America`s Pharmacist — May 2010

Transcription

america’s
Published by the
National Community
Pharmacists Association
PHARMACIST
MAY 2010
THE VOICE OF THE COMMUNITY PHARMACIST
The Key to Is
Prosperity
Specialty
OTC PROFIT PEARLS •
WEATHERING THE STORM •
STRATEGIC MANAGEMENT •
www.americaspharmacist.net
america’s
PHARMACIST
CONTENTS
THE VOICE OF THE COMMUNITY PHARMACIST
Features
From the Cover
Special Section: Profit Pearls
14 T he Key to Prosperity Is Specialty
y Jon Kaup and Johnathan Hamrick b
Virginia’s Prosperity Specialty Pharmacy sets
itself apart with multiple programs and a patient
centered approach
18 O
TCs for Fun and Profit
by Beverly Schaefer, RPh
22 W
eathering the Storm of
Industry Changes
by Chris Linville
Despite taking some hits, a rock solid foundation
lets Condo Pharmacy meet business challenges.
30 S trategic IT Management y Todd Eury
b
How independent pharmacy can leverage data
to improve outcomes.
Departments
4 U
p Front
by Joseph H. Harmison, PD
More student competitors needed.
18
6
Newswire
B
ruce Roberts leaving NCPA after eight years
at the helm.
7
America’s Pharmacist Volume 132, No. 5 (ISSN 1093-5401, USPS 535410) is published monthly by the National Community Pharmacists Association; 100 Daingerfield Road, Alexandria, VA 22314. © 2010 NCPA®.
All rights reserved.
Postmaster—Send address changes to: America’s Pharmacist, Circulation
Dept., 100 Daingerfield Road, Alexandria, VA 22314; 703-683-8200; info@
ncpanet.org. Periodical postage paid at Alexandria, VA, and other mailing
offices. Printed in the USA.
The Audit Advisor
W
hat’s the difference between the Red Flag
Rule and PCI compliance?
8
Inside Third Party
Eye on PBMs
For membership information, go to [email protected]. For other
information go to www.ncpanet.org.
america’s
Pharmacist | May 2010
Cover: Fairfax, Virginia-based Prosperity Pharmacy has set itself
apart and enhanced its bottom line with multiple programs and a
patient-centered approach. (Artwork by JLP/ Deimos.)
10
Foundation Report
b y Deleisa Johnson
NCPA student business plan competition
renamed.
12
Medication Safety
N
ew oral liquid iron concentration not well known.
37 C
ontinuing Education
by Marlowe Djuric Kachlic, PharmD
N
on-prescription self-treatment of GERD.
52
Pharmacy Law
by Jeffrey S. Baird, Esq.
Medicare’s overpayment hunters.
53
Pharmacy Management
by Andy Oaks
Exceeding customer expectations.
55 R
eader Resources
30
56
Notes From Capitol Hill
Letters to the Editor— If you would like to comment on
by Michael F. Conlan
When the legislator is at home, share an article, e-mail NCPA at info.ncpanet.org. Put AP in the subject line and include your phone number. Your letter may be
posted on the NCPA Web site and edited for length and clarity.
NCPA activities and our advertisers.
your views.
Executive Vice President and CEO Bruce T. Roberts
Director, Membership Colleen Agan, [email protected]
NCPA Officers
President Joseph H. Harmison
President-Elect Robert Greenwood
Secretary-Treasurer DeAnn Mullins
First Vice President David Smith
Second Vice President Bill Osborn
Third Vice President Brian Caswell
Fourth Vice President Michele Belcher
Fifth Vice President Hugh Chancy
Executive Committee
Chairman Lonny Wilson
Committee Members Donnie Calhoun, John Sherrer, Bradley Arthur,
Mark Riley, Keith Hodges
Magazine Staff
Editor and VP, Publications Michael F. Conlan, [email protected]
Managing Editor Chris Linville
Contributing Writers Jeffrey S. Baird, Bill G. Felkey, Mark Jacobs,
Deleisa Johnson, Bob Owens, Andy Oaks, Bruce Kneeland
Senior Director, Design & Production Enjua M. Claude
Senior Designer Sarah S. Diab
Director, Sales & Marketing Nina Dadgar, [email protected]
Account Manager Robert Reed, [email protected]
The National Community Pharmacists Association
(NCPA®) represents America’s community pharmacists, including the owners of more than 22,700
independent community pharmacies, pharmacy franchises, and chains.
Together they represent an $88 billion health care marketplace, employ
more than 65,000 pharmacists, and dispense some 40 percent of all
retail prescriptions. Visit the NCPA Web site at www.ncpanet.org.
America’s Pharmacist annual subscription rates: $50 domestic; $70 foreign; and $15 NCPA members, deducted from annual dues.
Ask Your Family Pharmacist®
May 2010 | america’s Pharmacist
Up front
More Student Competitors Needed
Last month I was pleasantly
reminded of what a great success
the NCPA Pruitt-Schutte Student
Business Plan Competition was with
an article in the April issue of this
magazine. I want to salute again
the 2009 winning team from the
University of Washington College
of Pharmacy—Dana Ling (captain), Alisha Fewins, Zsolt
Hepp, and Rachel Merrill, and advisers Jackie Gardner
and Don Downing. (A tip of that hat also to the University
of Arizona and the University of Georgia, which finished
second and third, respectively.)
But what really caught my eye was an accompanying article by Pat Epple, executive director of
the Pennsylvania Pharmacists Association. It was a
wonderful example of turning a disappointment into a
positive. Although nearly one-third of all U.S. pharmacy
schools competed in the NCPA competition, Pat and
her independent owner colleagues at PPA were disappointed that more of Pennsylvania’s seven schools of
pharmacy did not enter what is now the Good Neighbor Pharmacy NCPA Pruitt-Schutte Student Business
Plan Competition.
But instead of stewing about it, PPA’s Independent
Pharmacy Task Force, chaired by Larry Doud, CEO of
the independent pharmacy wholesaler Rochester Drug
Cooperative, believed that a smaller statewide competition with simpler requirements might still spark interest in
ownership and could be an important stepping stone to
ultimately participating in NCPA’s competition.
What a great idea. The task force, along with PPA’s
Academy of Community Pharmacists and the Special Interest Group of Independent Owners, moved from concept
to reality with the Achieving Independence competition.
It’s a competition for Pennsylvania student teams to
create posters that reflect the team’s concept for purchasing an existing pharmacy. There is an emphasis on
creative ideas that will enable this pharmacy to stand out
america’s
and thrive in the marketplace, while still ensuring an element of reality.
Each team has been provided with a
pharmacy scenario, based on an actual Pennsylvania pharmacy, and is expected to change/
update/design this pharmacy into an innovative
community practice. The judging will take place
at PPA’s Annual Conference in October.
I hope this competition is a success, and I
challenge other state associations to undertake
projects to engage pharmacy students in the
wonders and realities of independent pharmacy
ownership. (If you already are, my apologies. I’d
love to hear about them.)
I’d also like to challenge the schools of
pharmacy to encourage more participation in
the annual Good Neighbor Pharmacy NCPA
Pruitt-Schutte Student Business Plan Competition. Last October marked our sixth competition, but two-thirds of the nation’s pharmacy
schools did not enter a team.
We can do better than this. This competition is going to be around for a long time—in
perpetuity we believe thanks to a $750,000
multi-year pledge from AmerisourceBergen’s
Good Neighbor Pharmacy network. That moved
the NCPA Foundation to its goal of at least a $1
million endowment. Thank you one and all and
keep up the good ideas.
Joseph H. Harmison, PD
NCPA President 2009–10
Newswire
Bruce Roberts Leaving NCPA After
Eight Years at the Helm
Bruce T. Roberts, RPh,
NCPA executive vice
president and CEO
since 2002, will step
down June 25.
“I’m proud to have led
a team that has done so
much to make community pharmacy a political
powerhouse in Washington, D.C.,” Roberts said.
“Our members need and
deserve this type of political clout. The stronger
voice we’ve developed
for NCPA in the political
arena is producing policies that help local pharmacists continue to care
for their patients.
“With NCPA on solid
footing and well positioned to do great things
in the coming years, I
have decided it’s time
for me to move on to the
next chapter. I’m joining
BeneCard PBF, a transparent alternative to the
traditional PBM model,
as president and CEO.”
The Executive Committee has begun its
search for a new executive to lead the association going forward. Doug
Hoey, RPh, NCPA senior
vice president and COO,
will serve as acting executive vice president during
the search process.
“I want to thank
the members of NCPA
and its fabulous and
dedicated staff for all
the support, opportunities, and successes
they have given me over
the years and the many
kindnesses they have
shown me and my family,” Roberts said. “They
will not be forgotten.”
“Bruce’s vision and
passion for independent
community pharmacy
have greatly benefitted
NCPA members and
we deeply appreciate
his service,” said
➥
E-Prescribing Up Sharply in 2009,
Nearing 200 Million Scripts
The number of prescriptions routed electronically soared
building the network and the ecosystem to support it—
from 68 million in 2008 to 191 million last year, according
provides a definitive road map for how to drive adoption
to Surescripts, a jump of 181 percent.
of a broader electronic health record for all Americans.
By the end of 2009 approximately 18
percent of eligible prescriptions were prescribed
Prescriptions Routed Electronically
electronically compared with just 6.6 percent the
previous year. One in four office-based physicians
=Prescription Renewal Responses
35 million
=New Prescriptions
is now an e-prescriber, Surescripts, the nation’s
largest e-prescribing network, also reported.
181%
“For e-prescription use to jump from
6 to 18 percent in one year indicates several
things,” said Harry Totonis, president and CEO
13 million
of Surescripts, based in Alexandria, Virginia.
130%
“First, that the federal government’s leadership
5 million
and incentive structures are working. Second,
that the benefits of e-prescribing—including
24 million
55 million
156 million
increased safety, lower costs, and increased ef2007
2008
2009
ficiency—are widely understood. And last, that
•36,000
•74,000
•156,000
Active
Prescribers
the nation’s experience with e-prescribing—in
Connected Pharmacies
america’s
•41,000
•46,000
•53,000
➥ NCPA President Joseph H.
Harmison, PD, and Executive Committee Chairman Lonny Wilson, PD.
“On behalf of NCPA’s Executive
Committee and many others we
wish him all the best at Benecard
PBF, a prescription benefits facilitator. We know that he will continue
to be an energetic advocate for
NCPA members and for a transparent, pro-pharmacist approach to
pharmacy benefits management.”
NCPA Annual Report
Just Clicks Away
The NCPA 2009 Annual Report
provides a year in review of NCPA,
including our strategic goals and
special reports on legislative affairs, Community CCRx, student
chapters, and more. The 2009
report is now available online.
Non-Adherence Puzzler:
Why So Many Unfills?
More than 20 percent of prescriptions written for 75,000 Massachusetts patients over the course of
a year went unfilled, according to
findings in the Journal of General
Internal Medicine. The “unfilled” rate
was 28 percent for first time prescriptions and 22 percent overall.
Why many patients did not fill
their prescriptions was not determined by the study. All of the
patients had health insurance.
Louisiana Independent
Pharmacies Association
Members Sign Up
With NCPA
NCPA welcomes all of the member
pharmacies of the Louisiana Indewww.americaspharmacist.net
THE AUDIT ADVISOR
Red Flags Rule vs. PCI Compliance
Q: What’s the difference between the Red Flag Rule and PCI Compliance?
A: The “Red Flags” Rule is a written protocol that identifies and detects
possibilities of identity theft for businesses that offer deferred payment
through multiple transactions (such as first party charge accounts).
Procedures indicating how the pharmacy will prevent and reduce
those red flags need to be designed. Updating your program periodically
will enable you to stay current with the most relevant information and
changes. For a do-it-yourself program, go to: http://www.ftc.gov/bcp/edu/
microsites/redflagsrule/RedFlags_forLowRiskBusinesses.pdf
Originally set to be enforced last November, the Federal Trade Commission has delayed enforcement of the rule until June 1 for financial
institutions and creditors subject to enforcement by the FTC. For more
information about this rule please go to: http://ftc.gov/redflagsrule
PCI Compliance is a standard to prevent credit card fraud and is a
necessity for any merchant that processes credit card transactions. The
PCI DSS (Payment Card Industry Data Security Standard) ensures that
all processing, storing, and transmitting of credit card information is
being maintained in a secure environment. Payment card brands (such as
Visa and MasterCard) are responsible for enforcing compliance. At this
point, the federal government has no regulations in place, but various
states have some regulations alluding to PCI Compliance. Full compliance is necessary by July 1, 2010.
For information on the standards necessary for PCI Compliance, see
https://www.pcisecuritystandards.org/security_standards/pci_dss.shtml
By Deb Saeger CPhT, PAAS National the Pharmacy Audit Assistance Service.
For more information call 888-870-7227.
pendent Pharmacies Association as
members of NCPA. They joined en
masse in February. LIPA is devoted
to delivering quality information concerning issues affecting Louisiana
community pharmacists and advocating on behalf of the issues that
are a priority to their membership.
“We are excited to welcome
the members of the Louisiana
Independent Pharmacies Association and look forward to working
with them as active members of
the association” said Bruce T.
Roberts, RPh, NCPA executive vice
president and CEO.
Independent
Pharmacy
Today
Front-end sales accounted for
6.7% of total sales.
Products offered included:
• Greeting cards —78%
• Gifts—56%
• Seasonal merchandise—55%
• Diabetes food—38%
• Cosmetics—36%
Source: 2009 NCPA Digest,
sponsored by Cardinal Health
inside Third Party
E
ye on PBMs
E-mail your recent example of a problem you or a patient has had with
a PBM to [email protected], or fax it to 703-683-3619. We may
edit it for length and clarity.
Why Not Just Reduce the Price?
One of my patients received a “personalized” solicitation from her
PBM to “save 50% on prescription medications every month with the
half tablet program.” It included the promise of a reduced copay,
the offer of a free tablet splitter, and an invitation “to speak with a
member of our pharmacy team who can even facilitate a change in
your prescription.”
