Fred Gebhart, Contributing Editor

Contributing Editor Fred Gebhart works all over the world as a freelance writer and editor, but his home base is in San Francisco.

 bring a broad network of business experts who can help with everything from buying your first pharmacy through selling your final pharmacy before retirement and maximizing profits during the decades between. 

 supports the entire life cycle of pharmacy ownership and profitability.

“Pharmacy is evolving and pharmacy owners have to evolve with the profession,” says Jennifer Zilka, 

 group vice president of Field Programs and Services.

“Pharmacists go to pharmacy school because they want to help patients. The running of the business side is often secondary in terms of their own priorities. That is why it is so important to have partners who can help them identify what kind of opportunities will make the most impact for what they want to do in pharmacy. Our goal is to give our pharmacists more time with their patients.”

 Pharmacy Ownership Program matches pharmacists who want to sell with pharmacists who want to buy. And because sellers are most often existing 

 members, the prospective buyer has access to detailed sales and operations data that a typical buyer can only dream about.

 banking partners are ready to offer the best terms. They know the new pharmacist-owner will be in good hands with 

 business partners, consultants, and coaches. 

 business support network gives pharmacy owners important business and financial advantages.

AmerisourceBergen’s Pharmacy Services Administrative Organization (PSAO), Elevate Provider Network, doesn’t just negotiate contracts, it constantly monitors and reevaluates contract performance and changing market conditions. Detailed data from every 

“We know the insurance cards patients at each of our stores are using,” says Chuck Reed, AmerisourceBergen’s vice president for Pharmacy Innovation and Solutions. “We see every claim, we know the patient population, and we can see details like patient sensitivity to copay changes that aren’t always obvious at the store level. We have the data that prompts us to make some tough calls and the gumption to stay with those calls.”

In 2017, for example, AmerisourceBergen recommended that pharmacies not join a preferred provider network offered by one of the largest health plans in the nation. Data showed that the plan population was loyal and had a large proportion of low-income-subsidy Medicare patients. Pharmacies could maximize reimbursement by staying out of the preferred network and focusing on Medicare scripts.

“Not only have we not lost patients by not joining the preferred network, in this case, we are up double digits in that plan this year,” Reed says.

Elevate’s proprietary pharmacy analytics system, InSite, help pharmacies track and review every claim. Other programs help pharmacies correct rejected claims to move toward 100% reimbursement.

Inventory management is another vital issue.

“Independent pharmacists have a tendency to want to have every product all the time,” Zilka explains. “It goes back to wanting to help their patients. We can help pharmacists tailor their inventory to have the right products on the shelf at the right time so they aren’t carrying excess inventory and cutting into their own earnings.”

Other coaching programs help owners focus on specific areas such as employee training and motivation, front end operations, attracting the next generation of patients, and keeping one step ahead of the competition.

Advocacy is another vital area. AmerisourceBergen’s OurIndependentVoice.com gives independent pharmacists a voice by providing a centralized place to access tools and resources to join advocacy movements that impact care in their community setting, research policies supporting independent pharmacy, access letter templates, write to legislators and connect with other pharmacists and pharmacy organizations.

And when it’s time to sell, the Pharmacy Ownership Program can help once again.

“We like sales three to five years out where we can use business coaching to maximize the value of the business and find the ideal buyer,” Zilka says. “We are not reimbursed for our matchmaking services by our pharmacies, so a deal has to make sense for both buyer and seller or we don’t pursue it. Our goal is to keep independent pharmacies independent. That’s good for our owners and good for AmerisourceBergen.”

Articles

How the right partner can help protect the independence of community pharmacy.

AmerisourceBergen and Good Neighbor Pharmacy Work to Keep Independent Pharmacy Healthy, Profitable

Pharmacists in almost every setting are pushing for provider status. While provider status is the most direct and transparent way to get paid for clinical services, it’s not the only way. Pharmacists who learned how to navigate the reimbursement system have been getting paid for clinical services for years.

“We started our first pharmacist-managed ambulatory care clinic in 1996 and have been getting paid for our services from day one,” says Dean T. Parry, RPh, assistant vice president for clinical informatics at 

. “Today we have about 60 pharmacists working full time in ambulatory disease and medication management. Getting paid is a matter of figuring out where in your specific administrative and financial system you can fit in. Provider status would be nice, but it is not a prerequisite to getting reimbursed for clinical services,” says Parry.

Like many other integrated networks, Geisinger covers only about 40% of members through its own insurance program. The remaining 60% are covered by standard commercial payers. The key to convincing commercial payers to reimburse clinical pharmacy services is to provide a reasonable return on the payer’s investment, says Parry.

