Gail Kalinoski

Two transformational multibillion-dollar deals in the healthcare and pharmacy industries have been in the works for months-the $69 billion CVS-Aetna merger and the $52 billion Cigna-Express Scripts merger-despite concerns that more consolidation will mean higher costs and fewer choices for patients. Pharmacists, particularly independents, could also be affected, experts say. 

The Cigna-Express Scripts merger has gotten a go-ahead from the Department of Justice, but DOJ has not ruled on the CVS-Aetna merger at press time. However, Reg Blackburn, managing director of The Braff Group, a leading mergers and acquisitions firm specializing in healthcare services, expects the CVS-Aetna merger to go through. Both deals have shareholder backing.

“I think it’s part of an overall trend,” Blackburn says. “There used to be really large, medium, and small players with a lot of gray in between. What has evolved throughout healthcare is this gap where there are really larger players getting larger and very few players in the middle, and if they are in the middle, they are getting acquired or struggling.”

Frederick S. Mayer, RPh, MPH, FACA, and CEO of Pharmacists Planning Services Inc., is no fan of mergers. He fears that they could result in loss of pharmacy jobs due to closures of independent pharmacies that can no longer compete. Chain pharmacists could also have less job security as locations may close. Mayer also says consolidation could lead to higher prices, lower quality, and less choice for consumers.

“Pharmacists know how medications react and interact in the body. They are the experts regarding medication choice and side effects. They trained eight years for their PharmD, and now they are counting, pouring, and typing due to mergers,” says Mayer, who adds that pharmacists in larger settings don’t have adequate time for patient counseling.  “Over the past 10 years, mergers have resulted in poorer choices of medication for consumers and patients.”

“[Independent] pharmacies are getting less and less, and going out of business,” says Mayer, who notes there used to be 59 independent pharmacies in Marin County, CA, where he ran his pharmacy for decades before retiring. “Today there are three independent pharmacies. The chains are buying up all the pharmacies. [Independents] can’t stay in business.”

Stephen Schondelmeyer, PharmD, PhD, a professor of pharmaceutical economics and head of the Department of Pharmaceutical Care and Health Systems, University of Minnesota College of Pharmacy, agrees. “Chains that are in one of these vertically integrated systems have guaranteed volume without competition on price,” he says. “The independents in those systems may have seen an even faster loss of volume out there. They could be shut out.”

Perry Cohen, CEO of The Pharmacy Group, says the potential merger of CVS-Aetna and the potential merger of Cigna-Express Scripts are examples of a growing trend: Companies responding to the need for new care models for healthcare services. “The marketplace needs new care models and wants to embrace these companies that get ahead of the curve,” says Cohen.

Cohen says current care models are “healthcare professional driven, expensive, and inefficient,” adding they are “not a sustainable model going forward.” That’s why some of the biggest players are changing their strategies, and he gave the following examples:

CVS is trying to become a total healthcare provider with the Aetna merger.

United Healthcare is using numerous strategies, including buying a large physician practice, DaVita Medical Group, for $4.9 billion through its OptumCare direct-to-patient healthcare subsidiary.

Amazon is acquiring PillPack, an online pharmacy that delivers medications in premade dose packaging. “Amazon has 100 million users in the United States. They are trying to get those 100 million to buy their prescription drugs through Amazon,” he says. 

New care models will leverage technology to allow most care to happen in the patient’s home with the aid of telehealth, mail, Amazon deliveries of dose packages, or small in-home dispensing kiosks that combine the medication with patient engagement through a WiFi connection to the pharmacy, Cohen predicts. He says when he talks about pharmacy careers with students, he explains there are now jobs that didn’t exist in the business 20 years ago, particularly involving managed care and mail order.

Blackburn expects to see more vertical mergers and acquisitions, like the CVS-Aetna and Cigna-Express Scripts deals, and horizontal mergers and acquisitions, like the failed attempt by supermarket chain Albertsons to buy Rite Aid and its EnvisionRX PBM business. That proposed $24 billion deal collapsed in August because it was opposed by shareholders.

“The horizontal is being driven a lot by the reimbursement pressure,” Blackburn said. “The vertical is much more strategic around the control of the overall person’s healthcare.”

While the Rite Aid and Albertsons deal may have fallen apart, Blackburn expects that what is left of Rite Aid may eventually be absorbed by another chain. After attempts to sell its stores to Walgreens were stopped in June 2017 by federal antitrust issues, Rite Aid later transferred 1,932 stores and three distribution centers to Walgreens in March for about $4.4 billion

“From a government perspective, there are many, many pharmacies out there. Every Walmart, Target, Kroger’s, they all have pharmacies,” Blackburn says.

