Experts | University of the Sciences

Deception and Hypocrisy from Mail-order Pharmacies

By Dr. Daniel A. Hussar who is the Remington Professor of Pharmacy at University of the Sciences' Philadelphia College of Pharmacy. He serves as the author and editor of The Pharmacist Activist newsletter (http://www.pharmacistactivist.com) from which this editorial was taken.

Having devoted two recent editorials to the topic of mail-order pharmacies (please see the May and July issues of The Pharmacist Activist), I would much prefer to now address other subjects. However, recent comments by the CEOs of Medco and Express Scripts are too deceptive to be ignored.

CEO Insults Medco Pharmacists
At a meeting earlier this month, the CEO of Medco is reported to have stated that Medco's "robots" are "twenty-three times more accurate" than human pharmacists with respect to errors in dispensing prescriptions. Why is the "leader" of a pharmacy company even suggesting that robots and pharmacists can be compared, particularly when the comparison he states is so demeaning to pharmacists? His statement is most insulting to his own Medco pharmacists because these are the only pharmacists whose accuracy Medco is in a position to determine. Medco pharmacists must be furious! Only several months ago it was announced that Medco had agreed to be acquired by Express Scripts. If the acquisition is approved, there is every reason to believe that the CEO of Medco will become even wealthier than he is now as his "reward" for facilitating the acquisition. At the same time, however, many Medco pharmacists and other employees face the uncertainties of whether their positions will be eliminated or whether they may have to relocate to retain their positions. Then, to add insult to injury, Medco's CEO lauds the accuracy of its robots. However, someone had to program the robots. Could it have been Medco pharmacists that their CEO somehow overlooked?

But perhaps the Medco CEO was attempting to compare the Medco robots with pharmacists in local pharmacies. To my knowledge, there is no study that directly compares mail-order pharmacies and local pharmacies with respect to accuracy rates in dispensing prescriptions. So where does the Medco CEO's allegation that his robots are twenty-three times more accurate come from? Did Medco conduct a study that they have not published or otherwise made available? Or is this yet another extrapolation of a study done years ago that was designed by Medco personnel using study parameters that they selected, and that was conducted by individuals having a vested interest in the results. There were no local pharmacies included in this study. However, that did not stop the Medco personnel from attempting to compare the results of their "study" with the results of a different study in local pharmacies conducted by objective researchers. Medco and other mail-order pharmacies have attempted to use their data to claim that their pharmacies make fewer errors. However, this is blatant deception! Even the Medco authors of the paper they published regarding their study acknowledge that "Ébecause mail-service pharmacies differ in their operation and degree of automation, these findings cannot be generalized to mail-service pharmacies as a class." I agree with this acknowledgement. However, if the study findings can't even be considered applicable to other mail-order pharmacies, there is absolutely no credibility to the claims of Medco and others that these findings can be considered applicable to local pharmacies.

Dissing Retail Pharmacy
In the same meeting in which the comment about the robots was made, the Medco CEO made the observations about retail pharmacy that "Éthere's a fiction that a pharmacist comes out and dialogues with you. ÉIn reality, a high school student hands you a script from the shelf." He prefaced these comments by noting "I'm not dissing retail [pharmacy]É" However, this contradictory disclaimer can in no way diminish his outrageous denigration of community pharmacy practice. I will acknowledge that there are some local pharmacies in which there is no communication between the pharmacist and patient, and little or no professional service provided. I am critical of these pharmacies - but at least prescriptions are provided on a timely basis and a pharmacist is quickly available to respond to questions. How can the Medco CEO make such demeaning remarks about the profession of pharmacy from which his company has derived huge profits? How can he be so critical of community pharmacy practice and completely ignore the limitations and failures of the mail-order pharmacy for which he has responsibility?

Different Venue-Different Message
The planned acquisition of Medco by Express Scripts has raised numerous concerns that are being addressed by the Federal Trade Commission (FTC) and Congressional committees. Those opposing the acquisition are concerned that the merger of two of the three largest pharmacy benefit managers (PBMs) will result in a dominant and anticompetitive influence in the marketplace that will force an even larger number of consumers to obtain their prescriptions from the mail-order pharmacies that these PBMs own. Many local pharmacies will not be able to survive financially and the provision of medications and professional services on a timely basis for patients will be diminished.

The testimony provided by the Medco CEO before the FTC has strikingly different content and tone when compared with his comments identified earlier. His comments include: "More than 85% of prescriptions filled for Medco customers are filled through our networks of more than 60,000 retail pharmacies. Medco is dependent on the continued existence of strong independent retail pharmacies." Can these comments be provided by the same individual who speaks so disparagingly about the accuracy of pharmacists compared with his robots? The message clearly depends on the audience and, for the FTC, the message is that there are tens of thousands of local pharmacies on whom Medco is dependent and a competitive marketplace will continue. Compared with the other comments of the Medco CEO and the actions of Medco in the marketplace, this message is hypocritical.

The Express Scripts Message
At a hearing of a House subcommittee that is examining the planned acquisition of Medco, the CEO of Express Scripts noted that the acquisition would result in "safer and more affordable" drugs. I have already refuted the allegation that mail-order pharmacies are safer than local pharmacies. One response to the claim that drugs will be more affordable if the acquisition is permitted is the following question: What has happened to the cost of prescription drugs during the period of time in which the number of prescriptions dispensed by mail-order pharmacies has greatly increased? The answer is that the cost of prescription drugs has also greatly increased. If these PBMs were not able to make drugs more affordable during the period in which their size, power, and influence have markedly increased, why would they be able to do this if they were permitted to merge? The answer is they can't and they won't. This issue is addressed in greater detail in the editorial in the July issue of The Pharmacist Activist - "Express Scripts and Medco - A Fallen Giant or a Bigger Monster?"

When the CEO of Express Scripts was asked at the House subcommittee hearing to identify the best way to reduce prescription drug costs, his response was by reducing waste, fraud, and abuse. This is a laudable goal but his response invites attention to the most important reasons for the waste of medications and the resultant costs. The most frequent explanation is the large quantities of medications received from mail-order pharmacies that are not used.

The Drug Enforcement Administration (DEA) has held three National Drug Take-Back Days - in September, 2010, April, 2011, and on October 29, 2011. On the first two of these days, more than 309 tons of medications were collected. If a study was done of randomly selected quantities of the collected medications (while preserving the confidentiality of the patients who turned in the medications), my expectation is that the medications supplied by mail-order pharmacies would represent a disproportionately high percentage.

Actions
The National Community Pharmacists Association and the National Association of Chain Drug Stores, as well as a number of consumer organizations, have mounted strong opposition to the acquisition of Medco by Express Scripts. Individual pharmacists, particularly those in local pharmacies, must join this effort. Owners of pharmacies should individually assess their participation in prescription benefit programs in which there are non-negotiable, take-it-or-leave-it terms of participation, inadequate compensation, abusive audits, and insulting criticism from those administering the programs.