My concerns are the inaccuracy of the dose, the probable bad
taste, and possible decomposition of the tablet once cut.
Prompt Pay Undercut
By Some Part D Plans
NCPA has urged the Centers for
Medicare & Medicaid Services
to instruct Medicare Part D plan
providers to stop the “improper
and illegal imposition of extraneous fees and charges on Part D
network pharmacies” that have
been reported to NCPA since
new “prompt pay” provisions
took effect Jan. 1.
A recent letter from NCPA
states that many Part D plans
are “finding ways to charge
new fees to pharmacies, seemingly as a means of financially
recouping the loss from the
‘float’ they enjoyed from holding onto pharmacies’ money for
long periods.” NCPA member
pharmacies are reporting failures
to send necessary remittances,
claims reconciliation issues, new
prescription transaction fees,
electronic funds transfer fees,
failure to notify or honor electronic fund transfer options, and
america’s
requiring electronic remittances
for electronic fund transfers.
Trial Prescriptions
Dilemma: Less Waste,
More Work?
NCPA has expressed misgivings to
the Centers for Medicare & Medicaid Services over its suggestion to
provide Medicare Part D plans with
the authority to require dispensing
of less than a 30-day supply of a
prescription in an effort to reduce
pharmaceutical waste.
In comments on CMS’ 2011
“Call Letter,” NCPA cited operational concerns related to who
makes the ultimate determination
of partially filling a prescription,
making sure that appropriate
dispensing fees for each fill are
addressed, and that guidance
be provided to plans as to what
documentation would be required
for each trial fill, therefore avoiding
problems with audits.
“To make this potential policy
most effective, CMS may want to
focus on certain high cost drugs,
drugs that are known to have
a significant prevalence of side
effects, and certain controlled
substances,” NCPA said. “In general, generic drugs should not be
eligible for this policy.”
NCPA also noted that the
proposal seemingly ignores how
CMS will address waste in the
mail order setting, where one
study showed that mandatory mail
order plans create 3.3 times more
prescription drug waste than plans
that allow patients to choose their
own pharmacy.
Part D Plans Can’t
Switch Prescription
Locations at Will
Medicare Part D plans now must
get express permission from the
beneficiary to switch their scripts
to another pharmacy or mail
order. The requirement from the
Centers for Medicare & Medicaid
Services took effect Feb. 1. It
was issued after NCPA submitted
comments strongly objecting to
PDPs switching patients to mail
order pharmacies.
In addition, CMS gave plans
the option to indicate that the
receiving pharmacy be contacted
instead of customer service when
a beneficiary wants to transfer
his/her prescription(s). The beneficiary may fax or mail the optional
permission form to the plan.
Foundation report
Student Business Plan Competition Renamed
By Deleisa Johnson
I
n recognition for the AmerisourceBergen Good
Neighbor Pharmacy network’s $750,000 multiyear pledge, the NCPA Foundation has renamed
its annual student business plan contest. The
new name is the Good Neighbor Pharmacy NCPA
Pruitt-Schutte Student Business Plan Competition.
As announced last October, GNP’s pledge ensured
the NCPA Foundation met its goal of raising $1 million by
2012 to support the competition in perpetuity and sustain
its long-term viability.
NCPA and the NCPA Foundation established the
NCPA Pruitt-Schutte Annual Student Business Plan
Competition in 2004 in an effort to promote interest in
independent community pharmacy ownership. The goal
of the competition is to motivate pharmacy students to
create the blueprint necessary for buying an existing
independent community pharmacy or developing a new
pharmacy. Named in honor of the late Neil Pruitt, Sr., and
the late H. Joseph Schutte, two pillars of the independent pharmacy community, the Student Business Plan
Competition is the first national contest of its kind in the
pharmacy profession.
“This competition helps pharmacy students understand the importance of having a solid business plan,”
said NCPA Executive Vice President and CEO Bruce T.
Roberts, RPh. “By giving them the chance to develop
and test their planning models and receive valuable
feedback from pharmacy professionals, we are able to
better prepare tomorrow’s pharmacy entrepreneurs for
the future. In the short time since we began the competition, several competition participants have gone on to
successfully implement these plans after graduating from
pharmacy school.”
The top three finalists in the 2010 competition will
make their live presentations at NCPA’s 112th Annual
Convention Oct. 23–27 in Philadelphia.
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The competition is also supported by the
Pharmacists Mutual Insurance Company.
Wheels for Scholars: Give for a Chance to Drive
From now until Aug. 1, the first 2,011 people
who make a $100 tax-deductible contribution
to the NCPA Foundations’ Wheels for Scholars
campaign will be eligible for the award of a
2011 Chevrolet Equinox 2LT SUV (MSRP:
$29,567 estimate).
The award will be announced during the 112th
NCPA Annual Convention, in Philadelphia, Oct.
23–27. You need not be present.
The Wheels for Scholars campaign is
designed to increase the number of scholarships the NCPA Foundation awards to students interested in independent pharmacy
ownership, and to support other aspects of
the NCPA Foundation’s mission to advance
independent community pharmacy and the
public it serves through:
• Critical research and education to improve
Preserving the Legacy of
Independent Pharmacy is the mission
of the NCPA Foundation—a nonprofit, philanthropic 501(c)(3) organization. There is no
other foundation in the U.S. solely dedicated
to supporting independent pharmacy owners
and entrepreneurs and the public they serve
through research, education, disaster relief,
and student outreach.
itc century font used
for tagline
Give today—by mail or online— and your
tax-deductible, charitable donation will help
continue the NCPA Foundation’s mission
of “preserving the legacy of independent
pharmacy.” The NCPA Foundation can accept both company and personal donations
for any amount.
the success of independent pharmacies and improve
patient health outcomes
• The distribution of low-interest educational loans to
pharmacy students
•Helping communities by developing and distributing
community pharmacy-based health care prevention
and awareness programs
• The provision of financial assistance to independent
pharmacy owners for their recovery in the event of
disaster, accidents, illness, or adverse circumstances
• The development of programs and resources to stimulate pharmacy ownership, management and entrepreneurism in pharmacy
To donate to the Wheels for Scholars campaign and/or
to read the official rules for the campaign, visit the NCPA
Foundation Web site at www.ncpafoundation.org.
Deleisa Johnson is a freelance writer. She resides in Tyler, Texas.
MEDICATION SAFETY
New Oral Liquid Iron Concentration Not Well Known
P
Pharmacists and parents need to be
aware of a change made to Mead
Johnson Nutritionals’ oral liquid iron
supplement drops. The product,
FER-IN-SOL (ferrous sulfate drops),
has undergone a change in concentration.
In the past, the product contained 15 mg
of elemental iron per 0.6 mL (25 mg/mL). The
enclosed dropper for measuring doses had
marks at 0.3 mL for 7.5 mg of elemental iron
and 0.6 mL for 15 mg of elemental iron. The
strength was changed to conform to the standard concentration available in countries outside
the United States.
The new concentration is 15 mg of elemental
iron per mL (about 40 percent less elemental
iron per mL than the original formulation), which
is mentioned on the front label panel of the
carton. The enclosed dropper is now marked at
0.5 mL for a 7.5 mg of elemental iron dose and
1 mL for a 15 mg of elemental iron dose.
Many practitioners are unaware of this
change—a problem compounded by the fact
that iron drops made by other manufacturers remain available in the 15 mg per 0.6 mL
concentration. Also, the new concentration may
not be listed on pharmacy Web sites and drug
indexes, or even in drug information references.
Old and new packages are identical except for
a brief note about the changed concentration on
the new box. The NDC number and barcode are
also identical.
Because dosing errors with iron can be serious, practitioners must be aware of this change.
They should verify the concentration of iron in
the product being dispensed and administered,
and verify the volume needed to provide the intended dose. Consider storing iron supplements
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behind the pharmacy counter and require a pharmacist to
provide counseling regarding dosing instructions.
If this is not possible, place products near the pharmacy checkout in plain view of the pharmacist to capture an
important counseling opportunity. At minimum, use “shelftalkers” near these products that instruct patients to ask for
a pharmacist’s help when selecting iron supplements.
Parents should be educated if they will be purchasing
the over-the-counter product. Also, prescribers should write
the dose in milligrams (mg), ideally in mg of elemental iron.
Any prescription written in terms of volume alone
should be verified, as parents may be using measuring
devices other than the dropper that came with the bottle.
Generic manufacturers told us they are not planning to
change to a 15 mg/mL concentration, although such a
change may occur later.
Safety cap that won’t protect kids
The Consumer Product Safety Commission requires that
oral prescription drugs be dispensed in child-resistant
packaging unless the drug is exempted or the patient or
prescriber requests otherwise. But what about dual purpose caps that can be used as either a child-resistant cap
or “flipped over” to be used as a non child-resistant cap?
While these caps meet the requirements set in the
Poison Prevention Packaging Act, the CPSC discourages
their use. We agree. These caps can still result in child
poisoning if the non-resistant side is used.
Moreover, their use may actually increase the risk of
poisoning, as adults who previously never had problems
opening a child-resistant cap may now be using these
caps. You can learn more about the PPPA on the CPSC
Web site at www.cpsc.gov/BUSINFO/pppainfo.html.
This article is from the Institute for Safe Medication Practices (ISMP).
Errors, near misses, or hazardous conditions may be reported on the
ISMP (www.ismp.org) Web site. ISMP can be reached at 215-947-7797
or [email protected].
JLP/ Deimos
The Key to Prosperity Specialty
Is
By Jon Kaup and Johnathan Hamrick
14
america’s
pr
o
fit
pe
ar
ls
Virginia’s Prosperity
Specialty Pharmacy
sets itself apart with
multiple programs and
a patient-centered
approach
U
pon walking into Frank and Lisa Odeh’s Prosperity Specialty Pharmacy, you know right away that
you are not entering any ordinary pharmacy. You are
not greeted by aisles of OTC merchandise, but instead
you walk into a home-like waiting area where you are
greeted with friendly and smiling faces.
Frank Odeh graduated with a BS in pharmacy
from St. John’s University in New York, and worked
for more than eight years for a retail chain pharmacy.
His career in specialty pharmacy started at Grubb’s
Pharmacy in Washington D.C., where he focused on
HIV/AIDs. His wife Lisa received her BS in pharmacy
from Duquesne University in Pittsburgh. Like her
husband, Lisa spent several years working for a retail
chain pharmacy and later started working at Leesburg
Pharmacy in Leesburg, Virginia.
Frank and Lisa decided that they wanted to own
their own pharmacy where they could build patient
relationships and a unique level of care and services.
In 2003, they opened Prosperity Pharmacy in Fairfax,
Virginia, with only one additional employee. Frank
was in charge of marketing, where he reached out to
local clinics and physicians to build relationships and
to get the word out about their pharmacy. Meanwhile,
Lisa served as the sole pharmacist working with only
one technician. With time their business grew and they
began to pursue opportunities to specialize and further
expand their business. In 2005, they opened Prosperity
Outpatient Pharmacy in Inova Fairfax Hospital, serving
newly discharged hospital patients and hospital employees. By 2007, their specialty services had expanded to
the point that they decided to open Prosperity Specialty
Pharmacy to allow for growth and better patient care.
In 2009, Frank and Lisa opened Prosperity Pharmacy
Manassas, which in addition to being a community
pharmacy, also serves as their DME center.
Today Frank and Lisa employ more than 50
employees, including 13 pharmacists, 20 pharmacy
technicians, a fertility nurse specialist, four full-time
and one part-time sales representatives, a two-person
billing department, and a human resource officer. Their
pharmacies offer a variety of specialties that service not
only their community but also patients up and down
the East Coast.
How Did They Do It?
According to Frank, “The first step should be to conduct the necessary market research to understand the
services potential patients need and decide how to
deliver this to them in a timely, professional manner.”
In the beginning, fertility was Prosperity’s main focus
and since then, Frank and Lisa have grown their business by developing other specialties. Prior to entering
the fertility business, Frank knew that he was located
in a prime market area. Fairfax, Virginia, is part of the
Washington D.C., metropolitan area and has a concentration of young professionals that often wait until later
in life to start a family. In some circumstances, couples
need help conveiving, and there were already numerous
fertility clinics in the surrounding area. This is where
Frank started his marketing efforts, while Lisa managed
the pharmacy. They started slowly, using the one-on-one
approach with physicians and fertility clinics, letting
them know about the services that Prosperity offered.
This allowed them to develop a relationship with and
gain the trust of these physicians.
Frank also recommends taking the time to expand
education in the specific niche area. “The more you
know, the more equipped you will be to educate your
patients and the better off your business will be,” he
says. Frank and Lisa sought out ways to become more
educated about infertility, because it is an area that is
15
Another key to our success…
is that we do not simply have
numerous niches, but that we
are committed to
our patients having
the best possible care
and service needed.
not heavily emphasized in pharmacy school curriculums. It required a lot of self-learning. Their primary
mode of training was received directly from the nurses
and physicians at local infertility clinics. It was through
these techniques that Frank and Lisa were able to expand and grow their fertility niche. Once their business
was flourishing, they hired a fertility nurse specialist
to work in their pharmacy to aid in patient education.
Today Prosperity serves fertility patients from Maryland
to Florida.
Seeking Niches
After establishing their fertility niche, Frank and Lisa
began to look for other niches that were needed in their
area. As Prosperity was centrally located to oncology
centers and a transplant hospital, they took advantage
of the opportunity to expand into these areas. Since
then, Prosperity has branched out into other specialty
areas, including compounding, rheumatoid arthritis,
HIV, hepatitis C, Crohn’s disease, pain management, and
immunizations. Lisa said that one of the keys to their
success was targeting the patients in their area and educating the physicians on the services that they provide.
It’s more than just a niche.
