Why closer is better: pharmacy providers say proximity, communication, convenience boost medication compliance.
Article Type: Report
Subject: Pharmacy (Management)
Patient compliance (Analysis)
Mental illness (Care and treatment)
Drug interactions (Analysis)
Pharmacists (Powers and duties)
Author: Barba, Lindsay
Pub Date: 03/01/2010
Publication: Name: Behavioral Healthcare Publisher: Vendome Group LLC Audience: Academic; Trade Format: Magazine/Journal Subject: Health; Health care industry; Psychology and mental health Copyright: COPYRIGHT 2010 Vendome Group LLC ISSN: 1931-7093
Issue: Date: March, 2010 Source Volume: 30 Source Issue: 3
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8045000 Pharmacists NAICS Code: 44611 Pharmacies and Drug Stores
Accession Number: 223731733
Full Text: Medication compliance is often an essential part of effective, long-term treatment of serious mental illnesses and a number of substance abuse disorders. Yet, risks to effective medication compliance begin, literally, on the way to the pharmacy. For many reasons--a forgotten preauthorization, a transportation problem, an unexpected financial need, pharmacist questions about a possible drug interaction, or an inability to carefully follow medication instructions--a consumer may never get their prescription filled, or if filled, may never take it as recommended. And, the prescriber at the CMHC may know little or nothing about it until the consumer suffers an acute episode or relapse.

Whatever the case, the obstacles in place between the CMHC and off-site pharmacy are dangerous for clients and costly for providers. So how can a behavioral health organization recognize the right time and place to implement a more personalized pharmacy service that will offer increased convenience and confidence for prescribers, reduced workloads for staff, and boost consumer medication compliance and outcomes?

In general, a center should first consider its population size and prescription volume before deciding on whether or not to pursue a pharmacy services vendor. Genoa Healthcare, which specializes in providing CMHCs with on-site pharmacies, suggests that any center that either supplies more than 100 reimbursable scripts per day, 20 days per month (depending on the state) or at least four medications per client is a good candidate for an on-site pharmacy.

The common problem of medication compliance is another strong argument for the more personalized approach of a pharmacy services vendor. "There was a Wall Street Journal article out not too long ago that stated that after a six-month period, only 33 percent of people who are supposed to be on a maintenance medication continue to take it," Jim Smith, CEO of QoL meds, another provider of on-site pharmacy services to CMHCs, says. "I don't think there are any solid statistics on how many prescriptions are written and never filled, but that often happens in behavioral health, and the chances of that happening are greatly reduced if you have an on-site pharmacy."

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Because many CMHCs do not have close partnerships with a pharmacy--on or off site--verifying whether or not clients have complied with their medications is extremely difficult, if not impossible. The time and effort that staff would have to spend tracking down every client's activity at various pharmacies is not cost effective or operationally efficient. When such valuable time is wasted on these tedious tasks, both the center and its consumers lose resources.

This waste, when it occurs again and again, can be another indicator of a center's need for an on-site pharmacy services vendor. These vendors can not only track medication compliance rates and instantly report them back to the clinicians, but they also take the helm on clinical time-wasting tasks, such as completing prior authorizations for medications and communicating with clients about refill dates.

"Mental health clinics should be interested in this because it should help them improve the use of their own internal clinic resources and allow people to do what they've been trained to do," Mark Peterson, Vice President of Sales and Marketing for Genoa Healthcare, says. "I think many mental health clinics are so involved in managing the medications of their clients that I'll walk into a clinic that doesn't have a pharmacy and literally it's almost like they are running a pharmacy in there."

Finding the right fit

Once a center has evaluated its population size and need for supplemental medication management services, allowing just any pharmacy services vendor to establish itself as part of the center could do more harm than good. "This is a tow-way process," Peterson says. "The organization needs to make a decision about whether or not they want to have a pharmacy on site so they understand the benefits of it, and as a pharmacy business, I have to make sure that I'm going in understanding what it's going to look like as a business for me."

Peterson notes that the most important responsibility for the center to fulfill during this process is to check a pharmacy services vendor's references. "If you haven't even suggested you check references, you're doing your organization a real disservice," he adds.

Along with checking references, Peterson suggests that centers ensure that the different personalities from both the center and the pharmacy services vendor work will together before a contract is signed. The vendor is completely integrated into the CMHC, and any potential downfalls that could arise from this close partnership should be identified early on.

The center should also do thorough research to identify all of the potential services that prospective vendors can provide. Both Genoa Healthcare and QoL meds offer medication education and outreach programs, online patient tracking tools, flexible packaging and dosage options, and access to primary care medications outside of their standard prescription-filling services, which allows for a more in-depth, supportive partnership with the CMHC. Typically, these services are provided at no additional cost to the center.

Once the center has identified an appropriate vendor, the vendor will then assess the feasibility of opening a pharmacy at the center. "There's no criteria chat would prevent [us from partnering with] them other than are they big enough and do they serve enough clients," Smith says.

"We also have to look at the types of patients they serve and the programs they run," Larry Hart, QoL meds' Director of New Business Development, says. Oftentimes, these vendors will readjust their standard services to meet the needs of more specialized programs, such as patient assistance programs.

While pharmacy services vendors can work flexibly, centers should be prepared to provide vendors with as much information as they can so that vendors can anticipate just how flexible they need to be.

"Ultimately, we really need to understand how many clients you have, what does the payer mix look like, how many clients you have that don't have any insurance," Peterson says. "So we ask a whole series of questions, such as 'Do you have a local pharmacy that you have a tight relationship with?' In other words, are your patients and your staff going to be to be reluctant to make a change? And if they are, maybe now is not the right time. So I would call it a pretty touchy feely process, but we do come in and ask a fair amount of questions of the business."