Daniel A. Hussar

The Impacts of Our Profession

    Recognized as one of the most trusted of the health professions, pharmacists have always played a key role in the healthcare continuum. As young pharmacists in training, we are at the forefront of a profession that has taken on greater responsibility in providing patient care and management while helping to reduce healthcare costs.

    Did you know that pharmacists are not just responsible for dispensing medication but now provide important services such as:

• Immunization and flu shot administration 
• Diabetes counseling 
• Blood pressure medication management through medication therapy management and substance abuse counseling, just to name a few.

    With the ongoing debate in the United States regarding healthcare costs, pharmacists are on the front lines to:

• Increase access to healthcare and decrease costs by working with patients
• Guard for proper administration of medications that has the potential to cut down on ailments and ER visits
• Work on teams with other healthcare providers to ensure the best care for patients and provide important answers to many questions regarding medications and health conditions

    The fall months mark the start of Cold and Flu Season! That means more doctor visits and more so the increase in purchasing over the counter medications to combat the cold and flu.

• According to the American Pharmacists Association, 82% of consumers purchase over the counter products recommended by their pharmacist

• With so many medications on the market and their thousands of active ingredients, patients are encouraged to consult their pharmacist to maximize benefits.

• The role of the pharmacist is to provide and counsel patients with the right over the counter medications

    We can provide patients with information about drug-food interactions, drug-drug interactions, or drug-supplement interactions

     We help patients select products that address the patient’s individual needs and help them sort through the many products that are available

 

PHARMACISTS ARE MOST ACCESSIBLE WHEN IT COMES TO MEDICATION RELATED NEEDS!

 

 

-Alyssa Lesko, 2014 PharmD Candidate and APhA-ASP Chapter President-Elect 2011-2012

 

Express Scripts and Medco: A Fallen Giant OR a Bigger Monster?

By Dr. Daniel A. Hussar who is the Remington Professor of Pharmacy at University of the Sciences' Philadelphia College of Pharmacy. He serves as the author and editor of The Pharmacist Activist newsletter (http://www.pharmacistactivist.com) from which this editorial was taken.

It was only two months ago that my editorial was on the topic of mail-order pharmacy programs (May 2011 issue of The Pharmacist Activist - "Mail-Order Pharmacy Programs - Limitations, Inequities, and Deception"). However, the implications and concerns regarding the recent announcement that Express Scripts plans to buy Medco for $29.1 billion warrant further consideration of this topic.

Some background

The administration of prescription benefit programs has been dominated by three pharmacy benefit managers (PBMs) - Medco being the largest and followed in size by CVS Caremark and Express Scripts. Although it usually would not be expected that a smaller company would be in a position to acquire the largest company, Medco has recently lost three huge contracts including one with the insurer United Health Group (which now plans to manage its own prescription program) that accounts for approximately 17% of Medco's business. One suggested explanation underlying the planned acquisition is that Medco, rather than risking a further weakening of its position and unable to rule out the possibility of CVS Caremark selling its PBM to Express Scripts, identified to Express Scripts that it was receptive to being purchased. The proposed name for the combined company is Express Scripts Holdings Company and the current chairman and chief executive of Express Scripts will retain both his titles.

The potential for the new company to control the PBM marketplace in an anticompetitive manner has raised antitrust concerns and expectations of some that the acquisition will not be approved by the Federal Trade Commission (FTC). Others anticipate that the FTC will provide approval based on the reasoning that CVS Caremark, United Health, and smaller PBMs can provide sufficient competition in the marketplace.

Cost savings?

The executives of Express Scripts and Medco are promoting approval of the acquisition based, in large part, on their contention that the combined company will have sufficient influence to reduce the cost of prescription medications. Needless to say, a claim that a company can reduce the cost of any component of health care immediately attracts interest from government agencies, employers, unions, and others. However, before such a claim can be considered credible, important questions must be evaluated.

For a number of years the PBMs have operated in an essentially unregulated manner through which they have attained substantial influence, revenues, and growth. The first question that must be asked is: What has happened to the cost of prescription medications during this period of time in which the PBMs have had such a strong influence? The answer is that the cost of prescription drugs has markedly increased. Although some will quickly blame these increases on the pharmaceutical companies, why were the PBMs not able to reduce, or at least control, the costs of prescription medications in the recent past when they suggest they will be able to do so in the future if they are permitted to become bigger?

How will a combined Express Scripts and Medco be able to reduce the cost of prescription medications? The answer is that they will use their greater size and influence to obtain greater rebates from pharmaceutical companies and negotiate lower fees with chain pharmacies. And the independent pharmacies for which the PBMs dictate "take it or leave it" terms will be at an even greater disadvantage than they are now. The challenges that exist even now for independent pharmacies as a consequence of the PBMs' anticompetitive programs and policies should be reason just by itself for the FTC to reject the plan of Express Scripts to acquire Medco.

As unlikely as a reduction in overall costs of prescription medications would seem to be, some anticipated and unprecedented changes in the marketplace suggest that such a change could occur during the next several years. This is because there will be a large number of widely-prescribed and expensive medications (e.g., Lipitor, Plavix, Zyprexa, Lexapro, Seroquel) for which patent protection will expire and much less expensive generic formulations will become available. However, these opportunities for reduced costs of important medications will result regardless of whether Express Scripts and Medco exist as two companies or one company. Indeed, it will be very interesting to observe whether the PBMs pass on the savings to clients when they experience sharply reduced costs for these generic products.

If a reduction in the cost of prescription medications is attained as Express Scripts and Medco propose, who will be the beneficiaries of the savings? Most certainly these PBMs will retain as much of the savings as they can, and perhaps pass some of it on to their clients. If patients/consumers/the public experience any reduction in the cost of their prescription medications, it will be a very small fraction of the amount saved.

As I was writing this editorial, I received a communication from John Buck, the Editor-in-Chief of NEWS-Line Publishing, the organization that publishes The Pharmacist Activist. He is preparing a commentary regarding the proposed acquisition for another NEWS-Line publication, and shared the following observation:

"In searching for news and opinions about the merger, I found more articles on how to profit from it or on Wall Street's reaction to it, than its effect on the consumer, healthcare, or community pharmacies. That is just sad."

His comments are absolutely on target! The quality and scope of the services provided patients by pharmacists, as well as the timely availability and affordability of medications for patients, should receive the highest priority. However, these issues are rarely mentioned in the media coverage. Lest I also be considered guilty of an excessive focus on the economic issues, please also read my May 2011 editorial.

