Pharmacy Edge by APPA

Pharmacy Edge Magazin

Issue

Fifteen

Pharmacy Benefit Managers Role in Health Care Anthem Settles

Multidistrict

Litigation over 2015 Data Breach

July - August / 2017

Reining in Medicare Costs New Facilities Fees Rule is now in Effect

Members of Congress Call

for Review of FDA Guidance on Compoundingunder Section 503A

10 After

Dr. Michael Castagna

CEO of Mannkind Corp

Ways to Grow Your Independent Pharmacy

Table of Contents Issue 15 / July, 2017

Presidentâ&#x20AC;&#x2122;s message

Michael Castagna CEO of Mannkind Corp

10 Ways to Grow Your Independent Pharmacy

Anthem Settles Multidistrict Litigation over 2015 Data Breach

Reining in Medicare Costs: New Facilities Fees Rule is now in Effect

Which dietary supplements are best for back pain?

Pharmacy Benefit Managers Role in Health Care

Members of Congress Call for Review of FDA Guidance on Compounding under Section 503A

President’s message Joshua Pirestani First, on behalf of the American Pharmacy Purchasing Alliance, advisory board members, staff and myself, I sincerely appreciate all sponsors, members and industry peers for your support making 2017 a great year so far. Thank you! Each month we seek to “raise the bar” and I am pleased to share the 2017-midyear agenda as proof of the good things to come. »» Starting an independent pharmacy workshop - August 2017 Tampa, FL »» 340B advanced online webinar September 2017 »» Understanding employment law for independent pharmacy owners October 2017 Tampa, FL »» APPA Industry Holiday Party December 2017, Tampa, FL Education, networking, advocacy and group buying power are the driving force behind APPA’s growth and expansion. In

bringing value back and keeping prices affordable, APPA has become the premier pharmacy purchasing association in the nation. Membership in the APPA does not cost, it pays! When you become a member of the APPA your annual membership brings more than just the advantage of being part of a strong organization; it also provides you with tremendous networking opportunities, continuing education and advocacy. I am truly thankful for the support and commitment of our staff, members and sponsors who have brought the APPA to the forefront of the pharmaceutical industry. Thank you, Joshua R. Pirestani American Pharmacy Purchasing Alliance President (877) 570-2665 josh@joinappa.com

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At FisherBroyles, we take pride in our depth of knowledge and experience representing pharmacies, pharmacists, health systems and providers, drug wholesalers, technology companies and other entities involved in the drug delivery system. Our Health and Pharmacy attorneys oﬀer significant experience across the broad scope of issues facing the industry including: • Administrative/Regulatory Compliance Plans • PBM Audits/Network Exclusion Issues

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L I M I T E D

L I A B I L I T Y

PA R T N E R S H I P

Michael Castagna CEO of Mannkind Corp

ichael Castagna is our Chief Executive Officer. Dr. Castagna has over 20 years of experience in healthcare, pharmaceutical, biotech and specialty pharmacy industries. He joins MannKind from Amgen, Inc., where he spent over three years as Vice President, Global Commercial Lead for a portfolio of nine biosimilar drugs, and Vice President, Global Lifecycle Management. Prior to Amgen, Dr. Castagna, was Executive Director of Bristol-Myers Squibbâ&#x20AC;&#x2122;s Immunology franchise, where he served as co-lead to relaunch Orencia IV and launch Orencia SC, both rheumatoid arthritis drugs. Before BMS, Dr. Castagna was with Sandoz (Novartis) as Vice President and Division Head for Biopharmaceuticals, North America, where he established the US Biologics Business Unit and relaunched its lead product, Omnitrope, a human growth hormone. Prior to Sandoz, Dr. Castagna held a variety of positions with

6 pharmacy edge

EMD (Merck), Serono, Pharmasset and DuPont Pharmaceuticals. Dr. Castagna serves on the board of directors of Pet Partners headquartered in Bellevue, Washington. Dr. Castagna received his Bachelors of Science â&#x20AC;&#x201C; Pharmacy degree from Philadelphia College of Pharmacy, his Doctor of Pharmacy from Massachusetts College of Pharmacy, and his MBA from the Wharton School of Business at the University of Pennsylvania

Our jobs as pharmacists is to mentor and grow the next generation to ensure we continue to bring value to the patients we serve throughout all aspects of pharmacy