Other companies are making deals as well, like Fred’s Inc., which operates approximately 600 general merchandise and pharmacy stores, including 13 franchised locations. The company scrambled after its plan to become the third-largest drug store chain by buying 865 Rite-Aid stores, as part of the original Walgreens-Rite Aid deal that was scrapped.

Since then, Fred’s has been selling off pieces of the company. In June, it closed on a $40 million deal to sell assets from its specialty pharmacy unit to Advanced Care Scripts Inc. an affiliate of CVS Health. On September 10, Fred’s agreed to sell patient prescription files and pharmacy inventory of 185 stores in 10 Southeastern states to Walgreens for $165 million plus an amount equal to the value of the related pharmacy inventory.

Fred’s will continue to operate 162 pharmacies, but the company announced 80 layoffs and it’s unclear how many pharmacy jobs Walgreens will pick up.

Mayer, Cohen, and Schondelmeyer are members of the 

Articles

How Mergers Will Affect Pharmacists

Last year, generic drugs generated $265 billion in savings in the United States, with $6.06 as the average patient copay for a generic prescription. “The Generic Access and Savings Report in the United States 2018,” 

 by the Association for Accessible Medicines (AAM), found that 90% of generic prescriptions are filled at $20 or less and that generics account for nine out of every ten prescriptions filled in 2017.

“It’s absolutely spot on,” says Robert Frankil, RPh, president and owner of Sellersville Pharmacy, Inc., in Sellersville, PA. “Generics, for the most part, 19 out of 20 times, are going to deliver a quality product and savings to the consumer and the insurance company.”

Related article: Why Health Systems Are Making Their Own Generics

Savings for Medicare amounted to $82.7 billion, or $1,952 per enrollee.

Savings for Medicaid was $40.6 billion, or $568 per enrollee.

Medicines used by older adults (ages 40 to 64 years old) and seniors accounted for 80% of the $265 billion savings generated.

The average state saved $5.2 billion in 2017, ranging from $354 million in Alaska to $23.4 billion in California.

Brand name drugs represent only 10% of prescriptions, but 77% of drug spending.

The top 10 generic drugs ranked by savings are: atorvastatin (Lipitor); ondansetron (Zofran); omeprazole (Prilosec); gabapentin (Neurontin); simvastatin (Zocor); rosuvastatin (Crestor); amlodipine (Norvasc); aripiprazole (Abilify); montelukast (Singulair); and quetiapine (Seroquel).

For the first time, the study breaks down total savings by patient condition. Patients with mental illness saved the most through generics-$48.4 billion-followed by patients with heart conditions ($47.6 billion); epilepsy ($17.3 billion); cancer ($10.1 billion); and diabetes ($7.8 billion). The tenth edition of the AAM report was produced by the IQVIA Institute for Human Data Science.

Craig Burton, AAM vice president of policy, says there were no surprises about the impact of generics. “It really reiterates the value proposition. It is putting numbers to what people intuitively know about the value of generics,” he told Drug Topics.

While not a surprise due to the consolidation in the buying consortia, which has three main companies controlling 90% of the market, Burton says the report clearly showed price deflation.

“On the one hand, you have significant market penetration with 90% of all prescriptions filled by generics. Patients are benefitting. Payers are benefitting. Yet at the same time you have a historically high rate of price deflation on generics,” Burton says. “We’ve always had that. It’s the nature of the generic industry. But the trends we see over the last two years have been almost two years of solid, sustained, and steep price deflation.”

Frankil agrees, noting, “It used to be generics across the board were more profitable for pharmacies to dispense and that is being squashed down quite a bit. Sometimes I can actually make more money selling a brand drug.”

“I never would have dreamed 10 years ago that we’d be getting so much downward pressure on generics,” he adds.

In addition to market imbalance, the report, which also examines the biosimilars market, describes what it calls “anticompetitive abuses.”

“Some brand manufacturers are gaming regulations to attain unwarranted extensions of the market monopolies by keeping generic and biosimiliar competitors from developing and introducing lower-cost medicines,” the report states.

Related article: Why Generic Drug Prices Are Dropping

It also calls out federal and state lawmakers for not understanding differences between the generic and brand business models and enacting one-size-fits-all legislation and regulations that have “unintended and harmful outcomes.”

Burton says barriers need to be removed so more manufacturers can get into the market, adding that is also affecting the biosimilars market.

“The FDA has been making great progress in terms of approval. Today there are 11 approved biosimilars, which is great, but only three are on the market,” he says. 

The annual report on generic access and savings shows some impressive numbers for 2017.

