Audio from July 5, 2018 Lecture:
Audio for Session 2 — Lecture 4 — July 5, 2018 will be published next Wednesday July 11, 2018
Please review Quiz 3
After reviewing this Quiz, please review Session 2 — Quiz 1 & Quiz 2 PDF Documents
Please review the links from the previous post Preparation for Quiz 3 and lecture on July 5th 2018
Keep Studying! This session is almost complete!
For questions please feel free to contact me. Have a great weekend!
Hello. I’m Sam, and I’m a Pharmacist that has a passion for the practice of Pharmacy.
Our profession is growing by leaps and bounds each and every day. And our growth in the healthcare community can only fully take shape by how well we train our pharmacy techs to help us fulfill our daily duties and responsibilities to both patients and the community.
Thus, my blog.. This blog on pharmacy and management is a collection of my thoughts, opinions, and lecture materials from the pharmacy tech class that I teach. If you have questions or concerns for me, just find me on LinkedIn.
Teaching is difficult. Teachers — especially the great teachers, they just don’t receive enough credit. I have actively been teaching a non credit pharmacy technician class the past 8 weeks, while also performing Preceptor duties for 4th year Pharmacy School students.
What have I learned while doing both simultaneously?
Obviously the biggest difference is that teaching in the community pharmacy is a more hands on experience in that there’s real life scenarios and people versus teaching in the classroom where there’s only the lecturer, student, book, and white board/chalk board to convey the message.
In the classroom there’s the “audience effect”. You’re lecturing, and you can easily become the only speaker if there’s not a question you give your audience to answer. Thus, you have to exert more of your body and brain energy into focused segments to convey an effective message.
This burden of energy expenditure being on the speaker/lecturer can be lightened only by actively engaging the student by using the white board, computer, or book to create examples and questions of real life scenarios.
Energy expenditure while teaching in the pharmacy is reduced in comparison to the classroom. The drugs, the patients, the real life scenarios are there to be be used as living examples of why the student must study physiology, pharmacology, infectious disease, pharmaceutics, and so on and so forth.
The student can easily view the drug by going to the shelf. They can learn the pharmacology and use of the drug by simply looking at the package insert that comes with the drug. They can observe the practicing pharmacist or pharmacy technician and learn from their behaviors, movements, speech, and thought process in working together as a team to produce the appropriate final product. The examples do not have to be created in the pharmacy — because the examples are there to be observed, studied, learned, and memorized for the present and future use with patients that day and the days ahead.
This accumulation of knowledge by the pharmacy student and pharmacy technician while on externship can produce a foundation of knowledge for how to talk, when to talk, when not to talk, and when to act.
First point… Good teaching isn’t a lecture, it’s a conversation.
Second point… Good teachers find common ground with the student — so that the thoughts expressed by the teacher can be easily understood by the student.
Third point…Good teachers find out what their student’s baseline of knowledge is. By understanding their current knowledge or lack thereof — the Good teacher can elevate and motivate the student to an appropriate and/or desired level of competency.
Conclusion — I have a long way to go in becoming identified as one of the “good teachers”. However, I’ve identified these three points too consider while playing this role.
The practice of pharmacy grows by leaps and bounds each and everyday.
The education of Student Pharmacists to take on both current & emerging roles in providing pharmaceutical care has occurred and continues to evolve. I have a firm belief that this education will satisfactorily meet and exceed the needs of both current and future patients.
While the Pharmacists education is well defined in that Boards of Pharmacy and National Associations have criteria that you must meet prior to entry into the profession. The Pharmacy Technician’s education is not as well defined. Currently technicians are educated by for-profit institutions, some but not all Community Colleges, and there are some online programs.
How can Pharmacists fully utilize their education and knowledge in both current and emerging markets – if there is not an appropriate and affordable education model to satisfactorily keep pace with pharmacy technician demand in the market?
