The Redheaded Pharmacist

Patient Displacement

      “But….. I’ve been coming here for years!”  She was right too, she had been coming to the pharmacy I was working at one day for years.  She said it in a pleading way as if I was some judge assigned to rule on a case that would determine where this patient could continue to fill prescriptions there or not.  “I’m sorry, there is nothing we can do about it” I said as I gave her the news.  A phone call to her insurance plan confirmed that she was no longer allowed to get that medication at our pharmacy. 

     That patient’s dilemma seems to be an example of a growing trend in the healthcare system.  And for patients, this trend means less freedom to choose their own providers and more restrictions being placed on them by their health insurance companies.  For proof of this, simply go to your local pharmacy.   

     The patient from above who told me she had been filling prescriptions at our pharmacy needed an injectable medication.  It was a maintenance medication for a chronic condition.  But the actual drug or the condition it treats is irrelevant.  The bottom line is that after years of getting the injection in question from her local pharmacy, she was now forced to use either what was termed “a specialty pharmacy” or a mail order facility to fill the very same medication.  And guess who was behind those walking orders?  That’s right, the insurance company was to blame. 

     I feel bad for patients who have to uproot and move to a new pharmacy simply because of some insurance restriction.   I’m sure there are many patients who have Express Scripts insurance who can tell you about not being pleased at having to leave Walgreens at the beginning of this year.  I’ve seen plans that only allow a 90-days supply at certain retail pharmacy chains or not at all.  And other times patients must use mail order only for certain medications.  What ever happened to the patient being free to make the choice of where to fill their prescriptions on their own? 

     If one needs an example of just how large and powerful the health insurance industry has become, simply look at the number of patients who have been displaced away from a medical provider or pharmacy simply because of their insurance.  People are getting more and more maintenance medications through the mail not out of choice, but because their prescription insurance simply won’t pay for their Lipitor or Plavix any other way. 

     I remember years ago I received a phone call from my primary care doctor’s office.  It was late in the fall and the woman on the line told me “we’re very sorry, but as of the first of next year we will not be accepting your health insurance anymore.”  She went on to tell me that the insurance I had at the time didn’t pay them anything for their services and that they had to make the difficult decision to drop my plan. 

     This woman was tentative and very apologetic on the phone as she explained their new policy to me.  I bet she had been yelled at more than a few times when she gave a patient this news.  As for me, I told her I understood why they had to do what they were doing.  I told her I was a pharmacist and I knew how bad things could get for providers trying to get paid for their services.  It was inconvenient for me to leave the doctor who knew me and had treated me for years and years, but I understood.  These things happen in modern medicine.  But why?

     But what frustrates me is the fact that the patients always seem to be along for the ride now without any say in where their boat is taking them.  Why can’t the decision of which doctor to see or which pharmacy to fill prescriptions at be left to the patient, not their insurance company?  Why are there “preferred provider” lists or “network doctors” or however else insurance companies phrase their approved list of providers?  Does that just mean those are the providers willing to serve patients and get the paltry reimbursements back that an insurance company was willing to give? 

     I only ask because from my vantage point, this idea of patient displacement is a growing trend.  Patients are having to find new providers and pharmacies all the time now because their old doctor or pharmacy just isn’t on “the list.”  I guess I just wonder why it is the insurance company and not the patient who gets to make that list.  It doesn’t seem like the patient has any rights anymore. 

     Patients are already having to deal with rising costs and more restrictions on their healthcare.  The least they should be able to do is determine where they can get their medical care themselves instead of having those decisions made for them.  If you need any proof of the power and influence of the health insurance industry, go ask one hundred random patients why they shop at the pharmacy they do and see how many of them answer “because that is where my insurance tells me to go!” 

      It’s a shame that patients don’t have more rights these days.  It’s a shame that pharmacies can be shut out from serving a large group of patients simply because their insurance company tells them not to go to a given pharmacy.  This trend of patient displacement is happening all over the country because of the influence of the insurance industry.  And I’m afraid for patients everywhere, it will only get worse as time goes on. 

The Redheaded Pharmacist

A Match Made In ……..