“Another key to our success,” Lisa says, “is that we do
not simply have numerous niches, but that we are committed to our patients having the best possible care and
16
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service needed. It’s going above and beyond for both the
patient and physician that makes the difference.” One
way this personal touch is added at Prosperity is by having a real person answer the phone. People typically get
annoyed by automated answering systems. At Prosperity,
this is not going to happen. Frank and Lisa believe that
this is a way to build patient relationships, and say that
they have received a significant number of compliments
because of this policy.
At Prosperity, Frank and Lisa implemented a
patient-centered care team where they provide extra services to help patients in their time of need. For example,
insurance issues can be confusing for patients and they
often do not know the options they have. Prosperity prides itself on being insurance advocates. Its staff
will help patients understand their coverage and work
closely with physician offices to make sure the necessary paperwork is completed and submitted correctly.
This includes providing customized forms for physician
offices to order prescriptions, and offering account coordinators for support. These account coordinators gather
all required information for prior authorizations from
the physicians and fill out required processing forms.
This process helps free up more time that can be focused
on patient care.
Promoting Adherence
Another program that Prosperity provides is a refill
reminder program. With many specialty medications,
timing is important and adherence is crucial to optimize
Specialty Pharmacy Tips for Success
1. Identify Opportunities. Start in a small area and find
local practitioners/specialists who could become potential areas for business. Find out what they need, and
then develop your business to fit those needs and service
that provider. Once the kinks are worked out, market the
services to other providers in the same specialty.
2. S tart Slow and Grow. It is normal in the beginning
to have limited staff working on these specialty
projects and you may have to do most of the initial
work yourself. When the volume picks up you can
afford to hire more help, and then you can train
them to do specific tasks according to your protocol.
If you know every part of the process it also allows
you to fix problems down the road. It is not unusual
patient care. Therefore, pharmacy staff makes phone
calls to patients five to seven days before their next refill.
These phone calls are not just simple reminders about the
refills; the staff person uses this time as an opportunity
to discuss any problems the patient may be experiencing. Many times, patients experience side effects or drug
interactions throughout therapy, and Prosperity provides
counseling for these patients. Prosperity also has counseling rooms available onsite to educate patients in a private
setting where they can have individual attention with a
health care professional. The specialists at Prosperity are
prepared for any questions a patient might have, and are
sometimes just an ear for a people experiencing difficulties in trying to understand their treatment.
Prosperity also offers injectable medication education and support to help patients feel more comfortable and at ease with preparing and injecting their
medications. They have private, comfortable injection
instruction rooms, where patients can learn at their
own pace how to prepare the materials and correctly
administer the medications. The patients meet one
on one with a trained nurse educator or pharmacist
who ensures that patients leave the pharmacy prepared
to administer their medications at home. Prosperity
also provides all needed syringes and medical supplies, including a sharps container for safe disposal of
for this type of business to start out slowly.
3. Marketing, Marketing, Marketing. Many practitioners do not know what you can provide for them.
It is important to visit these doctors and show them
the type of services you can offer. They will never use
your services unless they know about them.
4. Be Open to New Ideas. Pharmacy is always changing and the way you do business is evolving every
day. Be open to suggestions from your peers, colleagues, and customers. These insights can be what
eventually differentiate you from the competition.
5. Get Educated. In specialty pharmacy, concentrating
on different disease states is a crucial segment of
the business. Do your own research and look for
continuing education in areas in which you want to
specialize. It is important to understand every aspect
of a certain disease to counsel patients on the drug
delivery, dosing, and long-term effects.
used needles and other medical waste, and at no extra
charge to fertility patients.
On top of these services, Prosperity provides convenient delivery options. Patients can pick up at one of
Prosperity’s four locations or they can have it delivered,
often at no extra charge, to homes, work, doctor’s offices,
or wherever is convenient. For all of these reasons and
more, Frank and Lisa have earned the trust and respect
in their community for the services they provide.
Jon Kaup and Johnathan Hamrick are PharmD candidates and
fourth year student pharmacists at the Mercer University College
of Pharmacy and Health Sciences in Atlanta. They are scheduled to graduate this month.
Editor’s Note: “Profit Pearls” is an occasional series
of articles by pharmacy experts in various specialties, offering tips and advice for improving patient
care and creating a healthier bottom line. This
month focuses on specialty pharmacy and over the
counter opportunities.
Jose Luis Pelaez
Frank and Lisa Odeh, owner of Prosperity Specialty
Pharmacy in Fairfax, Virginia, offered several tips for
entering the specialty pharmacy arena.
17
OTCs for Fun
and
T
By Beverly Schaefer, RPh
ime and again, over–the–counter (OTC) products
and gift items are neglected by independent pharmacists
as a viable revenue generating part of the business. Most
independent pharmacists spend a majority of their time
behind the counter. However reviving this part of the store
is not as hard as you might think. It just takes an open
18
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mind and a little time. The following are a few ways OTCs
can become a fun and profitable aspect of your independent pharmacy.
Product Selection
Product selection is the key to success. There is usually
pr
o
fit
pe
ar
ls
limited room in a pharmacy, so stocking quality products is more important than having a large quantity of
products. A well-selected product should create interest
from your customer—something new, different or in the
news. Product selection research entails staying current
with health news trends (think “green”), and the changing
needs and interests of your customer base, Select items
that you use or can recommend based on some prior experience. The goal is to find items people didn’t know they
needed, but cannot leave your store without purchasing.
Teach your customers to expect the unexpected, and make
every trip to the pharmacy an adventure.
Private Label
The Non-Traditional Approach
To create new business opportunities, it is important to
capture your own customers first. Many independent pharmacies have specialties that bring a certain clientele through
the door. It is important to know your customers and offer
products that are related to their need. For example, if you
have a large hormone replacement therapy (HRT) patient
base, offering and educating them about OTC products that
would also help them cope with this stage of their life, and
is a great way to expand your niche. It does not matter what
your niche is, the key is to tailor your OTC area to the needs
of your patients and educate them about new products.
Traditional avenues for purchasing new products include
pharmacy tradeshows and wholesalers. Other venues for
finding new and unique products are trade shows unrelated to pharmacy and local vendors. Visiting tradeshows
unrelated to pharmacy can spark new retailing options by
exposing you to new products and offering the opportunity
to speak with other business owners about what works in
their stores. The use of local vendors is a great way for you
to not only support local businesses, but also allow you to
provide products that are local favorites. When selecting a
local vendor, be sure that the product is of high quality and
is useful, or creates value for your target customers.
Keep an Open Mind
Pharmacy is an ever changing field and your product line
should be as well. Seasonal changes are important, but new
products should be introduced throughout the year as well.
Part of having fun when selecting items is taking risks on
items you would not normally think are sold in pharmacies.
For example, choosing a product or product line that you or
an employee is excited about is a good way to create interest
in a new area of business. Talk to everybody about your new
products. Plant seeds in their brains about the possibilities for
future use of this product, even if they are not interested right
now. Another opportunity to learn is by listening to your customers. If a customer asks about a specific product, instead of
saying, “Sorry we do not carry that item,” do some research
and eventually you could find and supply that product on a
regular basis. If one customer finds a need for that product, it
is likely others will have that same need in your area.
Private label products are excellent promotional items.
They bear the logo of your pharmacy on their label, which
creates a connection with your customers. They will
associate these products with your pharmacy, and will
keep coming back for these items. This also gives you the
opportunity to recommend less expensive products with
higher profit margins instead of brand name items. Private
labeling can be done by a secondary company for a low fee.
It is crucial to research your state laws to make sure private
labeling is a legal option for your pharmacy.
Expand Your Niche
Marketing Makes Money
Your first line of marketing is your employees. Educate
them to make recommendations and suggestions about
specific products. When promoting specialty products, it
is important to display them at prime locations, such as on
the top shelf or at the check out counter. Do not overcrowd these areas with too many products. Instead, choose
a few that you really want to promote and rotate them in
and out occasionally to create variety. By making one additional OTC sale per day, your bottom line profits would
increase by approximately $1,000 per year. It’s much easier
than filling more prescriptions
Beverly Schaefer is the owner of Katterman's Sand Point Pharmacy
in Seattle. If you would like to comment on this article, e-mail
[email protected].
19
By Chris Linville
Press-republic
Michael Betts:
Despite taking some
hits, a rock solid
foundation lets Condo
Pharmacy meet
business challenges
▲ Condo Pharmacy has been a fixture in the Plattsburgh, New York,
community for more than 60 years. With a lifetime NCPA membership,
Steve Moore is helping continue the independent ownership legacy
created by his mother and late father.
22
america’s
the
Storm
steve moore
of industry changes
When the forces of
nature are unleashed,
finding a shelter with a solid foundation is critical.
For many independent pharmacies, the challenge has
been to maintain strength and composure with their
business even as storms (in the form of outside pressures)
constantly batter them.
Condo Pharmacy in upstate New York is certainly
no exception. Even in the face of an increasingly trying
environment, it has maintained a firm foothold in the
Plattsburgh community for more than 60 years, and has
an NCPA membership that doesn’t expire for another
40 years. The pharmacy’s strong underpinnings also allowed the family-owned business to persevere in the face
of a devastating loss.
Condo Pharmacy was opened in the 1940s by Joe
Condo. In 1993, after a second owner had acquired the business, it was bought by pharmacists Gary and Jean Moore. At
the time, Gary was director of pharmacy at a local hospital,
and Jean had been working part time at Condo for many
years. She was also a hospital staff pharmacist. For the
Moore family, pharmacy roots run deep. Son Steve obtained
his PharmD in 2004 from the Ernest Mario School of Pharmacy at Rutgers, and his younger brother Dave is working
toward his PharmD from the University of Florida.
Steve Moore says that when his parents saw an opportunity to purchase a pharmacy, they didn’t hesitate.
“The previous owner became ill, and my mother
started working close to full time to help him out,” he says.
“They decided after he passed away that they didn’t want
it to become a chain. They were thinking about opening
their own store anyway, and it worked out that there was
an opportunity for them to purchase an existing business.”
23
Rallying Together
After finishing his pharmacy degree in 2004, Steve Moore
enrolled in an MBA program. However, everything changed
on Jan. 25, 2005, when his father suddenly died. He was
only 54 years old. At that point, the family rallied together.
Steve and Dave (who had started in pharmacy school) came
home to help their mother with the pharmacy. In Steve’s
opinion, it was the least they could do in a difficult time.
“My father worked hard for many years, and my mom
has as well,” he says, pointing out that often only one
parent could attend his and his brother’s sports activities
because the other was busy caring for patients.
“A month before he died, my father was in the store
Christmas Day helping somebody. My mother’s been the
same way. They have always tried to take care of their
patients, and there’s a responsibility that they felt toward
their patients.”
Less than a year before Gary Moore died, a new pharmacy building had been completed. In the years since,
Steve Moore, who just turned 30, has helped fortify the
foundation that his parents built, which includes a newly
opened pharmacy located in a hospital.
“I would like the store to be successful for both of
them,” Moore says. “They both worked hard, and my
mother’s getting to the point where she deserves a chance
to kind of slow down a little bit, and rather than worry
about the daily grind, to enjoy what she’s done and the
relationships she’s developed.
The Moores had owned Condo for about a decade
when they decided it was time for a major upgrade. At
that point they were still operating out of the original
building, which had received patchwork upgrading and
expansion over the years, but was essentially worn out
after close to 60 years of use.
Starting from scratch in May 2003, a new facility was
built next to the old one. The cramped older building had
about 3,000 square feet at the most, while the new pharmacy contained 6,400 square feet spread over two floors.
Each floor has about 3,200 square feet. The first floor contains the retail section and the pharmacy, and the second
floor has sitting rooms, offices, and sections for items such
as mastectomy products and compression stockings. The
upper level also has a compounding laboratory.
“The lab was the primary reason for expansion,”
Moore says. “We were doing more compounding, and
you can only do so much with existing rooms in old
24
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“A month before he died, my father
was in the store Christmas Day
helping somebody. My mother’s been
the same way. They have always tried
to take care of their patients, and
there’s a responsibility
that they felt toward
their patients.”
structures, as far as air quality and temperature monitoring are concerned.”
After 10 months of construction, the new Condo
Pharmacy was opened in the spring of 2004. “It was during my spring break from pharmacy school,” Moore says.
“We closed one night in the old store, and the new store’s
front end had been stocked. That night we moved the
computers and medications over to the new store from
the old store, which was about a 10-second walk across
a parking lot. We opened the next day. It was a nice opportunity to have a new building.”
Plattsburgh, located on Lake Champlain and about
20 miles south of the Quebec border, has about 18,000
residents, with about 12,000 more within a five-mile
radius. Moore says the median household income is
$28,000, significantly less than $42,000 national average.
Like many smaller communities in the United States,
it has been hit hard by the recession. Condo Pharmacy
has roughly 17–20 staff members in a given week. This
includes four full-time pharmacists, two part-time
pharmacists, three full-time technicians, four part-time
technicians, a full-time sales register clerk, a full-time
buyer, a few part-time delivery drivers, and three other
part-time support staff (general help). Anywhere from
200–300 prescriptions are dispensed daily.
Moore says that the sales growth has been modest for
a couple of reasons. Losing a long-term care account was
one. Also, several years ago Plattsburgh instituted mandatory mail order for city employees.
But, as Moore says, “We’re still here and still paying
our bills. If you take away LTC, and just focus on retail
and compounding, we’re probably up about 10 percent
in prescription count, and dollar wise, about 3–5 percent, which we’ll take.”
Product Mix
Along with the traditional prescription business,
Condo has a varied product mix. Moore says that nutritional supplements have become a growing portion
of the business.
“With more people paying for prescriptions out of
pocket, a lot are looking to stay healthy in the first place,”
he says. “We’ve been doing some things with pharmaceutical grade nutritional supplements and vitamins, and
we’ve seen some amazing results with people. It’s been an
interesting part of the business. It kind of helps to alleviate the need for pharmacy medications by keeping them
healthy in the first place.”
Condo also provides a limited supply of durable
medical equipment, or “DME lite” as Moore describes it.