It’s my opinion that the greatest demand for the Pharmacy Technician will be in the retail sector. There is a high turnover rate in this market and typically this is the space where an organization can take on registered pharmacy technicians that have no pharmacy experience. With an increase in mergers and acquisitions between chain pharmacy, benefit managers, and health insurers – the demand for registered pharmacy technicians will continue to increase.
Current state laws will also need to keep pace with changes in how both Pharmacists and Pharmacy Technicians are utilized in the Pharmacy.
- Pharmacy Technician verification via Barcode technology (http://www.ajhp.org/content/73/2/69?sso-checked=true)
- Medication therapy management
- Pharmacist Practitioners
- Collaborative practice models
- The increased market-share of “specialty pharmacy”
- Compounding pharmacies regulated by federal guidelines USP 795, 797, and 800
These are all topics to consider when considering the job market and demand for both the practicing Pharmacist and Pharmacy Technician.
What can fill the education gap?
I had never heard of the “Ready to Work” initiatives taking place in Birmingham, AL. But after meeting Ms. Dorothy Henry and leadership at Lawson State Community College — I stumbled upon an institution that is at the forefront of this community based initiative.
Ready to Work programs can offer job seekers foundational knowledge to take on entry level job positions. “Ready to Work” educational healthcare tracks include medical assistant, patient care assistant, and pharmacy technician. These programs help folks learn how to become registered and/or certified to take on entry level positions in the workforce.
Having a job that you care about and enjoy is good for the individual because it increases self-worth. It’s good for the family because it provides a stable source of income. It’s great for both the community and local economy because the money can be recycled into tangible purchases of goods, services, and long term assets.
I’ve had the pleasure of working with folks interested in becoming registered Pharmacy Technicians through this program. And I really believe that this could be an opportunity where more Pharmacists can serve and become involved in helping young people find a career in their local community. Programs like this help to ensure that there are affordable avenues for people to learn and become aware of professions that can be a source for both a rewarding career and steady income. I have posted my lecture materials online at www.samblakemore.com . Feel free to follow along and give back any comments and/or positive feedback.
The Dispense As Written Codes that I use regularly in my practice are:
DAW 0 = NO PRODUCT SELECTION INDICATED
DAW 1 = SUBSTITUTION NOT ALLOWED BY PRESCRIBER
DAW 9 = SUBSTITUTION ALLOWED PLAN REQUESTS BRAND
Why is this important?
Dispense as written codes are important in billing/filing claims correctly to a patient’s insurance plan. Claims must be billed/filed correctly so that patients receive the appropriate drug products at the correct price.
For me… DAW 0 is used most of the time (this holds true for most pharmacists), while DAW 1 is used sparingly; a drug example for those who are not Pharmacists as to when a Pharmacist uses DAW 1 is seen in the case of prescribing Brand Name Synthroid. Prescribers often write for Brand name Synthroid instead of Levothyroxine because this drug has a Narrow Therapeutic Index (NTI). Due to the NTI, formularies often include both the Brand and Generic products on their formularies so that patients receive appropriate pharmaceutical treatment for their thyroid conditions.
If you’re interested in reading more about NTI, please visit the FDA’s website and review the powerpoint “Quality and Bioequivalence Standards for Narrow Therapeutic Index Drugs.”
DAW 9 is increasingly becoming popular and being put into place by Pharmacy Benefit Managers (PBM’s). Typically generics have been dispensed because the generic product is the cheaper alternative when compared to the brand name product. However, increasingly manufacturers have been offering PBM’s rebates for the monies that they pay the pharmacies on the drugs cost.
In short…even when prescribers write a prescription and sign Product Substitution Permitted — the pharmacist must dispense the brand name product for the product to be covered by the patient’s insurance. This is done by changing the computer DAW code from a 0 to a 9.
So you may be asking, “how is it more profitable for the PBM’s to have higher priced drugs on their drug formularies?” I found a great article published by NCPA entitled “PBM Revenue Streams and Lack of Transparency”. The article is a quick read and outlines why Brand Name products continue to be on formulary even when a generic competitor enters the market.