Payers have seen all the data on the health and financial outcomes of clinical services. Parry says that they know just as well as pharmacists that the appropriate pharmacy interventions can improve health outcomes and reduce overall costs of care-over time.

“Payoff time is the obstacle for payers,” he explains. “They need to see a payoff in reduced total cost of care in less than one year. That might be possible in some disease states, but the return on investment for anticoagulation, asthma, COPD, cardiovascular disease, and most chronic diseases is too long term for most payers to work with.”

The current wave of consolidation among payers, 

s, pharmacies, wholesalers, and providers may ease the ROI problem. With far fewer payers in the system, each payer is more likely to retain patients for a longer period of time, Parry suggests. The longer patients remain with a single payer organization, the longer that payer’s time horizon for a return on its clinical pharmacy investment.

Integrated networks like Geisinger seldom worry about whether their pharmacists can bill payers directly, Parry said. Clinical pharmacists are part of the overall patient care team working to control costs, reduce admissions, improve adherence and provide more effective care. When pharmacists are part of the patient care team, the health system looks to the total cost of care versus the total reimbursement for care. Whether services are reimbursed directly or through some other provider becomes an accounting exercise for the integrated health network. The key to convincing commercial payers to reimburse clinical pharmacy services is to provide a reasonable return.

Getting Reimbursed for Services Rendered: It’s no Magic Trick

For now, closed systems like Kaiser, where a network is exposed to patients’ entire cost of care over multiple years, have an easier time justifying the financial investment in clinical pharmacy services. Pharmacists in other settings must find an appropriate work-around. Closed system pharmacists don't get reimbursed individually because the system is responsible for everything: insurance coverage, cost of care, quality of care, patient and provider satisfaction. If a third party payer is involved-Medicare, Medicaid, or some other public system-the system gets reimbursed, not the provider.

Up next: Collaborative agreements and how to get started

A work-around usually means teaming up with another provider who has the necessary reimbursement status, most often a physician or nurse practitioner. Many states have collaborative practice agreements that make it relatively straightforward for pharmacists to provide clinical services under protocol with another provider and bill for services through that provider. The billing provider shares reimbursement under terms agreed to by both provider and pharmacist. If pharmacy is part of an SSP, reimbursement is simply part of health plan revenues that go to pay all providers.

Geisinger started with a single pharmacist, Parry, and a collaborative practice agreement with a single neurologist to handle anticoagulation. Today, Geisinger pharmacists are covered by a network of overlapping collaborative agreements with multiple providers to ensure that clinical pharmacy services are eligible for reimbursement.

These agreements may not be the ideal reimbursement solution, but it’s a workaround that can work for an entire career.

“I’ve been prescribing and adjusting drug therapy almost since the day I got out of pharmacy school,” says pharmacy consultant Fred Pane, RPh, former hospital pharmacy director. “Granted, I worked mostly in hospital pharmacy, but there is always a way to work around not having provider status. You do it by solving clinical problems for providers who do have the right reimbursement status.  When you become an indispensable member of the patient care team, there are always ways to get paid for your services,” says Pane.

The key to building collaborative practice and reimbursement is creating a concrete plan that solves provider pain points, says Parry.

The first step is to evaluate published outcomes and cost data against your own practice and project returns locally. Once the program has local buy-in, pharmacy creates standardized work flows for interventions, data collection, and data reporting on patient and financial outcomes. Standardized clinical procedures and data collection makes it easier to document both interventions and outcomes.

“One of our programs worked with difficult-to-manage diabetes patients with elevated hemoglobin A1c levels,” Parry says. “Clinical pharmacists brought more than half of them to A1c goal in less than one year. That kind of data sells itself.”

Pharmacists are finding ways to get reimbursed for clinical services. See what you can do to get paid.

How to Get Paid for Pharmacy Services

 state to adopt telepharmacy legislation. The legislation is expected to be signed into law this year with the first outlets scheduled to open in early 2019.

	Six other states have authorized pilot programs that could apply to telepharmacy and five states permit waivers of legislative or administrative requirements that could allow for telepharmacy, according to the Rural Policy Research Institute at the 

University of Iowa College of Public Health

Telepharmacy: New Jobs, Expanded Opportunities

	As more states adopt telepharmacy legislation, some pharmacists are raising concerns over what it could mean for patients and the pharmacist job outlook. To help address those concerns and others, the 

, which supports the legislation, negotiated a series of protections for pharmacists and patients.