     It’s a shame the proposed Medco and Express Scripts pharmacy benefit management (PBM) merger is such a bad idea for patients, pharmacies, and the healthcare system overall.  Why would I say that?  Because those companies really are made for each other. 

     If they had a PBM match-making site, Express Scripts and Medco would surely exchange personal information and get to know one another more.  They are in fact, made for each other.  One can only look at recent comments from one of these company’s chief executive to validate the fact that these two giants in the PBM world are cut from the same cloth. 

     Just take a look at what Express Scripts Chairman and CEO George Paz said recently according to a quote printed in this Tom Murphy article I found on MSN-Money. ”At the end of the day … Nexium is Nexium, Lipitor is Lipitor, drugs are drugs, and it shouldn’t matter that much who’s counting to 30,” Paz said to some analysts on a conference call.  I can only assume that none of the analysts on the line were licensed pharmacists because if there had been one the c0nference call could have gotten really “interesting” for lack of a better word. 

      Seems like Paz took a page from Medco CEO David Snow’s playbook- demean and reduce the entire profession of pharmacy down to mere pill pushers.  Ah, the ignorance of a comment like Paz’s is so obvious I don’t even want to waste any of my reader’s time explaining it.  His comments echo some patient comments I’ve heard over the years.  People who are rushed and don’t know or care about what we do for a living simply think we count by fives and magically everything is perfect with every prescription ever written.   That overly simplistic view of what a pharmacist does is insulting and embarrassing. 

      The bottom line is simple for the Federal Trade Commission (FTC) as they sit down soon to make their final decision on the potential merger of Medco and Express Scripts- patients, pharmacies, and the healthcare system will all lose if such a merger is allowed.  And those two large PBMs care nothing for what pharmacists bring to the table as far as patient care and skill.  We’ve already been reduced to mere commodity brokers in the minds of the heads of the two companies in question.  And honestly, I’m surprised they even give us credit for counting to 30.  Shouldn’t robots be doing that according to Mr. Snow? 

     I was fortunate enough to briefly speak by phone with Eva Clayton the other day discussing the potential Medco and Express Scripts merger.  Clayton is the Chairperson for the organization Preserve Community Pharmacy Access NOW (PCPAN).  PCPAN is a coalition formed specifically to oppose the potential merger between Medco and Express Scripts.  In other words, this merger idea is so bad entire coalitions of businesses, consumers, and pharmacists have formed to simply to oppose such a merger from being completed. 

     Clayton echoed my concerns that community pharmacies will be squeezed to the point of having to close their doors if two of the three big PBMs in existence are allowed to merge.  She spoke about concerns that any potential cost savings that could be realized from such a large merger wouldn’t be passed on to the consumer. 

     We also worried that a combined PBM that handles prescription plans for an estimated 135 million Americans is simply too large of an organization with too much power.  Basically, these two PBMs already are too large and powerful and they will only pinch community pharmacies further through policies like mandatory mail order service or preferred providers if Medco and Express Scripts become one company. 

     There is however still time for individuals to try and help make a difference if they feel inclined to do so.  Sign the petition available on PCPAN’s website.   Go e-mail your Congressional representatives voicing your concerns about this merger.  Talk to your state’s pharmacy associations and tell them to write to the FTC if they haven’t already.  Every effort to block this merger is important and it could all culminate in the FTC listening and more importantly making the right call by blocking this merger. 

     This merger is a terrible idea.  And if you want an idea of what these companies really think about pharmacy, just read the quotes from their CEOs.  Those two men have revealed how they really feel about community pharmacy and the role of pharmacists in the healthcare system.  And they echo each other with their total disregard for patient care or the influence and positive contributions of the profession of pharmacy on the healthcare system.

     Medco and Express Scripts might think that they are a match made in heaven.  But to the rest of us, it is a match really made in …. well, let’s just say it’s a little south (and warmer) than heaven and leave it at that.  There is still time to join the efforts to block this merger from happening.  You can still do your part to stop something that will negatively impact the profession of pharmacy and patient care. 

     It really is a shame though.  Those two companies really are meant for each other.  Their shared negativity towards the profession of pharmacy coupled with their collective desires to make as much money as possible off the healthcare system is unmatched!  But that reveals the heart of the problem with allowing them to merge doesn’t it? 

