are a vital part of the pharmacy team and they are greatly valued. Unfortunately they are few and far between. Most of the really good, experienced techs are already working in a steady job and are less likely to apply for another one. That is why I end up hiring really young, inexperience ones so I don't want to see comments about unfair hiring practices. At this moment I am looking at hiring a brand-new, inexperienced tech who is older than me. I don't intentionally look at only the young ones.

Masked Man

One of the comments on my "Shingles" post asked the question, "Why don't more people wear masks like the sensible people in Japan?" (paraphrased). That made me giggle because my husband wears a mask 24/7. No kidding! He has very bad allergies and cannot take allergy meds. He uses his voice for a living and the meds mess with the quality of his voice. The funny thing is, when he goes out in public he is treated either like a criminal or a leper. Why is that? Even his doctors, who should understand, act like he's trying to hide something. Why is our society so hesitant to accept this? He has been accused of the strangest things! He has learned not to walk into banks or even pharmacies because they think he's there to rob the place! Even pharmacies, where we should be used to seeing sick people wearing masks!!! What's up with that!!! I feel really bad for him. He had a man in a wheelchair challenge him on why he was wearing the mask. He challenged right  back as to why the man was in the wheelchair. It shut him up. And it was a challenge not mere curiosity. Children are curios and that's o.k. Anyway, ask yourself, would you be ok with a society where everyone wore a mask?

Shingles!!

So, I've been dealing with a case of shingles. Anyone not familiar with this can Google it. I strongly believe that administering the shingles vaccine is what led to this. I am immune compromised due to the meds I take for rheumatoid arthritis (Remicade, Imuran, prednisone) and within 6 weeks of starting to administer the shingles vaccine I end up with shingles. I've been on these medications for 3 years now with no adverse events and suddenly I have shingles. It's too coincidental for me to believe it's cause was random. In case your not familiar with shingles in an immune compromised patient, the disease can disseminate causing wide spread consequences. The pain doesn't just stay localized to the rash area, but spreads along all nerve roots on that side of the body. Fun!
My big concern with this happening it that we spend alot of time learning safety measures for administering the vaccine to patients, but very little, if any, time on safety measures for those doing the administering. I have staff members who have never had chicken pox or the vaccine. Are they at risk? We toss the vaccine vial in the trash when we're through with it, but it still contains live virus. How safe is this? What exactly are the risks to the healthcare professional who handles live virus vaccines? Our employers aren't going to address this topic because all they want is for us to sell, sell, sell these vaccines. Is this a legitimate workers' comp claim? Are they going to compensate me for the hearing loss I now have?  Should I have known better than to administer this vaccine with my current health issues? Was this really the cause of my shingles? It's not like I experienced a needle-stick, but the event is too coincidental for me to believe otherwise. I am contacting the CDC to see if there is some way to report this kind of event. We use VAERS to report adverse events that patient experience, but I can't find any info on the web site on adverse events experienced by the healthcare professionals. Why is this subject not even addressed by the CDC? We talk about needle-stick injury all the time, but never about virus exposure injury. This subject needs to be addressed. I'm sure I'm not the first healthcare professional to become ill after exposure to a live virus vaccine. Any thoughts on this issue?