It primarily carries canes, walkers, and test strips, among
other items. With LTC, the pharmacy had a contract with
an assisted living facility before it decided to go with another pharmacy because it offered more ancillary services
than Condo was willing to provide. Moore suspects that
some pharmacies willing to push the ethical envelope a
bit, but he is adamant that Condo won’t go there.
“We’re in talks with some homes in the area who are
unhappy with the regional chains that seem to dominate
the long-term care market,” he says. “So we think we’ll get
back into that as well. But we’re going to do it the way it
should be done.”
Moore is an advocate of medication therapy management, thought he admits it’s been a tough sell at times.
“It’s a great idea in theory, but in practice it’s a little bit
more difficult,” he says. “People are still not quite used to
the idea of scheduling time to come to the pharmacy.
“We found that with a lot of Medicare Part D plans
that make up our payer mix, they weren’t really focusing
on the MTM from a community pharmacy standpoint.
Unfortunately, CCRx and MemberHealth weren’t a really
big player in this area. They aren’t a benchmark plan, so as
a result they aren’t prevalent in New York.”
Still, Condo seems to be building modest success
through the program. “We had a couple of patients the
first year, and we had 16 MTM eligible patients total
(through Mirixa) last year, which isn’t great, but it’s a step
in the right direction,” he says.
Condo has a fair amount of retail and OTC products,
along with some gifts and cards. However, Moore says he
would like to phase out the latter.
▲ Condo Pharmacy is located in Plattsburgh, New York, some 20
miles south of the Quebec border.
“We don’t have the space to be a destination gift
center,” he says. “And I didn’t go to school to become a
Hallmark. We’re taking a look at what we want to do with
pharmacy, and I don’t see that being a big part of our
future. It’s not a big profit center, it takes up a lot of space,
and you can get cards anyplace. So I think it makes more
sense for us to focus our time and efforts on the things
that you need to be a pharmacist to do. I would rather
take out my cards and put up a wall of diabetes shoes. At
the very least, I would like to have something that requires
personalized service and is health care related.
Second Store
In the winter of 2009, the CVPH (Champlain Valley Physicians’ Hospital) Medical Center in Plattsburgh decided
to outsource its outpatient pharmacy and sent out a request for bids to local area pharmacies. Moore responded
and his bid was chosen. It was set up as a separate entity
from Condo and goes by the name Prescription Shoppe.
Moore says the bid was driven by several factors,
including the desire to grow and diversify, and to remain
competitive. “You don’t always get an opportunity to
expand,” he says. “And in the past year we’ve had two new
chains open in area, and within Plattsburgh there are
probably 13 pharmacies. One other independent is left,
but one of the others was sold to a chain. We didn’t have to
take out a mortgage to build a new building. We’re renting
space, and there is a ready patient population waiting.”
25
Moore says the facility is not large (a 535-square-foot
room). Before opening in early December 2009, he had
all of the shelving replaced, and brought in a bagging
and workflow system. Previously, the hospital had been
using a pharmacy system that didn’t have electronic
signatures and was cash only.
“We updated the computer system, hardware, and the
product line—I don’t even think they had 100 different
products that they offered. We’re not quite a full line of
pharmaceuticals yet, but we’re getting there bit by bit.
And we’re close enough to our other store (less than a
mile away) that if I don’t have it here, I can have a delivery
driver drop it off if I need it that day, or I can have it the
next day from our wholesaler. We’re trying to minimize
the dollars that we have on our shelf.”
The Prescription Shoppe only does prescriptions and
OTC. The staff consists of pharmacists who rotate from
Condo Pharmacy (sometimes Moore) and a full-time
technician. Moore says the pharmacy is open to the general public, but is mostly focused on hospital employees
and discharged patients. A primary advantage is that it’s
in close proximity to several medical buildings where
physicians have their offices.
“One of the nice things is that we’re actually on site
with the doctors, physician assistants, and nurse practitioners,” Moore says. “They are actually able to see you
and talk to you face to face. So we’ve been able to put
some names with some faces of people we’ve been talking to for years over the phone. If people are thinking
of pharmacy and medicine, I’d like them to think of our
pharmacists rather than Wal-Mart. This helps reinforce
our position in the community.”
Moore says that the Prescription Shoppe is dispensing
between 30–40 prescriptions daily, up from about 20 per
day when it opened. He hopes to bump that up to about
75 before the end of its first full year.
The new location is set up for e-prescribing through
Surescripts (as is Condo Pharmacy). “The doctor can
write the prescriptions and the patient can pick it up
on the way out, or upon getting discharged, or it can be
sent electronically and a family member can go get them
before the patient even leaves the hospital,” Moore says.
“It’s not perfect, but it works out well. And it’s the way
the world is going.”
Moore has tried to keep the businesses ahead of the
curve on technology. The new location has been outfit-
26
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ted with enhanced tools, and Moore has been pleased
with the results.
“We have a workflow system and pharmacy management system and I’m very impressed with that,” he says.
“It’s a dedicated and tied into the POS [point of sale]
system. It’s been real nice to have a dedicated workflow
system. I can see where everything is, I can see if something was picked up from any station, who did it, and
check it at each step. Everything’s barcoded, and all of the
prescriptions are scanned. Everything seems to be built
from the ground up, as opposed to trying to make one
system work with another.”
Compounding
Non-sterile compounding has been a steadily increasing
part of Condo’s business in recent years. The decision to
focus on non-sterile came about as the new building was
being designed.
“There were some big revisions going on with USP
[United States Pharmacopeia] around 2004,” Moore says.
“It kind of helped guide the planning of the new store,
and what we wanted to do. We went to a meeting in
Washington, D.C., and found out that the sterile compounding regulations were going to change, and as we were
just building a new store, we didn’t want to build a sterile
room, and then find out that we would have to change it.”
Moore’s father had the most background in sterile
compounding, and when he died things were put on the
back burner for awhile.
“I obviously didn’t have any experience with it, and
that’s not just something you kind of decide to do on a
whim because you think it’s a good idea,” Moore says.
“It’s one of the things my brother is trying to focus on
in school through his work and rotation experiences.
We’ll revisit it [sterile compounding] as he gets closer
to graduation.”
As it is, Condo is preparing between 10–20 nonsterile compounds daily, and about 100 per week.
Among the offerings are bio-identical hormone
replacement products (progesterone and the various
estrogens); desiccated thyroid capsules (in response to
an Armour Thyroid shortage); acyclovir capsules (due
to an acyclovir shortage); 4 aminopyridine capsules
for multiple sclerosis; various creams and gels for pain
management (utilizing ingredients such as ketoprofen, gabapentin, baclofen, nifedipine and ketamine);
Independent Advocate
Some people shy away from long-term commitment.
Then on the other end of the spectrum you have Steve
Moore and Condo Pharmacy. “I bought a lifetime
[NCPA] membership, but it actually expires in 2050, I
guess I can deal with it then,” he says dryly.
So, to say that Moore, PharmD, is an avid supporter of independent community pharmacy is an
understatement. He and his mother Jean own the
Plattsburgh, New York-based business, and Moore
says that independent advocacy is more important
than ever. Moore, his mother, and younger brother (a
pharmacy student) have been active in NCPA’s political
efforts, and contribute to its PAC on a monthly basis.
“I think any pharmacist that doesn’t belong to
NCPA should re-think that position,” he says. “[NCPA]
are the ones who are fighting for us, and helping us to
advocate for ourselves.”
Moore is not one to hide his opinions, and he
admits that he has worries about the profession,
concerned that there is too much fragmentation.
“Whether it’s community pharmacists, hospital
pharmacists, or any others, we need to realize that we
are all in this together,” he says. “Unfortunately, retail is
the biggest importer of pharmacists, and as retail goes,
I think you are going to see the rest of the profession
go. And if they start eliminating jobs, decreasing ben-
pediatric dosing of medications for children (including furosemide, enalapril, and clopidogrel) until they
weigh enough for commercially available products;
and veterinary products such as potassium bromide
and methimazole.
“It’s been nice that we’ve been able to meet the needs
of the market,” Moore says. “Other pharmacies are telling
patients that there are no supplies of certain medications,
and that they have to back order or switch to something
different. A lot of patients don’t like that. We say we can
compound something equivalent for you. It’s a great way to
help people and helps us meet new patients. Prescribers say,
‘I’ve got a problem, we call this guy, he helped me out last
time.’ I just think that’s what pharmacists need to be doing.”
efits, and lowering salaries, then that’s going to spread
very quickly.”
Moore is also miffed that the poor economy has
made it tough to fight the image that independents
aren’t as competitive as lower cost health care providers.
“Wal-Mart doesn’t say that everyone else costs
more, but it’s certainly the impression that all of their
advertising leaves with you,” he says. “It’s hard to fight
that perception. You can’t compete with their marketing team.”
In Moore’s opinion, independent pharmacists need
to accentuate their strengths.
“There are things that pharmacists do that are
valuable,” he says. “We provide services that people
need. We provide services that lower health care costs.
Everybody talks about prescription drug spending,
but you can’t look at it in a vacuum. We as pharmacists have to make sure that people who are spending
that money on prescriptions are getting what they
need out of those dollars, and that it’s helping to
lower health care costs in other areas. We need to be
fighting for the profession because if we don’t, nobody
else is going to do so.
If nothing else, Moore says, “It’s going to be an
interesting next few years.”
–cl
“I want people to think of us when they think about
pharmacy. I would like them to be able to picture a
pharmacist, and not Wal-Mart or a mailman. If they
have a medication or health-related question or issue,
issue, I’d like to be in a position where they think of us as
somebody who can help solve it. We try to get to know
our patients. Some of the patients who have been coming
to our store are grandchildren of the patients who came
when the original store was opened. So we’ve been dealing
with generations. And you know, we’re lucky to be here.
Everybody who comes to our store probably drives by
three or four other pharmacies to get there at this point.
We enjoy what we do. I think we’re good at what we do.
And hopefully we’ll be around for another 60 years.”
Continuing the Legacy
Moore says he strives to continue the tradition of effective
community pharmacy that he says his parents established.
Chris Linville is managing editor of America’s Pharmacist. He can
be contacted at [email protected].
27
Strategic
30
america’s
Pharmacist | March 2010
IT
Management
How independent pharmacy can
leverage data to improve outcomes
By Todd Eury
Todd Davidson
W
ith the unprecedented business challenges facing independent
pharmacies today, owners must be searching, planning, and implementing alternative strategies that create efficiencies, increased productivity, and new profit
opportunities. Independent community pharmacy must accomplish more in any
given day on the job to create more opportunity for success, sustainability, and
increased patient services.
31
Making successful
technology selections
Managing your pharmacy’s technology, automation, and processes are keys to optimal effectiveness,
and can have a significant impact on your store’s
productivity and profitability. The use of pharmacy
automation is more than just medication counting
and packaging. Strategic planning and independent
pharmacy’s adoption of automation can affect the entire process, from receipt of a prescription order to the
actual dispensing of a finished product.
Before talking about how leveraging information
technology management can make a significant impact
to the success of your operation, let’s discuss the purpose
and selection of pharmacy technology.
Making successful technology selections is a matter of intentionality. With all that’s in the marketplace
to choose from, you need to be armed with articulated
objectives. Far too many owners and operators move
into the selection process unprepared, and they walk
away either confused, overwhelmed, or worst of all, taken
advantage of by vendors.
So how do you go about making successful technology
selections? Start with a stated business goal. Ask yourself
and your team, “What are we attempting to achieve for
our business? Where do we see ourselves three to five years
from now?” The responses to these questions will identify
several facets of the business you’ll want to consider.
• Market share—the number of customers or the size of
marketplace you are targeting.
• Offerings—the menu of products and/or services you
see yourself taking to market.
• Geographical footprint—the number and placement
of physical locations you aspire to have. This may also
encompass virtual locations as the Internet and its applications become a larger part of your business.
• Functional capabilities—the capacity to do more with
less, and doing more than you thought possible before.
• Financial growth and profitability—growing both the
top line and the bottom line of your business.
Technology plays a measurable role in each of these
facets, but technology isn’t the goal; instead it can be an
enabling factor to achieve your goals.
32
america’s
is a matter of intentionality.
With all that’s in the marketplace to
choose from, you need to be
armed with
articulated objectives.
Strategy Purposes
A well-articulated strategy is important. It sets the plan in
place and lays out the blueprint for your business. Without a guiding strategy, you’re no better off than a random
leaf on a stream going wherever the current takes you. In
other words, you’re not in control, and that most often
results in failed outcomes. Strategy places boundaries for
intent, action, and measures.
People need strategy to bind their efforts. Without
a vision (strategy) people are confused. Staff crave the
security of known parameters to give them purpose and
measured affirmation. Good strategy attracts effective
people. Your most valuable asset is your staff, so don’t
underestimate it while overestimating technology.
Process (business and functional), sets a context
for getting things done. Day in and day out, the work
performed by your business is accomplished through
process. Whether formalized or the stuff of historical
activity, process is the science of “doing,” which moves
your business forward. By formalizing your processes,
you can better predict the outcomes of what your staff is
doing. Technology is no substitute for process; it’s simply
an enabler through automation and measurement. Consider the business challenges you hope to resolve before
selecting a technology. In other words, don’t choose a
technology solution for a loosely identified problem. “No
prescription ought to be offered for an illness undefined.”
Know your business then choose your technology.
When considering a technology solution, separate the “nice to haves” from the “have to haves.” Far
too many technology selections are made based on
the nice to have features of a product instead of the
fundamental functionality businesses need to have to
succeed. Go into the selection process with a defined list of “have to have” functions that automate
your business processes, resulting in more and better
production output from your staff. Anything else will
leave you unsatisfied and frustrated.