Some responses

As noted earlier, one of the ways in which the combined Express Scripts and Medco would expect to reduce the costs of medications is to reduce the compensation to participating community pharmacies. Therefore, not surprisingly, the National Community Pharmacists Association (NCPA) and the National Association of Chain Drug Stores (NACDS) were among the first to respond to the announcement of the planned acquisition with a statement that reads, in part:

"Today's announcement that Express Scripts will buy Medco creates a middle man that is too big to play fair, and will have immense power to unfairly dominate the market. This combination will monopolize control of the supply line for brand and generic prescription drugs, threaten access to pharmacy patient care, and is a bad deal for America for healthcare plans, for pharmacies, and - most notably - for patients."

I fully concur with this statement. The characterization of "too big to play fair" also invites the observation that these two companies, as well as CVS Caremark, have been viewed by many as being unfair and worse even as separate entities. This is reflected, in part, by their payment of hundreds of millions of dollars to settle claims of fraud and deceptive practices so that these companies can avoid acknowledging any wrongdoing and escape further prosecution. The anticipated consequence of permitting these companies to become bigger and wield more influence would be a further abuse of their power.

It is appropriate that NACDS has taken a strong position against the proposed acquisition. Even though individual chains can negotiate program terms and compensation with the PBMs, most are in a weak bargaining position when dealing with a huge PBM. It is noteworthy that the immediate past chairman of the Board of Directors of NACDS is the president and CEO of CVS Caremark, the strongest competitor of Express Scripts and Medco. The vice chairman of the NACDS Board is the president and CEO of Walgreens. Walgreens recently announced that it would not accept the terms of a new contract (with estimated revenue of more than $5 billion) offered by Express Scripts to participate in its prescription programs. In the face of the implications of the proposed acquisition of Medco, it will be very interesting to observe whether Walgreens stands its ground against Express Scripts or whether it reaches an agreement as it did last year when it threatened to discontinue participation in programs administered by CVS Caremark.

There has been very little comment regarding the proposed acquisition from the pharmaceutical companies that the combined and more powerful PBM will expect to provide greater rebates for their medications. It is ironic that the same pharmaceutical companies that initially caused the chaos regarding the pricing of pharmaceuticals may now be victims of the giant PBMs to whose growth the companies' pricing policies significantly contributed.

No opportunity to respond

There is another important group who either do not have a forum in which they can respond or there is not enough interest on the part of their company, the media or others in whether they have a response. This group includes the Medco pharmacists and other employees. When a deal valued at $29 billion is planned and implemented, company stock holders are expected to benefit and the highest level executives are provided substantial additional compensation and/or other benefits. Little or no attention is given to the welfare of the employees whose dedication and efforts have significantly contributed to the growth of a company to the point that it motivates another company to acquire it.

As strongly as I feel that the type and scope of pharmacy practice that I advocate can not be provided through a mail-order pharmacy program, I have a genuine concern for the Medco pharmacists and other employees whose lives will be affected by a decision that they probably did not know was even being considered. They have been sold out by their executives. Uncertainties regarding closing of facilities and loss of jobs or need for relocation are challenging at any time but particularly during the current economic climate that includes a tightened employment market for pharmacists.

Actions

Although the proposed acquisition of Medco by Express Scripts would have the largest impact on pharmacy practice and patient care in the community setting, it has important implications for the entire profession of pharmacy. Accordingly, the associations of pharmacy practitioners should object to the acquisition in a unified and strong voice to the FTC and our legislators. However, this should be viewed as a short-term intervention to prevent a bad situation from becoming worse.

The prescription benefit programs that are currently available have serious flaws, are a disservice to patients with respect to their limitations in quality and scope, and are inequitable for pharmacists. The profession of pharmacy must design better prescription benefit plans that give the highest priority to the provision of optimal drug therapy for patients by pharmacists who meet with and participate in the direct care of patients.

I am convinced that better programs can be developed that will also be cost-effective. The flawed programs administered by PBM "middlemen" are extracting billions of dollars from the health care system without participation in direct patient care and contributing nothing to the overall quality of pharmacy services. These resources must be redirected to programs that will attain positive outcomes.

The profession of pharmacy can not expect that the government, insurance companies, or PBMs will develop prescription benefit programs that will fully utilize the expertise and scope of services of pharmacists for the benefit of patients. As a profession, we must accept the responsibility for the development of a model prescription benefit program and secure the resources to evaluate it on a pilot basis. I am optimistic that a model program can be so successful and cost-effective that the wisdom of using it for much larger programs will be quickly recognized and embraced.

Pharmacy's Vision for 2015 OR a Large Surplus of Pharmacists?

By Daniel A. Hussar who is the Remington Professor of Pharmacy at University of the Sciences' Philadelphia College of Pharmacy. He serves as the author and editor of The Pharmacist Activist newsletter (http://www.pharmacistactivist.com) from which this editorial was taken.

The Joint Commission of Pharmacy Practitioners (JCPP) provides a forum in which the chief executive officers and chief elected officers of the national pharmacy organizations meet to discuss issues that are of importance to the profession. In late 2004 the JCPP developed the following vision statement that was endorsed the following year by all of the major pharmacy practitioner organizations;

"Pharmacists will be the health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes."

This vision statement is followed by a discussion titled, "Pharmacy Practice in 2015," that addresses "The Foundations of Pharmacy Practice", "How Pharmacists Will Practice", and "How Pharmacy Practice Will Benefit Society". The section on "How Pharmacists Will Practice" is provided below:

How Pharmacists will Practice. Pharmacists will have the authority and autonomy to manage medication therapy and will be accountable for patients' therapeutic outcomes. In doing so, they will communicate and collaborate with patients, care givers, health care professionals, and qualified support personnel. As experts regarding medication use, pharmacists will be responsible for:

• rational use of medications, including the measurement and assurance of medication therapy outcomes;
• promotion of wellness, health improvement, and disease prevention;
• design and oversight of safe, accurate, and timely medication distribution systems.

Working cooperatively with practitioners of other disciplines to care for patients, pharmacists will be:

• the most trusted and accessible source of medications, and related devices and supplies;
• the primary resource for unbiased information and advice regarding the safe, appropriate, and cost-effective use of medications;
• valued patient care providers whom health care systems and payers recognize as having responsibility for assuring the desired outcomes of medication use.

I fully concur with this vision statement and its accompanying responsibilities. It is progressive and bold, and will serve individual patients, society, and the profession of pharmacy well. Nothing would please me more than to see this vision implemented in as comprehensive a manner as possible. However, I have serious concerns regarding what I consider to be the very slow pace in the progress toward implementing this vision, or even actively discussing it and establishing plans.

