International Pharmacy Rotation: Experiencing Healthcare & Culture in Honduras

By:

Nancy Tran, PharmD Candidate

Kristian Catahan, PharmD Candidate

Dr. Carrie L. Griffiths

Guachipilincito is a remote rural village in Southwestern Honduras in the state of Intibucá. This community is very poor, with most earning around $10 per day. The climate is tropical, with a rainy season in the fall. We had the privilege of doing an international Advanced Pharmacy Practice Experience (APPE) rotation in Guachi, Honduras. This opportunity is offered three times a year (February, June, and October) to Wingate University School of Pharmacy. These are the times of year the medical brigade travels to Guachi. Senior pharmacy students (max of 2 per brigade) and a faculty preceptor accompany a one-week medical brigade organized by Shoulder to Shoulder. Shoulder to Shoulder is a non-profit organization that collaborates with healthcare workers and community leaders to improve the quality of life of rural Hondurans. Their goal is to provide accessible healthcare to the people of Guachi by providing care for chronic disease states such as hypertension and diabetes. The medical brigades consist of at least one physician, one pharmacist, and other medical professionals such as dentists, nurses, physical therapists, and learners at all levels. Anyone can volunteer to serve on a brigade, including pharmacy technicians and non-medical volunteers. Some in-country physicians and nurses will volunteer their time if able.

The clinic can see patients Monday through Thursday during the week-long medical brigade. This includes providing care to patients that come to the clinic, currently by appointment, and providing home visits to special needs children or elderly patients who cannot travel to the clinic.

In preparation for our trip, we met online with our brigade team. When we saw the recommended packing list (e.g., toilet paper, a mosquito net, a flashlight, a reusable water bottle, a clothesline, bed sheets, etc.), we knew our living conditions for the week would be sparse. However, only when we arrived in Honduras could we appreciate the drastic differences in our surroundings compared to the United States (U.S.). For example, roads were not paved and were filled with ruts. Additionally, adults and children frequently approached us to sell us various products to make money.

In America, access to healthcare is a right, but in Guachi, healthcare access is more of a privilege. Some patients must travel far to the clinic, some pay for taxis, and some walk for over an hour. Patients came to the clinic in their best clothing and were excited to see us even when they were acutely ill. The people of Guachi emphasized how grateful they were for each member working in the clinic. Everyone seemed incredibly grateful to be at the clinic, from Iris, Health Promoter, in the registration area, to William or Alan, interpreters provided by Shoulder to Shoulder, interpreting for the doctors, to the pharmacy team counseling every patient. It almost seemed like everyone came to celebrate. The patients celebrated having access to a physician and receiving free medications. Medications were provided to minimize symptoms, control chronic conditions, and help stock their home medicine cabinets. (Figure 1) The pharmacy’s formulary was limited to essential medications, many of which are included in the World Health Organization Model List of Essential Medications. (https:// list.essentialmeds.org/) All dispensed medications were free of charge to the patient. Each prescription was filled for a 120-day supply to last them until the next brigade. Figure 2 shows our team preparing and pre-packaging medications.

Neither the clinic nor the pharmacy operated using computers. Instead, patient charts and documentation were all hand-written on paper. Our preceptor walked us through how to read the charts and the doctor’s handwriting. We used extra care when reading the prescriptions to avoid misreading a medication or instructions. Prescription labels were handwritten in Spanish. Filling and verifying prescriptions took longer than anticipated without the usual resources available in the U.S. We found ourselves referencing the Spanish dictionary and physical LexicompⓇ book when needed due to the lack of internet access.

There was no electricity for two days during the week in our living area or clinic. We had to fill prescriptions using the tiny sliver of light provided by the 2 x 4-foot window or a small flashlight. Working in hot temperatures with little light made working more difficult and stressful. In the U.S., we take the reliability of electricity for granted, giving us lights and air conditioning. Figures 3 and 4 show the small space available for the pharmacy.