Questions and Answers with CEO of Mannkind Corp - Michael Castagna What was your journey like to get where you are? I started my journey back in 1995 when I began pharmacy school at Philadelphia College of Pharmacy. I was excited to learn the original founders of incredibly successful companies like Eli Lilly and GSK graduated from my pharmacy school which peaked my interest into the pharmaceutical industry. I debated if I wanted to be a doctor or pursue a business degree and during my 1997 summer internship at DuPont Pharmaceuticals I decided my heart was in the pharmaceutical industry because I could see all the incredible innovation they do and the lives we were saving. My summer internship experience helped me understand how one could make a bigger impact on society if they could combine a passion for science with business where one could lead and build a biopharmaceutical company. If I choose to work in retail or in a hospital setting I would only be able to impact my local community or region, but bringing a successful brand to market can impact people all across the world. Over the last 20 years I have grown and built out my skills to lead 8 pharmacy edge

the commercialization of biologics and pharmaceuticals in areas such as sales, marketing, strategy, business development and manufacturing. This journey required many moves around the country and enabled me to work with and for incredibly brilliant people throughout the industry at companies like BMS, Sandoz(Novartis), EMD Serono, Amgen and now MannKind. How do you see the company changing in two years, and how do you see creating that change? Over the next two years MannKind will go from being a development company that originally licensed their lead product to a fully integrated biopharmaceutical company focused on launching Afrezza worldwide. The US will always be our main focus, but diabetes is a global pandemic and we plan to live up to our founder’s vision to make Afrezza a global success story. In order to achieve this change we have to stabilize and grow our US market while taking some calculated bets on where to file for approval next or who to partner with in markets where we don’t intend to launch ourselves. This requires us

to expand our talent base and build out capabilities we previously didn’t have. Can you share a time when you have had to expand a core product set through innovation? Many brands I have worked on expanded through innovation with their devices, packaging, customer service models and/ or payor contracting strategies. One of my first examples of innovation was helping the BMS team partner with Gilead to create the first 1 Pill Once a Day regiment for people living with HIV back in 2005. This was a monumental shift in how we thought about internal innovation versus partnering with external innovation to change the rules of the game. This helped transform Gilead and BMS as leaders in HIV. Another area of innovation was during my time at EMD (Merck) Serono in the fertility segment where there were 3 FSH brands competing on very little molecule differentiation because these products have been around a long time. Many innovations came from making the device user friendly as well as creation of cash pay programs because of the high out of pocket costs for fertility

I have seen too many potential pharmacy students change their major because of their experience in retail settings or feedback from colleagues expressing their disappointment in pharmacy. treatment. These two innovations positioned BMS to lead the way for their HIV franchise and EMD (Merck) Serono to regain market leadership in the FSH segment. How do you see the landscape of the independent pharmacy changing in the next few years with all the consolidation happening? In general independents don’t have a lot of leverage when it comes to negotiating fees for reimbursement from the PBMS so they are not able to increase the margin in that way given the dynamics that exist with the duopoly that exists between CVS Health and Express Scripts. Therefore, I see independents needing to reinvent themselves by grouping together to create customized programs that don’t allow them all to be so fragmented when it comes working with the industry, creating disease state pathway programs or thinking about how they can work with local employers to help them better manage compliance and outcomes on specific high cost disease areas. I personally see diabetes being an area where they can partner with their local doctors and health systems and create better pathways for treatment and titration of various insulin and oral pill regimens as we have had 40+ new Type 2 drugs in the last decade, but we haven’t made a dent in outcomes for patients. I see a big gap and opportunity here for someone to build a better mousetrap with incremental innovation focused on compliance, outcomes and rewards through integration at the local community level. I think this will be hard for a CVS, Walgreens or Express Scripts to compete with, despite their de-

sires. Independents have to remember people in companies and health plans react to data. This is a gap at the independent level because their resources and margins are scarce and people have been saying for 20+ years they were going to go out of business but yet they continue to find ways to thrive and survive! With several consolidations occurring industry wide, how are you helping your customers to compete in today’s marketplace? This would first have to focus on, “who is our real customer?” This is a question every company I have been with struggles to answer or the answer is often, everyone is a customer who touches our brand, in which case we probably serve a lot of people but please none. I personally focus MannKind on the customer being our patients, we have to make sure they are happy with their outcome and value they are paying to achieve that outcome. There are many “partners” along the way who touch our brand and impact the experience of our customer and that is a lot of what we all deal with today. The challenge is the distribution and reimbursement model is built to ensure everyone gets a percentage of your list price in order to make their margin and based on all the restrictions payors have placed it has created a new market of fee for service and contributed to the escalation of drug pricing we all debate about. Our partners along the value chain need to be sure they work with groups such as Asembia and other GPOs to ensure they can keep up with the buying power and fee for service agreements that are becoming the norm.