     Let’s hope the FTC does the right thing here.  Let’s hope that in the end David Snow and George Paz will be left wondering what could have been, instead of what is!  Hey George Paz- durgs are drugs, but bad ideas are bad ideas! 

(Special thanks to Eva Clayton, chairperson for PCPAN, for graciously taking time out of her busy schedule to speak with me by phone.  Her input was valuable and contributed to the contents of this article.  Thank you! ) 

The Redheaded Pharmacist

Federal Judge Rules on WA Emergency Contraception Mandate

      Should pharmacies be forced to stock emergency contraception pills?  What about pharmacists?  Should they be forced to dispense those medications even if it is against their personal religious beliefs?  A federal judge, ruling on a case out of Washington State, says no. 

     According to a Reuters report I found on Yahoo News, a United State district judge recently ruled that a Washington State mandate forcing pharmacists to dispense emergency contraception pills was unconstitutional.  The ruling raises the argument of patient access vs. the rights of a pharmacist.  It also raises the question about the proper role of government in healthcare and pharmacy operations. 

     Judge Ronald Leighton struck down the Washington State rule because he argued that it removed pharmacists rights to “concientiously object” to the dispensing of emergency contraception based on religious beliefs.  Leighton also imposed an injunction against the State of Washington to prevent them from enforcing their rule. 

     Those that support the Washington ruling worry that this injunction might prevent women from getting timely access to needed medication.  Emergency contraception is a uniquely time-sensitive drug.  Any excessive delay in a patient’s access to the medication may decrease its potential effectiveness. 

      But the other side of the debate argues that a compromise can be reached without forcing pharmacists to violate personal religious beliefs and force them to dispense these medications.  Pharmacist could, in theory, simply refer patients to another pharmacy that could dispense the emergency contraceptive in a timely manner.  That way a pharmacist could exercise their right to refusal to fill while still assisting a patient who desires to obtain the medication in question. 

      Supporters of the Washington ruling however argue that in some parts of the state there might not be another close pharmacy that would be a suitable alternative for patients.  That would mean if a pharmacy refuses to see the drug to a given patient, they might not have a good alternative to get that medication locally. 

     The heart of this debate in Washington State goes back to an older rule adopted by the WA Board of Pharmacy requiring pharmacies to stock medications that had a demonstrated need in the community.  Debates resulting from that ruling argued whether or not a pharmacy should have the right to make decisions on which medications to stock.  Leighton argued that if a pharmacy has the right to refuse to stock a medication for whatever reason, a pharmacist should have the leeway to refuse to dispense on grounds of personal religious beliefs. 

      The example that was brought up related to this case was the drug OxyContin.  Some pharmacies were refusing to stock the narcotic pain reliever based on concerns over the threat of pharmacy related crime.  Leighton argues that a pharmacist should have similar rights to refuse to dispense and the state should not impose a ruling forcing them to go against their personal religious beliefs. 

      So after the ruling by this federal judge in the Washington State case, the debate remains the same- should a state legislate that a pharmacist is required to dispense any medication for any reason?  Do pharmacists have the right to refuse to dispense an otherwise valid and legal prescription based on personal or religious beliefs?  And do mandates that force pharmacists to dispense anything like emergency contraception violate their constitutional rights?  That is the core of the debate. 

      Personally, I don’t think the government should have the right to force a pharmacy to stock or sell anything.  There are several legitimate reasons for a pharmacy owner that chooses not to stock a particular item.  That decision should be left with the store owner/operator, and not the government. 

      And with regards to the right of the pharmacist to refuse to dispense, I feel like pharmacists should be able to refuse as long as they can refer the patient to another pharmacy who can fill their prescription in a timely manner.  That way pharmacists maintain their rights and patients still have access to the medications they need.  Even if a pharmacist refused to fill a prescription based on moral beliefs, the patient should still be able to fill that prescription in a timely manner if there is a referral included with the refusal to fill. 

      Tell me what you think?  Did Judge Leighton make the right call when he struck down the Washington State ruling?  Or was the Washington rule the right move and should pharmacists be forced to fill prescriptions regardless of personal or religious beliefs?  Is forcing a pharmacist to fill a prescription against their beliefs a violation of their constitutional rights?  What do you think?