When shopping for teachnology, ask some straight
questions of the vendors promoting their products and
services. Are they willing to share the risk of the selection
by structuring a deferred payment arrangement until the
solution is proven? Will they credit back a portion of the
purchase if the offered solution doesn’t meet documented expectations? Responses to such questions will
tell you a lot about the vendor. If they stand behind their
offering, bounded by a responsible contract, then you
have a true technology partner. The devil is in the details
of the arrangement you make, and you also have to step
forward with reasonable responses, but the ultimate outcome is well worth it. Your selection will be safe because
you are in it together.
Pharmacies must take a look at their processes and
use of their technologies and determine where and how
each pharmacy technician can be properly and effectively
utilized to create efficiencies. The overall combination of
people, process, and technology can create the best pharmacy operation as an interworking system. The question
of “how each part of the equation of ‘the system’ can fit
into and support the overall mission of the pharmacy” is
necessary to answer in every pharmacy.
The Pharmacy Software
Management System
Proactive leadership has great influence on the success of the pharmacy. The variety and approaches to
pharmacy information systems make this area complex
yet exciting. Regardless of its size, an
independent pharmacy that knows
its information system is pivotal to
the operations, and uses that data
captured on a daily basis, can become
more profitable. Whether a business
is dispensing 30 prescriptions per
day or more than 1,000, benefits can
be seen from modern open database
pharmacy software systems coupled
with independent pharmacists who
understand the operational processes
and workflow steps. Some of the more
advanced systems are Windows-based
and are designed to “think like a
pharmacist.” There are key operational features that are
intended to free up prescription department personnel for other duties (most often associated with patient
care). The logic of the pharmacy system is in place to
ensure patient safety and lend support to the clinical
overview of patients. The team can ensure that processes are followed, while using the pharmacy system
to help fill prescriptions in a fast and safe manner while
safeguarding profit margins.
Independent pharmacist Heather Swaringen of
Lewisville Drug Co., in Lewisville, North Carolina, knows
the benefit of a modern pharmacy software system.
Previously she worked for a national chain and commented that its pharmacy system was antiquated and
unsophisticated. Her current pharmacy program layout
makes her job easier. "Our inventory and billing processes are seamless with the software compared to what I
remember while with a national chain for six years," she
says. "The technology, combined with my experience, has
given me about a 60 percent productivity advantage with
regard to prescription processing from start to finish.
From operations to production, the modern software is
a huge advantage for us.” Swaringen mentioned that she
uses barcode technology heavily throughout the day too.
“Using barcode in the process makes mundane data entry
less tedious and cuts down on data entry mistakes.”
As an independent pharmacist, Swaringen understands the importance of technologies that help her work
more efficiently. “With our software, it is possible to scan
the barcodes of prescriptions in the pickup bins to produce an exception report for follow up via telephone.”
Swaringen’s system also provides
an electronic signature capture and
retrieval at the time of dispensing for
HIPAA, third party, accounts receivable, credit/debit cards, and controlled
substance purposes. There are many
reputable pharmacy technology vendors available in the marketplace. As
discussed previously, it’s just a matter
of doing smart shopping and finding
the right match for your needs.
Security and
Infrastructure
The most valuable asset within U.S.
33
Alex Wong
health care is its data. The criticality of patient data
drives pharmaceutical development, bounds insurance
actuarial policies, fills tomes of learning for all health
care related education, and drives strategic placement
and development of health care related construction.
The list goes on and on. Make no mistake, the U.S.
health care industry of more than $2.3 trillion is driven
and bounded by patient data/information.
On the downside, patient data is the most sensitive
information about any given individual. It reveals Social
Security number, home address,
insurance coverage, health history,
medication management, and sometimes psychological and behavioral
life patterns and history. Any or all
of this can be used harmfully against
a patient in myriad ways. Additionally, fraud on a massive scale can be
perpetrated using falsified identities
for monetary gain and deeper intrusion into various health care industry
corporate organizations.
Prominent national security
analysis think tanks such as the
Rand Corp. and the Brookings
Institute believe such fraud has
direct implications to U.S. national
security via funding of terrorist
activities and strategic misuse of
data. There are inexpensive services
a pharmacy can employ to proactively monitor network
usage, perform security scans, and act as the pharmacy’s
IT network guard dog.
A fundamental approach to data and information
protection involves personnel orientation, performance
accountability, measurable workflow processes, and keen
use of technology across an organization.
aspect of business, creating additional savings initiatives through advanced business software services can
provide better profit margins. A proactive independent
pharmacy can leverage its understanding of claims
reconciliation to explain the benefits of these profit optimizing systems. Pharmacies can work with pharmacy-experienced analysts who can electronically connect
directly into the pharmacy system through a secure
connection. They diligently rebill erroneous transactions, adjust brand and generic pricing, and make other
adjustments to optimize future transactions. This can
include adjustments to AWP, billing errors, incorrectly
priced drugs, and other data issues that might have
been missed by the adjudication team.
Innovative Technology for
Competitive Advantages
For pharmacies to maximize their
effectiveness and time spent to generate greater profits, it’s necessary
to understand and use advanced
pharmacy technologies. Independent pharmacies that are using
various methods of workflow and
automation have an advantage over
pharmacies that do not. Today’s
independent pharmacy will have to
master a wider variety of business
challenges, process understanding,
and workload technologies to provide service to modern patients who
are technologically more in tune.
There is simply no alternative to a
pharmacy operation that employs
automation, technology, and processes together that
drive a competitive advantage. All independent pharmacies should seek opportunities to learn more about
different types of technology and IT management to
have a better chance of sustaining success.
Todd Eury is executive director of Pharmacy Technology
Reconciliation and Profit
Analyzing Pharmacy Data
For those independent pharmacies that excel more
in the billing, reconciliation, and financial reporting
34
america’s
Resource, LLC, in Evans City, Pennsylvania. He can be reached
at 412-735-4427 or [email protected].
continuing education
Non-Prescription Self-Treatment of GERD
By Marlowe Djuric Kachlic, PharmD
U
pon completing this article the
pharmacist should be able to:
Objectives
1. Describe the physiology of the anti
reflux barrier as it relates to the
pathophysiology of GERD.
2. Recognize the symptoms of GERD in a patient in the community
3. Differentiate patients with non prescription
treatable GERD and patients who need to be
referred to their physician.
4. Recommend appropriate lifestyle modifications for a given patient.
5. Discuss the available non prescription options for the treatment of GERD, and recognize which ones are appropriate in patientspecific situations.
6. Design a care plan for a patient in the community setting with GERD.
Introduction
Gastroesophageal reflux is common in the
United States and Europe, and its prevalence is
increasing in other countries. Gastroesophageal
reflux refers to the movement of acidic gastric
contents into the esophagus, which can cause
heartburn and acid regurgitation. When these
symptoms of reflux become more frequent and
bothersome to the patient, it can now be called
gastroesophageal reflux disease, or GERD.
The term “frequent” has been more specifically
defined as two or more heartburn episodes a
week. The American Gastroenterological Association (AGA)’s position statement in 2008
defines GERD as “a condiUseful Web Sites
tion which develops when
the reflux of the stomach
■ www.heartburnalliance.org
contents causes troubleThe National Heartburn Alliance Web site
some symptoms and/or
has patient education materials to print
complications.”
and order, research articles, and a down While the terms are still
loadable program called “Self Directed
Treatment of Heartburn” that reviews
used casually and interheartburn and educates pharmacists on
changeably, patients who
how to teach patients about it. The Nahave symptoms of GERD
tional Heartburn Alliance has partnered
without evidence of mucosal
with the American Pharmacists Associadamage technically have
tion Academy of Student Pharmacists in
non erosive reflux disease,
their national disease project “Heartburn
or NERD. To simplify terms
Awareness Challenge.”
so that a patient can understand, many times practi■ www.drgourmet.com
tioners use the term “heartThe “Dr. Gourmet” Web site has recipes
burn” to describe GERD,
for several diseases, including GERD.
which is fitting since heartRecipes here avoid ingredients that agburn is one of the hallmark
gravate GERD symptoms.
symptoms of GERD. To a
■ www.gastro.org
patient, heartburn usually
The American Gastroenterological Asrefers to a burning sensation
sociation Web site has a patient specific
that rises from behind the
section, with questions and answers
sternum to the throat. The
regarding GERD, and a GI doctor finder.
purpose of the AGA position statement’s definition is
through using the word “troublesome,” episodic heartburn
and GERD can be distinguished. Now that GERD receives
plenty of attention, in part due to direct to consumer
advertising for prescription and non prescription medications, the public is becoming increasingly aware of the
terminology. For the sake of consistency, GERD will be
used as an umbrella term to describe the disease of these
patients seeking relief from non prescription antacids,
37
Table 1. Foods and medications affecting LES pressure
Foods
Medications
Increase LES pressure
Protein
Metoclopramide
Prostaglandin
Cisapride
Bethanechol
Decrease LES pressure
Fat
Chocolate
Ethanol
Peppermint
Nitrates
Calcium channel blockers
Theophylline
Morphine
Meperidine
Diazepam
Barbiturates
histamine 2 receptor blockers (H2RAs), and proton pump
inhibitors (PPIs).
The importance of treating GERD relates not only to
the improvement in a patient’s quality of life, but in avoiding several serious complications. For example, deep
ulcers, which can cause hemorrhage, strictures, and
perforation were shown to be present in 6–8 percent of
patients with untreated erosive esophagitis. Hemorrhage
of esophageal lesions were shown in one study to be
responsible for 14 percent of upper GI bleed patients with
GERD, though these patients had other GI related complications. Barrett’s esophagus, a premalignant condition,
accounts for 10–15 percent of patients undergoing endoscopy for GERD. Strictures, which are considered one of
the most serious complications of GERD, were also once
considered the most frequent complication, with up to 22
percent of patients having esophagitis. More recently, the
incidence of strictures has decreased to about 0.2 percent
in one study, largely due to the wide availability of PPIs.
Community pharmacists are well equipped to screen,
counsel, and treat patients with typical GERD symptoms.
Additionally, with the ability to easily and frequently follow
up, we can not only ensure patients are experiencing
relief of symptoms, but also refer them to their physician
as needed.
Pathophysiology
It is physiologically normal for gastric contents to reflux
into the esophagus. However, when the esophageal
mucosa is subjected to excessive exposure of this acidic
fluid due to the breakdown of different defense mechanisms, then the reflux is destructive and physiologically
abnormal and can be considered GERD.
38
america’s
GERD occurs when the antireflux barrier
is not functioning properly, and allows gastric
contents to reflux and come in contact with the
esophagus. The antireflux barrier is comprised of
many anatomic mechanisms working together.
When these mechanisms break down, reflux can
occur. These mechanisms include defects in
esophageal acid clearance, salivation, and tissue
resistance. The most common mechanism by
which the antireflux barrier fails is related to the
lower esophageal sphincter (LES). The LES is
located at the esophago gastric junction (EGJ)
and serves as a valve, preventing fluid from re
entering the esophagus.
Transient LES relaxations (TLESRs) are
common, and present in those with and without
GERD. TLESRs occur when the intra abdominal
pressure changes, allowing the LES to open,
and thus allow gastric contents to reflux into the
esophagus. In patients without GERD, peristalsis and the neutralizing effect of saliva prevent
the esophagus from being exposed to the
acidic refluxate, thus preventing the patient from
experiencing symptoms. In patients with GERD,
esophageal clearance, mucosal resistance, and
salivation may all be impaired. Therefore, when
TLESRs in patients with GERD are not accompanied by normal esophageal defense mechanisms, they will experience heartburn and acid
regurgitation, possibly as far as the oropharynx,
among other symptoms.
Patients with GERD not only experience
symptoms with TLESRs, but also experience
more TLESRs than patients without GERD. The
most common trigger for TLESRs is gastric
distention. Gastric distention, obesity, and pregnancy can all increase intra-abdominal pressure, leading to TLESRs.
The LES can also undergo decreases in
pressure, leading to decreased tone and therefore increased reflux. Normal resting tone of the
LES is 10 to 30 mmHg over intragastric pressure,
though this can fluctuate throughout the day to
as high as 80 mmHg. LES pressure tends to
decrease in the postprandial state and increase
during sleep. Besides intra abdominal pressure
Table 2. Symptoms and risk factors indicating physician referral in patients with possible GERD
Alarm Symptoms
Atypical Symptoms
Risk Factors
• Unintentional weight loss
• Hematemasis (vomiting blood)
• Melena (tarry stools)
• Dysphagia (difficulty swallowing)
• Odynophagia (painful swallowing)
• Severe symptoms
• Chest pain
• Predominant epigastric pain
• Belching
• Hoarseness
• Sore throat
• Cough
• Age >40 in areas with high prevalence of gastric
cancer (otherwise >50–55)
• New onset of symptoms in patients >45
• Family history of gastric and/or esophageal cancer
• Chronic NSAID use due to irritation of the
esophageal mucosa
and gastric distention, several other factors affect LES pressure, including myogenic factors,
peptides, hormones, various foods, and medications. In the community, it is helpful to be aware
of the foods and medications that affect LES
pressure when counseling a patient with GERD.
Protein rich foods, metoclopramide, prostaglandins, cisapride, and bethanechol can all increase
LES pressure. Fatty foods, chocolate, peppermint, and alcohol and medications including
nitrates, calcium channel blockers, theophylline,
morphine, meperidine, diazepam, and barbiturates can all decrease LES pressure (Table 1).
Symptoms of GERD
As mentioned earlier, the hallmark symptoms
of GERD are heartburn and acid regurgitation.
The symptoms experienced by patients with
GERD fall into a fairly large spectrum. Patients’
symptoms tend to differ based on intensity,
duration, and frequency of GERD episodes.
In addition, patients may have symptoms that
are mild, periodic, and intermittent, or they may
have symptoms that occur daily and are severe
in nature. Given the varying nature of symptoms
and presentations of GERD, no single treatment
is appropriate for every patient. In a community
pharmacy setting, it is important to understand
the patient’s symptoms and choose the appropriate treatment accordingly. If a patient
has mild, periodic symptoms, or symptoms so
frequent that they have GERD, they can still use
non-prescription treatment.