PSE Sales

  When I first moved to this area, I saw allergy products on the pharmacy shelves that I had not personally dispensed in years. My first thought was "Oh no" because I suffer from ever worsening allergies. After extensive testing the conclusion was that I'm pretty much allergic to everything. I take more stuff to control my allergies that I do my RA! Anyway, what I'm getting at is that in this area we see ALOT of pseudoephendrine sales. The problem I have is that I would estimate about 90% of them are not legitimate. We now have a state wide, real-time data base that lets us know if these jokers have been buying somewhere else and have reached their limit (its always a suprise to them, huh?). However, where there's a law or a data base there are those that have found a way to get around it. We definitely see smurf parades on weekends especially. Many of us have been placing the most popular pse products out of sight of the public so that if we don't want to sell to someone we can just say we are out of stock instead of getting into a confrontation with them. Our state also just passed a law that says that all pse sales must first have a pharmacist consultation to make sure the product is being used for a legitimate medical purpose. What a joke!! Are they really going to tell us, "Naw, man, I'm going out to your parking lot and cook me up some meth"? So to make things simple we just deny having the product they want. Believe me we err on the side of the patient. I'm sure I have sold to plenty of cookers just so I wouldn't not sell to someone who really needed it. I've actually had people want to buy who had just been on the evening news for getting busted cooking meth (yeah, those I deny out-right). Well, now we are getting pressure from our corporate higher-ups that we have to display these products. They don't want to listen to anything we as front-line pharmacists have to say. Our jobs are actually being threatened over a $7 product! That's how much they value us as professionals. I can understand some of their arguements. The name brand products are contracted to be displayed, but why can't we display an empty box and still hide the stuff? That way we can still deny having it in stock without breaching the contract. Corp's arguement also is that if people don't see the product they will leave and never come back. Oh please! I wasn't born yesterday! We, as the pharmacists, are concerned about safety. We don't want to get into anymore conflicts than we have to. I actually denied pse to a guy, ended up calling 911 because he became violent, it  ended in a 3 county high-speed chase with the police, a shoot-out and attempted murder of an officer because the guy had an outstanding warrent for, you guessed it, meth cooking! I'm not sure what kind of world these corporate people think we live in but they really need to get out more. They also need to actually listen to our concerns and take them seriousely. We are not OVER REACTING!!! Personally, I rarely deny a sale anymore. If the data base allows the sale then I let it go. My life is worth more than $7 and there is no way anyone can prove that I knew it was not for legitimate purposes. Hey, junkies get colds too. What I do, however is limit the package size I sell. For some reason I only have the 24 count boxes in-stock. If they want to buy 2 boxes that's ok with me. Our state limits pse purchases to 2 packages per transaction per day and 3 packages total in 30 days. There is a gram limit also but it keeps changing so I'm not sure what it is now, but by selling 2 boxes of 24 they meet their package limit quicker without coming close to the gram limit. My boss is ok with this because 2 boxes of 24 is a bigger sale that 1 box of 48. Everybody's happy. I hate compromise but sometimes ya gotta. I think with pharmacist jobs becoming fewer and harder to get, the corporate world will have more leverage against us. I mentioned to a physician friend of mine the other day that it is really, really tough being an employee but also being a professional. We have two masters we have to please and they don't always agree. I would love to hear some feedback from other states (I'm in Tennessee) about your states' pse laws and how you guys handle this challenge. So many people don't want to see this stuff become rx only but I'm really getting tired of being the gate-keeper for this stuff. I personally hate the "grey area" products that are kept behind the counter but don't need an rx. How many of you feel more like cops than pharmacists?

I'm Back!!

  I know it's been forever since I last posted.  For some reason I couldn't access my account but it seems to be fixed now.
  The world of pharmacy hasn't changed much since my last post. Unless of course we want to talk about certain large chains and certain large PBMs not getting along. We all know the story. Personally, I can see the point of both parties. However, let's face it, neither party is going to be "ruined" by the decision not to play ball with each other. The ones caught in the middle are the patients. Thousands upon thousands of patients now have to find a new pharmacy. The PBM acts like its no big deal, but it is. I know I have patients that I have interacted with for years that now have to establish a new relationship with a new pharmacist. That can be unsettling. It's not that I'm any better at my job than any other pharmacist, but it's the point that these people have, at times, poured out their soul to me. We have laughed and cried together. I've seen their children grow up and get married and their families have become my patients. Over the last few weeks I have had to say good-bye to patients who have become my friends. They know it's not my fault and I know it's not theirs. We are all caught in the corporate whirlwind of money and greed. Every person I have had to say good-bye to has had the same look on their face. They don't know how to solve the problem, they really don't want to go anywhere else, but they also can't afford not to use their insurance. I know that feeling. I've had to change physicians before due to insurance issues. The medical professionals in our lives create an intimate relationship that a third party shouldn't be able to come between. Whether that third party is the PBM or the corporation who ultimately gets their money.
  So, am I upset about the decisions that have been made concerning my relationship with my patients? You're darn right I am! Is there really anything I can do about it? No, there is not! Like my abandoned patients, I will go on to forge new relationships with new patients and, hopefully, since I live in a small town, I will still see the ones who had to leave.