The Redheaded Pharmacist

Drug Delivery Microchip in Development

    What would you say to the idea of having a small microchip implanted under your skin that could be controlled remotely to deliver medications instantly into your body?  Does it sound like some sort of science fiction plot?  What if I told you that developers were working on just such an idea now and there are even human clinical trials underway as we speak?

     According to BBC News, there are United States scientists working on technology that they hope will yield an implantable device that could deliver medications to a patient on que.  The device, currently being tested in a select number of females for osteoporosis treatment, is a microchip that would be placed under a patient’s skin.  It could be loaded with medication which would be released remotely or at a set timed interval. 

     It could be one of the most elaborate drug delivery systems every conceived.  The devices would deliver drugs through a complicated system to the surrounding capillaries into the patient’s bloodstream.  But before you get too excited (or worried), this technology is still years away from being approved by the Food and Drug Administration (FDA) for treatment. 

     The thoughts of some little microchip releasing drugs at a given interval seems like it could be dangerous or even reckless.  But the possibility of an effective delivery system like a microchip opens the door for all kinds of practical applications in medicine.   You could make drug regimens that just aren’t possible now with traditional drug delivery systems. 

      Chronic pain patients could have pain medications delivered on a round the clock schedule to better control their condition.  Diabetes sufferers could get needs blood glucose regulation 24 hours a day.  The possibilities are endless, if the system proves to be both safe and reliable enough to trust loading it with potent prescription medications and then implanting those devices in patients.   But that is one big if in my opinion.

      The obvious upside to technology such as this drug delivery microchip is it’s potential to tackle one of the biggest obstacles to proper medical care- compliance.  Patients would no longer have to worry about giving themselves regular shots or taking regularly scheduled doses of a medication to treat a chronic condition.  Instead, there would be a programmed interval for the drug delivery by the chip or the patient could control the process using a remote.  Either way would most likely make it easier for patients to be on regular drug regimens. 

       But one can’t help but wonder if the promise of convenience is pushing modern medicine into areas better left uncovered.  Is convenience really worth the risks involved in a technology such as a microchip when complications could result in an overdose if the device malfunctions while implanted in a patient’s body?  

       Is this really how we should be spending our time, effort, and money with regards to medical research?  Or is a story like this simply a sign of the times and the great advances we’ve achieved over the years in the field of medical science?  

       I’d like to think an idea such as a drug delivery microchip to be an optimistic possibility down the road.  When you really think about it, this idea isn’t any more bizarre than say an artificial pacemaker.  If we can come up with a device that stimulates the heart to beat properly why can’t a device come to exist that delivers drugs on a regular basis? 

       Part of me wants to dismiss a story like this as simply fun medical research that will never become an actual treatment option for providers.  Just like the concept cars that never seem to hit the dealership showrooms, there is an expectation of failure to projects like this that are so far removed from traditional drug delivery systems. 

       But anything is possible.  And this technology is closer to becoming a reality than you might expect.  But would you feel comfortable having a device implanted inside your body that would deliver drugs into your bloodstream at the press of a button?  Is such an idea even safe to pursue in clinical trials?  I know one thing, that is one remote control you’d better not lose!   These are strange times in the world of medicine.  Very strange times indeed! 

The Redheaded Pharmacist

The FTC Should Follow Their Own Lead

     It isn’t everyday that a decision by the Federal Trade Commission (FTC) weighs so heavily on the future of community pharmacy.  But that is exactly what is at stake with the proposed Medco and Express Scripts merger the FTC is reviewing right now.   But what is likely to come out of all of this and how will it affect community pharmacy? 

      I have to admit that I don’t envy the FTC.  Their job of overseeing these large mergers and their intervention occasionally to prevent such combinations resulting in one company becoming too big and powerful is important but difficult work.  It almost seems like they can’t win because no matter how they rule, someone will be upset. 