A Look at the Year in Generics

Whether working in a hospital, specialty, or retail pharmacy, pharmacists will tell you special considerations are needed when dealing with children and infants. Pharmacists must contend with challenges like weight-based dosing calculations, metabolic differences, adverse reactions, and the use of off-label medications and compounds. Combine those concerns with the fact that many patients are too young to communicate about how medications are affecting them, and you have a recipe for potential errors.

A study on pediatric medication safety in emergency departments, published in 

 in March, notes the ED presents a high risk for medication errors including problems caused by a lack of standardized pediatric drug dosing and formulations, lack of clinical pharmacists, and weight-based dosing. For patients outside the hospital setting, medication errors can happen because of confusing product packaging or use of the wrong dosing tools.

“It’s definitely a challenge,” says Anita Siu, PharmD, BCPPS, of weight-based dosing issues. She is a clinical associate professor at the 

, Rutgers University, and a clinical neonatal/pediatric pharmacotherapy specialist at Jersey Shore University Medical Center. “You’re not going to treat a neonate within the first days of life the same way as we treat an infant or give the same doses as a child. Whether it’s younger children or older children, there is a lot of weight variation,” she says.

Drugs can be metabolized at different rates between pediatric and adult populations and within pediatric age ranges. Younger children, who weigh less, may metabolize certain medications faster so they might need a dose three times a day rather than twice as for adults. Body water volume impacts medication distribution and pharmacodynamics affects it, too. “Young kids are basically bags or buckets of water,” says Siu. “Because they have a larger volume of distribution, based on weight, we may need to give them more medicine.”

Related article: Pediatric Pharmacogenomics Offers Treatment Insights

This is often the case with neonates. For example, they may need more gentamicin than older patients, says Susan Warrington, PharmD, BCPPS, clinical pharmacy specialist at the 

Capturing and documenting patient weight accurately and converting pounds to kilograms is crucial because dosages are based on kilograms. If a parent says a child weighs 22 pounds but the weight is recorded as 22 kg, the child could get 2.2 times the dose he or she should be getting, Siu says. The Joint Commission recommends all pediatric hospital patients be weighed in kilograms at admission and within four hours of an emergency situation.

Siu asserts that clinicians should always write the weight on prescriptions and pharmacists should double check the calculations.

Warrington, who does clinical rounds as part of the hospital’s medical team, says she and her colleague, Kristin Held Wheatley, PharmD, BCOP, are able to assess how patients are handling medications and make modifications. Warrington says they also look at polypharmacy issues to “make sure every medication on the list is truly needed” and avoid therapeutic duplication.

Wheatley, a clinical pharmacy specialist in pediatric oncology and infectious diseases, says she often asks if a patient needs to receive a medication by IV or recommends an IV if an oral medicine nauseates the patient.

Another challenge is dealing with off-label medications that haven’t been studied for effectiveness in children. A 2014 statement from the American Academy of Pediatrics (AAP) noted that use of off-label drugs “remains an important public health issue, especially for infants, young children, and children with rare diseases.” AAP noted pediatric labeling information exists in less than 50% of products.

Wheatley says that, at Lehigh, they “use the best data available” and “make the best judgment as to best safely use the medication.”

 Skywalk Pharmacy is an independent community pharmacy that provides specialty pharmacy services for pediatric patients at four locations in Wisconsin. Many of its patients require compounding services for commercially available medications that are dosed, formulated, or FDA-approved only for adults, says Steven Finkenbinder, PharmD, AE-C, manager of clinical pharmacy services.

Making tablets and capsules into pleasantly flavored liquids for children who can’t swallow solid dosage forms.

Creating liquids compatible with enteral tubes or creating topical creams that are not otherwise available.

Creating capsules with the pediatric dose of medication.

Compounding sugar-free suspensions for neurology patients on a ketogenic diet or medications with no dyes and excipients for patients with allergies.

For example, ciprofloxacin liquid is labeled for oral use only, and is thick and can clog enteral or nasogastric tubes. Skywalk compounds ciprofloxacin in a formulation compatible with enteral tubes, Finkenbinder says. They also create gelatin capsules for oncology patients and educate them on how to encapsulate bad-tasting tablets, such as prednisone, to make them more tolerable.

Related article: Pediatric Asthma: An Update for Pharmacists

Finkenbinder emphasized the need for standardization of concentrations for compounded pediatric liquids.

He says Skywalk uses the same manufacturer for liquid compounds with narrow therapeutic windows, such as tacrolimus. Switching manufacturers of these medications can result in variations in blood levels, which could in extreme circumstances result in organ rejection. Skywalk is encouraging health systems to adopt programs like the 

Michigan Pediatric Safety Collaboration guidelines

, an initiative to standardize compounded liquid concentrations for pediatric patients. ASHP has also created an initiative called 

 to reduce errors associated with varying concentrations of compounded medications.