With the many changes occurring in the industry how do you think it will impact Medicare and Medicaid reimbursements for your customers? In general, I hope we start to move our focus on patient compliance/ outcomes and if so CMS will be the one to lead the charge to help empower the change that is necessary to revolutionize how we deliver care at the front lines. The bottom line is all about the incentives and in general the government is usually the first to drive the incentives and not the private/commercial payors. We as a pharmacy profession can either wait for them to tell us what they are going to do or you can work together to create the incentive structure and outcomes you desire along with the types of pilot programs and savings you think CMS could realize as a result of these programs. I personally don’t see how reimbursement at the pharmacy level can go much lower, but I also don’t have a crystal ball or work at CMS. Explain what MannKind Corp Does? We have a technology platform that allows us to deliver drugs across the lungs in a very efficient and effective way that minimizes absorption delays and helps potentially speed up the outcome patients may expect from their given treatment. Areas that I like to think about are acute conditions such as migraine, anxiety, allergies and anaphylaxis where you want an effect ASAP from the time you administer a drug. Our core focus right now is our lead brand Afrezza, an inhaled version of mealtime insulin for people living with diabetes. People living with diabetes who are dependent on insulin struggle to control their pharmacy edge

sugars quickly and with continuing innovation around glucose monitoring (CGM) we can now see live time where their sugars are. This will ultimately help keep people in a very tight time in range and minimize the sugar highs and lows people experience thousands of times a year. If I was an independent pharmacist today this is something I would be jumping on top of so that they can help patients understand the impact these highs and lows have and why it’s important to get to an A1C goal of <7% through appropriate interventions. Remember 70% of the people on insulin are not at goal despite spending billions of dollars on insulin, pumps and meters. There is a large unmet need here that we need to solve and I personally believe Afrezza will be a cornerstone in helping patients achieve their goals. We continue to invest in clinical data that will demonstrate coaching, proper titration and compliance that will lead to the real world outcomes we hear about. Think back and share a story about a personal life experience that defines who you are today. What was the value/lesson. My personal story is one many in America face, which was growing up in poverty without a father. My mother is someone who taught me a lot of valuable lessons about starting companies, taking risks and providing great customer service in order to differentiate your business. My mother was a self-starter who didn’t let the cards handed to her define who she was or limit how

successful she was going to be. These values of hard work, risk taking and focusing on the customer were instilled in me at a young age and have been with me throughout my career. I see many talented people rest on the comfort and safety of their employer because they lack the confidence in themselves to expand their ability and value in the competitive market place. When you come from nothing in life you realize the importance of giving back to the community, helping those less fortunate and I don’t have as many fears as the average person because of the experiences I have had in life. How do you allow ideas to flow through the chain of command? Ideas are usually sitting at the front lines of companies with the employees who interact with the customers such as our field sales and medical teams because they have thousands of interactions a week with patients, doctors and insurance companies. Many companies rely on market research to give them insights and I personally have found this not to be as reliable as talking with customers, employees and other key stakeholders. We are working on creating some listening sessions over the coming weeks and months, which will be the start to ensuring ideas flow up the chain of command! What Are Your 3 Biggest Accomplishments? a. Getting into and graduating from pharmacy school b. Having 3 wonderful children

c. Built the first commercial infrastructure at Sandoz to relaunch Omnitrope and set the stage for biosimilars to be successful in the US Any concluding thoughts or closing message you want to tell our readers? I have seen too many potential pharmacy students change their major because of their experience in retail settings or feedback from colleagues expressing their disappointment in pharmacy. It’s important we showcase the income earning potential with a six year degree not to mention the unlimited career potential a pharmacy degree can provide a young adult. Our jobs as pharmacists is to mentor and grow the next generation to ensure we continue to bring value to the patients we serve throughout all aspects of pharmacy. I believe anyone can achieve what they put their minds too and that there are many paths to success. If you want to work in academics, insurance companies, hospital, industry or retail we all need talented pharmacists in every aspect of healthcare. Young people look up to us as leaders and guideposts on what they can expect in terms of job satisfaction, happiness, work life balance, income potential etc. There are no shortcuts in life, in the end hard work, sacrifice, focus and dedication pay off in the long run. I am at my personal best when I surround myself with great talent who share a similar passion for success and this is the type of culture we are building here at MannKind!