     Such is the case for the potential blockbuster merger proposal of the pharmacy benefit management (PBM) world.  Already the two dominant players in the industry, Medco and Express Scripts now want to combine forces and become one large mega-PBM.  And for an industry that has already seen several rounds of consolidation and buy-outs, this merger would further whittle down the competitive landscape of the PBM industry.  And that it a very bad thing for pharmacies everywhere. 

      As you might expect, the two players involved in this potential merger are playing up the idea as a good one for the healthcare system and consumers.  Express Scripts has come out and argued that their potential merger with Medco would make the resulting PBM more capable of negotiating drug discounts as well as save plan patients money.   But my question to Express Scripts is this- who will really benefit from any cost savings realized from your merger with Medco?  I’m guessing patients isn’t the correct answer here. 

       What they fail to mention is the sheer market size domination they will obtain through this merger.  They also don’t give any evidence that those prescription discounts they make with manufacturers will ever make it into the pockets of consumers.  The problem with the drug discount argument is that even if they can prove they will lower drug costs (which they can’t), they definitely can show that those discounts will be doing anything other than making themselves lots of money. 

        Despite what UnitedHealthcare might have you to believe based on their television advertising campaign, the PBM world is only effective at doing one thing and it isn’t preventing drug interactions or helping patients.  The one thing PBMs have been able to do very effectively is siphon off money from the healthcare system to make themselves rich.  And with a mega-merger in the works you can bet that this one efficiency of the PBM world will continue if this merger is completed. 

         PBMs have this tired arguement about controlling healthcare costs.  Meanwhile, prescription drug costs have skyrocketed under the watch of the PBM industry.  Believing that a PBM will actually contain healthcare costs and pass those savings to consumers is believing a myth they’ve been able to perpetuate for a long time.  The only problem is they have no evidence to back up their claims.  But that shouldn’t surprise anyone familiar with this industry and their business practices.

         But there is hope for a happy ending out of this potential merger story.  The FTC can do the right thing here and stop this merger from happening.  They can look beyond the hype being presented by the PBM industry and realize that consumers and pharmacies will lose if this merger happens.  The arguement against the Express Scripts/Medco merger is an easy one to make. 

         The best part of all of this is the fact that the FTC can look towards some of their own actions for guideance on how to proceed with this PBM merger decision.  Just recently the FTC blocked the merger of Omnicare and PharMerica, the two biggest names in the long-term pharmacy services industry.  The FTC argued that if Omnicare was able to buy it’s main rival, it would have the ability to raise prices on elderly consumers.  That company would have become too large and powerful if the merger had been completed.  Sound familiar to anyone as they think about this potential Express Scripts and Medco merger? 

         That decision should be a good guideline for the FTC on how they should rule in this Medco and Express Scripts merger proposal.  I think deep down they know that this merger will be bad for consumers and for pharmacies.  The FTC doesn’t want to see the PBM industry gain more control over community pharmacy.  PBMs already have more power than they should have been granted.  Giving them more control and power would be a disaster for the healthcare system and specifically for community pharmacies. 

         There is absolutely no reason to believe that a Medco and Express Scripts merger won’t do anything other than create more profits for the newly combined company at the expense of the healthcare system and consumers.  All the systems and programs that PBMs have in place such as preferred providers and prior authorizations were originally designed to maintain some sort of concern over proper and cost effective care.  But now, the PBM industry has turned into a massive bureaucracy designed to skim off profits and deny care to patients. 

       I think the FTC has the ability to do the right thing here.  They have a history of fighting healthcare mergers that threaten to raise costs for patients.   This is just another example of a place where the FTC could intervene and really help patients.  I sure hope they will stand up and do the right thing here.  I hope they will follow their own lead.  

       The Medco and Express Scripts merger is a very bad idea that could spell disaster for patients, community pharmacies, and the healthcare system as a whole.  The PBM industry is already too large and too powerful even in its current form.  Allowing two of the largest players in that industry to merger would perpetuate the shortcomings of the system we have now. 

       So this is my plea to the FTC- do the right thing.  Block the merger of Medco and Express Scripts.  Trust me, a Medco/Express Scripts PBM won’t turn out well for consumers or pharmacies.  Just follow your instincts.  Better yet, just follow your own lead!  You already know what to do here. 

The Redheaded Pharmacist