Examples of using DAW 9 in my practice (Generic Drug — Condition Treated)
Dexmethylphenidate ER — ADHD
Diazepam Rectal Gel — Seizures
Methylphenidate ER — ADHD
Budesonide Respules — Asthma
What’s the effect on people and the market?
In my practice this leads to a major consultation point…
- You and/or your family member is on a drug that insurance is requiring that Brand Name be dispensed (DAW 9). I’m not sure if your local pharmacy carries the Brand Name or Generic product. Thus, it is imperative that you contact your pharmacy days in advance to ensure this product is in stock when you attempt to refill your medication. If you don’t call ahead of time, this could potentially delay when you receive your medication, which could lead you to become non-compliant with your medication(s).
The reason that this is so important…
- Finding the medication for your patient is important…but ensuring that your patient has access to this medication is just as important. If they can’t obtain or access the medication, then you can’t ensure their compliance on the medicine. And non-compliance ultimately can lead to hospital readmission.
- When patient’s transition from an inpatient admission to being discharged to the outpatient setting, prescribers are often unaware of what’s on or not on the patient’s drug formularies. This can lead to confusion and delay and/or impede discharge planning which can potentially lengthen their hospital admission.
DAW 0 versus DAW 9 seems like such a trivial issue, but the increased prevalence of this small change can impact our patient’s compliance and can drive up the cost for providing healthcare.
If you have Questions related to this topic? Please feel free to leave a comment.
My Operations Management (OM) Professor in B-school had one question for our final exam.
Explain if this course will or will not be relevant in your chosen profession or career path?
I revisited my short summary a few days ago and considered the role of the Pharmacist in relation to the current healthcare model. How can Pharmacists help create efficiency when we see inefficiency? How can individual Pharmacists help bring order to a process and fill in the gaps when we see an opportunity to help?
I believe the Pharmacist can fill in the “gaps” and find an opportunity to serve in new ways. This will further our value to the healthcare team. Dispensing medications correctly should always be the foundation of our Profession, yet there are more bricks to be put in place to create the final framework in our bid to be seen as “healthcare providers”. With the broad knowledge base that Pharmacists have in their toolbox, there is an opportunity to be more than “retail or clinical.”
December 4th 2015 at 9:53PM I submitted the following.
Sam Blakemore, PharmD
Personal Operations Management
I have been a practicing Pharmacist for three years. In that time period, Walgreens purchased Alliance Boots, CVS Caremark purchased Target’s in store pharmacies, and most recently Walgreens made another large investment in agreeing to purchase Rite Aid Pharmacies.
The number of patients that the healthcare system takes care of will continue to rise due to more people having access to healthcare with the implementation of the Affordable Care Act. Yet, the reimbursements for these services has become more competitive due to increased demand for better pricing by federal and state funded programs.
The Affordable Care Act has made mergers the new norm. Hospitals, Pharmacies, and Home Health Care Agencies have decided that the key to survival is to become as “lean” as possible. In becoming “lean”, the merged companies streamline operations by initiating new workflow processes, retire outdated facilities, and layoff under-performing workers in the hopes of increasing productivity and profits.
Mergers within the pharmaceutical industry are creating shifts in the supply chain. This will impact the drug companies, wholesalers, and retail pharmacies both independent and chain. In the article Drug Partnership Could Trigger Major Supply-Chain Changes, the author states the following:
For now, drug manufacturers mostly use wholesalers like AmerisourceBergen to ship their product to pharmacies. But if manufacturers are squeezed too much by the arrangement, some could opt to bypass wholesalers altogether and peddle their drugs straight to the drug stores…1
Pharmacy mergers have increased for the purpose of survival in a market with a reimbursement structure that changes by the day. In the article, Reassessing the pharmacy supply chain for a healthier bottom line, the author states the following:
The unpredictable and shrinking reimbursement landscape requires these organizations to reassess expenses and processes –especially within the supply chain—across all facilities and departments to determine cost-effective operational strategies.2
Forecasting reimbursement and cost of drugs in pharmacy is key to success. As an example, Rite Aid Pharmacies earnings per share decreased due to a cut in Medicare reimbursement rates.