GERD is not limited to esophageal symptoms. Some patients with severe disease, or
disease that has been present for a while and
not treated, may have extraesophageal symptoms, or atypical symptoms. These patients
should be initially evaluated by their physician to rule
out serious mucosal damage. These symptoms include
laryngitis, non cardiac chest pain, and asthma, which
tend to manifest because of constant acid regurgitation
and subsequent esophageal irritation. Other patients,
in particular those who present initially to a community
pharmacy, may experience associated symptoms in addition to heartburn and acid regurgitation. These symptoms
may include nausea, lower GI complaints, and sleep
disturbances.
Diagnosis of GERD
Many patients rely on self diagnosis of GERD, taking
antacids and H2RAs that are available in the pharmacy
without a prescription. This is appropriate in cases of mild
and uncomplicated GERD, which can easily be treated
with non prescription medications. Patients who present
to their physician for evaluation of GERD symptoms are
often treated empirically for eight weeks with a PPI. Diagnostic tools such as upper endoscopy, barium esophogram, and pH monitoring are used in patients who have
symptoms of complications or have failed a PPI trial.
When counseling a patient seeking treatment for
GERD, it is important to ensure the patient is using the
term “heartburn” in the same way it is understood by
health care providers. By establishing that a patient’s description of their symptoms includes a feeling of burning
behind the breastbone that rises up to the throat or neck
might help differentiate between GERD and other types of
GI discomfort or cardiac symptoms.
Once it is determined that a patient is in fact suffering
from typical heartburn, further information must be gathered to rule out complicated GERD that should be referred
to a physician. Two criteria in particular that indicate a patient can be self treated for GERD are symptoms that occur
in the post prandial period, and symptoms that are relieved
quickly with antacids. Any patient presenting with symptoms indicating complications from GERD, also known as
39
Table 3. Foods that decrease LES pressure and irritate esophageal mucosa and that should be avoided in
patients with GERD
Foods that cause reflux by decreasing LES pressure
Foods that irritate the esophageal mucosa
Fatty or fried foods
Coffee, tea, caffeinated beverages
Chocolate
Mint
Citrus
Tomatoes
Onions
Carbonated beverages
Spicy foods
alarm symptoms, should consult with a physician before
starting a treatment plan. Alarm symptoms include unintentional weight loss, hematemasis (vomiting blood), melena
(tarry stools), dysphagia (difficulty swallowing), odynophagia (painful swallowing), and severe symptoms. Additionally, patients presenting with atypical symptoms, or who fall
into risk categories for esophageal or gastric cancer should
consult with a physician before starting self treatment.
Atypical symptoms include chest pain, primarily epigastric
pain, belching, hoarseness, sore throat, and cough. Risk
factors for esophageal or gastric cancer include patients
in the 50–55 age group or older than 40 in areas with high
prevalence of gastric cancer, new onset of symptoms in patients older than 45, family history of esophageal or gastric
cancer, and chronic NSAID use. These symptoms and risk
factors can be found in Table 2.
In addition, patients who have had a trial of a non
prescription PPI after two to four weeks and have persistent symptoms should also be referred to their physician
for further analysis. It also may be prudent to refer patients
who are being treated for other disease states requiring
medical management and who are taking multiple medications. Finally, patients who have had success with a two
or four week trial of a non-prescription PPI that need to
repeat the therapy frequently may benefit from continuous
PPI treatment, and should be referred to a physician.
Treatment
Goals of Treatment
The goals of treatment (figure 1) with medications
used for GERD include: symptom relief or reduction of
symptom frequency, symptom resolution or remission,
and prevention of complications and healing of erosive
esophagitis. Table 5 contains a medication selection and
patient counseling guide.
Lifestyle Modifications
It has been shown that patients do benefit from adopting
40
america’s
lifestyle modifications as part of their treatment
for GERD. There are a great deal of lifestyle
modifications that have shown to help alleviate
and prevent GERD symptoms, but there are too
many to recommend every one to every patient.
Several sources indicate that specific lifestyle
modifications that are appropriate to a particular
patient are effective, but recommending every
modification to every patient is not effective. For
example, weight loss should not be recommended universally, as some patients may have GERD
without being overweight.
Lifestyle modifications can be classified into
three different categories: avoiding foods that
cause reflux by decreasing LES pressure; avoiding foods that precipitate heartburn by being
irritating to the mucosa; and avoiding factors
that increase risk of esophageal acid exposure.
Foods that decrease LES pressure include
fatty or fried foods, chocolate, mint, coffee, tea,
and other caffeinated beverages. Foods that
irritate the esophageal mucosa include citrus,
tomatoes, onions, carbonated beverages, and
spicy foods. These foods can all be found in
Table 3. Some medications also can irritate the
esophagus. These include oral potassium, non
steroidal anti-inflammatory drugs (NSAIDs),
and alendronate. Esophageal acid exposure is
increased in patients who smoke, those who are
overweight or obese, and those who consume
alcohol. In that case, patients who fall into these
categories should be counseled about how their
lifestyle choices may exacerbate their symptoms.
Patients who smoke should stop, and patients
who consume alcohol should reduce their intake.
Patients who are overweight or obese should
not only lose weight, but also avoid wearing tight
clothing and undergarments, which can affect
Table 4. Available non-prescription H2RAs and PPIs: products and dosing
Class
Drug Name (Brand)
Dosing
H2RA
Nizatidine (Axid AR)
Famotidine (Pepcid AC)
Cimetidine (Tagamet HB)
Ranitinde (Zantac)
75–150 mg BID prn
10–20 mg BID prn
200 mg BID prn
75–150 mg BID prn
PPIs
Omeprazole (Prilosec)
Lansoprazole (Prevacid)
20 mg daily
15 mg daily
intra abdominal pressure. It is possible that overweight or obese patients who lose weight first
might avoid the need for medication treatment.
It is not uncommon for patients to complain of
symptoms after meals and at bedtime. For patients
with symptoms after meals, it is recommended to
eat smaller, more frequent meals to avoid gastric
distention, which is a main trigger for reflux. It is
also advised that patients avoid lying down within
two to three hours after eating. Patients with symptoms at bedtime should avoid eating within three
hours of going to bed to allow for gastric clearance. Also, these patients may try elevating the
head of the bed by several inches, allowing gravity
to clear refluxate from the esophagus.
Antacids
Antacids are readily available, very widely used,
and usually the first treatment patients use for
heartburn. Many of these patients find relief and
do not seek further treatment for their GERD.
While antacids are effective in treating mild to
moderate GERD symptoms, their role in GERD
treatment is primarily for ameliorating breakthrough symptoms while taking H2RAs or PPIs.
Using antacids alone for GERD is not effective
in preventing esophagitis.
Antacids act locally to increase the pH and
neutralize the contents of the stomach, but do
not suppress acid production like H2RAs and
PPIs. Antacids are very rapid acting but have
short duration, but when used in combination
with a PPI or H2RA can alleviate immediate
symptoms with a longer effect. Studies comparing antacids to placebo or H2RAs generally show
that antacids are better at symptom relief than
placebo, but not better at symptom relief or healing of esophagitis than H2RAs.
Available Dosage Forms/Products
Antacids are available in both chewable tablet and liquid
formulations. They contain one or more of the following
salts: magnesium hydroxide, aluminum hydroxide, calcium carbonate, and sodium bicarbonate. A few antacid
products are available with alginic acid, which reacts with
saliva to form sodium alginate. Sodium alginate sits on
top of the stomach contents and acts as a barrier, keeping the esophageal mucosa from being exposed to the
acidic fluid. While alginic acid containing are theoretically
useful, they have not been shown to be more effective
than other antacids.
It is important to not concentrate on brand names, as
some companies use a single name to market products
with different ingredients. In February 2010, the FDA issued
a warning to consumers regarding Maalox Total Relief.
Other Maalox products contain aluminum hydroxide, magnesium hydroxide, or calcium carbonate. Maalox Total Relief actually contains bismuth subsalicylate, putting patients
with aspirin allergy in danger, as well as patients taking
medications that interact with aspirin related compounds.
Adverse Effects
Due to the chemical reaction of the salt with the hydrochloric acid of the stomach, some antacids can produce CO2,
which will in turn increase intragastric pressure, and increase TLESRs. For this reason, some combination antacid
products also contain simethicone. Antacid products that
contain aluminum or calcium can cause constipation, and
products that contain magnesium salts can cause diarrhea.
Drug Interactions
Antacids can reduce the bioavailability of drugs like fluoroquinolones and tetracycline due to adsorption. Drugs
such as ferrous sulfate that require an acidic environment
to function, interact with antacids due to alteration of
gastric pH.
41
Figure 1. Algorithm for Non-Prescription Treatment of GERD
Mild, Infrequent
Heartburn
Moderate, Infrequent
Heartburn
Frequent Heartburn: 2
days/week
Lifestyle modifications
plus antacid or low-dose
H2RA or antacid/H2RA
combo
plus antacid or higher dose
H2RA or antacid/H2RA
combo
plus omeprazole 20 mg po
daily or lansoprazole 15 mg
po daily for 14 days
If continued heartburn, switch to higher dose H2RA or
OTC PPI if needed. Repeat up to 2 weeks.
Dosing
Dosing and maximum daily doses are generally product specific, but their purpose is to be used only as
needed. Antacids are indicated for treatment of occasional heartburn.
Contraindications
Antacids containing aluminum or magnesium, when
given to patients with renal impairment, can accumulate, and should be avoided. Additionally, antacids
with sodium bicarbonate should be avoided in patients
with hypertension or congestive heart failure who are
sodium restricted.
Use in Pregnancy
During pregnancy, women are more likely to suffer GERD
symptoms due to hormone changes and a growing uterus,
causing the LES to relax more often. In these patients,
calcium containing antacids are first line treatment, though
products with aluminum and magnesium should be avoided.
Histamine 2 Receptor Antagonists
H2RAs are available as both non-prescription and prescrip-
42
america’s
If continued heartburn,
consult physician.
May repeat 2 week course
every 4 months.
tion products, based on their strengths. They work
by competitively and reversibly blocking parietal
cell histamine2 receptors, which stimulate gastric
acid production. This blockade decreases basal
and meal stimulated acid secretion and increases
the pH of the refluxate. However, acid suppression with H2RAs is about 70 percent, compared
with 97 percent with PPIs, so they are less effective in healing esophagitis.
Peak plasma concentration of H2RAs occurs within one to three hours. A single dose
inhibits acids secretion for anywhere from four
to eight hours. The effect of H2RAs on acid secretion is much more pronounced and effective
when they are taken in the evening or before
bed. Many studies have shown that the H2RAs
as a class have similar efficacy, and can be
recommended interchangeably.
Available Dosage Forms/Products
See Table 4 for commercially available non
prescription H2RAs. The non prescription
strengths available are half that of the prescrip-
Table 5. Medication Selection and Patient Counseling Guide
Class
Name
Treatment/
Prevention?
Onset/
Duration
Dose
Notes
Antacids
Tums (CaCO3)
Treatment
Short
onset/
Short
duration
1–2 tabs po
(chewed) Q2
hrs PRN
• chewable tabs
should be
followed with
water
• pts may need gas
relief as well
Medium
onset/
Medium
duration
10 mg 20 mg
po BID PRN
Mylanta (AlOH,
MgOH, simethicone)
H2RAs
Pepcid (famotidine)
Treatment
and
Prevention
Zantac (ranitidine)
Axid (nizatidine)
2 to 4 tsp po
Q4–6 hrs PRN
75 mg 150 mg
po BID PRN
• take 15 to 60
min before
offending foods
for prevention
• use only PRN
75 mg 150mg
po BID PRN
200 mg po BID
PRN
Tagamet (cimetidine)
Antacid + H2RA
Pepcid Complete
and Tums Dual
Action (famotidine
10 mg/CaCO3 800
mg/MgOH 165 mg)
Treatment
and
Prevention
Short
onset/
Medium
duration
1 tab po
(chewed) BID
PRN
PPI
Prilosec OTC
Prevention
Long
onset/
Long
duration
Prevacid 24 HR
(lansoprazole)
Prevention
20 mg po QAM • should only be
taken in AM
• can be taken
w/antacids and
H2RAs
• takes a few days
15 mg po QAM
to start working
initially
tion strengths of the medications. Additionally,
combination products are available that contain
calcium carbonate and magnesium hydroxide
as antacids, as well as famotidine 10 mg in a
chewable tablet. This provides for the fast onset
of an antacid along with the longer duration of
an H2RA.
Adverse Effects
Non-prescription H2RAs have few side effects,
• should be
followed with
water
• do not exceed
2 tablets in 24
hours
the most common being headache, constipation, and diarrhea, and are considered to be very safe.
Drug Interactions
H2RAs are metabolized via CYP450, so caution should be
used in patients taking medications also metabolized through
this pathway, as drug interactions may occur. Cimetidine, in
particular, has several drug interactions with many commonly
prescribed medications. These include warfarin, phenytoin,
propranolol, calcium channel blockers, chlordiazepoxide,
43
diazepam, metronidazole, lidocaine, theophylline, and some
tricyclic antidepressants. Due to these serious drug interactions, cimetidine is less frequently recommended.
Dosing
H2RAs can be taken up to twice a day, as shown in Table
4, due to their duration of action. Many experts agree that
tolerance to H2RAs builds around seven to 14 days, so
daily scheduled dosing is not effective. Self treatment with
H2RAs should not exceed 14 days. It is appropriate for
H2RAs to be taken on an as needed basis. Because of
the onset of action of H2RAs, taking them for treatment of
heartburn is not ideal, but they still carry this indication as
their duration is much longer than that of antacids. H2RAs
are also indicated for prevention of heartburn, allowing
the patient to take one as a single dose one hour before a
meal known to cause heartburn.
Dose Adjustment
As H2RAs are hepatically metabolized and excreted in
the urine, dose reductions are necessary in patients with
hepatic or renal dysfunction. These patients should consult with their physician before starting an H2RA.