We had plenty of opportunities to interact directly with patients. Before the trip, we took a medical Spanish class where we learned essential vocabulary to communicate with patients in a pharmacy setting. We counseled over 100 patients within the week, but it was challenging even with the help of interpreters. They sometimes repeat incorrect instructions when asking patients to “teach back” how to use their new medications. At the same time, some patients got confused about their medicines due to only recognizing them by their color and shape. As the week progressed, our Spanish improved, and we spoke more confidently. Eventually, we had moments where the entire conversation was spoken in Spanish without the interpreter.

One day, we visited an elementary school to educate children about dental hygiene (Figure 5), including how to brush their teeth properly. Since dental care is scarce, many have cavities, crowns, or missing teeth. We administered fluoride treatments and gave them toothbrushes.

Every time we went on a home visit, we had to walk through the different landscapes carefully. Each patient we saw lived in a house at the bottom of a steep hill causing us to wonder how the residents of Guachi walk long and strenuous distances without having proper footwear. Many women wore plastic shoes that were Croc-like or flip-flops, while men typically wore boots or flip-flops. Everyone who walked by the clinic or our Shoulder to Shoulder trucks seemed unphased by having to walk such long distances. They did not appear uncomfortable or unhappy. To them, it was normal. It was a similar situation with the patients who traveled to the clinic— they even came in the pouring rain!

As we reflect on our APPE experience in Honduras, we have a stronger appreciation for what we used to take for granted, such as technology and electricity, but also healthcare and medication access and availability. Even the most basic of items, such as a toothbrush, is a commodity for many. This experience taught us how to adapt quickly to a new environment and the importance of interprofessional collaboration. It reemphasized the importance of good communication and showed us that stepping out of your comfort zone is okay while attempting to counsel patients who speak a different language. We saw that a fast-paced pharmacy work environment occurs in rural, remote areas of Honduras. Communicating with the healthcare team and taking breaks to relieve anxiety or stress is always important for minimizing errors no matter where you work! We also realized that even through times that seemed super busy at the clinic, every healthcare provider and volunteer made the time to ensure each patient was cared for and made to feel important. This seemingly small gesture greatly impacted our patients and the overall work environment.

To a student interested in an international rotation or a pharmacist who wants to work abroad, we feel confident in proclaiming, “the experience is unlike any other!” This trip reminded us to take a step back, breathe, and remember “why” we wanted to pursue pharmacy as a career. We will use this experience to recognize health disparities and minimize the differences through our care.

Authors: Nancy Tran, PharmD Candidate, Class of 2023, Wingate University School of Pharmacy; Kristian Catahan, PharmD Candidate, Class of 2023, Wingate University School of Pharmacy, and Carrie L. Griffiths, PharmD, BCCCP, FCCM (corresponding author), Associate Professor, Wingate University School of Pharmacy, Levine College of Health Sciences, Wingate, NC 28174; clgriffiths@wingate.edu.

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160 Business Park Circle, Stoughton, WI 53589 Phone: 888.870.7227 or 608.873.1342 count card transactions are for branded products. For Medicare patients, nearly 1 in 5 (19%) used a discount card. Commercial patients were 12%, but that doubled to 24% for those with an observed deductible. Cash paying patients represented 56% of all patients, and 52% of transactions.

Discount/Cash Cards Are Disruptors in the Industry

On February 25, 2023, PAAS National, had the privilege of participating in a Panel Discussion entitled Marketplace Prescription Dynamics Sure to Shape Your Business Strategies at NCPA Multiple Locations Conference. While traversing several different topic areas, one of the core issues important to community pharmacies is discount/cash cards.