There are no shortcuts in life, in the end hard work, sacrifice, focus and dedication pay off in the long run. 10 pharmacy edge

New Year, New Look...

New Content AJPB® is continually seeking submissions on a variety of topics. Areas of particular interest include utilization management, outcomes research on Medicare Part D, analysis of drug therapies, cost utility analyses, and more.

www.ajpb.com/call-for-papers/information-for-authors 2017 TOPICS: • Alternative Payment Models

• Economic Burden of Disease

• Readmissions

• Biosimilars

• e-Prescribing

• Specialty Pharmacy

• Cost-sharing Strategies

• Opioid Agonists

• Value-based Care

OUR JOURNAL BOASTS: • Circulation to over 20,000 pharmacy benefit decisionmakers

• An expedited review process • Exposure through Web and print publication opportunities

• Indexing in 2 scientific databases: EMBASE/ Excerpta Medica and Cumulative Index to Nursing and Allied Health Literature

Anthem Settles Multidistrict Litigation over 2015 Data Breach $115 Deal Sets Record for a Data-Breach Settlement

ealth insurance giant Anthem Inc. reported on February 4, 2015, that its computer systems had been targeted in a â&#x20AC;&#x153;very sophisticated external cyber attack.â&#x20AC;? The hackers stole personal information from nearly 80 million Anthem employees and customers, including names, birthdates, Social Security numbers, and addresses. Anthem reported at the time that all of its product lines were impacted, including Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Empire Blue Cross, Unicare and others. Following the attack, over 100 lawsuits were filed against Anthem nationwide. Those cases were ultimately consolidated in the U.S. District Court, Northern District of California. Now, just over two years after the attack, lawyers for the plaintiffs in the case announced that they had reached a settlement with Anthem.

The $115 million dollar deal represents the largest data-breach settlement in history. The settlement funds will be used to pay for two years of credit monitoring (over and above the two-years of monitoring already provided), or, for those who choose to forgo credit monitoring, a cash payment of up to $50 per person. This record-setting settlement demonstrates the need for constant vigilance of corporate IT systems, particularly in those sectors that maintain data subject to HIPAA and HITECH. Given the potential legal liability for non-compliance, and the increased focus on enforcement seen in the last several years, companies must count data security as among their highest priorities.

FisherBroyles Health Care and Pharmacy Law attorneys have experience handling breaches, from discovery through mitigation and reporting, to ensure compliance with federal and state laws and regulations. Contact any of the attorneys listed for more information:

Brian E. Dickerson, Esq. brian.dickerson@fisherbroyles.com fisherbroyles.com

12 pharmacy edge

Anthony j. Calamunci anthony.calamunci@fisherbroyles.com fisherbroyles.com

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Pharmacy Benefit Managers Role in Health Care By: Rizwan Khaliq

harmacy benefit managers (PBM) are entities that facilitate prescription drug programs as third-party entities. PBMs are deeply entrenched into obtaining and delivery of medications process in the health care system within the United States. Historically speaking, PBMs originally started as pharmacy claims processors for insurance companies. A small amount of monetary compensation was given for their service. Over time they have developed into larger entities that have their hands on an estimated

pharmacy benefits administration of 253 million Americans. The top 3 largest PBMs are Express Scripts, Medco, and Caremark, which now control approximately 78% of prescription drug benefit transactions. Common activities that PBMs have within their operations includes that of formulary management for standard clients (vs formulary benefit build for custom clients who create their own formulary), creation of contracts with pharmacies, Pharmacy Services Administrative Organizations (PSAOs), oversight