	“The big issue that came up from some of our members and other stakeholders is to ensure that this is a safe practice,” says association CEO Kelly Fine, RPh. “We are equipping and training both technicians and pharmacists, making sure that security and surveillance are sufficient, and requiring HIPAA-compliant high-definition video conferencing for face-to-face interaction with the remote pharmacist.”

	Most telepharmacy locations will likely be in rural areas, at least to start, she says. But community health centers and hospitals have also expressed interest. "So have independent pharmacists who want to expand into pharmacy deserts, areas with few or no pharmacies and severely limited local access to pharmacy care."

	The potential for urban expansion has raised objections among some pharmacists. “This bill can and will likely be used to lay off hundreds of pharmacists and convert hundreds of ‘underperforming’ pharmacies in urban areas, effectively reducing pharmacist jobs by over 75%,” says P. Charles Zaffrey, RPh, pharmacist at 

, a supermarket chain pharmacy in Tempe, AZ, who opposed the legislation.

Kmart Opens First Telepharmacy with Plans for More

	The Arizona Pharmacy Association insisted on including language in the telepharmacy legislation that may help prevent such problems from occurring. The legislation limits pharmacists to overseeing one remote location in addition to managing operations in their own physical location. Pharmacists who do not have oversight responsibilities for a physical pharmacy will be allowed to oversee two remote locations. 

	Adam Chesler, PharmD, director of regulatory affairs for 

, which is backing the legislation, says many providers who fear job loss due to telepharmacy may have misconceptions about state-level legislation.  

	“One of the lessons we have learned is the need for provider education,” he says. “Anything and everything a pharmacist has to do in a physical pharmacy today still has to be done in a telepharmacy. None of the steps of pharmacist involvement in oversight, counseling, and clinical responsibilities is gone with telepharmacy. If anything, you see increasing clinical involvement by pharmacists because they are able to see more patients as telepharmacy expands access.”

	Mark J. Hardy, PharmD, executive director of the 

, says pharmacist employment hasn’t fallen since North Dakota became the first state to authorize telepharmacy in 2002.

Genoa MMS: Medication Management for its Community Pharmacies

	“If anything, telepharmacy has expanded the hiring of pharmacists across the state,” he says. “It has allowed them to focus on clinical duties and interact with more patients than ever before by expanding pharmacy access. If there have been job losses, they are attributable more to economics than to telepharmacy.” 

	Beyond jobs, telepharmacy is also creating opportunities for patients.

	“The big pro for telepharmacy is better access to medications and to pharmacists,” says Mohamed A. Jalloh, PharmD, assistant professor at 

Touro University California College of Pharmacy

, community pharmacist, and a spokesperson for the APhA. “The reality is there are places in every state where access to pharmacy is difficult to impossible. Telepharmacy can increase access.”

	Telepharmacy seems to be expanding steadily, if not quickly.

	“Pharmacists are learning about it and state boards are taking deliberate approaches to be sure it will work in their state,” says Lisa Schwartz, PharmD, senior director of professional affairs for the NCPA. “And thanks to software advances, you no longer have to come up with technology solutions by yourself. When you have a turnkey package, the business case makes more sense.”

Arizona joins a growing list of states to adopt telepharmacy legislation. Here’s how it could affect pharmacists. 

Is Telepharmacy Taking Pharmacy Jobs?

Though continued political uncertainty threatens to cloud the New Year, medication trends are clearly up. Experts predict considerable growth in U.S. medication spending, and improved insurance coverage is driving increased medication use.

At the same time, a growing number of patients are abandoning their prescriptions at the pharmacy counter because of higher copays. Generic drugs account for about 90% of all prescriptions and a growing proportion of brand introductions are specialty products. 

Against this overall backdrop of uncertainty, here are seven key challenges-and opportunities-for pharmacy for 2018.

Retroactive direct and indirect remuneration (DIR) fees are a growing problem for many pharmacists.

“Pharmacy benefit managers are pulling money back months down the road,” said Marvin Moore, PharmD, Owner and President of 

. “The toughest part is that DIR fees are not transparent to us. We just get PBM reports saying they have pulled dollars back. You don’t know what factors are being evaluated over what period. It is out of our control.”

 and other pharmacy groups have been pushing legislative and regulatory reforms for years and the Centers for Medicare and Medicaid Services (CMS) is listening. CMS’s proposed Part D rule for 2019 calls for pharmacy price concessions to be included in the negotiated price.

Drugstore Chains, Pharmacy Groups Support CMS DIR Fee Rule

The proposed rule would eliminate retroactive DIR fees for the roughly one-third of prescriptions covered by Part D. The Improving Transparency and Accuracy in Medicare Part D Drug Spending Act, a legislative fix that is stalled in Congress, would ban retroactive DIR fees altogether.