I recognize that the year 2015 is a goal and not a rigid deadline for implementing the vision statement. However, we are now closer to 2015 than to 2004 when the statement was developed, and it is appropriate to assess the progress that has been made and what remains to be accomplished. The profession can identify programs such as the Asheville project, an increasing number of medication therapy management (MTM) programs, the Pharmacy Practice Model Initiative, and some innovative practice opportunities as evidence of positive steps in implementing the vision. As important as these activities are, they often exist in isolation rather than as a type or standard of practice that is provided for more than a limited population. The result is that the vast majority of patients/society has no understanding or experience with the role and responsibilities articulated for pharmacists in the vision statement. Indeed, there are many pharmacists who do not feel prepared or are not otherwise eager to assume the responsibilities of the vision.

It would be expected that organizations of pharmacists, colleges of pharmacy, and pharmaceutical manufacturers would be among those having the strongest interest and commitment to having pharmacists assure optimal medication therapy outcomes. Yet, it is my impression that only a small fraction of these organizations provide a health benefit program for their employees that includes MTM and related services from pharmacists. If the organizations whose own interests are best served by the inclusion of such a benefit for their employees do not insist on this coverage, how can it be expected that other organizations and government programs with less knowledge of the value of these services will be motivated to provide them as a benefit?

Whose responsibility?
It was appropriate that the vision statement for pharmacy practice was developed by representatives of a coalition of pharmacy practitioner organizations. However, the development of the statement can be considered to be the easy part of the process. To make this vision a reality is a much more formidable challenge.

The implementation of the vision will not occur without clear direction, strategies, and plans, as well as the resources to support them and the collaboration of the other professions and organizations whose support will be necessary. It will not be accomplished by the action of one or several pharmacy organizations, or even multiple organizations working independently. The same coalition of pharmacy organizations that developed the vision statement must assume the responsibility for the planning and implementation steps that will ensure the intended outcomes. But is this discussion and collaboration occurring?

The need
There is no question that there is an important need for the outcomes identified in the vision for pharmacy practice (i.e., optimal medication therapy outcomes). Pharmacists have the expertise and are strategically positioned to provide the information, counseling, monitoring, and services needed to ensure optimal drug therapy outcomes and their resultant overall contributions to the improvement of health care. There has been extensive publicity regarding drug-related problems (e.g., adverse events, drug interactions, noncompliance, medication errors) and their resultant harm to patients, as well as the billions of dollars in costs incurred to manage often-preventable problems. Patients, health professionals, and society should not continue to tolerate the current situation. But, if pharmacy will not assume the responsibility for ensuring optimal medication therapy outcomes, others (e.g., nurse practitioners, physician assistants) will have to!

The supply of pharmacists
Until recently there had been a shortage of pharmacists in many areas of the United States. However, during the last two years the job market for pharmacists has tightened and there is now a surplus of pharmacists in some areas. A paradoxical situation exists in which, at the same time that there has probably never been a greater need for the expertise and services of pharmacists, many pharmacists are having difficulty identifying a full-time position. This situation makes it all the more important that the profession of pharmacy be successful in implementing its vision for pharmacy practice.

If pharmacists are used to ensure optimal medication therapy outcomes to the extent such services are needed, many more pharmacists will be needed than are currently available. Indeed, there could be a shortage of pharmacists for the foreseeable future, even with the rapidly increasing number of pharmacy graduates. If, however, our profession is not successful in implementing its vision and/or health professionals other than pharmacists assume these responsibilities, the surplus of pharmacists being observed in some areas could increase precipitously with numerous ramifications. The potential for this situation must also be addressed with high priority by our profession (please also access the editorials in the August 2008 and July 2010 issues of The Pharmacist Activist).

Urgent action is needed
Through the JCPP the profession has identified an exceptional vision for the practice of pharmacy that is of great value for patients and society. The "match" between the need for better medication outcomes for patients and the expertise and services that can be provided by pharmacists is seemingly a perfect fit. However, the challenges to successfully implement the vision are huge and demand an unprecedented commitment and collaboration of our practitioner organizations. I want to believe that within our profession we have the will, resolve, and leadership to be successful in attaining our vision.

Mail-Order Pharmacy Programs – Limitations, Inequities, and Deception

By Daniel A. Hussar who is the Remington Professor of Pharmacy at University of the Sciences' Philadelphia College of Pharmacy. He serves as the author and editor of The Pharmacist Activist newsletter (http://www.pharmacistactivist.com) from which this editorial was taken.

Like many within our profession, I was more of an observer than a critic of mail-order pharmacy during the early years of its development. However, as it subsequently experienced a period of rapid growth, its limitations and problems were exposed and its proponents resorted to tactics that I consider to be anticompetitive and a disservice to patients. It is these tactics that have been primarily responsible for my becoming a strong critic of mail-order pharmacy programs that have mandated or provided incentives for their employees/clients to participate in these programs. Sometimes, however, the almost exclusive focus on these tactics and their consequences precludes a broader awareness and concern regarding the scope and quality of the health care for patients and the professional services they should be able to expect from pharmacists. It is the purpose of this commentary to address the larger range of implications and consequences associated with the provision of prescription medications through the mail.

Implications for Patients

Freedom of choice may be denied. Some prescription benefit programs mandate the use of a mail-order pharmacy for certain medications if patients are to receive financial coverage. These patients are being denied the opportunity to obtain these medications from the pharmacist with whom they have had a valued and longstanding professional relationship. Many patients consider this relationship with their local pharmacist to have a value equal to that of their relationship with their personal physician.

Mail-order pharmacy is not personal. Patients are denied the opportunity to meet with the invisible and unidentified pharmacist who is providing their medications from a mail-order pharmacy. The benefits of a face-to-face discussion can not be provided in a patient package insert or telephone conversation. I am convinced that it is not possible to provide optimal health care and optimal drug therapy and outcomes, and also to avoid drug-related problems, without the personal services and "touch" of caring pharmacists and other health professionals (please see my editorial in the March 2011 issue of The Pharmacist Activist regarding the need for a personal touch). There has been extensive recent attention to the provision of "personalized medicine." It is contradictory and regressive that mail-order pharmacy is depersonalizing the provision of medication and denying access to a personal pharmacist in a manner that commonly exists in a local community pharmacy.

Mail-order pharmacy fragments the provision of medications and services. Prescription benefit programs that require or provide financial incentives to obtain certain medications from a mail-order pharmacy increase the complexity and potential for confusion and error with respect to the availability and use of medications. The involvement of two or more pharmacies makes it more difficult and, sometimes, impossible, for any of the pharmacists to have a complete record of the medications a patient is using.