Proton Pump Inhibitors
As PPIs have become available without a prescription,
their use will likely become more common, as is the case
with H2RAs and antacids. PPIs have continually been
shown to be more effective at both symptom control and
healing of esophagitis than H2RAs.
PPIs irreversibly inhibit hydrogen potassium adenosine triphosphatase (H+-K+-ATPase), which is the acid
producing “proton pump” of the gastric parietal cells. The
profound inhibition that PPIs provide leads to a significantly longer duration of action compared to H2RAs,
allowing for once daily dosing.
Omeprazole and lansoprazole, both available without a prescription as Prilosec OTC and Prevacid 24HR
respectively, provide acid suppression that increases
with continued dosing. A 20 mg dose of omeprazole can
inhibit acid secretion by 65 percent after four to six hours,
which decreases to 25 percent after 24 hours. After four
to six doses of omeprazole, acid inhibition increases and
then plateaus. Also, omeprazole is unique in that its bioavailability increases with continued dosing. With a single
dose, bioavailability is about 35 percent, but increases to
44
america’s
60 percent with subsequent doses. Similarly, a
15 mg dose of lansoprazole resulted in an intragastric pH of greater than 4.0 for 22 percent of
the time on the first day. By the fifth day, intragastric pH was greater than 4.0 for 49 percent
of the time. Continued dosing of lansoprazole
does not affect its bioavailability, which is about
80 percent. However administration 30 minutes
before food does decrease its bioavailability.
Patients who present to the community pharmacy with uncomplicated, typical GERD symptoms two or more times a week should start a
PPI. FDA labeling of the non prescription PPIs
is very specific regarding how long a patient
may take them. According to both packages of
Prilosec OTC (omeprazole) and Prevacid 24HR
(lansoprazole), they can be taken once daily for
14 days, then discontinued. This 14 day regimen
can be repeated as needed every four months.
A suggested plan for the patient treated
with non prescription PPIs is suggested by
Haag and colleagues, as a response to their
increasing availability. A patient with typical
symptoms should start non prescription PPI
therapy and continue for two weeks. At the
end of the two week treatment, if the patient’s
symptoms persist, then referral to the physician is necessary for further evaluation. If the
patient’s symptoms have resolved, then there
is no need to continue the PPI. If, after four
months, the patient experiences a relapse of
symptoms, then a two week course can be repeated. If the patient has frequent relapses, or
begins to develop alarm symptoms at any time,
then physician referral is essential.
Available Products
Table 4 lists the available non prescription PPIs.
Adverse Effects
Headache and diarrhea are the most commonly
reported side effects, though PPIs are generally
very well tolerated. Long term use of PPIs has
been linked to serious adverse effects, such as
increased risk of skeletal fractures and community acquired pneumonia. These effects are
limited to long term use and should not be a
concern with short term self treatment of GERD.
Drug Interactions
Omeprazole interacts with phenytoin, diazepam,
the R isomer of warfarin, antipyrine and aminopyrine
by inhibiting their metabolism. In November 2009,
the FDA issued an alert regarding decreased
efficacy of clopidogrel (Plavix) when taken with
omeprazole. This is theoretically due to omeprazole’s inhibition of CYP2C19, which prevents the
conversion of clopidogrel to its active metabolite,
thus decreasing its effect on platelets. Patients
taking clopidogrel should avoid omeprazole, and
some studies suggest this is a class effect. These
patients should check with their physician before
starting any PPI. Lansoprazole has been shown
to increase the metabolism of theophylline by 10
percent. Both PPIs may affect the absorption of
certain medications that rely on an acidic environment to function, such as ketoconazole.
Dosing
Dosing of the non-prescription PPIs can be found
in Table 4. It is important to counsel the patient
to take his or her PPI first thing in the morning, at
least 30 minutes before breakfast, which is when
the PPI can optimally bind to the H+-K+-ATPase
pumps. A study done in 2003 showed that only
36 percent of patients were not told by their
physicians to take their PPI in the morning before
a meal. This can lead to treatment failure, so it is
important for pharmacists to convey this information when recommending a PPI to a patient.
Cases
Case No. 1
AB is a 30-year-old male who presents to the
pharmacy counter, asking you for advice on
what to take for his heartburn.
HPI: AB is currently having a heartburn
episode, and is looking for relief. He was on
his way home from dinner at a local sports
bar and started to feel what he describes as
“burning in my chest.” He experiences episodes like this a couple of times a month, but
has never taken anything for it before. According to
AB, the symptoms usually go away within a few hours.
However, he needs to go to bed early this evening, and
knows he won’t be able to sleep with heartburn.
PSH: tonsillectomy in 1990
PMH: none
Meds:multivitamin daily
acetaminophen for headaches, takes one
500 mg tablet about 4 times/month
Allergies: penicillin (rash)
FH: father, 58, has HTN
SH:Tobacco: Smokes about half a pack on
weekends
Alcohol: Drinks 2–3 alcoholic beverages 2–3
times per week
Caffeine: Drinks three cups of coffee each
morning
Diet: Does not adhere to any diet
Exercise:mostly weight training, three times per week
Weight: 85kg
Height: 6’0”
What counseling on lifestyle modifications would you
give AB?
AB’s social history indicates that he may be able to make
some changes to prevent having more heartburn episodes than he currently has. Although he smokes only on
the weekends, tobacco cessation has been shown to decrease esophageal acid exposure. Alcohol and coffee can
both have an irritant effect on the esophageal mucosa, so
decreasing consumption of both would be advised.
To address his current complaint, what would you
recommend?
For AB’s heartburn, there are a few valid options. First,
an antacid would be appropriate for the fast relief he is
seeking. Liquid antacids work slightly faster than chewable
tablets, but are not usually convenient to take if the patient
is not at home. Chewable antacids are easy to carry and
easy to take. When followed with a glass of water, their onset of action is similar to that of a liquid antacid. As AB has
no contraindications to aluminum or magnesium formulations, any brand will do. If AB would like to take a dose
now, so that it can start working by the time he gets home,
a chewable tablet would probably be the best choice.
45
Another possibility would be to recommend an H2RA
for future heartburn. If AB can pinpoint what types of food
in particular cause his heartburn, he can take a preventative H2RA before eating a meal. For example, if he meets
his friends once a month for hot wings at a local sports
bar, and he always ends up with heartburn, he can take an
H2RA one hour before eating to prevent symptoms later.
Finally, as it has been shown that H2RAs work well for
nocturnal heartburn, AB could take Pepcid Complete to
ensure that he won’t wake up in the middle of the night
with symptoms. The antacid component would provide
him with quick relief, and the famotidine component would
continue to suppress acid production while he sleeps.
Case No. 2
KD is a 37-year-old female who presents to the pharmacy counter, asking you for advice on what to take for
her heartburn.
HPI: KD has been having heartburn episodes more
frequently of late. Currently, she states she has had
heartburn episodes about two to three times a week for
the last three weeks. She feels as though it is interfering with her sleep, as well as work, as she finds it hard
to concentrate with heartburn. She doesn’t notice that
her heartburn occurs at any particular time of day, but
has stopped drinking soda pop because she felt her
symptoms were worse when she was drinking it. She
called her physician, who told her to try something at the
pharmacy for a few weeks and then come in. This week,
she has been taking Tums, which help for a short time,
but then the heartburn returns.
PSH: none
PMH: uterine fibroids
Meds:ibuprofen 600 mg Q6H prn menstrual pain,
takes 4–8 doses/month
Loestrin 1/20 daily
Allergies: None
FH:mother, 63, has diabetes
father, 64, has hyperlipidemia
SH: Tobacco: denies
Alcohol: Drinks 2 alcoholic beverages 3 to 4
times per month
Caffeine: D
rinks 1 cup of tea each morning
Diet:Does not adhere to any diet, but watches
sugars and fats
46
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Exercise: Walks ~2 miles every day
Weight: 65 kg
Height: 5’7”
What counseling on lifestyle modifications
would you give KD?
KD has already started modifying what she drinks
by discontinuing soda pop. In addition, she has
a prescription dose of ibuprofen for menstrual
cramps, which she takes four to eight times over
the course of one or two days. KD should make
sure she eats before taking each dose. Also,
recommending acetaminophen for pain might
also be an option. While KD does not drink frequently, limiting herself to one drink three to four
times per month would be better. If KD finds that
her heartburn interrupts her sleep in the future,
elevating the head of the bed by adding blocks,
would also help by encouraging the refluxate to
travel downwards with the help of gravity.
To address her current complaint, what
would you recommend?
KD’s symptoms fit into a typical description of
GERD, with no alarm or atypical symptoms that
would necessitate immediate referral to her physician. She did say that she has tried Tums over
the last week with no long lasting relief, so appropriate options for her would be an H2RA or a
PPI for their longer durations of action. However,
as she is having symptoms more than two times
per week, and they seem to be interfering with
her daily life and reducing her quality of life, a
PPI would be the best option for her.
Either omeprazole 20 mg daily or lansoprazole 15 mg daily can be recommended to
take for the next two weeks. KD should take the
PPI first thing in the morning, at least 30 minutes before eating breakfast. She should also
be sure to take the PPI daily, and not just for
symptoms, as PPIs have been shown to have
greater effects after about four days of continuous use. After two weeks, KD can discontinue
the PPI, and re evaluate her symptoms. If she
has found complete relief, then no further action
is needed. If she finds her symptoms recur with
the same frequency, she can repeat a two week
course of the PPI as long as it is four months
after her previous treatment. If she continues to
relapse, or if after her first two weeks of treatment, she finds she is still having symptoms,
she should be referred back to her physician.
Case No. 3
SL is a 48-year-old male who currently takes a
PPI, but is having breakthrough symptoms and
presents to your pharmacy counter for a recommendation.
HPI: SL has been treated with a prescription
PPI for the last two months, but over the last two
weeks has noticed that he has heartburn one or
two evenings a week, despite being compliant
with his PPI. His physician is aware of his breakthrough symptoms, and suggested he try Tums.
SL states that he does not like taking Tums
because of their chalky taste, and wants to take
something different. When you question him
further, you find out that he gets home late from
work and is so tired after eating dinner, that he
tends to fall asleep laying on the couch at least
a couple of times a week. It is usually those
evenings that he wakes up with heartburn.
PSH: hernia repair 1996
PMH: GERD
hyperlipidemia
Meds: simvastatin 20 mg po daily
pantoprazole 40 mg po daily
Allergies: iodinated contrast dye shellfish
FH: father, 72, has diabetes
Mother, 70, had breast cancer, in
remission
SH: Tobacco: denies
Alcohol: denies
Caffeine: used to drink 2 cups
of coffee/day, but stopped 3
months ago
Diet:Adheres to a low fat diet and
recently lost 10 pounds
Weight: 115 kg
Height: 5’9”
What counseling on lifestyle modifications would you
give SL?
SL likely can’t change his work schedule, but suggesting
he get at least six to eight hours of sleep each night might
prevent him from feeling so tired in the evenings. Recommending that SL not lay down within two to three hours after eating dinner will also help. Given his schedule, it might
be better for him to eat a larger lunch and a lighter dinner,
to avoid gastric distention late at night, and avoid him having to delay his bedtime. SL has already lost 10 pounds
recently, due to changes in his diet, but recommending
and encouraging continued weight loss will be beneficial
not only to his GERD, but also to his cardiovascular health.
To address his current complaint, what would you
recommend?
SL’s breakthrough symptoms may be related to what he
is eating for dinner or his evening activities, or a combination of the two. Since SL has already stated that he does
not like Tums for their chalky taste, then chewable antacids
can be eliminated as treatment possibilities. For patients
objecting to the taste of chewable antacids, liquid antacids
may be a viable treatment option. While H2RAs have a longer onset, they are still a viable option, especially because
of their enhanced effect on nocturnal symptoms. Another
option is to help SL identify particular foods that cause
heartburn, such as spicy or acidic foods, and if he knows
he’ll be eating them for dinner, he can take an H2RA one
hour before eating. Also, on evenings where SL is particularly tired and suspects he will fall asleep after dinner, he
can take an H2RA before dinner. Additionally, though SL
states he is compliant with his PPI, making sure that he is
taking it 30 minutes before breakfast would be prudent.
Conclusion
Over the last 10 years, more medications for heartburn
and GERD that were once prescription only have become
non prescription. Now, with a second PPI available without
a prescription, pharmacists must be prepared to identify,
counsel, and appropriately refer patients with GERD.
Marlowe Djuric Kachlic, PharmD, is a clinical staff pharmacist at University Village Pharmacy, a clinical pharmacist at the Family Medicine
Center at the University of Illinois at Chicago, and a clinical assistant
professor at the University of Illinois at Chicago College of Pharmacy.
47
Continuing Education Quiz
Select the correct answer.