The CMS change would save federal payers $3.4 billion over 10 years according to a study sponsored by the NCPA. CMS noted that banning retroactive DIR fees would also save patients $10.4 billion and give community pharmacies greater financial predictability.

“It is hard to dispense a medication and not know your ultimate reimbursement for months,” Moore told 

. “It would help to have the fees become transparent and even more to have them at the point of sale.”

The pharmacy world seems to believe that bigger is more profitable: Manufacturers are consolidating, pharmacy chains are consolidating, payers and insurers are consolidating, PBMs are consolidating. The industry is integrating vertically as well, with pharmacy chains acquiring PBMs and insurers acquiring PBMs.

’ proposed acquisition of Aetna. If approved by regulators, the deal would integrate one of the largest pharmacy chains, CVS-which has one of the largest PBMs, Caremark-and one of the largest health insurance companies, Aetna.

“We did a double take,” said Joe Hill, Director of Government Relations for the 

. “This is one more step in a continuing trend of the big players getting both bigger and fewer. At this point, it’s hard to predict the outcome, but it is clearly an important question for five-year strategic planning.”

Industry analyst Adam Fein, PhD, noted that the deal could help CVS protect itself from other vertically integrated PBMs, including 

 (owned in part by 14 Blue Cross and Blue Shield plans).

Hill added that vertical integration could offer opportunities for pharmacy to highlight their growing role in patient care.

Moore isn’t convinced. “Patients are being limited more and more in where they can go,” he said. “People want to come here, but it’s a challenge when they have to pay more. Growing consolidation and ever more-restricted networks is frustrating for patients and frustrating for us.” 

Many pharmacies could not survive without technicians. And as pharmacists focus more on direct patient care, well-trained technicians have the capabilities to assume new responsibilities.

“Technicians are taking an ever-expanding role in almost every health care and pharmacy setting,” said Glen Gard, CPhT, Manager of Pharmacy Compliance for the home infusion provider 

. “Their roles include medication reconciliation, quality control and patient satisfaction, pharmacy compliance oversight, blood draws in anticoagulation clinics, medication therapy management, patient preadmission workups, and more traditional roles. As our pharmacists have become more integrated into clinical care, their other roles are being assumed by techs.”

For a preview of where technicians are headed, look to pharmacists. Just as the Board of Pharmacy Specialties is raising the bar for pharmacy specialists, the Pharmacy Technician Certification Board (

) unveiled a beta version of its first specialty certification in late 2017, the PTCB 

Certified Compounded Sterile Preparation Technician

“Sterile compounding is a familiar role for technicians, but the CSPT certification is a new measure of competence,” said PTCB Executive Director and CEO William Schimmel. “We are looking at similarly common sets of knowledge and skills in community pharmacy and other areas.”

Technician practice is advancing steadily at the state level, he added. Idaho recently became the first state to allow technicians to administer immunizations. Early results from Iowa’s community pharmacy tech-check-tech program shows a sharp decline in pharmacist time devoted to dispensing duties and a corresponding increase in direct patient care with no change in error rates.

“More than 90% of Americans live within two miles of a pharmacy,” Schimmel said. “That is a huge opportunity to expand patient care. As pharmacists evolve their practice, technicians are ready to backfill the tasks they leave behind, as well as manage and lead pharmacy initiatives.”

Specialty pharmacy doesn’t get many kind words. Community pharmacists complain that specialty is poaching patients. Health-system pharmacists complain that specialty complicates everything from patient care to inventory and continuity of care.

“Specialty pharmacy isn’t looking to steal patients,” said Sheila Arquette, RPh, Executive Director of the National Association of Specialty Pharmacy. “The move to specialty pharmacy is driven by the payer. There is no choice involved for either the patient or the prescriber.”

 would like to see a synergistic relation with other pharmacists.

Specialty pharmacy is no more able to deal with patients’ nonspecialty needs than other pharmacies can meet specialty needs. She would like to see specialty and nonspecialty pharmacists share information to improve patients’ overall care.

Independent Pharmacies, Chains Enter Specialty Pharmacy

There are few-if any-formal information- or patient-sharing arrangements, but some community pharmacists are proactively tracking specialty use, noted Lynnae Mahaney, BSPharm, MBA. She is ASHP’s Director of Pharmacy Accreditation and facilitates specialty pharmacy accreditation for the group’s Center for Pharmacy Practice Accreditation (CPPA).

But expansion into specialty pharmacy is possible and is being done. Community and health-system pharmacies are successfully providing a variety of HIV, 

, rheumatoid arthritis, and other specialty products. The key is working with CPPA to become an accredited specialty pharmacy, Mahaney said.