The top 3 largest PBMs are Express Scripts, Medco, and Caremark, which now control approximately 78% of prescription drug benefit transactions. 16 pharmacy edge

of prescription drug claims, and the negotiation of rebates with pharmaceutical manufacturers. The services offered by PBMs help to control the ballooning of costs to their clients. Cost containment services include that of offering therapeutic alternatives that are cost friendly, formation of tiers for particular medications within therapeutic class, assessment of clinical programs which are designed for large populations, MTM services, specialty programs, and delivery of medications through the mail. PBMs have vital relation-

ships with various components of the pharmacy industry. The relationships include that of chain and independent pharmacies, pharmaceutical manufacturers, and health insurance plans. The relationship with independent and retail pharmacies involve that of claim payments on medications based on a frequency related to the line of business such as Medicare, Medicaid, or Commercial plan claims. Occasionally, a PBM will take money back due to an audit of claims that appear to have been dispensed outside of a ‘normal’ prescription volume or frequency. This is an issue PBMs have when meeting prompt pay procedures for pharmacy payment services; it gives them limited time to review fraudulent pharmacies that are not compliant with contractual obligations set out before them. This is a sensitive matter to both PBMs and independent pharmacies. An independent pharmacy depends on this income to able to restock their shelves with the appropriate inventory for their patients’ needs whereas PBMs do not want to pay out for drug claim that appears to be inappropriate or incorrect.

A PBM’s relationship with pharmaceutical manufacturers is complex and focused on negotiating competitive drug rebate rates that will be to the satisfaction of the health insurers that they are servicing. In the case of health plans that create and administer their own custom formularies, there is still a partnership created regarding rebating between the health plan and the PBM. Health plans with custom formularies can have the PBM model various branded drug coverage scenarios for their formulary that will both meet the needs of their membership while receiving high rebate value. PBM communication with health plans is vital as they help with proper implementation of rules and regulations from that of Medicare and other regulatory bodies to ensure the plan is in compliance and will perform well in a variety of audits to avoid fines and/or sanctions. Although health plans and their PBMs have a collaborative relationship, one frequent issue concerns cost transparency. For example, Maximum Allowable Cost(MAC) pricing is important to predict costs for a health plan

References: https://www.pharmacist.com/sites/default/files/files/Profile_26%20PBM%20Final%20071213.pdf http://www.ncpa.co/pdf/PBM-Storybook-12pg.pdf

based on generic unit costs, but there is no clearly defined MAC list calculation definition. This is also a concern of smaller pharmacies and independent pharmacies. The reality of the situation within the United States of America is that we live in a challenging health care climate that consists of rising medical costs with that of a graying population of baby boomers aging over 65 at a record pace, high cost specialty medications usage increasing, entry of biologics and biosimilar drugs working on finding their niche in the landscape, and health insurance companies looking to find the right balance in providing as close to universal health care as possible without closing their doors due to having high risk population patients enrolling without those who are fairly healthy signing up to offset the high cost claims that the high risk patients entail. The goal is to provide quality healthcare to patients at an affordable cost. Such success in the current environment will take a team effort amongst all entities involved.

The goal is to provide quality healthcare to patients at an affordable cost. Such success in the current environment will take a team effort amongst all entities involved. pharmacy edge

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Members of Congress Call for Review of FDA Guidance on Compounding under Section 503A

arlier this year, we focused one of our client alerts on a new Guidance issued by the Food and Drug Administration (FDA) concerning certain prescription requirements for compounding human drug products under section 503A of the Federal Food, Drug, and Cosmetic Act. See “FDA Issues Guidance on Prescription Requirement for Compounded Drugs”. Since the release of that Guidance, members of Congress have taken issue with the FDA’s interpretation of section 503A and, in a letter signed by 65 members, asked FDA Commissioner Scott Gottlieb to rescind the Guidance. At the core of the dispute is the Guidance position

that state-licensed pharmacies cannot compound medications pursuant to state pharmacy laws for administration to patients in office or clinical settings (i.e. “in-office compounding”). The language used by the members is quite strong: “Compounding for officeuse done pursuant to state pharmacy laws does not make a pharmacy a drug manufacturer, and Congress never intended for the FDA to assert regulatory authority over the traditional practice of pharmacy, which has always been regulated at the state level. “The policies finalized in this GFI are contrary to the plain

language of Section 503A as amended by the Drug Quality and Security Act (DQSA) and ignore clear, bipartisan, bicameral congressional intent expressed during passage of the bill. The FDA has unfortunately chosen to ignore broad and diverse stakeholder input, multiple congressional letters from both chambers, legislation….” The letter concludes by asking Commissioner Gottlieb to immediately rescind the Guidance and issue a proposed rule that conforms to the language and intent of the DQSA and allows for office-use compounding by state-licensed pharmacies where such is permitted under applicable state pharmacy laws.