Rising generic drug prices are hurting drug store operators as insurers and pharmacy benefit managers have been slow in raising reimbursement rates for those drugs…reimbursement rates for Medicare Part D drug plans, which cover prescription drugs for senior citizens and the disabled, are falling due to growing competition to win these contracts.3
Appropriately forecasting revenues and expenses, using lean/six sigma principles to eliminate drug errors, and having a firm grasp of inventory management are the big three principles I will remember from this course. Having a firm grip on these concepts can be the difference between thriving and failure in this market. It is imperative that a pharmacist have a firm grasp of operations management to thrive in this market and differentiate one’s self against other pharmacists they’re competing against for a job.
I want my patients to have a good experience. I want them to receive the right drug, at the right dose, at the right time, and for the right price. With that in mind, this quote grabbed my attention when I first read it.
“With the country focused on controlling the escalating costs of healthcare, every entity in the healthcare system is under increased pressure to lower costs—while at the same time not jeopardizing the quality of care that patients receive.”4
It is my opinion that schools of medicine, nursing, pharmacy, public health and so forth should require or offer as an elective an operations management course. This course has challenged me to reconsider how I manage employees and myself. This operations management course offered me the information, vocabulary, and resources that I’ll be able to draw from in a healthcare environment that is rapidly undergoing change due both to increased competition and decreased net margins.
1.) Martin, Timothy W. Drug Partnership Could Trigger Major Supply-Chain Changes. 22 March 2013. http://www.wsj.com/articles/SB10001424127887324373204578374801163395308. Accessed 23 Nov. 2015.
2.) Piotrowski, Cary. Reassessing the pharmacy supply chain for a healthier bottom line. 17 July 2015. http://www.beckershospitalreview.com/finance/reassessing-the-pharmacy-supply-chain-for-a-healthier-bottom-line.html, Accessed 18 Nov.
3.) Ramakrishnan, Sruthi. Rite Aid cuts full year forecasts citing reimbursements. 17 Sept. 2015. http://www.reuters.com/article/2015/09/17/us-rite-aid-results-idUSKCN0RH1I920150917#BMoHOwRPdPZFJMVo.97. Accessed 18 Nov. 2015.
4.) Pharmacy Inventory Project: Improving Inventory Management at Genesis Healthcare System Pharmacies. 19 Nov. 2014. http://fisher.osu.edu/supplements/10/14252/white_paper_genesis_2014_2.pdf. Assessed 18 Nov. 2015.
It’s not always about how much money a business makes; oftentimes its more important to understand how much money the business can save.
I asked a Pharmacist the following question:
“Who is probably the most famous and richest industrial engineer? Your hint… he grew up in Mobile, AL?”
He paused and thought about it for a few moments…
Then he said, “I’m not sure…who?”
I said, “look at your smartphone… Tim Cook ring a bell…”
Tim Cook…iPhone…ring a bell…”HAHA.” I know…I know…so funny, not really. Our discussion began when he asked me about my experiences in B-school (business graduate school). I discussed various points in my journey as a manager, and how I sought some answers to my many managerial questions. B-school helped fill some of those gaps.
Quantitative Analysis for Managers I explained was an interesting but difficult course. I really had to work hard to put all the concepts together. It was business math on steroids. A taste of algebra with a pinch of calculus and a dollop of excel spreadsheet. One week we were discussing linear programming models; the next week we were discussing transportation models.
I felt like I could study all week for the tests, and still not feel good about my prospects of passing. The Professor would allow us to have a formula cheat sheet, but that was of little value. The course took time and was intense. The tests were tough. He ended up curving our final grades that semester.