Mail-order pharmacies increase the risk of drug-related problems. Even when the mail-order pharmacy is owned by the pharmacy benefit manager (PBM) that administers the prescription benefit program and is thought to have a complete record of a patient's prescription medications, the involvement of multiple pharmacies increases the risk of drug interactions and other drug-related problems. For example, a PBM and its mail-order pharmacy is not likely to be aware of prescriptions for which a patient pays cash in response to promotions such as a 30-day supply of a generic medication for $4.00 or free prescriptions for generic antibiotics. Likewise, a mail-order pharmacy is not aware of nonprescription medications that a patient is using that may interact with prescription medications. The approach that provides the best opportunity to assure the most effective and safest use of medications is one in which a patient obtains all of their prescription and nonprescription medications at one local pharmacy.

Mail-order pharmacies can not meet many patient needs for medications. There are many medical problems for which it is important to start treatment as soon as possible. Examples include infections that should be promptly treated with an antibiotic and acute pain for which rapid relief of symptoms is needed. The inherent limitations of a mail distribution system preclude a mail-order pharmacy from being able to provide many of the medications that patients need on a timely basis. This situation reflects an underlying philosophy of limiting the scope of medications and "services" to those that will provide maximum profit for the mail-order pharmacy, rather than providing a full range of medications and services that are in the best interest of patients.

Mail-order pharmacies can not provide medications in a timely manner. Even the fastest mail distribution system has inherent delays both in receiving prescriptions and sending the completed prescriptions. Other operational and unanticipated delays add to the time that elapses from the time that a patient requests a prescription and the time that it is received. Every local pharmacy has received multiple requests from patients for small quantities of their prescription medications to hold them over until the supply from the mail-order pharmacy arrives.

Implications for Communities and States

I have often heard pharmacy owners make the observation that they anticipate and can successfully contend with competition at the local level. However, they find it extremely difficult, and sometimes impossible, to compete with programs that include unfair and non-negotiable terms, and require patients to obtain certain prescriptions at a mail-order pharmacy or provide a financial incentive to do so. These circumstances may cause or contribute to the closure of a local pharmacy, with the result that people in the community have less convenient access to medications and services of a pharmacist. The closure of a pharmacy also results in a loss of jobs for residents of the community

At the state level there is a loss of tax and other revenues when a pharmacy closes and jobs are lost. In addition, there is also a high probability that the millions of dollars generated from prescriptions dispensed by mail-order pharmacies are going to another state rather than being retained within the states where the patients reside when they obtained these prescriptions in local pharmacies. Mail-order pharmacy has become a huge business with most of the revenues and jobs being concentrated in the small number of states in which the highly-automated, high-capacity pharmacies and office facilities are located. An example of the financial implications is included in a recent press release from Express Scripts in which it is announced that it generates about $1 billion in economic benefits each year for the state of Missouri in which its headquarters and many of its facilities are based.

Inequities and Deception

The largest administrators (PBMs) of prescription benefit programs (CVS Caremark, Express Scripts, Medco) have their own mail-order pharmacies. Their profits are highest when they are not only paid for administering a program, but also receive revenues when prescriptions are dispensed by the mail-order pharmacies they own. Many local pharmacies would be satisfied with a peaceful co-existence with mail-order pharmacies if the terms of participation were the same for all pharmacies and if patients had the freedom to choose the pharmacy they wished to use. However, this is not the case.

PBMs have conflicts of interest. The PBMs determine the terms and conditions of prescription benefit programs unilaterally without an opportunity for pharmacists to be involved in the planning of the programs. The terms, conditions, and compensation are non-negotiable and presented to pharmacies on a take it or leave it basis. Because these PBMs have their own mail-order pharmacies, the terms and conditions are constructed to favor these pharmacies and to restrict, or even exclude, the participation of other pharmacies. The PBMs get away with this obvious conflict of interest because local pharmacies are restricted by federal antitrust legislation from working together or through professional organizations to negotiate the terms of a program.

Programs are anticompetitive and inequitable. Some prescription benefit programs require patients to obtain certain medications from a mail-order pharmacy if all or most of the cost of the prescription is to be covered by the benefit program. Many programs provide a financial incentive to use a mail-order pharmacy rather than a local pharmacy, typically by permitting the mail-order pharmacy to provide a 90-day supply of medication for one or two co-payments, whereas local pharmacies are restricted to providing a 30-day supply that would necessitate three co-payments over a 90-day period.

Attempted justification is disingenuous and deceptive. The attempts of the PBMs to justify the terms and restrictions in their programs usually focus on two claims, both of which are unsupported and deceptive:

Claim # 1: The cost of dispensing prescriptions from a mail-order pharmacy is less than from local pharmacies, and the cost of the prescription benefit program would be much greater if there were not requirements/incentives to use the mail-order pharmacy.

When asked for the data and other information to support this claim, the PBMs respond that they cannot provide it because the data is proprietary and they can't risk having it become known to their competitors. In the few situations in which limited information is available, the data that is made available has been selected by the PBM and provided in a format and manner that supports its position. The claim and the information can not be independently verified. To my knowledge, there is no study that has been conducted by independent researchers who have full access to pertinent information that supports the claim that a mail-order pharmacy program is less costly than a program in which prescriptions are provided through local pharmacies.

Some suggest that mail-order pharmacies should be able to operate more efficiently because of the greater discounts attained when purchasing large quantities of medications needed for their high prescription volume, as well as the use of highly automated equipment to process and prepare prescriptions. However, these efficiencies could be offset by the costs incurred in mailing the prescriptions, the wastage of medications that are often very expensive because of the emphasis in dispensing 90-day supplies (only to have the prescriber change the dosage or discontinue the medication), and the cost of the automated equipment.

If the claim that mail-order pharmacy programs are less expensive is valid, I have to think that credible, independently-verified documentation would be quickly provided. It has not been and I can not accept the claim.

Claim # 2: Mail-order pharmacies make fewer errors and are, therefore, safer than local pharmacies.

Information that is available regarding errors that have occurred in mail-order pharmacies is essentially limited to one study that was conducted by Medco. The study was designed by Medco personnel using study parameters that they selected (that did not include, for example, whether the initiation of treatment was delayed because the medication did not reach the patient via the mail on a timely basis). The study was not conducted by "outside" researchers or other individuals who did not have a vested interest in the results. The results of this study have been widely cited by the PBMs with mail-order pharmacies. However, they conveniently ignore the following limitation of this study that the authors acknowledge in the published paper - "because mail-service pharmacies differ in their operation and degree of automation, these findings cannot be generalized to mail-service pharmacies as a class."

Although these authors indicate that their results cannot be generalized to other mail-order pharmacies, they attempt to compare their findings with those of studies in community pharmacies. This is a flawed comparison as their study did not include a direct comparison with the experience in community pharmacies.