“Whether you are a health system or an independent, you can build a very successful specialty business if you invest the time and the effort,” she said. “Good pharmacy care can be provided anywhere and the key is providing services that help patients achieve desired, cost-effective outcomes from their specialty medications.”

Activity monitors and other wearable technology are already moving into clinical trials to reliably evaluate changes in activity and other physical outcomes. Other trials are evaluating the use of cell phones and other mobile tech to improve medication adherence in diabetes and other chronic conditions. Pharmacy is next.

The ASHP Foundation Pharmacy Forecast 2018 predicts that health insurers will offer incentives to beneficiaries who can document that they are meeting goals for health behaviors by using wearables. Incentives for using wearables could open the door to entirely new categories of devices, software and training for activity monitoring and reporting products. There is also the potential for new counseling opportunities in the most appropriate use of wearables and activity reporting.

Six Healthcare Technologies Coming in the Next Five Years

Information sharing is another area ripe for pharmacist action. Pharmacists are being called on to take more active roles in patient care, but providing quality care requires quality patient data. Few pharmacists have reliable access to patient medical data.

“We have technology to share patient data, but we don’t have the policy to make effective data sharing happen,” said Tom Bizzaro, RPh, Vice President of Health Policy and Industry Relations for pharmacy data provider 

. “All of the health-care providers who touch a patient need access to patient information at their own point of care. Pharmacy should be taking a lead in making sure we have standardized access to information using standardized vocabularies when we talk about health care.”

Provider status for pharmacists has arrived, at least in a few states. Federal legislation has the backing of more than half the House and half the Senate, but companion bills HR 592 and S 109 have been stalled by partisan politics.

“It’s been a tough year to get anything accomplished in Washington,” said Tom O’Donnell, Senior Vice President for Government Affairs and Public Policy at the 

. The NACDS, NCPA, ASHP, the American Pharmacists Association, and other groups have backed repeated attempts to have pharmacists added to the short list of Medicare providers.

The Patient Access to Pharmacists’ Care Coalition is gearing up for another attempt at passage in 2018, O’Donnell added. This bill would give Medicare beneficiaries access to pharmacist-provided services in medically underserved areas based on state scope of practice laws. Pharmacists, like other non-physician practitioners, would be reimbursed at 85% of the physician fee schedule.

“It is unprecedented for a bill to have that kind of cosponsorship,” said Christopher Topoloski, ASHP Director of Federal Legislative Affairs. “This is a bill that everyone can rally around. It is good health policy.”

Both NACDS and ASHP are encouraging pharmacists to contact their representatives and senators to push for action on the respective bills. The next legislative step is hearings in both the House Energy and Commerce Committee and the Senate Finance Committee. Every congressperson and a third of senators are looking for positive positions they can use during midterm elections in 2018.

“It is pharmacists, constituents, voters, who move that process,” Topoloski said. “When it comes to dealing with Congress, pharmacists can be their own best advocates.”

Abuse of prescription opioids shows no signs of abating. Data released in late 2017 showed drug-related deaths fueled a second successive year of declining life expectancy for Americans.

NCPA warned that pharmacists can expect an expansion of programs to limit initial fills of controlled substances, expanded electronic prescribing for controlled substances, and increased efforts around the disposal of controlled substances. Prescription drug monitoring programs (PDMPs) will remain a key tool in combating misuse.

PDMPs are being developed at the state level to deal with state-specific issues. The Prescription Drug Monitoring Program Training and Technical Assistance Center at 

 reports that as of November, 2017, 25 states require prescribers to query the state PDMP before prescribing controlled substances. PDMPs can be highly effective in limiting inappropriate dispensing, but PDMP reports are outside the normal workflow and can slow operations. Fourteen states require both prescribers and dispensers to check the state database, while 13 states do not require checking a PDMP.

Minnesota is one of the states that require prescribers to check the state database before prescribing controlled substances. “For years, we had to call prescribers every time we saw a patient come in with multiple prescriptions or who we suspected was doctor shopping,” Moore said. “Now that those questionable prescriptions aren’t being written, we don’t have to play good cop-bad cop or go back and forth with physician offices.”

What’s the difference between a challenge and an opportunity? In 2018, for pharmacy, they may be the same thing.

Author | Fred Gebhart, Contributing Editor

Articles

AmerisourceBergen and Good Neighbor Pharmacy Work to Keep Independent Pharmacy Healthy, Profitable

How to Get Paid for Pharmacy Services

Is Telepharmacy Taking Pharmacy Jobs?

Top 7 Challenges (and Opportunities) for Pharmacy in 2018