It was tedious work. It took time to wrap your mind around some of the concepts; but studying those concepts gave me satisfaction. My mind was being pushed and thats what I wanted as a student. It made me appreciate the skill and art it takes to make complex business processes less complex. I began trying to understand the formulas behind business principles. I enjoy learning about a Professor’s educational background. It always explains why some concepts just feel so natural to the teacher/lecturer. Turns out our Professor that semester was an expert in the field of industrial engineering. I had heard about civil engineering, chemical engineering, electrical engineering, etc.. But I had never heard of industrial engineering.
Pharmacist in general have an appreciation for math and science. So I decided to show my Pharmacist “buddy” an old video on linear programming that the Professor had uploaded on the web. The Pharmacist became “giddy” with anticipation on how to setup the correct mathematical equation to reach an appropriate business decision based on profitability.
We then lightly touched on transportation models…
I said, “driving a 18-wheeler seems simple enough…but then imagine all the routes and paths those trucks can take to get to their destination.”
He said, “yea…that’s right…isn’t that why some mail couriers only take right hand turns? That’s why they have people doing that research…think of all the money they save on gas, and all the time they save by making routes more efficient…”
I said, “you know where most of these principles fall under? Industrial engineering…”
Industrial engineers bring science to our everyday lives by engineering efficiency; they use math to bring order to a process. Pharmacists practice the same methods with medications. We ensure patient safety by being the medication experts of the healthcare team. We bring order and create efficiency in the dispensing and consumption of medications.
So what’s stopping Pharmacists from reaching our full potential as the “industrial engineers” of drug management? Gaining status as “healthcare providers” will go a long way in creating a structure for the reimbursement of our services. But until that “provider status” reaches all 50 states; what can our Profession do to show the “system” our value?
Currently the market is focused on volume to magnify shrinking profit margins. However, the market will gradually shift to a focus on reducing costs. In part because rising costs will lead to skyrocketing debt in our current healthcare model. The market is at risk of collapse due in part to rising medication costs. While we can’t control how Pharma prices new drug regimens.. Pharmacists can be on the front lines of change by initiating the following principles:
- Limit “defects”–use “lean” principles to ensure patient safety and accurate dispensing of medications with appropriate operations management principles
- Improve discharge planning—ensure patients receive the appropriate medications upon discharge.
- Improve access—ensure that upon discharge from hospitals or clinics; patients have access in the community to the appropriate medications from local pharmacies, mail-orders, and patient assistance programs.
- Engage in dialogue with prescribers—regarding the prior authorization process, formulary additions and deletions, an analysis on patterns seen at the pharmacy in the local community.
- Build an alliance—with social workers, churches, community organizers so that when patients need help the Pharmacist can give guidance.
- Data mine–effectively gather data about medication usage and prescriber patters; then turn data into usable information to enhance quality of care.
- Reduce expense—have an active engagement in knowing the costs of medications, and the copay tiers of pharmacy benefit managers. Have an active discussion with patient’s and their families regarding their ability to manage these expenses.
There are more PharmD’s graduating with dual degrees; Pubic Health, Business, and Law. There are more PharmD’s entering pharmacy school having already obtained a bachelors degree. The “Millenial PharmD” has the potential to step outside the box to meet the changing demands of the market.
My version of the Pharmacist Industry Engineer (PIE) does not epitomize the traditional meaning of Pharmaceutical Industrial Engineering in that traditionally the framework of the definition was focused on manufacturing for “Big Pharma”. I simply seek to use this term to reframe how we are defined as agents of change in the current marketplace.
A PIE as defined by me—both optimizes and individualizes pharmaceutical care, creates new processes to improve pharmacy access, improves operations to ensure patient safety, and builds communication channels with both prescribers and patients to reduce waste and expense for the individual and healthcare system.
Efficiency. Accuracy. Reduced Defects. Reduced Costs.