When individuals or organizations claim that mail-order pharmacies make fewer errors or are safer than community pharmacies, the following questions should be asked in response:

• Have studies of errors been conducted in the mail-order pharmacy you are using/recommending? If so, who conducted the studies (e.g., the pharmacy's own employees) and what types of errors were included in the study parameters?
• What are the results of these studies (e.g., error rates) in this mail-order pharmacy, and what other data are available regarding errors?
• How many lawsuits alleging errors (including those settled out of court) have been filed against this mail-order pharmacy?

I have asked these questions on several occasions. No responses have been forthcoming. The claims that mail-order pharmacies are less costly and safer than local pharmacies are flawed and deceptive. They must be rejected.

Priorities for our Profession - Pharmacy

By Daniel A. Hussar is the Remington Professor of Pharmacy at University of the Sciences' Philadelphia College of Pharmacy. He serves as the author and editor of The Pharmacist Activist newsletter (http://www.pharmacistactivist.com) from which this editorial was taken.

Choosing the topic for this month's issue of The Pharmacist Activist was more of a challenge than usual. Not because there are not enough important issues to address, but rather because there are so many. Indeed, pharmacy faces so many challenges that identifying the degree of priority with which they should be addressed is an important decision in and of itself. Therefore, the purpose of this editorial is to identify the issues that, in my opinion, require our profession's highest priority attention.

1. Commitment, passion, and activism
Many pharmacists are apathetic or even negative about pharmacy and their individual responsibilities, and it is no consolation that this situation exists in every profession and area of employment. Tens of thousands of pharmacists are not members of even one professional association. Some would contend that the wide availability of employment opportunities (at least until recently) and high salaries have contributed to the apathy and complacency that is so widespread. Pharmacy has provided a good livelihood for the vast majority of pharmacists and every pharmacist should recognize a responsibility to give something back to our profession. This should be motivated by our enthusiasm for and pride in our profession, and demonstrated through a commitment to and passion for what we represent and can do individually and collectively for our patients and profession. We need thousands more activists within pharmacy. The colleges of pharmacy have an extremely important responsibility in encouraging these attitudes, qualities, and involvement among student pharmacists that will be continued through their professional careers. Our professional organizations must be more innovative and effective in increasing membership and active participation in professional initiatives.


2. More effective professional organizations
Our profession needs an organizational structure at the national, state/regional, and local levels that will serve and advance the interests of pharmacy in a more effective manner than is being accomplished through our current system (please see the editorial in the January 2011 issue [www.pharmacistactivist.com] for possible national organizational structure options). Leaders of the national pharmacy organizations should meet to actively consider these options in the context of what is best for the profession, and not just what is best for individual organizations. Many state/regional pharmacy organizations are struggling financially and have limited effectiveness. In my opinion, the profession is best served by having one organization of pharmacists in each state, and the leaders of the multiple pharmacy organizations within a state should be encouraged to develop and approve such a structure.


3. Independent pharmacies must thrive
Notwithstanding the importance of the roles and accomplishments of pharmacists in all areas of professional responsibility, it is the independent pharmacists who are the "face" of our profession with the public and who have the most prominent identity that is responsible for the reputation for trust and integrity that our profession enjoys. It is also the independent pharmacists who are the most likely to have the personal interaction with the largest number of patients who receive the medications and services around which the expanding roles of pharmacists are based. As the number of chain/corporate and mail-order pharmacies has increased in recent years and the number of independent pharmacies has declined, some have predicted the disappearance of independent pharmacies. However, we must not let that happen! A number of years ago I voiced the opinion that the future roles and success of the profession of pharmacy are inextricably linked to the extent that independent pharmacists can be successful in their professional responsibilities. My conviction regarding the validity and importance of this opinion is even stronger today. Our entire profession must be strongly supportive of efforts that will enable independent pharmacies to not only survive, but thrive.


4. Tightening of the job market
The economic challenges of the last several years coupled with the large increase in the numbers of colleges of pharmacy and pharmacy graduates have resulted in a significant tightening of the employment opportunities for pharmacists and student pharmacists. This situation has many extremely important implications that are as positive as a much larger number of opportunities in which the abilities and skills of pharmacists can be utilized in providing optimal drug therapy for many more patients, and as negative as widespread pharmacist unemployment. We must not be content to sit back and watch how this situation evolves. Our profession must be actively engaged in developing plans and strategies that will result in the assimilation of a much larger number of pharmacists in the provision of more comprehensive services of documented value to an increasingly elderly patient population with greater needs for optimal drug therapy. The alternative would be the worst possible contradiction - a country with millions of people who have a great need for the expertise possessed by pharmacists who can not provide it because of the failure of a healthcare system that does not recognize and pay for that expertise.


5. "Walking the talk"
As much as many of us extol the expertise of pharmacists and the value of our advice and services, optimal services are not the norm and, indeed, for many, are not evident at all. We must provide to a much greater extent what we claim as the value of our role and responsibilities. We must do much better in providing even the most basic information and services, and develop programs that will provide pharmacists with the information and confidence necessary to extend their services. As a profession we have the potential to assume "ownership" of important challenges such as the prevention of medication/dispensing errors and increasing patient compliance with the instructions for using medications. If pharmacists do not respond to these opportunities that can be viewed as such a natural part of our domain of responsibilities, it will only be a matter of time before other health professionals will.


6. Prescription benefit programs
The inequitable compensation and conditions of most prescription benefit programs are continuing important concerns for pharmacists. Pharmacists must document the value of their services and the cost of dispensing a prescription so that they are well positioned to demonstrate inequities in programs in which they are asked to participate. Pharmacists should not reduce the scope and quality of their services to try to adjust for the inadequacies of the program but rather should decline to participate in programs in which the compensation or other conditions are not equitable. Notwithstanding the need to avoid specifics of compensation issues because of antitrust implications, the profession should develop a model prescription benefit program that would effectively address the drug therapy needs of patients, and encourage and recognize the value of the information and services provided by pharmacists.


7. Legislative influence
Pharmacists and our professional associations must have much more extensive and effective communication with our legislators. The geographical distribution of pharmacists provides an excellent opportunity for legislative influence. However, we are not even close to reaching our potential in this regard. In addition to having pharmacy's interests and services considered in new and revised national health insurance legislation (e.g., Obamacare), other issues require the attention of the profession. Examples include legislative changes that would permit pharmacists and our organizations to collectively negotiate for equitable compensation for the services we provide, and changes that would prevent mandated participation of patients in mail-order pharmacy programs.