pharmacy edge

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10 Ways to Grow Your Independent Pharmacy

Pharmacies are here to provide for the health needs of a local community. While that may be one of the main goals, the need to generate profit is also of importance. The main product in pharmacies is ultimately medicine but even big-name companies like CVS Pharmacy have ventured into selling miscellaneous items such as beverages, drinks, cosmetics, books, and magazines. Should you do the same for your independent pharmacy? In business, being different can reap rewards but how far are you willing to go in being a pharmacy that goes beyond providing services in traditional areas? Here are 10 ways to grow your independent pharmacy:

Provide prescriptions for pets There might be specialized shops dedicated to furry creatures but if you do business in an area that has a high pet ownership and the specialist shop is miles away, wouldn’t you want to offer comfort and convenience to local residents at the same time boost your revenue? A number of households own pets, whether the same kind or multitudes of different ones. While owners should keep them healthy, there are occasions that may call for prescription medication. One of the best things you can do to draw customers to your pharmacy is to build relationships with local veterinarians. This way, they can refer their clients to you for pet prescription.

Offer immunization services Vaccinations are important for the prevention and treatment of diseases such as flu, shingles, and pneumonia. Wouldn’t it be encouraging then to have a local pharmacy that offers such services to encourage residents to get

22 pharmacy edge

their shots. You could be that provider in your area. You can even partner with local businesses as well as non-profit organizations to rake in more profit.

Supply durable medical equipment There might be patients who are suffering from certain medical conditions or illnesses and need special equipment to make their lives better. Whether it’s walking aids or bath safety equipment, offering these products in your pharmacy can help those who need it. Then again, providing these items works best if you can manage the space requirements. Durable medical equipment tends to occupy space so you need quite the ample amount to display a few products. The good news is that you don’t need to offer every kind of durable medical equipment.

Be the go-to local pharmacy for diabetes patients Although a large number of Americans suffer from diabetes, it still helps to know whether there is a

big enough population within or close to the area you do business in. You will have to do research to get accurate information but once you’ve confirmed it, there are lots of products and services you can offer diabetes patients. For a start, you can offer different supplies such as test strips and meters to help patients monitor and treat their condition. You can even venture to food products like sugar-free candy and basic needs like compression socks. Even better, you can sell cookbooks for diabetics.

Update your front end Just like retail stores change up their displays to attract customers, you can use the same concept to make your pharmacy more appealing. One of the simplest things you can do is to decorate based on festivities. For instance, you can put on a festive display for the Christmas holidays or use a lot of red for Valentine’s Day. A little bit of visual appeal always helps draw the attention. Other than putting up displays, you can also arrange your supplies accordingly. For example, you can reserve a space for displaying new

items. You can also save a spot for some seasonal items.

Be a specialty pharmacy The specialty segment of the pharmacy industry is growing fast. However, transforming your pharmacy into one requires heavy investment. In other words, only a few would be willing to go into this. You will need to do a lot of research just to make sure the kind of specialization you want to go into will get you clients in the area you plan to do business in. All that said, there is some good in heading the specialist route: it allows you to build relationships with patients and as such, bring in revenue your pharmacy needs. But if you ever want to get into being a specialty pharmacy, it helps to do a lot of research to see which area you can best serve in the community.

Offer services for HIV patients Venturing into the area of HIV care is not something to be treated lightly. In fact, you have to consider HIV

certification if you want to offer HIV treatment in your pharmacy. HIV is complex and you need to know what you are doing in order to know how best to help patients.

Make sure your website has relevant information An online presence is important given that many people now conduct internet searches when looking for information. It would be nice if the name of your pharmacy pops up when they look for pharmacies in their local area. Having a website helps in making this happen but you also have to include relevant information in it like the products that you sell. You can also keep a blog for posting relevant articles that would be of help to customers; it’s also a way of showcasing your expertise.

Get a business listing on Google A Google business listing goes a long way. You can use it to show your business hours, display your phone number, and even provide directions. A listing is also a good way to inform clients when you’re

closing down for the holidays or any other day when you’re not offering any services.