Peterson adds that assessing whether or not an on-site pharmacy will work for a particular CMHC is not always a straight forward process. "It's still more of an art than it is a science," he explains.

Putting the pharmacy in place

Once feasibility has been established, the CMHC and the vendor will choose a location for the pharmacy and sign a lease. Lease terms vary according to vendor and can be as short as one year or as long as five years. For a pharmacy startup, a two-year initial contract with one-year renewal options is often recommended, since, according to Peterson, about six months is needed to establish normal operations following startup. Then, various contracts will be drawn up to solidify the partnership. These contracts are in congruence with HIPAA regulations and designate the pharmacy services vendor as liable for all activity within the pharmacy.

Once the location has been chosen, the pharmacy services vendor will typically finance the entire cost of constructing the pharmacy, to applicable state board requirements, into this pre-established space. "We do all of that and that's all our cost. Really the center has very little involvement in that at all; we cry to make it as seamless for them as possible," Smith says.

The pharmacy services vendor will be responsible for the staffing of the on-site pharmacy as well, though the distinction between pharmacy and CMHC staff is essentially transparent to the consumer. "We encourage our pharmacists to join the meetings that are held on a regular basis by the prescribers," Smith says. "It really is what we want to believe is a true partnership. That interaction makes it work better."

Bringing benefits on site

Once the on-site pharmacy has been established and opened within the CMHC, staff, consumers, and even payers can reap the benefits of having a full-service pharmacy staff working in support of a shared objective: better client outcomes.

"Every center is unique, and the key is for us to find out what they want and in what ways we can meet their needs, and then produce that for them," Smith says. "So it's kind of interesting chat even though all of the centers are caring and compassionate, they all do it in a little different way so that we have to adjust what we do to help them."

For CMHCs who want to be better recognized or more competitive in their region, an on-site pharmacy can help. "Not all mental health agencies are going to have a pharmacy on-site, and having that one-stop shop feel gives you an advantage," Peterson says. "Not all communities have that kind of feeling of competitiveness, but in some areas they do. I think having a more comprehensive set of services in the mental health clinic helps to set that clinic apart."

Consumers benefit with the convenience of obtaining essential prescriptions at competitive prices, with service and support few retail pharmacies can match. The chance that a prescription might go unfilled is dramatically reduced, since the on-site pharmacist knows their needs, their prescriber, their insurer, and their typical medication requirements. Any range of problems--from drug interactions to pre-certifications to financial problems, or more--can be solved in moments, all before the patient leaves the CMHC.

Payers may also see possible benefits from the partnership established between the CMHC and its on-site pharmacy. Perhaps the greatest benefit to payers is the reduced risk of relapse or acute episodes, due to higher rates of consumer medication compliance. Yet there are other benefits as well: "I think there are some things that an on-site pharmacy can do to reduce the cost for Medicaid agencies and Medicaid Part D plans," Peterson says. "For clients that are not as stable, you can provide a smaller quantity of medication. If you can hand out a week supply, and then the medication gets changed, you essentially save that payer organization three weeks of expensive medication."

One of the only challenges that stand in the way of bringing these benefits directly to staff, consumers, and payers is breaking the habits of consumers, who are accustomed to having to take their prescriptions off site to be filled. As the staff welcomes the opportunity to concentrate on their clinical duties, rather than medication management and its associated administrative tasks, consumers may need a little more convincing.

"Patients should and do have choices, and some will continue to use other pharmacies, but it's our responsibility to do a better job of servicing the ones that come and have their prescriptions filled with us," Smith says. "We believe that the way we handle it, we're going to win over the trust of those patients. It doesn't happen on day one, but it does happen."

BY LINDSAY BARBA, ASSOCIATE EDITOR

RELATED ARTICLE: How closed-door pharmacies compete

The in-house pharmacies that operate within CMHCs are typically "closed door" pharmacies, operating in leased space and limited to "in-house" prescriptions for CMHC consumers only. Though they can't compete in volume or product range with local retail pharmacies, the characteristics and needs of the CMHC and its consumers often enable closed-door pharmacies to provide a specialized range of medications, packaging options, and support services--all with competitive pricing.

1) Though they typically dispense far fewer prescriptions than typical retail pharmacies, closed door pharmacies can operate successfully due to a different product mix {more higher-priced, brand-name prescriptions; fewer low-cost or generic products) and their ability to utilize special "non-retail" purchasing options from drug makers.

2) Their lower volume of prescription filling typically means that a closed-door pharmacy can invest more time in getting to know individual patients and their needs and can, through those relationships, bolster patient recovery.

3) Closed-door pharmacies can work with manufacturers to acquire and dispense sample medications, which retail pharmacies cannot. The presence of a closed-door pharmacy at a CMHC eliminates CMHC compliance risks involving inventory, management, and access to and distribution of samples.

4) Closed-door pharmacies can supply center staff with essential compliance-related data and services, which are unavailable in a retail pharmacy relationship:

* On-site pharmacies can report on prescription fill rates, prescribing trends, and assist in efforts to measure consumer compliance with medication programs.

* Can offer special medication supports, including packaging, etc., for consumers who require strict medication compliance.

* Per contract arrangements, can interact closely with center prescribers in HIPAA-compliant chart reviews or meetings that review consumer needs.

* Detailed knowledge of consumer concerns, finances, and needs enables pharmacists to leverage pharmaceutical company drug programs for specialized financial/medication assistance.

QoL meds

CEO: Jim Smith

Founded: 1999

Headquarters: Pittsburgh, PA

On-site Pharmacies: In 32 CMHCs across the nation

Genoa Healthcare

CEO: Kevin Martyn

Founded: 2002

Headquarters: Auburn, WA

On-site Pharmacies: In 72 CMHCs across the nation
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