IQVIA published a white paper entitled Pharmacy Discount Card Utilization and Impact1 in August of 2022 with several interesting findings. Among them, discount card utilization has grown to 5.4% of all pharmacy adjudications in 2021, a 63% increase over 2017 - of which “Not So GoodRx” now represents 46%. Only 9% of dis-

While the discount card growth has been remarkable, what makes them disruptors in the industry has been their impact on the traditional PBM model. Discount cards have been effective at undermining the perceived benefit that PBMs are supposed to provide (i.e., why is GoodRx able to offer a better price on my prescriptions than my insurance). Additionally, patients’ out of pocket costs are typically not captured when they use discount cards unless a patient is going to submit claims on their own (in addition to gaps in adherence metrics and other quality measures). In response, Express Scripts announced2 a partnership with GoodRx to include a “lesser of” logic when processing prescription claims through their Price Assure program. Not to be outdone, OptumRx launched Price Edge3 which will review direct-to-consumer prescription drug prices and offer members the lowest available price. Comically, OptumRx said they currently offer the best price to their members about 90% of the time, meaning 10% of the time patients are getting a raw deal. Both of these programs are automatically including these drug purchases into member’s deductibles going forward.

Pharmacies know4 that discount cards are really just another form of spread pricing, benefiting the discount card provider and PBM. GoodRx reports that it earns 15% of the patient’s total retail prescription cost, and that doesn’t include a fee for the PBM processor. Interestingly, GoodRx had disclosed that Kroger had accounted for only 5% of participating pharmacies, but nearly 25% of prescription transaction revenue. How could it have been that high? As a chain, Kroger was more likely dutiful in their utilization and/or promotion of GoodRx for patients. Most independents despise GoodRx and will create work arounds to avoid utilizing the card (e.g., with aggressive cash pricing or price-matching). Pharmacies should always be careful not to jeopardize their usual and customary. With the integration from these new programs by the PBMs, bypassing discount cards will likely no longer be an option for insured patients. The impact on BER, GER and even DIR fees for 2023, and beyond, are not clear.

Speaking of jeopardizing your Usual & Customary pricing, Amazon’s RxPass5 should be a flop. If you haven’t heard or read about it, Amazon is offering their Prime members “eligible medications for one flat, low monthly fee of $5, and have them delivered free of charge”. Patients with Medicare, Medicaid, or located in one of the seven states they exclude are not eligible to participate. The broader question is how long it will take the DOJ and HHS-OIG to enforce the U&C issue that has already played out with Walgreens (and many others). PAAS previously illuminated the $60 million settlement with the Prescription Savings Club in the March 2019

PAAS Newsline: AVOID “Discount Clubs” for Cash Patients6. That same DOJ announcement7 also discussed the infamous Insulin Pen Box Settlement for $200 million. Amazon clearly missed this settlement, as the PillPack subsidiary paid a $5.79 million settlement8 in May 2022 for the same insulin pen dispensing practices.

PAAS National® is committed to serving community pharmacies and helping keep hard-earned money where it belongs. Contact PAAS today at (608) 873-1342 or info@paasnational.com to see why PAAS Audit Assistance membership might be right for you.

By Trenton Thiede, PharmD,

MBA, President at PAAS National®, expert third party audit assistance and FWA/HIPAA compliance.

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References:

1. https://www.iqvia.com/locations/united-states/library/ white-papers/pharmacy-discount-card-utilization-and-impact

2. https://www.evernorth.com/ articles/increased-pharmacy-savings-and-affordable-prescription-medication

3. https://www.optum.com/ about-us/news/page.hub.optumrx-price-edge-for-best-prescription-price.html

4. https://www.drugchannels. net/2022/05/the-goodrx-kroger-blowup-spread-pricing. html

5. https://pharmacy.amazon. com/rxpass

6. https://portal.paasnational. com/Paas/Newsletter/Go/553

7. https://www.justice.gov/ usao-sdny/pr/manhattan-us-attorney-announces-2692-million-recovery-walgreens-two-civil-healthcare

8. https://www.justice.gov/ usao-sdny/pr/us-attorney-announces-settlement-fraud-lawsuit-against-online-pharmacy-overdispensing

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