Take advantage of social media Social media sites such as Facebook and Twitter are available for free and can help boost your online presence along with having a website and a Google business listing. You can use the platforms to inform followers of new products and services as well as answer their queries. While independent pharmacies are still all about providing for the healthcare needs of the local community, you can branch out to provide related products and services for a healthier bottom line. With these 10 ways to grow your independent pharmacy, you can get different ideas that will work for your business. There are certainly more than 10 ways to grow your independent pharmacy but the ideas presented here provide the basics, which you can refine to suit your business and audience. pharmacy edge

Reining in Medicare Costs:

New Facilities Fees Rule is now in Effect

nder Medicare rules in effect since 2000, hospital systems have been permitted to charge so called “facility fees” on top of their normal charges for professional care based on where the care took place. Reports issued in both 2012 and 2014 by the Medicare Payment Advisory Commission (MedPAC) found that Medicare often pays double for office visits and routine tests performed at hospital-owned doctor’s offices, clinics, and outpatient facilities when compared to the same procedures conducted at private physician offices. MedPAC determined that a failure to equalize payments between hospital-owned and private physician offices would increase Medicare spending by over $2 billion by 2020. Given these figures, MedPAC has long lobbied Con-

24 pharmacy edge

gress for the reduction or outright elimination of facility fee payments and the implementation of “site payment neutrality.” MedPAC has achieved a partial victory. On January 1 of this year, Medicare implemented a new payment schedule for services and procedures at many hospital-owned facilities by decreasing facility fee payments by 50%. The new rule applies only to outpatient facilities that are not on a hospital’s main campus and in locations where providers had not timely billed for services as of November 2, 2015. While the new rule will save Medicare (along with consumers) some pretty substantial dollars, it has potentially interesting implications for the future of private practice

acquisitions by larger hospitals and hospital systems. A recent article from Medical Economics notes that many hospital systems have been incentivized to acquire independent medical facilities and practices as a way enhance revenues with facility fees may drive down the pace of private practice acquisitions. Private practitioners, who may be used to being the pursued parties in the hospital acquisition game, may now find themselves having to do a bit more of the courting if they are interested in selling their practice. Demonstrations of practice efficiencies, board certifications, healthy specialist referral figures, and the use of up-to-date technologies will be much more attractive to potential buyers than a practice that has fallen behind in terms of its facility and technologies.

Which dietary supplements are best for back pain? By: Brianna Choyce and Nicholas Micciche (Doctor of Pharmacy candidates - University of South Florida) Back pain is the fifth most common healthcare complaint in the US, with 80% of Americans experiencing back pain at some point during their lifetime. Not only is back pain uncomfortable but it can affect exercise, sleep, and other daily activities as well as cost Americans almost $50 billion annually in treatment expenditures. An additional $100 billion is spent in indirect costs such as lost wages and family impact. With the high cost of physician visits and potential surgeries, many

Americans resort to using traditional over-the-counter non-steroidal anti-inflammatory drugs (NSAIDS) to relieve their pain. NSAIDS, such as ibuprofen or naproxen, may offer temporary relief, but leave users with unwanted side effects such as stomach upset or constipation These products may also prove harmful to the kidneys and/or liver with long-term use. Many chronic pain sufferers are looking for a more natural approach to pain relief and supplements could be the answer.

Why is inflammation so harmful? Health and science communities have identified chronic inflammation as one of the greatest contributors to disease and illness. Seemingly diverse health concerns including: migraines, skin conditions, depression, heart disease, cancer, certain autoimmune diseases, degenerative conditions of the brain, muscle, and skeletal systems, arthritis, diabetes, and pain can all be attributed at least in-part to inflammation.

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Pain is classified as chronic if lasting longer than 12 weeks. Sometimes it may be the result of an injury or causative agent or it may occur for seemingly no reason at all. Chronic pain is very serious because it does more than just hurt. Persistent, unremitting pain has adverse effects on the body’s endocrine, immune, musculoskeletal, and neurologic systems. When the body senses chronic pain, it will decondition and cease to perform the usual activity that is perceived to cause the pain. This can lead to serious complications such as muscle wasting, nerve deterioration and joint pain. Often times the body will compensate for the area of chronic pain, putting extra strain or workload on another area leading to even more inflammation. This chronic inflammation cycle can cause myopathies (muscle-related diseases), neuropathies (nerve-related diseases), and arthropathies (diseases of the joints).