1. Gastroesophageal reflux can be considered a
“disease” when:
a. The patient is experiencing extraesophageal symptoms.
b. The patient has esophageal damage.
c. The symptoms are bothersome to the patient and occur
at least twice per week
d. The patient is experiencing alarm symptoms
2. The American Gastroenterological Association’s
position statement uses the word “troublesome” to
differentiate GERD from what?
a. Non erosive reflux disease
b. Episodic heartburn
c. Barrett’s esophagus
d.Zollinger Ellison syndrome
3. Patients who have symptoms of GERD without
evidence of esophageal damage actually have:
a. Heartburn
b. Non erosive reflux disease
c. Strictures
d. Acid regurgitation
4. Which of the following is true about strictures?
a. Was once the least common complication of GERD, but
is becoming increasingly more prevalent
b. Is the least severe complication of GERD
c. Is considered a typical symptom of GERD
d. Due to wide use of PPIs, has become less prevalent
than in the past
48
america’s
5. The failure of what part of the antireflux barrier
is the most common?
a. Lower esophageal sphincter
b. Peristalsis
c. Esophageal mucosa
d. Saliva
6. Which of the following can increase intraabdominal pressure and cause an increase in
TLESRs?
a. Gastric distention
b. Obesity
c. Pregnancy
d. All of the above
7. Of the following medications, which one does
NOT cause a decrease in LES pressure?
a. Calcium Channel Blockers
b. Metoclopramide
c. Theophylline
d. Diazepam
8. Of the following foods, which one causes an
increase in LES pressure?
a. Chocolate
b. Peppermint
c. Protein
d. Fat
9. Which of the following is considered an
associated symptom, which a patient might
present with along with heartburn and acid
regurgitation?
a. Nausea
b. Lower GI complaints
c. Sleep disturbances
d. All of the above
10. What two criteria generally indicate that a
patient is eligible for self-treatment of GERD?
i. Symptoms that occur in the post prandial
period, ii Severe symptoms; iii Symptoms
that are relieved quickly with antacids; iv
Predominant epigastric pain
a. i and ii
b. ii and iii
c. i and iii
d. iii and iv
11. Which of the following is considered an
alarm symptom, indicating that the patient
needs to be referred to their physician?
a. Hematemasis
b. Dysphagia
c. Melena
d. All of the above
12. Which of the following is a typical symptom
of GERD?
a. Chest pain
b. Regurgitation into the oropharynx
c. Belching
d. Sore throat
13. NSAIDs should be avoided in patients with
GERD because of their ability to:
a. Irritate the esophageal mucosa
b. Increase LES pressure
c. Decrease LES pressure
d. Cause gastric distention
15. Patients who experience symptoms at night could try
which of the following lifestyle modifications?
a. Elevating the head of the bed
b. Avoid eating within three hours of laying down
c. Eat smaller, more frequent meals to avoid gastric
distention
d. All of the above
16. Antacids are appropriate for:
a. Prevention of heartburn
b. Treating mild to moderate GERD symptoms
c. Treating breakthrough symptoms while taking other
medications for GERD
d. B and C
17. Bioavailability of which of the following medications is
NOT affected by concurrent use of antacids?
a. Ortho-TriCyclen
b. Levaquin
c. Tetracycline
d. Ferrous sulfate
18. Which of the following antacids is safe for pregnant
women to take?
a. Aluminum hydroxide
b. Magnesium hydroxide
c. Calcium carbonate
d. Aluminum phosphate
14. Caffeinated soda should be avoided in
patients with GERD because of its ability to:
a. Irritate the esophageal mucosa
b. Increase LES pressure
c. Decrease LES pressure
d. A and C
49
19. H2RAs block parietal cell histamine2receptors, resulting in:
a. Decreased basal acid secretion
b. Decreased meal stimulated acid
secretion
c. Increase in gastric pH
d. All of the above
20. Which of the following statements is
NOT true regarding H2RAs?
a. Peak plasma concentration occurs within
one to three hours after taking.
b. Acid suppression increases with
subsequent dosing.
c. Acid suppression is more pronounced
when taken in the evening.
d. The H2RAs all have similar efficacy.
Non-Prescription Self-Treatment of GERD
May. 3, 2010 (expires May 3, 2013)
Activity Type: Knowledge-based
FREE ONLINE C.E. Pharmacists now have online access to NCPA’s
C.E. programs through Powered by CECity. By taking this test online—go to the Continuing Education section of the NCPA Web site
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the Education heading you will receive immediate online test results
and certificates of completion at no charge.
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A score of 70 percent is required to successfully complete the C.E. quiz.
If a passing score is not achieved, one free reexamination is permitted.
Statements of credit for mail-in exams will be available online for you
to print out approximately three weeks after the date of the program
(transcript Web site: www.cecerts.ORG). If you do not have access to a
computer, check this box and we will make other arrangements to send
you a statement of credit: q
Record your quiz answers and the following information on this form.
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Store e-mail (if avail.) Quiz: Shade in your choice
Date quiz taken
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Quiz: Circle your choice
21. Is this program used to meet your mandatory C.E. requirements?
a. yes b. no
22. Type of pharmacist: a. owner b. manager c. employee
23. Age group: a. 21–30 b. 31–40 c. 41–50 d. 51–60 e. Over 60
24. Did this article achieve its stated objectives? a. yes b. no
25. How much of this program can you apply in practice?
a. all b. some c. very little d. none
How long did it take you to complete both the reading and the quiz? ______ minutes
50
america’s
NCPA® is accredited by the Accreditation Council for Pharmacy Education as a provider
of continuing pharmacy education. NCPA has assigned two contact hours (0.2 CEU)
of continuing education credit to this article. Eligibilitywww.americaspharmacist.net
to receive continuing education
credit for this article expires three years from the month published.
Pharmacy law
Medicare’s Overpayment Hunters
By Jeffrey S. Baird, Esq.
The Medicare Modernization
Act authorized a three-year demonstration project to test the value
of using recovery audit contractors
(RACs), paid in contingency fees,
to review and identify improper
payments. The RACs were given
information on about $317 billion in claims covering 2001 to 2007. They were free to
review any claim that they felt was most likely to contain
improper payments, with some minor exceptions.
During the 2005–08 project, providers became concerned that the RACs were not correctly interpreting policies and procedures of the Centers for Medicare & Medicaid Services. To correct this problem, CMS engaged
a RAC Validation Contractor (RVC). For each new issue
a RAC wanted to pursue, it had to submit information to
CMS to determine whether the RAC should proceed or
whether the issue needed to be reviewed by the RVC.
If CMS felt the RVC should review the issue, the RAC
would send the RVC a small sample of claims. The RVC
would review them and recommend to CMS whether the
RAC should continue.
Four main reasons accounted for the overpayments
identified by the RACs. A finding that the services were
medically unnecessary amounted to 40 percent of
the overpayments. Incorrect coding accounted for 35
percent of the denials. Insufficient documentation was
the basis for 8 percent with the final 17 percent being
denied for other reasons.
The cost of the RAC program amounted to 20 cents
for every a RAC dollar recovered. After deducting those
costs, the RACs returned $693.6 million to Medicare.
Based on that return, a permanent RAC program now
is being rolled out.
Perhaps the biggest change implemented in the
permanent program is the limit on the number of
52
america’s
services were
medically unnecessary
amounted to 40 percent of
the overpayments. Incorrect
coding accounted for 35
percent of the denials.
A finding that the
records that can be requested. The review
period has been shortened from four years to
three. During the demonstration project, it was
optional for the RAC to have a medical director or certified coder on staff. Both positions
now are mandatory.
In the permanent program, the RACs are
required to return phone calls within 24 hours.
Providers have a right to speak with the individual who reviewed their claim, and they have a
right to speak with the RAC medical director. The
RACs will be required to pay back their fee if the
denial is overturned at any level of the appeal.
CMS is often asked about the phase-in
strategy for RAC reviews. It has implemented
a phase-in strategy by review type, but has not
put a phase-in strategy in place by provider
type. Any reviews completed by the RAC must
have been first approved by CMS and posted
to the RAC Web sites. More information is
available at www.cms.hhs.gov/RAC/.
Jeffrey S. Baird, Esq. is Chairman of the Health Care Group
at Brown & Fortunato, P.C., a law firm based in Amarillo,
Texas. He represents pharmacies, infusion companies,
home medical equipment companies and other health care
providers throughout the United States. Mr. Baird is Board
Certified in Health Law by the Texas Board of Legal Specialization. He can be reached at (806) 345-6320 or jbaird@
bf-law.com.
pharmacy management
Exceeding Customer Expectations
By Andy Oaks
It was a downpour,
and I was running behind
schedule on my way to
an important meeting. I
only had a few minutes to
spare and had not eaten
all day. There was a fast
food restaurant close by
and this would be my only chance to grab a
quick bite to eat.
As I pulled into the parking lot, I noticed at
least 12 vehicles in line. I did not have the time to
wait so I was about to leave hungry and disappointed in the restaurant because of the long wait.
I considered parking and getting out to go inside
but the rain had intensified. I’d be soaked and in
no condition for my meeting.
And then I saw something
that I have never seen
before or since. An employee
of the restaurant was wading through
the parking lot in a rain coat and boots
escorting customers to and from their
cars while carrying one of those oversized
golf umbrellas.
And then I saw something that I have never
seen before or since. An employee of the restaurant was wading through the parking lot in a rain
coat and boots escorting customers to and from
their cars while carrying one of those oversized
golf umbrellas. I witnessed his total unselfishness
for his own comfort in order to keep his employer’s
faithful customers dry and happy. And I took advantage of this opportunity to eat while staying dry
and on time.
This true story happened to me nearly 10
years ago. I continue to tell it still because I have never
witnessed this type of service from any other fast food restaurant. I never expected this level of service from this type
of eatery. Obviously, it made a lasting impression on me. By
exceeding my expectations, this company has created a
customer for life.
The lesson to be learned is that every retail business or
service provider should always look for those creative ways
to exceed the customer’s expectations. Successful implementation will create more loyal customers who are sure to
spread the word about their experience. And we all know the
value in word of mouth advertising.
How about the addition of personalized promotional
products to help exceed customer expectations? Putting the
two together is sure to bring much success. Your community
will be talking about the experience and the products will
serve as a constant reminder that will further separate your
store from the competition.
What’s the one thing your customers most frequently
have in common when visiting your pharmacy? They are ill
and need medicine and advice to help make them feel better. Give them more than this and your business is building
loyal customers. Loyal customers are what give businesses
prosperity and longevity. Hopefully some of the examples
below will help.
RAIN CAPES to the RESCUE
A cousin of the umbrella story, rain capes may just save the
day when loyal customers have forgotten their umbrella or
an unexpected storm hits. Present them with an inexpensive
rain cape with their prescription and be sure and let them
know how much you appreciate them and their business.
With your company name and logo on their back, they
are sure to tell many others of the special treatment they
received while shopping at your pharmacy.
PLUSH TOYS for TOTS
Stuffed animals are one of the top three most-collected
53
items in America (coins and stamps are the others). We all love to squeeze and feel them and to
give them to loved ones. They typically remind us
of a special someone or moment in time. They can
do the same for your pharmacy.
Give one to a mom or dad who comes in
about or with a sick child and watch the immediate impact it has on everyone’s mood. Mom and
dad will never forget the extra comfort you gave
to their little one. Remember to have your pharmacy name and logo printed on this item to serve
as a reminder to all that see and feel it how much
your pharmacy cares.
WATER for the THIRSTY
I recently saw a sign in a pharmacy that read, “You
come in as a customer, you leave as a friend.”
What a great message to tell any customer during those hot months that come in to patronize
your business. Tell them this or your own favorite
message when you offer them a bottle of ice cold
water. Be sure to include your logo and pharmacy
information on the bottle. This will remind them of
a business that exceeded expectations when they
tell their friends and loved ones.
Bottled water may also be a most appreciated item at community events. Charity funs runs,
walk-a-thons, marathons, school functions, and
holiday parades provide great exposure for your
business as one that is involved and appreciates
the community it serves.
Remember, the goal is to continuously reach
out to those you serve and potentially to others.
Service beyond the sale is what separates many
independent operators from mass merchants
and deep discounters. Be creative and consistent in your efforts and further distinguish your
pharmacy from all others not taking such actions.
Exceed your customer’s expectations and expect
to see them time and again and again
Andy Oaks is the president of Retail Pharmacy Management Services, Inc. RPMS provides solutions and support
to independent pharmacists throughout the United States.
For additional information, visit www.rpms.biz. For inquiries pertaining to this article, please contact Oaks at 800662-9035, or [email protected].
Reader Resources
NCPA activities and our advertisers
Clotamin.........................................................................13
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Medicine-On-Time......................................... Back Cover
QS/1 .................................................... Inside Front Cover
Spenco............................................................................. 1
NCPA
Annual Convention .................................................... 35
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Notes from capitol hill
When the Legislator Is Home, Share Your Views
By Michael F. Conlan
R
epresentatives and senators return to their
home districts and states almost every weekend. For some, that’s where their families are.
But all schedule time to consult with their nonWashington staff and keep in touch with local
issues and voters.
It’s easy for you to call a district office and arrange
an appointment to meet with your elected representative
when they are in your area. Getting an appointment is
easier if you have already established a relationship with
the district staff. If you are visiting Washington, D.C., call
ahead and set up an appointment to visit your legislators
in their congressional offices. No matter where you meet,
most lawmakers appreciate you taking the time to share
your views with them person to person.
No matter where you meet, most lawmakers
appreciate you taking the time to share your
views with them person to person.
Tips for Meeting With Legislators
Let your NCPA government affairs team in Washington,
D.C., know that you are scheduling a meeting. They can
provide you with valuable information about the legislator
and his or her positions. Your state association can provide the same type of assistance when you are planning
to meet a state legislator. Some other advice:
• Call ahead for an appointment and tell the staff what
issues you wish to discuss.
• Time with legislators is extremely valuable. Have an
agenda so that you don’t “chat” until the clock runs out.
Ask the staff person how much time you will have and
plan accordingly. Most meetings last about 30 minutes.
Take notes.
• Don’t be disappointed if you only meet with staff. Staff
members play a key role in advising elected officials.
56
america’s
Treat a meeting with staff as you would a
meeting with any elected official.
• Don’t be disappointed if the legislator says
that they will have their staff “look at the
issue.” That’s OK. Your NCPA government
affairs team will follow up with staff.
• Volunteer yourself as a source of local expertise on health care issues.
• Consider including other pharmacists or even
concerned patients in the meeting you schedule to show unity and leadership.
• Stick to facts. Don’t give way to emotional arguments or unsubstantiated opinions. If you
don’t know the answer, admit it and say you
will provide it later. Moreover, never stretch
the truth.
• Give the legislator a one-page paper describing the issue and the solution. NCPA can
provide you with simple issue briefs.
• Be a good listener, even if the legislator disagrees with aspects of our position.
• Acknowledge where other views have merit,
and stress that you want to work more closely
wherever possible.
• Leave the meeting open-ended for further
discussions—and always follow up with a
personal “thank you” note.
Michael F. Conlan is editor of America’s Pharmacist.

America`s Pharmacist — May 2010

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