Children need to be watched closely for adverse drug reactions. A British study found at least one in 500 children will experience adverse drug reactions each year; and one in ten for hospitalized youngsters. Siu says children may be more vulnerable to different adverse reactions than adults.

Transitioning care and educating caregivers is a key role for all pharmacists. “Discharge can be overwhelming, particularly for the more chronically ill or complex pediatric patient,” says Warrington, adding that Lehigh Valley Health Network emphasizes creating a partnership with retail pharmacies and outpatient clinics.

Pharmacists may do all they can to ensure patients receive the appropriate medications, but caregivers can make errors. For Finkenbinder, education is a big part of ensuring caregivers understand how to administer medication appropriately. He uses demonstration bottles to show caregivers how to use syringe adapters to remove a dose from the bottle and how to properly measure the dose in milliliters.

Many pediatric patients need doses that require a medication patch be cut into smaller pieces, he says. If a patient needs portions of a patch, he demonstrates how to cut and properly apply the patch. He educates on the proper way to dissolve hazardous medications such as methotrexate to reduce exposure to parents or caregivers.

With education, “it’s important to go the extra mile and ask open-ended questions,” he says. 

The smallest patients can sometimes present the biggest issues.

Pediatric Problems, and How Pharmacists Can Solve Them

If you are struggling to engage and motivate your pharmacy technicians, making some small changes can help. Here are some tips.

Shane P. Desselle, RPh, PhD, FAPhA, professor at 

Touro University California College of Pharmacy

 in Vallejo, CA, says it’s important for pharmacists to “provide an organizational climate that allows for technicians to mentor one another, in addition to the pharmacist mentoring them.”

Related article: Standardization a Pressing Issue for Pharmacy Technicians

Desselle says mentoring gives the senior technicians pride and accomplishment and the desire to remain with the organization. At the same time, it allows the junior technician to learn more than just technical responsibilities, such as customer service, organization norms, and attitudes. Desselle is editor of 

Research in Social and Administrative Pharmacy

Pharmacy Management: Essentials for All Practice Settings

Pharmacy technicians want more responsibility and one of the most important things a pharmacist can do is “delegate any and every responsibility procedures that they are legally accorded to do. I can’t overstate the importance of that,” Desselle says.

Tiffany Bartlett, CPhT, CSPT, agrees. She has been a certified pharmacy technician for more than 20 years and a specialty pharmacy technician at 

 in Spring, TX, for almost three years. “I think there are many responsibilities that can be delegated to the technician, such as insurance specialist, educator, medication therapy management, and quality control. With each new opportunity, each role should be evaluated and minimum guidelines should be established relating to educational requirements and work experience in order to choose the right candidate for the position,” says Bartlett. “Pharmacy technicians are anxious to break out of their traditional roles in retail and hospital and use their skills and knowledge to practice in exciting new opportunities.”

Kilee Yarosh, RPh, MBA, market pharmacy director, Turnbull Memorial Hospital, Northside Medical Center, Hillside Rehabilitation Hospital, and Steward Family Hospital in Ohio, notes that technicians have more opportunities to expand their roles.

“As we continue to see the practice of pharmacy transform, it will be integral to our profession’s success that we indeed work hand-in-hand with our technician workforce to ensure adequate training, credentialing, and support to provide the best care possible to our patients, regardless of practice setting,” Yarosh says.

She recalls working with a technician who came into the field with a business background.

“Over the course of several years, I had the opportunity to work with this technician and help develop their skills, especially in the area of informatics. This tech had an opportunity recently to become a team lead for an informatics group.”

Bartlett, who has a national specialty certification in sterile compounding from the Pharmacy Technician Certification Board, creates continuing education content for the approximately 180 pharmacy technicians at the cancer center. She often seeks advice from clinical pharmacists on her team to troubleshoot problems within an online training module or receive constructive feedback on the best way to present a real-life scenario to trainees.

Related article: The Future of Pharm Techs

“On the other hand, the same clinical pharmacists on my team will seek advice from me on real-life scenarios experienced by technicians working in the clean room. Moreover, they may ask questions regarding inpatient work flow improvement options and gain insight from my work experience on preparing a patient-specific sterile compound,” Bartlett says.

Yarosh says that providing transparent feedback to technicians is one way to help them improve their job performance. Pharmacists should also set clear expectations, have goal-setting discussions, and “provide projects that capitalize on their strengths but also push their comfort zone,” he says.