8. Taking a stand
The profession of pharmacy, primarily through its professional organizations, must demonstrate the courage to address situations that place patients at risk and/or are potentially damaging to the profession, even if they may be controversial or sensitive. For example, excessively busy and stressful working conditions that increase the risk of dispensing errors must not be tolerated. Employers who persist with policies that place patient safety in jeopardy must be challenged. Likewise, prescription benefit programs that require or provide financial incentives for patients to obtain medications from a mail-order pharmacy and decrease personal communication between patients and pharmacists must be challenged. The continuing establishment of new colleges of pharmacy in the face of a saturated marketplace for pharmacists is another situation that must be questioned.


9. Developing leaders
The urgent attention that is needed to address the numerous current issues can easily obscure the importance of developing the future leaders for the profession. The identification and development of new leaders is a critical component of plans to position pharmacy for success in the future.
 
10. Expanded and new opportunities
At the same time that current challenges demand priority attention, there must be a vision for expanding some existing opportunities and developing new ones. The manner in which some pharmacists have developed practices that focus on compounding prescriptions to meet individualized needs of patients is one such example. Other examples include expanded roles in medication therapy management (MTM) programs, immunization programs, the self-care of patients with nonprescription products, the provision of durable medical equipment products and services, and the provision of specialty pharmaceuticals.

Agreeing with FDA Actions on Acetaminophen

In June 2009 the FDA convened 37 health professionals who serve on three of its advisory committees to address concerns regarding acetaminophen. My editorial in the July 2009 issue of The Pharmacist Activist identifies many of the recommendations of the advisory committees, and also includes my responses/observations. The advisory committee statements are recommendations and do not become policy until the FDA approves them, which it has not done.

Interestingly, the action that the FDA just announced addresses just one component of a much larger picture. The recommendation applies only to prescription products that contain acetaminophen in combination with other medications (almost always a narcotic [also known as an opioid]).  The recommendation does not pertain to nonprescription (OTC) products such as those available under the Tylenol brand name.

I fully agree with the action that the FDA has just taken. At the present time prescription combination products that contain a narcotic and acetaminophen may contain widely varying amounts of acetaminophen (e.g., 325 mg, 500 mg, 650 mg, 750 mg). The narcotic component of the combination is a much more potent pain killer than acetaminophen and is also associated with a greater number of risks.

As a result, many may overlook the inclusion of acetaminophen in the product or not be attentive to its quantity in each tablet or capsule.  This could result in the use of an excessive dosage/quantity of acetaminophen, even when the amount of the narcotic may be appropriate.  The use of excessive amounts of acetaminophen may result in serious liver toxicity and even death.

By limiting the amount of acetaminophen (to 325 mg) that may be included in prescription combination products that also contain a narcotic, the FDA will be providing greater clarity and safety with respect to the use of these products.

Daniel A. Hussar is the Remington Professor of Pharmacy at University of the Sciences' Philadelphia College of Pharmacy.

 

 

Unique partnership will promote sustainability training for pharmacists

The issue of pharmaceuticals in the environment is multifaceted—ranging from the excretion of animal and human waste, to improper disposal like flushing, to residues transferred from skin (e.g., sunscreens, ointments).

Pharmacists serving in the role of public health advisor are in a unique position to educate patients and providers on strategies to decrease the amount that gets into the environment. This partnership couples Practice Greenhealth’s known expertise in this area with the knowledge and expertise of the nation’s first college of pharmacy to provide outstanding educational opportunities for pharmacists to learn themselves and how to educate others. 

The partnership is designed to develop educational modules for pharmacists working in community/retail settings, hospital settings and long term care settings. Further, the intent of the partnership is to develop educational programming for students in colleges of pharmacy and public health programs to learn about this important issue.

-- Andrew Peterson is dean of Mayes College of Healthcare Business and Policy

Prescription Benefit Programs - Pharmacy Needs Greater Strength and New Strategies!

By Daniel A. Hussar is the Remington Professor of Pharmacy at University of the Sciences' Philadelphia College of Pharmacy. He serves as the author and editor of The Pharmacist Activist newsletter (http://www.pharmacistactivist.com) from which this editorial was taken.

It has happened again! For the third consecutive Pennsylvania legislative session, each of which is two years in length, proposed legislation that addresses the inequities of many prescription benefit programs has died in committee. The proposed legislation would have prevented insurance companies and pharmacy benefit managers (PBMs) from requiring patients to obtain certain prescriptions from a mail-order pharmacy and would prevent the use of financial incentives for patients to use a mail-order pharmacy. The proposed legislation was approved by a large margin in the House of Representatives and, following considerable delay, was approved by the Senate Banking and Insurance Committee. It was then referred to the Senate Appropriations Committee and discussions with the individual senators on this Committee indicated that there were enough votes for approval. However, the Chairman of the Committee refused to place this proposed legislation on the agenda and, as a consequence, it died in his committee and the full Senate was denied the opportunity to consider it before the conclusion of the legislative session.

Throughout the legislative session, the insurance companies, PBMs, and the legislators who opposed the proposal insisted that the legislation would increase the cost of prescription programs, and that the required or incentivized use of mail-order programs reduced costs. However, when requested to provide the studies and other information that supports their position, they either did not have it or claimed that it was proprietary information and could not be released. None of the legislators or their aides with whom I met had actually personally seen any studies or data. However, some of them were willing to accept these claims from companies who are in a position to present financial information in a manner that supports their own interests and plans to drive more patients and prescriptions to the mail-order pharmacies they own.

The word "frustration" is an understatement in describing the experience of the pharmacists who committed extensive time and effort in support of the legislative proposal. We consider our position to be so valid and important that it is difficult to accept rejection, even though it is temporary, when it is seemingly based on politics, secrecy, and deception. But we must learn from these experiences and further strengthen our support for the legislators who are willing to address our concerns, and challenge those who do not. It has also become very clear that the profession of pharmacy in general, and community pharmacists in particular, need much greater financial and political strength, as well as new strategies for attaining greater effectiveness in addressing our concerns. The following recommendations are proposed for evaluation and action.

Pharmacy networks

Many independent pharmacists are participants in buying groups or networks that increase their purchasing power and efficiency. This has proven to be an effective model on a local or regional basis but we must work toward the development of a national network of independent pharmacies. A critical question that must be addressed is whether the numerous local and regional groups/networks view each other as competitors or as colleagues who can work together in constructing a national network that has the potential for synergies in attaining greater purchasing and political strength. A network of 10,000 independent pharmacies would be considerably larger than even CVS and Walgreens.

It will take considerable planning and time to establish this national network of pharmacies. Therefore, we should concurrently identify one or more states that have the greatest potential to establish a statewide network of independent pharmacies. The development of such a network would provide a model that could be subsequently extended to the national level.

Negotiating

Antitrust is the word that is screamed as a warning to pharmacists who might consider working together as individuals or within a professional organization to insist on a higher rate of compensation for dispensing prescriptions and better terms of participation in the current "take it or leave it" prescription benefit programs. As a result, independent pharmacists are not able to effectively "negotiate" as individuals when dealing with a huge insurance company or PBM.