What supplements will help with back pain? Devil’s Claw Devil’s claw, an herb from the African plant Harpagophytum procum-

bens, has been proven to reduce pain in several clinical trials.1,2,4 Devil’s claw has also been shown to significantly reduce muscle stiffness without causing serious adverse effects.2 Another study showed that Devil’s claw, when given twice daily for 8 weeks, significantly improved back pain symptoms and mobility of the affected sections of the spine.3 Devil’s claw has proven effectiveness in treatment of osteoarthritis of the spine, hip, and knee as well as in chronic lower back pain.4 Willow Bark Willow bark is an herbal medication that has been used throughout history for pain relief. During the age of Hippocrates, people chewed on willow bark to help relieve pain and fever. Willow bark has also proven to be effective in treating chronic lower back and joint pain, as well as osteoarthritis. Willow bark extracts are widely used in sports performance because of their anti-inflammatory and analgesic (pain relieving) properties. The mechanism by which willow bark exhibits its’ anti-inflammatory properties is not yet fully understood. It is hypothesized that willow bark aids in the down regulation of an inflammatory chemical

in the body called tumor necrosis factor (TNF).5 TNF is identified as a major factor in a multitude of diseases such as rheumatoid arthritis, psoriasis, and inflammatory bowel disease (IBD). A study was conducted to test the efficacy and safety of willow bark extract. Results showed that willow bark was effective and can be used as a supplemental therapy in long-term treatment of painful musculoskeletal disorders. It can also be combined with NSAIDs and/ or opioids if needed.6 White willow bark is also effective when used as a rescue medication for short-term or breakthrough pain.1,7 Turmeric Turmeric, a member of the ginger family, is most widely recognized as a cooking spice traditionally used in South Asian and Middle Eastern dishes. While turmeric has its’ applications in culinary culture, turmeric has also been shown to have countless health benefits. Curcumin, the medicinal active ingredient in turmeric, has been shown to decrease inflammation, making it an attractive treatment option for back pain. Curcumin significantly reduces inflammatory chemicals, such as TNF and interleukins (IL), in the body.8 A study

Chronic pain is very serious because it does more than just hurt. Persistent, unremitting pain has adverse effects on the body’s endocrine, immune, musculoskeletal, and neurologic systems. 26 pharmacy edge

comparing curcumin to ibuprofen for treatment of osteoarthritis produced surprising and monumental results. Curcumin was shown to be as effective as ibuprofen, with less risk of potential side effects.9 Several randomized controlled trials are now supporting the overwhelming evidence that curcumin is efficacious in the treatment of arthritic pain and inflammation.10 Bromelain Bromelain, a naturally occurring enzyme found in pineapples, is a powerful anti-inflammatory that can help pain sufferers. Bromelain fights inflammation by preventing the formation of kinin, which acts on tissues to cause vasodilation and

unwanted contractions of smooth muscle. It is by this mechanism that bromelain has been used successfully to reduce swelling and significantly reduce pain.11 Bromelain was also compared with diclofenac, a prescription-only NSAID, and was shown to reduce the symptoms of mild-to-moderate osteoarthritis with equal efficacy. Pain, stiffness, and function scores were also improved with bromelain.12 Not only is this promising for back pain sufferers, but other pain-associated conditions as well. Bromelain has proven to be effective in treating knee pain and Achilles tendon injury.12,13 Boswellia Boswellia, also known as frankin-

cense, is considered a super-herb due to itsâ&#x20AC;&#x2122; powerful anti-inflammatory properties. Boswellia has been proven to significantly increase the pain threshold and tolerance compared to placebo.14 Supplementation with Boswellia significantly decreased pain and stiffness and improved function and walking distance in patients with osteoarthritis.15,16 In addition to relieving back pain, boswellia can help with arthritis, asthma, allergies, ulcerative colitis, and other inflammatory conditions.17 It is important to talk with your doctor or pharmacist before starting any new supplement to ensure that there are no interactions with your current medications or health conditions.

Curcumin, the medicinal active ingredient in turmeric, has been shown to decrease inflammation, making it an attractive treatment option for back pain.

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