In stark contrast is the charade in which Walgreens and CVS Caremark were engaged earlier this year. Walgreens announced that it would be discontinuing its participation in prescription programs administered by CVS Caremark, but that it was receptive to further discussions. CVS Caremark responded by announcing that it would be dropping Walgreens from the programs it administers. The next announcement followed quickly-an agreement had been reached although the terms would not be disclosed. Clearly, Walgreens received a better deal, and it is just as clear that its deal is better than the ones available to independent pharmacists. This situation illustrates the power of numbers when the negotiator is a single corporate entity.

The profession of pharmacy must continue to pursue changes in the antitrust laws that would exempt individual pharmacists and permit them to work together and through our organizations to resolve the inequities of current prescription benefit programs. However, progress in this direction has been very limited and other alternatives must also be considered. As with the benefits identified earlier in the purchase of medications using the size and influence of networks, the concept of a large network of independent pharmacies requires active exploration with respect to having legal authority to negotiate on behalf of its members. The structure of such a network would have to include financial arrangements that would permit negotiating authority without violating antitrust laws. Would a parent "company" that would own a small fraction of each independent pharmacy in its network have the legal authority to negotiate for its members? Would 1% of the ownership be sufficient to have such authority and, if not, what percentage of ownership would provide such authority?

This is also a situation in which the implementation of such a network within a state might be accomplished much more quickly than on a national basis. Although each of the issues being considered is deserving of high-priority attention, the challenges of the prescription benefit programs must be considered urgent. Some PBMs are already moving in the direction of using preferred pharmacies or networks of pharmacies in programs that could prevent the involvement of independent pharmacies that wish to participate.

Pharmacist services

Community pharmacists must greatly expand the comprehensiveness and quality of the professional services provided to patients. Medication therapy management (MTM) services are extensively discussed but most pharmacists do not currently provide such services. The widespread provision of MTM services will go a long way towards demonstrating and documenting the value of the services we claim we are capable of providing. I recognize the difficulty encountered by community pharmacists in finding the time to participate in educational programs that will provide the competence and skills to provide such services, and then finding the time in a busy practice setting to provide these services on a timely basis. Some pharmacists will conclude that it is not possible to expand their professional services, particularly at a time when the compensation for dispensing prescriptions is inadequate and it is not known whether there will be compensation for additional services. However, it will be the pharmacists who do find a way to extend their services whose practices will have the best opportunity to not only survive, but thrive. The services these pharmacists provide should also result in higher levels of compensation (please see the editorial, "Prescription Benefit Programs - Classes of Pharmacies Should be Established," in the September 2009 issue of The Pharmacist Activist, www.pharmacistactivist.com).

Prescription benefit programs

The traditional terms and policies of many prescription benefit programs need to be reconsidered. Many of the components of these programs are coercive, restrictive, and inequitable for both patients and pharmacists. Some policies place patients at greater risk and extensive revisions are warranted (please see the editorial, "Prescription Benefit Programs - A New Model is Needed," in the June 2009 issue of The Pharmacist Activist, www.pharmacistactivist.com).

Medication packaging and distribution

In many countries prescription medications are dispensed in the packaging in which they are supplied by the manufacturer. This has not usually been the situation in the United States although there are an increasing number of examples in which commonly prescribed quantities of tablet and capsule formulations are prepackaged. There are many advantages of utilizing unit-of-use packaging including the elimination of the need and cost for a second container to be supplied by the pharmacy, the reduction in the amount of staff time utilized in the preparation of the prescription to be dispensed, and the decreased likelihood of a counterfeit product and/or contamination when the medication is dispensed in the sealed container supplied by the manufacturer. The opportunity to have a patient information leaflet directly affixed to the container by the manufacturer has also been suggested by some as an advantage; however, others have identified potential problems and questions as disadvantages.

Unit-of-use packaging can be both practical and efficient for the dispensing and use of many, but not all, medications. One example of how such a system would work advantageously for many medications would be to package them in containers containing 7-day and 30-day supplies that are consistent with the usual dosage recommendations. Some would also add a 90-day supply but I would contend that there is value in having patients obtain medications for chronic conditions at not more than 30-day intervals. This will permit closer monitoring of patient compliance in using the medication, an opportunity to discuss possible adverse events and for the patient to ask questions, and less wastage if the drug is discontinued or the dosage is changed.

Prepackaged quantities of commonly prescribed medications are already in widespread use in selected situations such as the discount generic prescription programs in certain chain pharmacies and in the offices of physicians who dispense medications. This approach to the packaging and dispensing of medications should be adopted on a much wider basis. Companies that market a large number of generic medications are best positioned to implement this strategy quickly although all companies should participate.

The topics considered in this commentary are diverse and challenging. However, they also include opportunities that we must not ignore and which offer exciting possibilities for pharmacists to extend the value of their services to patients.

 

Research Day Showcases Faculty and Student Research

From metabolic engineering to computational chemistry and from structural prediction of proteins to rational design of new therapeutics, University of the Sciences in Philadelphia showcased the diversity and growth of research pursuits on campus during its 7th Annual Research Day starting on Thursday, April 2, 2009. Posters representing approximately 120 topics were on display.

Research Day recognizes undergraduate and graduate student research efforts, and highlights aspects of faculty scholarly activity to encourage and promote communication and collaboration among investigators. The University is distinctive in that most undergraduate students conduct research with faculty early in their academic careers.

The diverse research activity on display spans several aspects of the University’s scholarly pursuits, including:

• Biological Sciences: Dr. Jennifer Anthony’s research involving the metabolic engineering of E. coli for the production of vitamin A.
  • Chemistry: Dr. Randy Zauhar’s use of computer-aided drug design to identify new antimicrobial lead compounds.
• Pharmaceutical Sciences: Dr. Bin Chen’s evaluation of the effects of vascular-targeting photodynamic therapy on prostate cancer metastasis.
• Physical Therapy: Dr. Therese Johnston’s usage of treadmill training for children with cerebral palsy.
• Social Sciences: Psychology major Mark Paullin’s (Philadelphia, Pa.) study of mild cognitive impairment in Alzheimer’s disease.
• Health Policy: Master in public health major Sekinat Kekere-Ekun’s (Deptford, N.J.) work on the descriptive epidemiology of viral hepatitis in methadone maintenance clients.
• Pharmacy Practice: Doctor of pharmacy students Neha Patel (Fairless Hills, Pa.), Puja Patel (Hillsborough, N.J.), and Isha Shah’s (Bensalem, Pa.) analysis of the usage of ondansetron in non-chemotherapy patients at a community teaching hospital.